FAIRVIEW HEALTH SERVICES INPATIENT DIABETES INITIATIVE

1. FAIRVIEW HEALTH SERVICES INPATIENT DIABETES INITIATIVE 2006

2. Diabetes Mellitus is a chronic disorder of metabolism characterized by alterations in the metabolism of glucose, proteins and fats.

3. Classification of Diabetes Mellitus Type 1-an absolute deficiency of insulin secretion exists. Type 2-one or a combination of significant insulin resistance, receptor cell defect and an insulin secretory defect exist. Other-genetic defects of beta cell or insulin action, diseases of the exocrine pancreas, endocrinopathies, drug or chemical-induced, infections, uncommon forms of immune-mediated disease, other genetic syndromes sometimes associated with DM. Gestational –any degree of glucose intolerance with onset or first recognition during pregnancy. Impaired glucose tolerance and impaired fasting glucose-> 100 mg/dl but < 126 mg/dl.

4. Pre-Diabetes is this last group!It is real and efforts to achieve early detection and intervention within this population need to be highlighted, publicized and promoted!

5. Diabetes in Acute Care Fourth most common co-morbid condition complicating all hospital discharges DM present in 12.4 % of all discharges and the principal diagnosis in 8% of the hospitalizations Prevalence of DM in acute care about 40% 29% of those undergoing cardiac surgery have DM Causes 2-4 fold increase in hospitalization rates DM increases length of stay by 1-3 days; average 5.4 days Annual cost of diabetes inpatient care equals $40 billion

6. Who is the client? Individuals previously diagnosed with diabetes. Individuals admitted with unrecognized diabetes. Individuals with stress-induced hyperglycemia.

7. Hyperglycemia is an independent risk factor for adverse outcomes!

8. Inpatient DM Management:Risks with Hyperglycemia Hyperglycemia is associated with increased in-hospital mortality, CHF, prolonged hospital stay, increased risk of infections1-4 Diabetes and hyperglycemia associated with poor outcomes in patients with CVA and CABG

9. Inpatient DM Management:Glucose Control Makes a Difference

10. Blood Glucose Threshold in Cardiac Surgery and Critical Care Lowest mortality occurs in patients with blood glucose levels < 150 mg/dl. Anthony Furnary et al: Continuous intravenous insulin infusion reduces the incidence of deep sternal wound infection in diabetic patients after cardiac surgical procedures. Annals of Thoracic Surgery 67: 352-362, 1999.

12. Hyperglycemia and Poor Outcomes

13. Hyperglycemia and Poor Outcomes

14. In acutely ill and critically ill individuals, there is a 20% risk of death and substantial morbidity as a result of hyperglycemia and sub-optimal management!

15. Glucose uptake is actually increased in insulin-independent tissues which include:the brain and neuronsred blood cellswounds

16. Outcomes of sub-optimal glycemic management include: decreased host resistance with altered phagocytic cell function. increased fungal growth of pathogens. impaired wound healing. Diabetic Ketoacidosis (DKA). Hyperosmolar Hyperglycemic Non-Ketotic Syndrome (HHNS). hypoglycemia.

17. Outcomes of sub-optimal glycemic management include: electrolyte and fluid imbalances, especially hypokalemia and hyperkalemia. post-operative myocardial infarction. post-operative cerebral vascular accident. thrombosis. acute renal failure. mechanical factors such as ischemic alterations, decreased cough reflex, impaired bladder emptying, fecal incontinence, and impaired mobility.

18. The etiologies of these outcomes include: the stress cascade which triggers increased secretion of ACTH and the counter-regulatory hormones cortisol, catecholamines, glucagon and growth hormone. decreased insulin secretion in some individuals. altered insulin action.

19. The etiologies of these outcomes include: oxidative stress. increased cytokines and inflammatory response. vascular reactivity. platelet hyperactivation. endothelial cell dysfunction. immune system impairment. neuronal damage. polyol pathways. glycation processes.

20. American College of EndocrinologyPosition Statement on Inpatient Diabetes and Metabolic ControlJanuary/February, 2004Vol. 10, No. 1Endocrine Practice American College of Endocrinology (ACE) American Association of Clinical Endocrinologists (AACE)

21. Upper Limits for Glycemic Targets Inpatient Intensive Care: BG <110 mg/dl Non-Critical Care Units Pre-prandial BG <110 mg/dl Maximal BG <180 mg/dl

22. Upper Limits for Glycemic Targets in Pregnancy Pre-labor Pre-prandial 100 mg/dl 1 hour Post-prandial 120 mg/dl • Labor and Delivery 100 mg/dl

23. Intraoperative Glycemic Control Target to maintain blood glucose between 80-150 mg/dl Achieved with intravenous insulin infusion Avoid hypoglycemia

24. When are targets set outside of the standard? Neonates-immature glucose regulation Pediatrics-according to developmental stage and safe management by parents/caregiver Geriatrics-Dementia, altered mental status. Renal Insufficiency Hepatic Insufficiency Gastroparesis

25. The treatment modalities for optimal glycemic management include: frequent blood glucose monitoring. the administration of exogenous insulin. fluid and electrolyte replacement and maintenance. nutrition. hypoglycemia prevention.

26. Evidence –Based Protocols Continuous Intravenous Insulin Infusions Subcutaneous Insulin Management Continuous Subcutaneous Insulin Infusion Hypoglycemia DKA HHNS

31. Onset, Peak , and Duration of Different Insulins Insulin Onset Peak Duration Lispro 0.25 hrs 0.5-1.5 hrs 3-5 hrs Aspart 0.25 hrs 0.5-1.5 hrs 3-5 hrs Glulisine 0.2 hrs 1-3 hrs 3-5 hrs Regular 0.5-1 hr 2-3 hrs 6-8 hrs NPH 1-1.5 hrs 6-8 hrs 12-18 hrs Lente 1-2.5 hrs 7-15 hrs 12-18 hrs Ultralente 4-8 hrs 10-13 hrs 12-24 hrs Glargine 2-4 hrs no peak 24 plus hrs Detemir 2 hrs 4-8 hrs 12-20 hrs

32. Basal Insulin 24 hour coverage Needed to cover glucose uptake from the liver. Needed to cover glucose rises in response to counter-regulatory hormones. Lente and Ultralente are no longer being manufactured. Glargine or Detemir are to be used. NPH works effectively for cycled feedings and steroid bursts.

33. Bolus Insulin Prandial or Mealtime insulin-Rapid insulin prescribed in an insulin to carbohydrate ratio to cover the amount of Carbohydrate Units taken in a meal and/or snack. Correction Insulin (Sliding Scale)-Rapid insulin in fed state; short or rapid insulin if NPO and/or on continuous TPN or continuous enteral feeds. The insulin sensitivity factor (ISF) is the number of units needed to drop the blood glucose a specific number of mg/dl to achieve the target glucose.

34. Insulin Dosing Guidelines TDI (Total Daily Insulin) or TDD (Total Daily Dose) 0.4 to 1 units/kg/24 hr 50% of this is basal insulin 50% of this is bolus insulin Basal: Detemir or Glargine choose to use 40-50% of TDI. NPH, choose to use 50% with 2/3 in AM dose and 1/3 in HS dose. Bolus: 50% Bolus and Correction

35. Prandial Insulin Most patients require 1 unit of insulin to dispose of 10-15 grams of ingested carbohydrate. Begin with a ratio of 1:15; 1 unit of Aspart for every 15 grams of CHO eaten. If the ratio is correct, the 2 hour post-prandial glucose is no more than 40 mg/dl higher than the pre-prandial glucose.

36. ISF-Insulin Sensitivity Factor Also known as the correction factor. To determine the glucose-lowering response of 1 unit of insulin, utilize the rule of 1800. 1800 divided by the TDI=____mg/dl This will be the number of mg/dl that 1 unit will drop the blood glucose. Some choose to use 1500 instead of 1800.

37. Why use Insulin/Carb Ratios? Easy to teach and comprehend-focuses on food and blood glucose relationships No need for rigid/complicated meal plans-allows people to vary food choices Flexible-works with varying caloric intakes Empowering-empowers people to learn self-management skills to balance effects of food, insulin, activity, stress, and medications

38. Insulin/Carbohydrate Ratio: Factors to Consider Background Insulin · Glargine, Detemir, NPH Meal Coverage Insulin Aspart/NovoLog, Lispro/Humalog Start with 1 unit for each 10-15 grams carbohydrate Ratio can vary from 1 unit per 5-30 grams carbohydrate Correction Factor 1 unit of meal coverage insulin decreases blood sugar by approximately 50 mg/dl. Adjust according to blood glucose results Range can vary widely for correction depending on insulin sensitivity

39. Changing Circumstances Insulin/Carbohydrate ratios are subject to change with changing circumstances: workdays vs. weekdays exercise/activity vs. non-exercise/activity days changes in body weight sickness/medications changing from MDI to CSII dialysis run days vs. non-run days ratios need periodic re-evaluation

40. Assessment Time of day Insulin dose, type Blood glucose value before each meal and snack, and two-hours postprandial Amount of carbohydrate consumed Activity/exercise Stress/illness/medications

41. How Nutrients in Food Affect Blood Sugar

42. Steroid Induced or Chemically Induced Hyperglycemia • Select insulin to peak at time steroid burst peaks. Thus, if daily dosing of steroid in AM, NPH works quite well because of peak time with corresponding elevation in blood glucose from the steroid. • May choose to use a basal insulin overnight with correction through the day.

43. TPN and Enteral Feeds Basal Insulin Basal/Bolus to cover cycled feeds Replacement with Dextrose 10% if feed interrupted Bolus Feeds and Bolus Insulin What is optimal?

44. FV Subcutaneous Insulin Management Orders*

45. Estimating Initial Insulin Dose

46. Estimating Initial Insulin Dose – Basal Insulin

47. Ordering Basal Dose

48. Ordering Basal Dose

49. Estimating Initial Insulin Dose – Prandial Insulin

50. Ordering Bolus (Prandial) Dose

51. Ordering Bolus (Prandial) Dose

52. Estimating Initial Insulin Dose – Correction Insulin

53. Ordering Bolus Correction Dose

54. Ordering Bolus Correction Dose

55. Bolus Correction Dose- Bedtime Supplement and Changes in Nutrition

56. Bolus Correction Dose- Bedtime Supplement and Changes in Nutrition

57. Estimating Initial Insulin Dose Severity of illness Fragility of patient Renal function Body weight Expected nutritional intake Medications (e.g. steroids)

58. Transition from IV to SC Insulin

60. Hypoglycemia Prevention Hypoglycemia can cause harm! Thus, proper dosing of insulin, monitoring of blood glucose, appropriate nutrition and evaluation of other pharmaceuticals is crucial to achieve and maintain glycemic control without causing harm from hypoglycemia.

61. Hypoglycemia Order Set Profiled so that there is no need for an over ride in pyxsis Allows for rescue without over shooting target goal range Allows nursing staff to feel more confident with aggressive glycemic management

62. In conclusion, the evidence demonstrates that the achievement of euglycemia in acutely ill individuals does have a direct result on the reduction of their mortality and morbidity. Acute care providers are compelled to manage hyperglycemia safely and to target goals, respecting individual needs as much as is safely possible.