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Diabetes in Hospitalized Patients 1997. 3.5 Million US Hospitalizations15% of Admissions14 Million Hospital Days20% of All Hospital Days36% First Diagnosed in Hospital 66% No Documentation by Physician 27% Labeled Hyperglycemia 2% Diag
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3. Diabetes in Hospitalized Patients1997
4. Diabetes in Hospitalized Patients1997 Costs
5. Diabetes in Hospitalized PatientsReason for Higher Costs Higher Rate of Hospitalization
Longer Stays
More Procedures, Medications
Chronic Complications
More Arteriosclerotic Disease
More Infections
Complicated Pregnancies
7. Infections in Diabetes More Frequent
Bacteremia
Septic Shock
Pyelonephritis
Candida
TPN
Unique
Necrotizing Fasciitis
Fournier’s Gangrene
Mucoromycosis
Emphysematous GB
Malignant External Otitis
8. Infections in Diabetes One BG >220 mg/dl results in 5.8 times increase in nosocomial infection rate
Two hours hyperglycemia results in impaired WBC function for weeks
9. TPN In DiabetesVA Cooperative Trial Benefit Negated
Increased Infections
Related to Hyperglycemia
10. Side Effects of BG >200 mg/dl Reduced Intravascular Volume
Dehydration
Electrolyte Fluxes
Impaired WBC Function
Immunoglobulin Inactivation
Complement Disabling
Increased Collagenase, Decreased Wound Collagen
11. Psychology of Diabetes in Hospital Patients expect good glycemic control as part of hospital care
They strive for recommended goals at home
Difficult to understand staff’s casual approach to BG’s >150
12. Evidence for Immediate Benefit of Normoglycemia in Hospitalized Patients Numerous Publications on in Vitro Evidence
Neutrophil Dysfunction
Complement Inhibition
Altered Redox State (Pseudohypoxia)
Glucose Rich Edema as Culture Media
Six Recent Clinical Publications supporting good glucose control in the hospital setting
13. Open Heart Surgery in DiabetesPortland St. Vincent Medical Center Control Group
N=968
1987-1991
SubQ Insulin q 4 h
Goal 200 mg/dl
Standard Deviation 36
All Mean BG’s <200 47% Study Group
N=1499
1991-1997
IV Insulin
Goal 150-200 mg/dl
Standard Deviation 26
All Mean BG’s <200 84%
14. Open Heart Surgery in DiabetesPortland CII ProtocolDemographics Total Open Heart Surgery Patients 14,468
Diabetes at Admission 2467 (17%)
Age 65 SD 10
Males 62%
Insulin Rx 36%
OHA 48%
15. Open Heart Surgery in DiabetesPortland St. Vincent Medical Center Perioperative Blood Glucose
16. Incidence of DSWI: 1987-1997
17. Open Heart Surgery in DiabetesPortland CII ProtocolInfectious Complications Diabetes
31/2467 (1.3%) Deep Sternal Wound Infection (DSWI)
23/31 Required Second Admission
22 Micrococcus
0 Anaerobes, fungal, yeast
Non-Diabetes
40/12,005 (0.3%)
18. Open Heart Surgery in DiabetesPortland CII ProtocolMortality All (99/2467) 4.0%
SQI 6.1%
CII 3.0%
DSWI 19.0%
No DSWI 3.8%
Recent Experience
1994-1997 DSWI as in non-diabetics
1996-7 No DSWI in last 15 mo.
19. Open Heart Surgery in DiabetesPortland CII ProtocolComparison of GroupsHigher Risk Patients in CII Group
20. Open Heart Surgery in DiabetesPortland CII ProtocolUnivariate Analysis of DSWI
22. Open Heart Surgery in DiabetesPortland CII ProtocolWeakness of Study Not Randomized
Temporal Sequential Nature
Subtle Cumulative Improvements in Techniques
23. Open Heart Surgery in DiabetesPortland CII ProtocolConclusions Magnitude and Strength of Study is Compelling
Ethics of Confirming Study Would be Questionable
Application of CII is Simple and Safe
Hyperglycemia Predicts DSWI
CII Prevents DSWI
24. Open Heart Surgery in DiabetesJohn Hopkins Prospective Cohort Study of 411 OHS pts with Diabetes 1990 – 1995
Diabetes based on history (42% insulin treated, 45% oral agents)
SMBG 4x/day with sliding scale
Measured relationship between peri-operative control and risk of all infections
25. Open Heart Surgery in DiabetesJohn Hopkins 24.3% with infections
BG divided into quartiles Relative Odds
Q1 121-206 20.1%
Q2 207-229 21.6% 1.17
Q3 230-252 29.8% 1.86*
Q4 252-352 25.7% 1.72*
26. DIGAMI StudyDiabetes, Insulin Glucose Infusion in Acute Myocardial Infarction(1997) Acute MI With BG > 200 mg/dl
Intensive Insulin Treatment
IV Insulin For > 24 Hours
Four Insulin Injections/Day For > 3 Months
Reduced Risk of Mortality By:
28% Over 3.4 Years
51% in Those Not Previous Diagnosed
27. Cardiovascular RiskMortality After MI Reduced by Insulin Therapy in the DIGAMI Study Slide 6-11
BARRIERS TO INSULIN THERAPY
Cardiovascular Risk
Mortality After MI Reduced by Insulin Therapy in the DIGAMI Study
Patients at high risk of cardiovascular disease are often thought to be inappropriate candidates for treatment with insulin because of the belief that hypoglycemia, hyperinsulinemia, or other metabolic effects of insulin might provoke or worsen the outcome of major cardiovascular events. This figure shows data from the Diabetes Mellitus Insulin-Glucose Infusion in Acute Myocardial Infarction (DIGAMI) trial. This Swedish trial studied the short-term and long-term effects of intensive insulin treatment of patients with diabetes who were enrolled in the trial at the time of a myocardial infarction. The subjects were immediately randomized to continued management according to the judgment of their physicians, or to intravenous infusion of insulin and glucose for 48 hours followed by a four-injection regimen subsequently for as long as 5 years. Other aspects of management of the infarction included treatment with b-blockers, angiotensin-converting enzyme inhibitors, fibrinolytic agents, and aspirin in high proportions of both groups. The rationale underlying the study was the old observation that, in animal experiments and studies of small numbers of humans, infarct size and outcome are improved by insulin-glucose infusion, in part because of suppression of otherwise elevated free fatty acid levels in plasma. The figure shows the cumulative total mortality rates in the whole population of 620 subjects randomized to the two treatments, as well as the rates for a predefined subgroup of subjects who were judged likely to survive the initial hospitalization and were not previously using insulin. The whole population showed an 11% actual and a 28% relative risk reduction with intensive insulin treatment after 5 years, and the subgroup showed a 15% actual and a 51% relative risk reduction. Most of the benefit was apparent in the first month of treatment and presumably was partly due to immediate intravenous infusion of insulin; however, the survival curves tended to separate further over time, suggesting an ongoing benefit from intensive treatment. This study suggests that insulin is an entirely appropriate treatment for patients with type 2 diabetes and high cardiovascular risk, especially at the time of myocardial infarction.
Malmberg K, Rydén L, Hamsten A, Herlitz J, Waldenström, Wedel H, and the DIGAMI study group. Effects of insulin treatment on cause-specific one-year mortality and morbidity in diabetic patients with acute myocardial infarction. Eur Heart J. 1996;17:1337-1344; Nattrass M. Managing diabetes after myocardial infarction: time for a more aggressive approach. BMJ. 1997;314:1497; Malmberg K, and the DIGAMI study group. Prospective randomised study of intensive insulin treatment on long term survival after acute myocardial infarction in patients with diabetes mellitus. BMJ. 1997;314:1512-1515.Slide 6-11
BARRIERS TO INSULIN THERAPY
Cardiovascular Risk
Mortality After MI Reduced by Insulin Therapy in the DIGAMI Study
Patients at high risk of cardiovascular disease are often thought to be inappropriate candidates for treatment with insulin because of the belief that hypoglycemia, hyperinsulinemia, or other metabolic effects of insulin might provoke or worsen the outcome of major cardiovascular events. This figure shows data from the Diabetes Mellitus Insulin-Glucose Infusion in Acute Myocardial Infarction (DIGAMI) trial. This Swedish trial studied the short-term and long-term effects of intensive insulin treatment of patients with diabetes who were enrolled in the trial at the time of a myocardial infarction. The subjects were immediately randomized to continued management according to the judgment of their physicians, or to intravenous infusion of insulin and glucose for 48 hours followed by a four-injection regimen subsequently for as long as 5 years. Other aspects of management of the infarction included treatment with b-blockers, angiotensin-converting enzyme inhibitors, fibrinolytic agents, and aspirin in high proportions of both groups. The rationale underlying the study was the old observation that, in animal experiments and studies of small numbers of humans, infarct size and outcome are improved by insulin-glucose infusion, in part because of suppression of otherwise elevated free fatty acid levels in plasma. The figure shows the cumulative total mortality rates in the whole population of 620 subjects randomized to the two treatments, as well as the rates for a predefined subgroup of subjects who were judged likely to survive the initial hospitalization and were not previously using insulin. The whole population showed an 11% actual and a 28% relative risk reduction with intensive insulin treatment after 5 years, and the subgroup showed a 15% actual and a 51% relative risk reduction. Most of the benefit was apparent in the first month of treatment and presumably was partly due to immediate intravenous infusion of insulin; however, the survival curves tended to separate further over time, suggesting an ongoing benefit from intensive treatment. This study suggests that insulin is an entirely appropriate treatment for patients with type 2 diabetes and high cardiovascular risk, especially at the time of myocardial infarction.
Malmberg K, Rydén L, Hamsten A, Herlitz J, Waldenström, Wedel H, and the DIGAMI study group. Effects of insulin treatment on cause-specific one-year mortality and morbidity in diabetic patients with acute myocardial infarction. Eur Heart J. 1996;17:1337-1344; Nattrass M. Managing diabetes after myocardial infarction: time for a more aggressive approach. BMJ. 1997;314:1497; Malmberg K, and the DIGAMI study group. Prospective randomised study of intensive insulin treatment on long term survival after acute myocardial infarction in patients with diabetes mellitus. BMJ. 1997;314:1512-1515.
28. ICU Survival 1548 Patients (mostly OHS pts.)
All with BG >200 mg/dl
Randomized into two groups
Maintained on IV insulin
Conventional group (BG 180-200)
Intensive group (BG 80-110)
Conventional Group had 1.74 X mortality
29. ICU IV Insulin Protocol If > 100 mg/dl, 2 U/h If > 200 mg/dl, 4 U/h
If > 140 mg/dl, increase by 1 – 2 U/h
If 121 to 140 mg/dl, increase by 0.5 – 1 U/h
If 111 to 120 mg/dl, increase by 0.1 – 0.5 U/h
If 81 to 110 mg/dl, no change
If 61 to 80 mg/dl, change back to prior rate
30. ICU Survival Blood glucose control:
Convetional Intensive
Mean AM BG 153 103
% Receiving Insulin 39% 100%
BG < 40 mg/dl 6 39
31. ICU Survival Intensive Therapy (80 to 110 mg/dL) resulted in:
34% reduction in mortality
46% reduction in sepsis
41% reduction in dialysis
50% reduction in blood transfusion
44% reduction in polyneuropathy
32. Conclusion All hospital patients should have normal glucose
33. Insulin The agent we haveto control glucose
34. Comparison of Human Insulins / Analogues Insulin Onset of Duration ofpreparations action Peak action
35. Physiological Serum Insulin Secretion Profile
36. Basal/Bolus Treatment Program withRapid-acting and Long-acting Analogs
37. Methods For Managing Hospitalized Persons with Diabetes Continuous Variable Rate IV Insulin Drip
Major Surgery, NPO, Unstable, MI, DKA, Hyperglycemia, Steroids, Gastroparesis, Delivery, etc
Basal / Bolus Therapy (MDI) when eating
38. Continuous Variable Rate IV Insulin Drip Mix Drip with 125 units Regular Insulin into
250 cc NS
Starting Rate Units / hour = (BG – 60) x 0.02
where BG is current Blood Glucose
and 0.02 is the multiplier
Check glucose every hour and adjust drip
Adjust Multiplier to keep in desired glucose
target range (100 to 140 mg/dl)
39. Continuous Variable Rate IV Insulin Drip
Adjust Multiplier (initially 0.02) to obtain glucose in target range 100 to 140 mg/dL
If BG > 140 mg/dL, increase by 0.01
If BG < 100 mg/dL, decrease by 0.01
If BG 100 to 140 mg/dL, no change in Multiplier
If BG is < 80 mg/dL, Give D50 cc = (100 – BG) x 0.3
Give continuous rate of Glucose in IVF’s
Once eating, continue drip till 1 hour post SQ insulin
40. Glucose Management System
41. Glucommander Based on 15 Year Experience with a Computer Based Algorithm for the Administration of IV Insulin
Developed for Marketing by MiniMed and Roche
GMS System
Shelved Pending FDA Approval of IV Use of Insulin
Useful and Safe for Any Application of IV Insulin
43. Glucommander Effectiveness Initial blood glucose
Median 292 mg/dl
Range 181-1,568
Time to achieve glucose < 180 mg/dl
Median 3 hours
Range 0.3 - 19.7
Time to achieve three consecutive glucose results between 60 - 180 mg/dL
Median 3. 1 hours
Range 0.3 - 22.5
44. Converting to SQ insulin Establish Daily Insulin Requirement
IV Insulin First Night
(BG - 60) x Multiplier = Ins/hr Targeted to 120
60 x Multiplier x 24 = Daily Insulin Requirement
Give One-Half Amount As Basal
Give p.c. Boluses Based on CHO Intake
Start at CHO/Ins 1 CHO = 1.5 units Rapid-acting
Monitor a.c. tid, hs, and 3 am
Supplement All BG >150
(BG-100)/(1700/Daily Insulin Requirement)
45. Protocol for SQ Insulin in Hospitalized Patient
Bedtime: Wt (kg) x 0.2 = Units of Glargine
Meals Eaten: 1.5 units per 15 Gm CHO eaten
BG >150: (BG-100) / CF
CF = 3000 / Wt (kg)
Do Not Use Sliding Scale Only
Any BG <80: D50 = (100-BG) x 0.3 ml
Maintain INT
Do Not Hold Insulin When BG Normal
46. How to Initiate MDI Starting dose = 0.4 to 0.5 x weight in kilograms
Bolus dose (aspart/lispro) = 20% of starting dose at each meal
Basal dose (glargine) = 40% of starting dose given at bedtime or anytime
Correction bolus = (BG - 100)/ Correction Factor, where CF = 1700/total daily dose
47. How to Initiate MDI starting dose = 0.45 x wgt. in kg
Wt. is 80 kg; 0.45 x 80 = 36 units
Bolus dose (aspart / lispro) = 20% of starting dose at each meal; 0.2 x 36 = 7 units ac (tid)
Basal dose (glargine) = 40% of starting dose at HS; 0.4 x 36 = 14 units at HS
Correction bolus = (BG - 100)/ CF, where CF = 1700/total daily dose; CF = 50
48. Correction Bolus Formula Example:
Current BG: 250 mg/dl
Ideal BG: 100 mg/dl
Glucose Correction Factor: 50 mg/dl
49. Piedmont Diabetes PlanWhat Can We Do For Patients Admitted To Hospital? NPO Pathway For All Diabetes Patients
Finger Stick BG ac qid on ALL Admissions
Check All Steroid Treated Patients
Diagnose Diabetes
FBG >126 mg/dl
Any BG >200 mg/dl
50. Piedmont Diabetes PlanWhat Can We Do For Patients Admitted To Hospital? Document Diagnosis in Chart
Hyperglycemia Is Diabetes Until Proven
Bring to All Physician’s Attention
Note on Problem List and Face Sheet
Check Hemoglobin A1C
Hold Metformin; Hold TZD with CHF, Liver Dysfunction
Start Insulin in All Hospitalized Patients Not Already on Insulin
51. Piedmont Diabetes PlanWhat Can We Do For Patients Admitted To Hospital? Get Diabetes Education Consult
Instruct Patient in Monitoring and Recording
See That Patient Has Meter on Discharge
Decide on Case Specific Program for Discharge
Arrange Early F/U with PCP
52. Piedmont Diabetes PlanWhat Can We Do For Patients Admitted To Hospital? Follow Guidelines For Endocrinology Consult
Any Hypoglycemia Requiring Intervention
DKA or HHNC
Patient on Insulin Pump
Diabetes in Pregnancy
Glucocorticoid Therapy in Diabetes
Progressive Diabetes Complications
A1C >8%, Microalbuminuria >30 mg
53. Treat Any Patient With BG > 150 With Insulin
Treat Any BG >150 with Rapid-acting Insulin (BG-100) / (5000 / wt #) or (3000 / wt kg)
Treat Any Recurrent BG >200 with IV Insulin
If More than 0.5 u/hr IV Insulin Required with Normal BG Start Long Acting Insulin
Protocol for Insulin in Hospitalized Patient
54. Protocol for Insulin in Hospitalized Patient Daily Total: Pre-Admission or Weight (#) x 0.2 u
40 % as Glargine (Basal)
60% as Rapid-acting insulin (Bolus)
Give in Proportion to Meal’s CHO Eaten
BG >150: (BG-100) / CF
CF = 5000 / Wt(#) or 3000 / Wt(kg)
Do Not Use Sliding Scale As Only Diabetes Management
55. Protocol for Insulin in Hospitalized Patient Treatment of Hypoglycemia
Any BG <80 mg/dl: D50 = (100-BG) x 0.3 ml IV
Do Not Hold Insulin When BG Normal
56. Diabetes at Piedmont HospitalConclusions Any BG >200 mg/dl Is Diabetes (Fasting >126 mg/dl)
Most Diabetes Is Type 2
All DM patients Must Self-Monitor BG’s and Record
No BG >150 mg/dl Should Go Untreated
Most Hospitalized DM [atients Should Be on Insulin
IV Insulin is Most Effective, Efficient, Safest Rx in Acute Illness (Glucommander)
57. Diabetes at Piedmont HospitalConclusions 2 Type 2 Diabetics Are Resistant to Insulin Reactions
Treat Insulin Reactions in Hospital With IV Glucose
Do Not Be Hold Insulin for Normal BG, i.e. 80-120 mg/dl
A1C Values >7% Indicates Sub-optimal Care
58. Diabetes at Piedmont HospitalConclusions 3 Discharge Plan For BG Control
You Are the Link Between the Best Diabetes Care and the Patient
Use Your Diabetes Resources
Diabetes Education Center Endocrinologists
59. The Paradigm for the MilleniumHyperglycemia: A Mortal Sin A blood glucose over 200 in a hospitalized patient causes increased morbidity and mortality.
In the 21st Century Neglecting a BG >200 Will Be Malpractice
60. Conclusion Intensive therapy is
the best way to treat
patients with diabetes
61. QUESTIONS For a copy or viewing of these slides, contact
WWW.adaendo.com