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Glycemic Control In the Hospital Setting

Glycemic Control In The Hospital Setting. The Evidence For Tight Glycemic Control The Achievement of Better Control: Strategies and Protocols A Few Cases . . Glycemic Control In The Hospital. Many Observational StudiesMajor Prospective Studies. Glycemic Control In The Hospital Major Pros

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Glycemic Control In the Hospital Setting

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    1. Glycemic Control In the Hospital Setting

    2. Glycemic Control In The Hospital Setting The Evidence For Tight Glycemic Control The Achievement of Better Control: Strategies and Protocols A Few Cases

    3. Glycemic Control In The Hospital Many Observational Studies Major Prospective Studies

    4. Glycemic Control In The Hospital Major Prospective Studies DIGAMI Post MI BMJ, 1997 Leuven 1 SICU NEJM, 2001 Leuvan 2 MICU NEJM, 2006 28% Decreased All Cause Mortality 34% Decreased In Hospital Mortality + Reduced Morbidity 16 % Decrease In Hospital Mortality* + Reduced Morbidity

    5. Glycemic Control In The Hospital Major Prospective Studies Furnary Post CABG J Thoracic Cardiovasc Surg 2003 Lazar Post CABG Circulation, 2004 26% Decrease Mortality Major Morbidity Reduction*

    6. Insulin In The Hospital Setting The Rest of the Story…

    7. Insulin In The Hospital Setting The Rest of the Story…

    8. Insulin In The Hospital Setting The Rest of the Story…

    9. Insulin In The Hospital Setting The Rest of the Story…

    10. Insulin In The Hospital Setting The Rest of the Story…

    11. Glucose-Insulin-Potassium Therapy

    12. Glucose-Insulin-Potassium Therapy Control Of Glycemia Meta-Analysis of 35 Studies; 8,478 Patients In Trials That Targeted Glucose, 29% Reduction In Mortality With Insulin No Benefit When Insulin Was Administered Without Regard To Glucose Levels

    14. New Trials On The Horizon… NICE (NormoGlycemia In Intensive Care Evaluation): 4,000 Patients in 20 ICU’s In Australia & New Zealand SUGAR (Survival Using Glucose Algorithm Regulation): Another 1,000 ICU Patients In Canada

    15. Is It Less Serious If a Patient Has Not Had a Previous Diagnosis of Diabetes?

    16. Hyperglycemia: An Independent Marker of In-Hospital Mortality in Patients with Undiagnosed Diabetes Question: Does Hyperglycemia, New or Established, Predict Mortality? 2030 Consecutive Records of Adults Admitted to Georgia Baptist Hospital Hyperglycemia: FBG = 126 mg/dl or Random Glucose = 200 mg/dl New Hyperglycemia 223 Pts. (12%)

    17. Hyperglycemia: An Independent Marker of In-Hospital Mortality in Patients with Undiagnosed Diabetes

    18. A Marker of In-Hospital Mortality in Patients with Undiagnosed Diabetes New Hyperglycemia Patients ~3 x’s As Likely to Be Admitted to ICU New Hyperglycemia Patients Had Twice the Length of Stay

    19. There are other benefits…

    20. Glycemic Management In The Hospital Financial Aspects

    21. Glycemic Management In The Hospital Financial Aspects

    22. Glycemic Management In The Hospital Financial Aspects

    23. Insulin In The Hospital Setting The days of casual glycemic control for critically ill patients should be over!

    24. Glycemic Control In The Hospital Setting The Evidence For Tight Glycemic Control The Achievement of Better Control: Strategies and Protocols A Few Cases

    25. What Are The Treatment Goals?

    26. Hospital Glycemic Goals Intensive Care Units: 110 mg/dL Non-Critical Care Units: Pre-Prandial 110 mg/dL Max. Glucose 180 mg/dL

    27. Strategies and Protocols for Achieving Inpatient Glycemic Control Strategies and Protocols for Achieving Inpatient Glycemic ControlStrategies and Protocols for Achieving Inpatient Glycemic Control

    28. IV Insulin Infusion Protocols

    29. The Ideal IV Insulin Protocol Easily Ordered (Signature Only) Effective (Reach Goal Quickly) Safe (Minimal Risk Of Hypoglycemia) Easily Implemented The Ideal IV Insulin Protocol In addition to specifying insulin dose, protocols should include specific guidelines for identifying patients at risk for hypoglycemia and actions to be taken to prevent and treat hypoglycemia. The Ideal IV Insulin Protocol In addition to specifying insulin dose, protocols should include specific guidelines for identifying patients at risk for hypoglycemia and actions to be taken to prevent and treat hypoglycemia.

    30. IV Insulin Protocol Based On Insulin Sensitivity

    31. Intravenous Insulin Infusion Targeting BG 80–110 mg/dL Intravenous Insulin Infusion Targeting BG 80–110 mg/dL

    32. < 70 Off 70-109 0.2 110-119 0.5 120-149 1.0 150-179 1.5 180-209 2.0 210-239 2.0 240-269 3.0 270-299 3.0 300-329 4.0 Etc.

    33. < 70 Off 70-109 0.2 110-119 0.5 120-149 1.0 150-179 1.5 180-209 2.0 210-239 2.0 240-269 3.0 270-299 3.0 300-329 4.0 Etc.

    34. < 70 Off < 70 Off 70-109 0.2 70-109 0.5 110-119 0.5 110-119 1.0 120-149 1.0 120-149 1.5 150-179 1.5 150-179 2.0 180-209 2.0 180-209 3.0 210-239 2.0 210-239 4.0 240-269 3.0 240-269 5.0 270-299 3.0 270-299 6.0 300-329 4.0 300-329 7.0 Etc. Etc.

    35. Shifting Between Several Algorithms Makes It Possible To Discover The Insulin Requirement That Maintains Normoglycemia

    36. Recommended IV Fluids To Prevent Hypoglycemia, Hypokalemia & Ketosis: Glucose: 5-10 gms/hour Potassium: 20 meq/L The Primary Service Should Choose the Type and the Rate of the Fluid Depending on the Underlying Disease

    37. Other Protocols Exist DIGAMI (Studied In Acute MI Setting) Van den Berghe (Critical Care Setting) Portland Protocol (Surgical Setting) Markovitz (Postoperative Heart Surgery) Yale Protocol (Medical Intensive Care Setting) Glucommander.com; Endotool.com; Medicaldecisions.com (Critical Care & Non- Critical Care) Various Protocols Exist A number of protocols have been published for the administration of continuous insulin infusion. The use of standardized protocols is associated with improved glycemic control and low rates of hypoglycemia. Various Protocols Exist A number of protocols have been published for the administration of continuous insulin infusion. The use of standardized protocols is associated with improved glycemic control and low rates of hypoglycemia.

    38. Other Protocols Exist Various Protocols Exist A number of protocols have been published for the administration of continuous insulin infusion. The use of standardized protocols is associated with improved glycemic control and low rates of hypoglycemia. Various Protocols Exist A number of protocols have been published for the administration of continuous insulin infusion. The use of standardized protocols is associated with improved glycemic control and low rates of hypoglycemia.

    39. Life After The Drip….

    40. Physiologic Insulin Secretion : Basal/Bolus Concept When we consider glucose control, we need to focus on both postprandial and basal requirements. This slide illustrates the normal diurnal physiologic response, which highlights the need for both basal and meal insulin. Meal-insulin release occurs in response to nutrient ingestion. Basal insulin is continually secreted over a 24-hour period to maintain homeostasis in the body energy requirements and balance. The “normal” human adult secretes about 25-30 units of insulin a day. As you can see, about ˝ of this is in “BASAL” insulin. You can also see that a “normal” patient would likely not exceed PG = 150 mg/dL, even after a meal. These ambient glucose levels (euglycemia) are reflected in a “normal” GHbA1c range of 4.5-6.5% in the USA. NOTE – if you take a random BG (about 15-20% less in value than PG) and it is >130mg/dL, it would be suspect. I will show you what I mean in later slides, but keep this in mind. - If the patient just ate, or it he/she ate 2-3 hours before, it would make a difference in how you may advise him/her concerning seeking medical advise. (Refer to OGTT – Oral Glucose Tolerance Test – data) In the past, we have had to make due with various insulin formulations that did not have adequate pharmacokinetics to duplicate these profiles. However, within the past few years, new insulin analogs have been developed, which provide more physiologic profiles. When we consider glucose control, we need to focus on both postprandial and basal requirements. This slide illustrates the normal diurnal physiologic response, which highlights the need for both basal and meal insulin. Meal-insulin release occurs in response to nutrient ingestion. Basal insulin is continually secreted over a 24-hour period to maintain homeostasis in the body energy requirements and balance. The “normal” human adult secretes about 25-30 units of insulin a day. As you can see, about ˝ of this is in “BASAL” insulin. You can also see that a “normal” patient would likely not exceed PG = 150 mg/dL, even after a meal. These ambient glucose levels (euglycemia) are reflected in a “normal” GHbA1c range of 4.5-6.5% in the USA. NOTE – if you take a random BG (about 15-20% less in value than PG) and it is >130mg/dL, it would be suspect. I will show you what I mean in later slides, but keep this in mind. - If the patient just ate, or it he/she ate 2-3 hours before, it would make a difference in how you may advise him/her concerning seeking medical advise. (Refer to OGTT – Oral Glucose Tolerance Test – data) In the past, we have had to make due with various insulin formulations that did not have adequate pharmacokinetics to duplicate these profiles. However, within the past few years, new insulin analogs have been developed, which provide more physiologic profiles.

    41. Transition From IV to SQ Insulin In The Adult Patient Basal Insulin Bolus Insulin Prandial Insulin Correction Factor Insulin

    42. Onset Peak Effective Duration Lispro/Aspart/Glulisine <15 min 1 hr 3 hr Regular 1/2-1 hr 2-3 hr 3-6 hr NPH 2-4 hr 7-8 hr 10-12 hr Insulin Glargine 1-2 hr Flat 24 hr Insulin Detemir 0.8-2 hr * ~8-9 hr * Up to 24 hr * Current Insulin Preparations

    43. Insulin Detemir Pharmacokinetics

    44. Transition to SQ: An Approach To Transition A Patient From An IV Insulin Infusion To SQ Insulin: Multiply Last Drip Dose By 20, And Give This Amount As Glargine Turn The IV Drip Off 2 Hours Later

    45. Glucose Levels after Starting Lantus

    46. Transition to SQ: An Approach To Transition A Patient From An IV Insulin Infusion To SQ Insulin: Multiply Last Drip Dose By 20, And Give This Amount As Glargine Turn The IV Drip Off 2 Hours Later

    47. Hypoglycemia After CV Surgery: NPH/Reg vs Glargine Insulin

    48. Transition to SQ: An Approach To Transition A Patient From An IV Insulin Infusion To SQ Insulin: Multiply Last Drip Dose By 20, And Give This Amount As Glargine Turn The IV Drip Off 2 Hours Later

    49. Example: Last Drip Dose Is 1.5 Unit/Hour; Give 1.5 X 20 = 30 units Of Glargine SQ; Discontinue Drip Two Hours Later This Is Basal Insulin

    50. Adjust Basal Insulin By FBS: Decrease 4 U if FBS are below 60 mg/dL Decrease 2 U if FBS Is 60-80 mg/dL If FBS Is 80-100mg/dL, At Goal-No Change is Needed Increase 2 U If FBS Is 100 to 120 mg/dL Increase 4 U If FBS Is 121 to 140 mg/dL Increase 6 U If FBS Is 141 to 160 mg/dL Increase 8 U If FBS Is 161 to 180 mg/dL Increase 10 U If FBS Is > 180 mg/dL

    51. Transition From IV to SQ Insulin In The Adult Patient Basal Insulin Bolus Insulin Prandial Insulin Correction Factor Insulin

    52. Onset Peak Effective Duration Lispro/Aspart/Glulisine <15 min 1 hr 3 hr Regular ˝ -1 hr 2-3 hr 3-6 hr NPH 2- 4 hr 7-8 hr 10-12 hr Insulin Glargine 1-2 hr Flat 24 hr Insulin Detemir 0.8-2 hr * ~8-9 hr * Up to 24 hr * Current Insulin Preparations

    53. Insulin Profiles

    54. When Patient Is Able To Eat, Add Rapid-Acting Insulin For Mealtime Coverage Rule Of Thumb: 50% Basal 50% Prandial, Divided Over 3 Meals

    55. Example: Patient Is On 30 units Glargine Daily; Give 10 units With Each Meal Of Lispro (Humalog), Aspart (Novolog), Or Glulisine (Apidra) This Is Prandial Insulin

    56. Basal-Bolus Insulin Therapy: Glargine and Mealtime log Slide 6-31 INSULIN TACTICS Multiple Daily Injections (MDI) The Quest for Basal Insulin Replacement An experimental intensive insulin regimen tested by Italian researchers in patients with type 1 diabetes illustrates the lack of adequate long-acting insulin preparations to provide a reliable and consistent basal insulin. The quest for basal insulin replacement has prompted the use of multiple daily injections of mealtime insulin lispro + NPH and NPH at bedtime. The combination of four doses of NPH with higher proportions of lispro provides a constant basal insulin, with the desired insulin peak effects after mealtimes, as well as maintenance of better glycemic control during the night and between meals. Bolli GB, Di Marchi RD, Park GD, Pramming S, Koivisto VA. Insulin analogues and their potential in the management of diabetes mellitus. Diabetologia. 1999;42:1151-1167.Slide 6-31 INSULIN TACTICS Multiple Daily Injections (MDI) The Quest for Basal Insulin Replacement An experimental intensive insulin regimen tested by Italian researchers in patients with type 1 diabetes illustrates the lack of adequate long-acting insulin preparations to provide a reliable and consistent basal insulin. The quest for basal insulin replacement has prompted the use of multiple daily injections of mealtime insulin lispro + NPH and NPH at bedtime. The combination of four doses of NPH with higher proportions of lispro provides a constant basal insulin, with the desired insulin peak effects after mealtimes, as well as maintenance of better glycemic control during the night and between meals. Bolli GB, Di Marchi RD, Park GD, Pramming S, Koivisto VA. Insulin analogues and their potential in the management of diabetes mellitus. Diabetologia. 1999;42:1151-1167.

    57. Transition From IV to SQ Insulin In The Adult Patient Basal Insulin Bolus Insulin Prandial Insulin Correction Factor Insulin

    58. Basal-Bolus Insulin Therapy: Glargine and Mealtime log Slide 6-31 INSULIN TACTICS Multiple Daily Injections (MDI) The Quest for Basal Insulin Replacement An experimental intensive insulin regimen tested by Italian researchers in patients with type 1 diabetes illustrates the lack of adequate long-acting insulin preparations to provide a reliable and consistent basal insulin. The quest for basal insulin replacement has prompted the use of multiple daily injections of mealtime insulin lispro + NPH and NPH at bedtime. The combination of four doses of NPH with higher proportions of lispro provides a constant basal insulin, with the desired insulin peak effects after mealtimes, as well as maintenance of better glycemic control during the night and between meals. Bolli GB, Di Marchi RD, Park GD, Pramming S, Koivisto VA. Insulin analogues and their potential in the management of diabetes mellitus. Diabetologia. 1999;42:1151-1167.Slide 6-31 INSULIN TACTICS Multiple Daily Injections (MDI) The Quest for Basal Insulin Replacement An experimental intensive insulin regimen tested by Italian researchers in patients with type 1 diabetes illustrates the lack of adequate long-acting insulin preparations to provide a reliable and consistent basal insulin. The quest for basal insulin replacement has prompted the use of multiple daily injections of mealtime insulin lispro + NPH and NPH at bedtime. The combination of four doses of NPH with higher proportions of lispro provides a constant basal insulin, with the desired insulin peak effects after mealtimes, as well as maintenance of better glycemic control during the night and between meals. Bolli GB, Di Marchi RD, Park GD, Pramming S, Koivisto VA. Insulin analogues and their potential in the management of diabetes mellitus. Diabetologia. 1999;42:1151-1167.

    59. Correction Factor Dose, Added To Prandial Dose

    60. How Long On The Drip?

    61. How Long On The Drip?

    62. What About Patients Admitted With Hyperglycemia On The Floor?

    63. Sliding Scale Episodic Bolus Insulin WITHOUT Basal Insulin

    64. Glucose Patterns in Type 2 Diabetes Mellitus Slide 6-18 MIMICKING NATURE WITH INSULIN THERAPY Insulin and Glucose Patterns Basal vs Mealtime Hyperglycemia in Early Type 2 Diabetes This slide shows patterns displayed in the preceding slide in a more dramatic way. The 24-hour plasma glycemic pattern typical of healthy individuals is indicated by the lower border of the blue area, and that of patients with mild type 2 diabetes is indicated by the upper border of the green area. The green area shows the part of the glycemic abnormality of diabetes accounted for by excessive postprandial hyperglycemia related to meals, while the blue area shows the part due to elevated basal glycemia. The pattern shown in the slide consists of (a) a fasting elevation of plasma glucose, with a superimposed additional elevation after each meal throughout the day, (b) a nadir at approximately 0300, and (c) in some cases an increase from the nadir prior to breakfast. Basal hyperglycemia contributes more to total daytime hyperglycemia than the elevation after meals. In addition, the greater the basal hyperglycemia, the more this elevation dominates the total glycemic abnormality. The need for carefully timed overnight delivery of insulin is suggested by the presence of fasting hyperglycemia and the occurrence of the dawn phenomenon in many patients with type 2 diabetes. RiddLe MC. Evening insulin strategy. Diabetes Care. 1990;13:676-686. Slide 6-18 MIMICKING NATURE WITH INSULIN THERAPY Insulin and Glucose Patterns Basal vs Mealtime Hyperglycemia in Early Type 2 Diabetes This slide shows patterns displayed in the preceding slide in a more dramatic way. The 24-hour plasma glycemic pattern typical of healthy individuals is indicated by the lower border of the blue area, and that of patients with mild type 2 diabetes is indicated by the upper border of the green area. The green area shows the part of the glycemic abnormality of diabetes accounted for by excessive postprandial hyperglycemia related to meals, while the blue area shows the part due to elevated basal glycemia. The pattern shown in the slide consists of (a) a fasting elevation of plasma glucose, with a superimposed additional elevation after each meal throughout the day, (b) a nadir at approximately 0300, and (c) in some cases an increase from the nadir prior to breakfast. Basal hyperglycemia contributes more to total daytime hyperglycemia than the elevation after meals. In addition, the greater the basal hyperglycemia, the more this elevation dominates the total glycemic abnormality. The need for carefully timed overnight delivery of insulin is suggested by the presence of fasting hyperglycemia and the occurrence of the dawn phenomenon in many patients with type 2 diabetes. RiddLe MC. Evening insulin strategy. Diabetes Care. 1990;13:676-686.

    65. Pitfalls of Sliding Scale Common Problems With SS Only Is Reactive Rather Than Proactive Often Mismatched With Changes In Patient’s Insulin Sensitivity It Does Not Meet The Physiologic Needs Of The Patient Leads To Insulin Stacking

    67. RABBIT 2 Trial Target Glucose Of <140mg/dl Achieved In: 66% of Patients With Glargine + Glulisine 33% of Patients With Sliding Scale No Difference In Hypoglycemic Events or Length of Stay

    68. Summary Despite increasing insulin doses, 14% of patients treated with SSRI had persistently elevated BG > 240 mg/dL In such patients, glycemic control rapidly improved achieving the glucose target of < 140 mg/dL after switching to the basal/bolus regimen

    69. Calculate Starting Total Daily Dose (TDD) Previous Total Daily Insulin Units Used or 0.4 units/kg (Type 1 DM) 0.6 units/kg (New Onset Or Lean Type 2) 0.8 units/kg (Type 2 DM) This Is Very Conservative and Actual Needs May Turn Out to Be Substantially More

    70.

    71. Glucose Patterns in Type 2 Diabetes Mellitus Slide 6-18 MIMICKING NATURE WITH INSULIN THERAPY Insulin and Glucose Patterns Basal vs Mealtime Hyperglycemia in Early Type 2 Diabetes This slide shows patterns displayed in the preceding slide in a more dramatic way. The 24-hour plasma glycemic pattern typical of healthy individuals is indicated by the lower border of the blue area, and that of patients with mild type 2 diabetes is indicated by the upper border of the green area. The green area shows the part of the glycemic abnormality of diabetes accounted for by excessive postprandial hyperglycemia related to meals, while the blue area shows the part due to elevated basal glycemia. The pattern shown in the slide consists of (a) a fasting elevation of plasma glucose, with a superimposed additional elevation after each meal throughout the day, (b) a nadir at approximately 0300, and (c) in some cases an increase from the nadir prior to breakfast. Basal hyperglycemia contributes more to total daytime hyperglycemia than the elevation after meals. In addition, the greater the basal hyperglycemia, the more this elevation dominates the total glycemic abnormality. The need for carefully timed overnight delivery of insulin is suggested by the presence of fasting hyperglycemia and the occurrence of the dawn phenomenon in many patients with type 2 diabetes. Riddle MC. Evening insulin strategy. Diabetes Care. 1990;13:676-686. Slide 6-18 MIMICKING NATURE WITH INSULIN THERAPY Insulin and Glucose Patterns Basal vs Mealtime Hyperglycemia in Early Type 2 Diabetes This slide shows patterns displayed in the preceding slide in a more dramatic way. The 24-hour plasma glycemic pattern typical of healthy individuals is indicated by the lower border of the blue area, and that of patients with mild type 2 diabetes is indicated by the upper border of the green area. The green area shows the part of the glycemic abnormality of diabetes accounted for by excessive postprandial hyperglycemia related to meals, while the blue area shows the part due to elevated basal glycemia. The pattern shown in the slide consists of (a) a fasting elevation of plasma glucose, with a superimposed additional elevation after each meal throughout the day, (b) a nadir at approximately 0300, and (c) in some cases an increase from the nadir prior to breakfast. Basal hyperglycemia contributes more to total daytime hyperglycemia than the elevation after meals. In addition, the greater the basal hyperglycemia, the more this elevation dominates the total glycemic abnormality. The need for carefully timed overnight delivery of insulin is suggested by the presence of fasting hyperglycemia and the occurrence of the dawn phenomenon in many patients with type 2 diabetes. Riddle MC. Evening insulin strategy. Diabetes Care. 1990;13:676-686.

    72. Correction Factor Dose, Added To Prandial Dose

    74. A Word About Oral Agents….

    75. Therapy of Type 2 Diabetes Mellitus: Hospital Use of Oral Agents

    76. Common Errors in Glucose Management in Hospital Patients Discontinuing All Diabetes Medicines On Admission (Some Pills Must Be Stopped) Setting High Glycemic Targets (>200 mg/dL) Not Changing Therapy With The Situation Or The Glucose Profile Overutilization Of Sliding Scale Insulin Underutilization Of Insulin Infusions and Basal Insulin

    77. Have A Discharge Plan

    78. Admission HbA1C Very Helpful Can A Patient Go Back To Oral Agents At Discharge?

    79. Admission HbA1C Very Helpful If Known Diabetic and Pre-Admission Control Acceptable ? YES!!! If > 7.5% on Maximum Oral Agents, Needs Basal Insulin Can A Patient Go Back To Oral Agents At Discharge?

    80. Natural History of Type 2 Diabetes

    82. Glycemic Management Teams: Nurse Practioners/Physician Assistants Physician Students/Residents

    85. Inpatient Diabetes Management: Is Cost a Barrier? Use of a Diabetes Management Team: Reduction in LOS Cost Reduction of $2353/ Patient MICU: Annual Savings $40,000/ ICU Bed SICU: Savings $3,000/Patient

    86. Glycemic Control In The Hospital Setting The Evidence For Tight Glycemic Control The Achievement of Better Control: Strategies and Protocols A Few Cases

    87. Floor Patient 65 y/o Male With DM2, Hyperlipidemia, HTN, and DJD Admitted To General Medicine With Chest Pain Metformin 1000mg BID and Glipizide 5mg BID; HbA1c 6.4% 2 Weeks Ago Glucose On Floor Arrival 195 mg/dl Admit Orders Serial Troponins Possible Adenosine Myoview

    88. Floor Patient 65 y/o Male DM2, Hyperlipidemia, HTN, and DJD Metformin 1000mg BID and Glipizide 5mg BID HbA1c 6.4% Glucose 195 mg/dl Admit Orders Serial Troponins Possible Adenosine Myoview

    89. Floor Patient 65 y/o Male (75kg) DM2, Hyperlipidemia, HTN, and DJD Metformin 1000mg BID and Glipizide 5mg BID HbA1c 6.4% Glucose 195 mg/dl Admit Orders Serial Troponins Possible Adenosine Myoview Start Glargine and Log

    90. Floor Patient 65 y/o male (75kg) DM2, hyperlipidemia, HTN, and DJD Metformin 1000mg BID and glipizide 5mg BID HbA1c 6.4% Glucose 195 mg/dl Admit orders Serial troponins Possible adenosine myoview Start glargine and log

    91. Floor Patient 65 y/o male (75kg) DM2, hyperlipidemia, HTN, and DJD Metformin 1000mg BID and glipizide 5mg BID HbA1c 6.4% Glucose 195 mg/dl Admit orders Serial troponins Possible adenosine myoview Start glargine and log

    92. ICU Patient 65 y/o female with DM2, HTN, & hyperlipidemia Admitted to the MICU with sepsis Metformin 1000mg BID, glipizide 10mg BID, pioglitazone 8mg qday HbA1c 8% 3 months ago Glucose on MICU arrival 230 mg/dl What therapy should be started for glucose control? a. Continue metformin and glipizide b. Start glargine and log c. Start an insulin drip

    93. ICU Patient 65 y/o female with DM2, HTN, & hyperlipidemia Admitted to the MICU with sepsis Glucose on MICU arrival 230 mg/dl Insulin drip started

    94. Insulin Infusion Protocol One Size Does Not Fit All Based on Current Blood Glucose Level Modified by Rate of Change in Blood Glucose Modified by Insulin Resistance & Disease State Historical protocols for IV infusions were based on the patient’s blood glucose , with fixed changes in rate for all patients. In practice, this approach is unlikely to work because it considers neither differences in insulin sensitivity or the rate of change in blood glucose. Historical protocols for IV infusions were based on the patient’s blood glucose , with fixed changes in rate for all patients. In practice, this approach is unlikely to work because it considers neither differences in insulin sensitivity or the rate of change in blood glucose.

    95. ICU Patient Starting an insulin drip Glucose checks every hour until stable Usually algorithm 1 Exceptions Glucose > 600mg/dl After CABG or solid organ transplant Steroids At least 80U of insulin per day at home

    96. ICU Patient

    97. ICU Patient 1 hour later glucose 170 1 hour later glucose 160 1 hour later glucose 120

    98. ICU Patient 65 y/o female with DM2, HTN, & hyperlipidemia Admitted to the MICU with sepsis Glucose on MICU arrival 230 mg/dl Insulin drip started Clear liquids started

    99. ICU Patient 65 y/o female with DM2, HTN, & hyperlipidemia Admitted to the MICU with sepsis Glucose on MICU arrival 230 mg/dl Insulin drip started Clear liquids started Transferring to Gen Med

    100. ICU Patient 65 y/o female with DM2, HTN, & hyperlipidemia Admitted to the MICU with sepsis Glucose on MICU arrival 230 mg/dl Insulin drip started Clear liquids started Transferring to Gen Med

    101. ICU Patient 65 y/o female with DM2, HTN, & hyperlipidemia Admitted to the MICU with sepsis Glucose on MICU arrival 230 mg/dl Insulin drip started Clear liquids started Transferring to Gen Med

    102. Former ICU, Now Floor, Patient 65 y/o female with DM2 and sepsis Glargine 30 units daily and log 10 units TID Medium dose correction factor Second morning on the floor Fasting glucose 138 mg/dl Increase next glargine dose to 34U

    103. Adjust Basal Insulin By FBS: Decrease 4 U if FBS are below 60 mg/dL Decrease 2 U if FBS Is 60-80 mg/dL If FBS Is 80-100mg/dL, At Goal-No Change is Needed Increase 2 U If FBS Is 100 to 120 mg/dL Increase 4 U If FBS Is 121 to 140 mg/dL Increase 6 U If FBS Is 141 to 160 mg/dL Increase 8 U If FBS Is 161 to 180 mg/dL Increase 10 U If FBS Is > 180 mg/dL

    104. Former ICU, Now Floor, Patient 65 y/o female with DM2 and sepsis Glargine 30 units daily and log 10 units TID Medium dose correction factor Second morning on the floor Fasting glucose 138 mg/dl Increase next glargine dose to 34 units Third morning on the floor Fasting glucose 110mg/dl Continue glargine 34 units

    105. Former ICU, Now Floor, Patient Patient going home!! Glargine 34 units daily and log 10 units TID Medium dose correction factor HbA1c 9%

    106. In Hospitalized Patients, Meticulous Glycemic Control With Intravenous And Subcutaneous Insulin Is Becoming The Standard Of Care

    107. To Be Avoided…

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