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Management of Inpatient Blood Glucose at Temple

Management of Inpatient Blood Glucose at Temple. Housestaff Orientation 2014. ICU Ward Surgical Medical. Endocarditis Pneumonia Renal transplantation COPD exacerbation Post-MI Stroke Infection Wound healing. Hyperglycemia is Associated with Morbidity and Mortality in Inpatients.

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Management of Inpatient Blood Glucose at Temple

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  1. Management of Inpatient Blood Glucose at Temple Housestaff Orientation 2014

  2. ICU Ward Surgical Medical Endocarditis Pneumonia Renal transplantation COPD exacerbation Post-MI Stroke Infection Wound healing Hyperglycemia is Associated with Morbidity and Mortality in Inpatients

  3. Glycemic Control Targets in Non–ICU Patients Premeal BG <140 mg/dL Random BG <180 mg/dL To avoid hypoglycemia (BG <70 mg/dl), reassess insulin if BG levels fall below 100 mg/dL

  4. Estimating Insulin Requirement Home insulin regimen Weight-based dose Recent insulin given (as inpatient) Clinical status (hypoglycemia and insulin resistance factors)

  5. Hypoglycemia and insulin resistance factors Hypoglycemia risk factors Insulin resistance factors Obesity Infection Open wounds Steroids Glucotoxicity BG > ~300 mg/dl A1c > ~10% • Type 1 diabetes • Renal dysfunction • Severe cardiac dysfunction • Severe hepatic dysfunction • Advanced age

  6. Continuing home insulin program in hospital • Must fully assess • Glucose control at home • Hypoglycemia, hyperglycemia, A1c • Compliance (confirm meds/doses) • Does the regimen make sense? • Consider along with weight-based estimate to calculate dose: use clinical judgment

  7. Weight-based SC insulin dosing • Estimate Total Daily Dose (TDD, U/kg) • 0.3 U/kg if high risk of hypoglycemia • 0.4 – 0.5 U/kg average type 2 diabetes • 0.6 U/kg if insulin resistant

  8. How to dose SC insulin • TDD = 50% basal insulin + 50% bolus insulin • Basal insulin = Lantus (glargine) qHS or NPH q12 h • Do not hold for NPO (give 50-80%) • Bolus (nutritional, prandial) insulin = Humalog (lispro) qAC • Given with meal (or tube feeds) • Given as long as premeal BG >70 mg/dl

  9. Case: 78 yo woman, type 2 DM on metformin 1000mg BID + glargine20units qHSadmitted for COPD, BG is 320 mg/dl, A1c is 9% • Hypoglycemia risk factors: age, Cr 1.6 • Insulin resistance factors: steroids, hyperglycemia • Estimated TDD = 0.5 units/kg/day • TDD = 66 kg x 0.5 U/kg = 33 units • 50% basal = 33/2 = 16 units glargine qHS • 50% bolus = 16/3 meals = 5 units lisproqAC • STOP all oral diabetes meds • Assess glucose and titrate daily

  10. What about correction insulin? 150-200 2U 201-250 4U 251-300 6U…

  11. Sensitivity Factor • The expected drop in glucose after administering 1 unit of insulin • HIS SF= 10 HER SF = 50 • AVERAGE SF= 30 • This scale assumes SF=25 • 2 units for 50 mg/dl intervals 150-200 2U 201-250 4U 251-300 6U…

  12. Correction Scales at TUH

  13. Rule of 1500 • SF = 1500/TDD • From prior ex., TDD = 33 • SF = 1500/33 = 45 • Use correction scale #1 • Better to use lower-dose scale if SF is between scales Rubin DJ, Golden SH. Hypoglycemia in non-critically ill, hospitalized patients with diabetes: evaluation, prevention, and management. Hosp Pract (1995). 2013

  14. A complete insulin program • Basal + Bolus + Correction • Correction is given regardless of nutrition status (NPO) • Should be ordered for: • All type 1 diabetes • Most type 2 diabetes • Except diet-controlled and BGs <140 mg/dL

  15. Key Points • Inpatient blood glucose is important • Non-ICU BG targets: <140 premeal, <180 random • Do not use sliding scale alone • Stop oral diabetes meds • Order a complete SC insulin program • Check A1c on every diabetic or BG >140

  16. TUH Diabetes Protocols

  17. TUH Diabetes Protocols • Located in SharePoint • Hypoglycemia protocol • MIS Diabetes orderset instructions • Prandial insulin hold Guideline • DKA/HHS Guideline • Critical Care IV Insulin Guideline • Transitioning IV to SC insulin • Insulin instructions for discharge

  18. How to access SharePoint • From any TUH computer, type “diabetes” in web browser

  19. How to access SharePoint • From any TUHS network computer or via Citrix, use SharePoint directory

  20. Select “SharePoint site directory”

  21. Select “TUH Glycemic Control”

  22. Hypoglycemia algorithm

  23. Diabetes Orderset

  24. Diabetes Orderset

  25. Diabetes Orderset

  26. Diabetes Orderset

  27. Diabetes Orderset

  28. Diabetes Orderset

  29. Prandial Insulin Hold Guideline “Hold” parameters for Prandial/nutritional/bolus insulin, i.e., Humalog (lispro) or Regular insulin 􀂆 Do not give dose if blood glucose <70 mg/dL 􀂆 Give ½ the ordered dose if blood glucose is 70-99 mg/dL 􀂆 Give all of the ordered dose if blood glucose is ≥100 mg/dl

  30. DKA/HHS Guideline

  31. DKA/HHS Guideline

  32. Critical Care Insulin Infusion • Applies to all patients in all ICUs except • DKA or HHS or expected transfer out of unit within 24 hrs • Start when 2 BG >160 mg/dl within 24-48 hr • Target 120-160 mg/dl • Nurses titrate • Give SC insulin (usually glargine) 2 hrs before stopping insulin drip

  33. Transitioning IV to SC Insulin

  34. Transitioning IV to SC Insulin

  35. Transitioning IV to SC Insulin

  36. Insulin DischargeInstructions

  37. Order HBA1C in Common Lab Tests Menu

  38. Questions?

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