Hyperglycemia in Hospitalized Patients

1
Hyperglycemia in Hospitalized Patients

• Strategies For Implementing Change
• Nuts and bolts of management

• Robert J. Rushakoff, MD
• Professor of Medicine
• University of California, San Francisco
• robert.rushakoff_at_ucsf.edu

2
Strategies For Implementing Inpatient Glycemic
Control

• www.rushakoff.com
• www.endotext.com
• ucsfinpatientdiabetes.pbworks.com

3
What is inpatient diabetes care?
4
Inpatient Diabetes Goals Normal glucoses for
everyone A high glucose means failure Sliding
Scales are banned Some hypoglycemia is
acceptable
Inpatient Diabetes Goals Who Cares Just get
patient home Sliding Scales are fine Avoid that
scary hypoglycemia
5
Care of the Hospitalized Diabetic Patient

• Goals for Inpatient management
• Evidence, if any, for stated goals
• Methods to Achieve Glucose Goals
• Insulin order forms
• NPO patients
• Patients eating
• TPN and hyperalimentation

• Special Situations
• Glucocorticoids
• Implementation
• Cases

6
Target Glucose Levels
Alive
7
Target Glucose Levels
No DKA or Hyperosmolar Coma
8
Quantifying the Impact of a Short-Interval Interru
ption of Insulin-Pump Infusion Sets on Glycemic
Excursions
Diabetes Care 31238239, 2008
9
Target Glucose Levels
Occasional hypo- and hyperglycemia
10
Target Glucose Levels
No hypo- or hyperglycemia

• Prevent fluid and electrolyte abnormalities
  secondary to osmotic diuresis
• Improve WBC function
• Improve gastric emptying
• Decrease surgical complications
• Earlier hospital dischange

• Decreased post-MI mortality
• Decreased post-CABG morbidity and mortality

11
Target Glucose Levels
Normal Glucoses
Decreased Morbidity and Mortality
12
Problems With High Glucoses
13

• Increased Infections

Early postoperative glucose control predicts
nosocomial infections rate in diabetic patients
Pomposelli et al J Parenteral Ent Nut. 1998
2277-81

• Relative risk for serious postop infections
  increased to 5.7 when glucose gt220 mg/dl

14

• Increased Infections

Perioperative Glycemic Control and the Risk of
Infectious Complications in a Cohort of Adults
with Diabetes Golden et al Diabetes Care,
221408, 1999
411 diabetics who underwent CABGLeg and chest
wounds, pneumonia and UTI
15

• Glucose and post-CABG morbidity and mortality

Diabetes and Coronary Artery Bypass Surgery. An
examination of perioperative glycemic control and
outcomes Diabetes Care 2003 261518-1524

• Retrospective Review of 291 patients surviving 24
  h post op
• 40 with retinopathy, nephropathy or neuropathy

Inpatient Complications For each 1 mmol/l (18
mg/dl) increase in postop day 1 over 6.1 mmol/l
(110 mg/dl), a 17 increase risk of complications

16

• HIGH BLOOD GLUCOSE LEVELS ASSOCIATED WITH
  INCREASED MORTALITY IN ICU

• Retrospective Review of 216,000 critically ill
  patients conducted by the Veterans Affairs
  Inpatient Evaluation Center based in Cincinnati

• Hyperglycemia was an independent predictor of
  mortality starting at 111 mg/dl.
• Effect was greatest with acute myocardial
  infarction, unstable angina, and stroke
• heart attack - 1.6-5 time
• a stroke it raised risk from 3.4 to 15.1 times
• unstable angina it raised risk from 1.7 to 6.2
  times

Falciglia et al ADA Scientific Meetings, 2006,
late breaking abstracts
17

• HIGH BLOOD GLUCOSE LEVELS ASSOCIATED WITH
  INCREASED MORTALITY IN ICU

• Retrospective Review of 216,000 critically ill
  patients conducted by the Veterans Affairs
  Inpatient Evaluation Center based in Cincinnati

• A significant but weaker effect was seen in
  patients with sepsis, pneumonia, and pulmonary
  embolism. Hyperglycemia was not found to be
  associated with mortality in diseases such as
  COPD and hepatic failure.
• In diabetes patients, the increase in mortality
  risk was not seen until mean glucose was gt146
  mg/dl

Falciglia et al ADA Scientific Meetings, 2006,
late breaking abstracts
18
Hyperglycemia an independent marker of
in-hospital mortality in patients with
undiagnosed diabetes

• Retrospective Review
• Hyperglycemia in 38
• 26 known diabetes
• 12 no known diabetes
• Mortality
• New hyperglycemia 16
• Known Diabetes 3
• Nondiabetics 1.7

J. Clin Endocrinol. 200287978-982.
19

• TPN Adverse Outcomes

Hyperglycemia Is Associated With Adverse Outcomes
in Patients Receiving Total Parenteral
Nutrition Cheung et al Diabetes Care,
282367-2371, 2005
Risk of complications in relation to mean daily
blood glucose level

20
Risk of Complications by glucose level quartile
after adjusting for age, sex and presence of
preexisting diabetes
Cheung et al Diabetes Care, 282367-2371, 2005
21
Intervention Studies
22

• Decreased post-CABG morbidity and mortality

Intensive Intervention by a Diabetes Team
Diminishes Excess Hospital Mortality in Patients
with diabetes who undergo CABG Kalin et al.
Diabetes Suppl. 47A87 1998
Diabetes team followed patientPerioperative IV
insulin infusionAlgorithm based SQ premeal
insulin
Mortality during CABG 1993-96
Relative risk National 1.46Beth
Israel 1.02
23

• Decreased post-MI mortality

Effects of insulin treatment on cause-specific
one year mortality and morbidity in diabetic
patients with acute myocardial infarction.
DIGAMI Study Group. Malmberg et al. Eur Heart J
1996
PeriMI IV insulin infusionAlgorithm based SQ
premeal insulin for 1 year
Mortality () 1 year 3.4 years Control
26 44 Insulin 19 33
24
DIGAMI Design

• 620 patients
• MI within 24 hours
• Previous known DM with glucose gt 11 mmol/l (198
  mg/dl) or glucose gt 11 mmol/l without known DM
• Exclusion (50 of 1240 were excluded)
• To sick for consent
• Unable to manage multidose insulin
• Usual acute CCU MI care
• Treatment group
• Infusion for gt24 hours (until stable) , then 3
  months multiple shots insulin

J Am Coll Cardiol 19952657-65
25
DIGAMI Metabolic Data

• Control Infusion p
• Entry HgA1c 8.02.0 8.21.9
• Glucose
• At randomization 15.74.2 (283) 15.44.1
  (277)
• 24 hours 11.74.1 (211) 9.63.3 (173) lt.0001
• Discharge 9.03.0 (162) 8.23.1 (147) lt.01

J Am Coll Cardiol 19952657-65
26
DIGAMI2 (European Heart J. Prepublication Feb
2005)

• Group 1 IV insulin then long term SQ insulin
• Group 2 IV insulin then standard treatment
• Group 3 Standard treatment

Mortality
27

• Decreased Infections

Insulin infusion improves neutrophil function in
diabetic cardiac surgery patients. Rassias AJ,
Marrin CA, Arruda J, Whalen PK, Beach M, Yeager
MP. Anesth Analg 1999 881011-6.
Perioperative IV insulin infusion
Neutrophil phagocytic activity baseline
Control 47 Insulin 75
28

• Decreased Infections

Glucose control lowers the risk of wound
infection in diabetics after open heart
operations Zerr et al Ann Thoracic Surgery,
1997, 63356-61 Furnary et al. Annals of
Thoracic Surgery 1999, 67352-60 Furnary et al.
J Thoracic Cardiovascular Surgery 2003, 125
1007-1021
Perioperative IV insulin infusionProtocol to
maintain glucoses lt200
Incidence of Deep Wound Infections () 1997 1999
Routine Control 2.4 2.0Tight
Control 1.5 0.8
29

• Decreased Infections

Glucose control decreases mortality in diabetics
after open heart operations Furnary et al. J
Thoracic Cardiovascular Surgery 2003, 125
1007-1021
14.5
6.0
4.1
2.3
1.3
0.9
30

• Decreased Morbidity and Mortality

Intensive Insulin Therapy in Critically Ill
Patients. Van den Berghe G, Wouters P, Weekers
F, et al. N Engl J Med 2001 3451359-1367.
Patients (all) on mechanical Ventilation in
ICU Randomly assigned to IV insulin maintaining
glucoses between 80-110 mg/dl or conventional
treatment (iv insulin if glucose gt215 mg/dl then
maintain glucose between 180-200.)
given Insulin 24 hour dose AM
glucose Intensive 99 71U 103 Conventional 39 33U
153
31

• Decreased Morbidity and Mortality

Intensive Insulin Therapy in Critically Ill
Patients. Van den Berghe G, Wouters P, Weekers
F, et al. N Engl J Med 2001 3451359-1367.
Patients (all) on mechanical Ventilation in
ICU Randomly assigned to IV insulin maintaining
glucoses between 80-110 mg/dl or conventional
treatment (iv insulin if glucose gt215 mg/dl then
maintain glucose between 180-200.)
32

• Decreased Morbidity and Mortality

Intensive Insulin Therapy in Critically Ill
Patients. Van den Berghe G, Wouters P, Weekers
F, et al. N Engl J Med 2001 3451359-1367.
Patients (all) on mechanical Ventilation in
ICU Randomly assigned to IV insulin maintaining
glucoses between 80-110 mg/dl or conventional
treatment (iv insulin if glucose gt215 mg/dl then
maintain glucose between 180-200.)

• Intensive Treatment reduced
• In hospital mortality 34
• Sepsis 46
• Need for dialysis 41
• Number of transfusions 44

33

• Decreased Morbidity and Mortality

Intensive Insulin Therapy in Critically Ill
Patients. Van den Berghe G, Wouters P, Weekers
F, et al. N Engl J Med 2001 3451359-1367.
Patients (all) on mechanical Ventilation in
ICU Randomly assigned to IV insulin maintaining
glucoses between 80-110 mg/dl or conventional
treatment (iv insulin if glucose gt215 mg/dl then
maintain glucose between 180-200.)
Any algorithm for achieving and maintaining
normoglycemia in the ICU can only be a
recommendation and must be adapted to the
individual condition of each patient. Insulin
dosing should be conducted with a degree of
common sense.
34

• Decreased Morbidity and Mortality

Intensive Insulin Therapy in Critically Ill
Patients. Van den Berghe G, Wouters P, Weekers
F, et al. N Engl J Med 2001 3451359-1367.
Patients (all) on mechanical Ventilation in
ICU Randomly assigned to IV insulin maintaining
glucoses between 80-110 mg/dl or conventional
treatment (iv insulin if glucose gt215 mg/dl then
maintain glucose between 180-200.)
35
Decreased Morbidity and Mortality

• Post-op received high dose glucose - 200-300 g
  in 24 hours
• All adults receiving mechanical ventilation who
  were admitted to intensive care unit
• 63 had cardiac surgery
• 59 percent had undergone coronary bypass surgery,
  27 percent valve replacement, and 14 percent a
  combined procedure
• Randomly assigned to IV insulin maintaining
  glucoses between 80-110 mg/dl or conventional
  treatment (iv insulin if glucose gt215 mg/dl then
  maintain glucose between 180-200.)
• Whole glucose, so Plasma range would be 90-123
  mg/dl

36
Intensive Intraoperative Insulin Therapy versus
Conventional Glucose Management during Cardiac
Surgery

• Patients Adults with and without diabetes who
  were undergoing on-pump cardiac surgery.
• Primary outcome composite of death, sternal
  infections, prolonged ventilation, cardiac
  arrhythmias, stroke, and renal failure within 30
  days after surgery. Secondary outcome measures
  were length of stay in the intensive care unit
  and hospital.
• Intervention
• continuous insulin infusion to maintain
  intraoperative glucose levels between 4.4 (80
  mg/dL) and 5.6 mmol/L (100 mg/dL) (n 199)
• not given insulin during surgery unless glucose
  levels were greater than 11.1 mmol/L (gt200
  mg/dL).
• Both groups were treated with insulin infusion to
  maintain normoglycemia after surgery.

Ann Int Med. 2007 146 233-243
37
Intensive Intraoperative Insulin Therapy versus
Conventional Glucose Management during Cardiac
Surgery

• The groups had the same risk for perioperative
  adverse events (risk ratio, 1.0 95 CI, 0.8 to
  1.2).
• The intensive treatment group had more strokes (8
  vs. 1) and more deaths (4 vs. 0) than the
  conventional treatment group.

Ann Int Med. 2007 146 233-243
38
Kaplan-Meier Curves for In-Hospital Survival
Van den Berghe, G. et al. N Engl J Med
2006354449-461
39
Intensive insulin therapy in patient with severe
sepsis and septic shock is associated with an
increased rate of hypoglycemia
Multicenter German study (the VISEP trial),
designed to randomize 600 subjects with medical
or surgical severe sepsis to conventional or
intensive insulin therapy, was stopped after
recruitment of 488 subjects because of no
difference in mortality (21.9 vs. 21.6, p 1.0)
and frequent hypoglycemia in the intensive
insulin therapy arm (12.1 vs. 2.1, p lt 0.001)
abstract. Brunkhorstet al Infection
2005331920.
40
Hawthorne Effect

• Tight glucose control
• investigator commitment and bedside presence,
  more tests, more attention, more patient visits,
  more interventions and overall better care

41
Intensive Insulin Therapy and Pentastarch
Resuscitation in Severe Sepsis VISEP trial

• Multicenter, two-by-two factorial trial
• 537 patients
• 18 academic tertiary hospitals in Germany
• Patients with severe sepsis receive either
  intensive insulin therapy to maintain euglycemia
  or conventional insulin therapy and either 10
  pentastarch, a low-molecular-weight hydroxyethyl
  starch (HES 200/0.5), or modified Ringer's
  lactate for fluid resuscitation.
• The rate of death at 28 days and the mean score
  for organ failure were coprimary end points.
• The trial was stopped early for safety reasons

Brunkhorst F et al. N Engl J Med 2008358125-139
42
Intensive Insulin Therapy and Pentastarch
Resuscitation in Severe Sepsis
Kaplan-Meier Curves for Overall Survival
Blood Glucose According to the Type of Insulin
Therapy
Brunkhorst F et al. N Engl J Med 2008358125-139
43
Intensive Insulin Therapy and Pentastarch
Resuscitation in Severe Sepsis

• Findings similar to second study by Van den
  Berghe et al
• Nonsignificant differences in the rates of death
  at 28 days and at 90 days in the
  intensive-therapy group and the
  conventional-therapy group
• Increase in hypoglycemic episodes the same
• VB 18.7 vs. 3.1
• VSEP 17.0 vs. 4.1
• Hypoglycemia the same
• VB (32 mg and 31 mg per deciliter,
  respectively P0.50
• VISEP 31 mg and 28 mg per deciliter,
  respectively P0.30
• Glucose levels the same
• VB 11129 mg and 15331 mg per deciliter,
  respectively
• VISEP 11218 mg and 15133 mg per deciliter,
  respectively
• Taken together, these studies establish that
  intensive insulin therapy has no measurable,
  consistent benefit in critically ill patients in
  a medical ICU, regardless of whether the patients
  have severe sepsis, and that such therapy
  increases the risk of hypoglycemic episodes.

Brunkhorst F et al. N Engl J Med 2008358125-139
44
Pending Studies

• NICE-SUGAR
• 2 multicenter prospective studies
• Australia and New Zealand Intensive Care Society
  and the Canadian Critical Care
• 5000 patients
• GLUControl
• Europe
• 3500 patients

45
GluControl Study

• Anticipated 3500 subjects to be randomized
• 80-110 vs 140-180 mg/dl
• Stopped because of safety concerns
• 1082 subjects recruited.

46
Intensive versus Conventional Glucose Control in
Critically Ill Patients
The NICE-SUGAR Study Investigators
N Engl J Med Volume 360(13)1283-1297 March 26,
2009
47
Study Overview

• In this study, adults who were expected to
  require treatment in the intensive care unit on 3
  or more consecutive days were randomly assigned
  to undergo intensive blood glucose control
  (target range, 81 to 108 mg per deciliter 4.5 to
  6.0 mmol per liter) or conventional blood
  glucose control (180 mg per deciliter 10.0 mmol
  per liter)
• The primary end point was death from any cause
  within 90 days after randomization
• Intensive glucose control increased mortality
  among the patients

48
Data on Blood Glucose Level, According to
Treatment Group
The NICE-SUGAR Study Investigators. N Engl J Med
20093601283-1297
49
NICE- SUGAR Data on Blood Glucose Level,
According to Treatment Group
The NICE-SUGAR Study Investigators. N Engl J Med
20093601283-1297
50
Outcomes and Adverse Events
The NICE-SUGAR Study Investigators. N Engl J Med
20093601283-1297
51
NICE-SUGAR Probability of Survival and Odds
Ratios for Death, According to Treatment Group
The NICE-SUGAR Study Investigators. N Engl J Med
20093601283-1297
52
NICE-SUGAR Probability of Survival and Odds
Ratios for Death, According to Treatment Group
The NICE-SUGAR Study Investigators. N Engl J Med
20093601283-1297
53
AACE Position Statement Hospital Glycemic Goals

• Intensive Care Units 110 mg/dL
• Non-Critical Care Units
• Pre-Prandial 110 mg/dL
• Max. Glucose 180 mg/dL

54
2009 Inpatient Glucose Goals
55
How to Obtain Tight Control

• Bedside glucose monitoring
• IV insulin drips
• Diabetic Flow sheets
• Discourage the use of traditional Sliding Scale
  insulin

56
INSULIN SLIDING SCALE
57
INSULIN SLIDING SCALE
58
Roller Coaster Effect of Insulin Sliding Scale
59
Mr. And Mrs. XXXXX are admitted for spring
fever. Mr. XXXXX has Type 2 diabetes and takes
a total of 75 Units insulin per day (2 shots).
Glucoses at home are poorly controlled. Mrs.
XXXXX also has Type 2 diabetes but she has good
control taking about 25 units of Lispro premeal
and 40 Units glargine at night.
60
Fingerstick qid with regular insulin SQ coverage
FSBG Action lt 50 1 amp D50 iv and call
HO 51-80 give juice and repeat in 0.5-1
hr 81-200 no coverage 201-250 3U regular insulin
SQ 251-300 6U regular insulin SQ 301-350 8U
regular insulin SQ 351-400 10U regular insulin
SQ gt400 12U regular insulin SQ, call HO
61
Advice May need to increase doses for patients
who are septic or treated with steroids (insulin
resistance) Hyperglycemia is better than
hypoglycemia Patients appreciate changing to
FSBG qd once their insulin requirements are
established Endocrinologists absolutely HATE
sliding scales. They are not meant to treat
diabetes, but exist merely to prevent
hypoglycemia. Do not discharge patients on
insulin sliding scales instead, find an
appropriate outpatient regimen before discharge.
62
Action Without BenefitThe Sliding Scale of
Insulin UseSawin, Arch Int Med 157489, 1997

• Routine multiple measurements of capillary blood
  glucose levels, along with sliding scale insulin
  doses, offer no benefit to sick patients with
  diabetes, and when such patients come to the
  hospital, they need to follow their previous
  treatment of insulin or an oral hypoglycemic
  drug.
• Burden of proof is on those who continue to use a
  sliding scale regimen
• Use of sliding scale insulinhad best be avoided

63
INSULIN SLIDING SCALE
64
IV Insulin Algorithm

• lt80 mg/dl decrease insulin by 1 U/h give
  25 ml IV 50 dextrose
• 80-119 decrease insulin by 0.5 U/h
• 120-180 no change
• 181-240 increase insulin by 0.5 U/h
• gt240 increase insulin by 0.5 U/h and give
  5 U IV bolus

65
Subcutaneous Insulin Algorithm

• 80-119 Give 2 U less than 4 hours earlier
• 120-180 Give same dose as 4 hours earlier
• gt181 Give 2 U more than 4 hours earlier

66
Insulins Available in the US
Rapid-acting Lispro/aspart/
glulisine 0.25 0.5-1.5 3-5 Regular 0.5 2-5 6-8 I
ntermediate-acting NPH 1-2 4-12 18-26 U-500 1-3
6-12 12-18 Long-acting Glargine 1.5 ---- 24 Dete
mir 1 ---- 23
67
Insulin Use and Adjustments
Rapid-acting Lispro/aspart/ 10 min premeal 2
hour post meal glulisine and before next
meal Regular 30 min premeal before next meal
Intermediate-acting NPH Morning Pre-dinner
Night Fasting Long-acting Glargine/detemir PM
Fasting
68
Insulin and Glucose Patterns
Normal
Glucose
Insulin
400
120
100
300
80
mg/dL
?U/mL
200
60
40
100
20
0600
1000
1800
1400
0200
2200
0600
0600
1000
1800
1400
0200
2200
0600
B
L
S
B
L
S
Time of Day
Time of Day
Polonsky, et al. N Engl J Med. 19883181231-1239.
69
Insulin Regimens

Relative Insulin Level
Breakfast
12pm
Lunch
Dinner
Time
70
Insulin Regimens

AM NPH
Relative Insulin Level
Breakfast
12pm
Lunch
Dinner
Time
71
Insulin Regimens

PM NPH
Relative Insulin Level
NPH
Breakfast
Lunch
Dinner
12pm
Time
72
Insulin Regimens

BID NPH
Relative Insulin Level
NPH
Breakfast
Lunch
Dinner
12pm
Time
73
Insulin Regimens

BID R and NPH
regular
Relative Insulin Level
NPH
Breakfast
Lunch
Dinner
12pm
Time
74
Insulin Regimens

BID R and NPH
regular
Relative Insulin Level
NPH
Breakfast
Lunch
Dinner
12pm
Time
75
Insulin Regimens

TID R and hs NPH
regular
Relative Insulin Level
NPH
Breakfast
Lunch
Dinner
12pm
Time
76
Insulin Regimens

BID lispro/aspart
Lispro/aspart
Relative Insulin Level
Long analogue
Breakfast
Lunch
Dinner
12pm
Time
77
Insulin Regimens

TID lispro/aspart and hs NPH
Relative Insulin Level
Lispro/aspart
NPH
Breakfast
Lunch
Dinner
12pm
Time
78
Insulin Regimens

TID lispro/aspart and ultralente
Relative Insulin Level
Lispro/aspart
ultralente
Breakfast
Lunch
Dinner
12pm
Time
79
Insulin Regimens

PM glargine
Relative Insulin Level
glargine
Breakfast
12pm
Lunch
Dinner
Time
80
Insulin Regimens

TID lispro/aspart/glulisine and hs glargine
Relative Insulin Level
Lispro/aspart/glulisine
glargine
Breakfast
Lunch
Dinner
12pm
Time
81
Insulin Regimens

Insulin pump
Relative Insulin Level
Lispro/aspart
Breakfast
Lunch
Dinner
12pm
Time
82
Randomized Study of Basal-Bolus Insulin Therapy
in the Inpatient Management of Patients With Type
2 Diabetes (RABBIT 2 Trial)

• Prospective, multicenter, randomized trial to
  compare the efficacy and safety of a basal-bolus
  insulin regimen with that of sliding-scale
  regular insulin (SSI)
• Type 2 diabetes. 130 insulin-naive patients were
  randomized to receive glargine and glulisine (n
  65) or a standard SSI protocol (n 65).
• Glargine was given once daily and glulisine
  before meals at a starting dose of 0.4 units
  kg1 day1 for blood glucose 140200 mg/dl or
  0.5 units kg1 day1 for blood glucose
  201400 mg/dl. SSI was given four times per day
  for blood glucose gt140 mg/dl.

Diabetes Care 302181-2186, 2007
83
Randomized Study of Basal-Bolus Insulin Therapy
in the Inpatient Management of Patients With Type
2 Diabetes (RABBIT 2 Trial)
Changes in blood glucose concentrations in
patients treated with glargine plus glulisine ()
and with SSI (?). P lt 0.01 P lt 0.05.
Diabetes Care 302181-2186, 2007
84
Current Insulin Order Forms

• Adult
• DKA
• Adult SQ Insulin Patient eating
• Adult SQ Insulin NPO, TPN, Tube Feeding
• IV insulin ICU protocol
• IV insulin Med-Surgical Unit protocol
• Adult Insulin pump
• Patient waver form to use pump
• Adult SQ insulin algorithm for NPO patients

• OB-GYN
• SQ Insulin Patient eating
• Pump Form
• Pediatrics
• SQ Insulin Patient eating
• Pump Form
• DKA
• IV insulin

major update or under development
85
Subcutaneous Insulin Order Sheet

• Introduction

86
Subcutaneous Insulin Order Sheet - PATIENT
EATING
87
Subcutaneous Insulin Order Sheet Meal time
insulin adjustments
88
Subcutaneous Insulin Order Sheet Bedtime and
2am insulin adjustments
Shown below is the section C the page for
patients eating. The area indicates the orders
for supplemental insulin that should be given at
bedtime and/or 2am. Aspart insulin is to be used
at these times. These testing times are
important not just for checking for high glucoses
but also to monitor and treat low glucoses.
These checks are also important in helping to
adjust the overall insulin doses.
89
Subcutaneous Insulin Order Sheet - NPO, Tube
Feeds or TPN
90
Subcutaneous Insulin Order Sheet q4hour
correctional dosing for NPO, Tube Feeds or TPN
q4hour correctional insulin options are shown.
Here correctional insulin is generally used to
add or subtract insulin from the q4hour
nutritional insulin ordered in section A. There
are times it can be used even if no standing
q4hour dose is written.
91
Low Glucose Reading
The final section of the both forms of the order
sheets describes the treatment for hypoglycemia.
The key item is that when a person can eat, the
hypoglycemia is treated by oral glucose.

• For BG lt70 mg/dl, use Hypoglycemia Protocol
  belowFor patient taking PO, give 20 g of oral
  fast-acting carbohydrate ? 4 glucose
  tablets (5 grams glucose/tablet)
  -OR- ? Give 6 oz. fruit juice ? Give 25
  ml of D50 IV push If patient cannot take PO ?
  Check fingerstick glucose every15 minutes and
  repeat above treatment until BG is
  100 mg/dl.

92
Transition from IV to SQ Insulin
Take 80 of last 24 h insulin infusion Basal
½ of the value premeal ½ of the value
divided for the meals Example 1.5
units per hour 36U 36 x .8 29 Basal
30x.515 premeal 30x.515 5 per meal
93
Transition from IV to SQ Insulin
94
Transition from IV to SQ Insulin

• What to do if unclear how much the patient will
  eat? What if transition to clear liquids?
• Basal calculation remains unchanged
• Premeal 0-50 of calculated dose

95
Transition from IV to SQ Insulin
96
Transition from IV to SQ Insulin
Glucose 140 255 180 150 Insulin 5 A(50) 8
A(53) 6 A(51) 15 glargine
Change for next day would be increase in
Breakfast and lunch Aspart
97
Patient on Insulin who is Eating
Easy method Choose the U/kg (.3 to .5
U/kg) Basal ½ of the value premeal ½ of
the value divided for the
meals If on premixed insulin changing to
MDI Basal ½ of the total dose premeal ½
of the total dose divided
for the meals
Patient on 40Uam,30Upm of 70/30 Poorly
controlled, 80kg 30 U glargine 10U aspart/humalog
premeal
98
Patient on Diet or Oral Agents who is Eating
Depending on which oral agents may or may not
be continuing- - - -
99
Pharmacologic Classes of Agents to Control
Hyperglycemia in Type 2 Diabetes
Class
Action
Thiazolidinedionese.g., rosiglitazone,
pioglitazone
Bind to peroxisome proliferator activated
receptor-gamma (PPAR?) in muscle, fat and liver
to decrease insulin resistance
Insulin secretagoguese.g., sulfonylureas
(glyburide, glipizide) repaglinide
Stimulate pancreatic ?-cells to increase insulin
output
Biguanidese.g., metformin
Target liver to decrease glucose production
Alpha-glucosidaseinhibitorse.g.,acarbose
miglitol
Inhibit intestinal enzymes that break down
carbohydrates, which delays carbohydrate
absorption
Insulin
Target insulin-sensitive tissue to increase
glucose uptake
100
Pharmacologic Classes of Agents to Control
Hyperglycemia in Type 2 Diabetes
Class
Special Considerations
Thiazolidinedionese.g., rosiglitazone,
pioglitazone
Takes 2-3 weeks to see initial effect. Effects
continue for weeks or months after
discontinuation of medication. Issues with fluid
retention, CHF
Insulin secretagoguese.g., sulfonylureas
(glyburide, glipizide) repaglinide
Keep in mind the metabolic t1/2 of each drug
Biguanidese.g., metformin
Withhold in conditions predisposing to renal
insufficiency and/or hypoxia CV collapse Acute MI
or acute CHF Severe infection Use of iodinated
contrast material Major surgical procedures
Alpha-glucosidaseinhibitorse.g.,acarbose
miglitol
In case of hypoglycemia(due to sulfonylurea or
insulin treatment) Glucose (dextrose) must be
administered Sucrose and complex carbohydrates
should not be administered
Insulin
101
Patient on Diet alone or Oral Agents who is Eating
Day 1 Use Correctional dosing only Base on
BMI, anticipated sensitivity
102
Patient on Diet alone or Oral Agents who is Eating
Glucose 140 255 180 190 Insulin 1 A(01) 6
A(06) 2 A(2) 0 glargine

• Change for next day
• FBS gt130 so start basal insulin at .1 to .3 U/kg
• Preprandial gt130 so start premeal insulin

103
Patient Scheduled for NPO Procedure
Patient is scheduled for a CT scan and is NPO
tomorrow morning. Glucoses at what would be
breakfast time is 240. Orders are as follows.
What should be done with the insulin?
104
Patient on Insulin who is Eating
Glucose 240 Insulin 6 A(06) 65 glargine
105
Tube Feeds
Method 1 Take the last 24 hour insulin
infusion Basal 24 hour total/2 Aspart 24
hour total/10 given q4h Example 2 units per
hour 48U Basal 48/224U glargine aspart
48/104.8 (5 U aspart q4h)
Method 2 Similar to Method 1 just using a
higher proportion of basal insulin
Method 3 If no IV just use 1 unit per 6-10g
CHO to start and calculate as per 1
106
Tube Feeds
107
Tube Feeds
Glucose 140 255 180 260 Insulin 6 A(51) 11
A(56) 7 A(52) 11 A(56) 24 glargine
Change for next day would be increase in glargine
108
Glucocorticoids and Diabetes
Peripheral Tissues (Muscle)
postreceptor defect
Insulin resistance
Glucose
Liver
Increased glucose production
Pancreas
Impaired insulin secretion
109
Glucocorticoids and Diabetes
Glucose
Breakfast
Lunch
Bedtime
Dinner
Breakfast
110
Glucocorticoids and Diabetes
Typical sliding scale insulin
Glucose
Breakfast
Lunch
Bedtime
Dinner
Breakfast
111
Glucocorticoids and Diabetes
Typical sliding scale insulin
Glucose
Breakfast
Lunch
Bedtime
Dinner
Breakfast
112
Glucocorticoids and Diabetes
Revved Up sliding scale insulin
Glucose
Breakfast
Lunch
Bedtime
Dinner
Breakfast
113
Glucocorticoids and Diabetes
Revved Up sliding scale insulin
Glucose
Breakfast
Lunch
Bedtime
Dinner
Breakfast
114
Glucocorticoids and Diabetes
NPH andRegular
Glucose
Breakfast
Lunch
Bedtime
Dinner
Breakfast
115
Glucocorticoids and Diabetes
NPH andRegular
Glucose
Breakfast
Lunch
Bedtime
Dinner
Breakfast
116
Glucocorticoids and Diabetes
Increase NPH andRegular
Glucose
Breakfast
Lunch
Bedtime
Dinner
Breakfast
117
Glucocorticoids and Diabetes
Glucose 151 220 340 350 Insulin 12 A(102) 14
A(104) 18 A(108) 3A(3) 15 glargine
Change for next day would be increase
Aspart Breakfast 16units Lunch 18 units
Dinner 18 units
118
Committee Members

• Physicians Endocrinologist, Hospitalist
• Clinical Nurse Specialists Diabetes, education
• Nurses ICU Manager, at least one manager from
  medical floor (or their representative)
• Clinical Pharmacist
• Administration presence from level of quality
  assurance or similar title
• Discharge Coordinator not required for initial
  discussions and implementation, but needed later
• Nutritional services not required for initial
  design and implementation of forms.

119
TASKS

• Formulary
• Clean up insulin
• Clean up oral agents
• Nursing Issues
• Policy on IV insulin use
• Policy on frequency of glucose monitoring
• Forms
• Design forms
• IV insulin forms
• SQ insulin forms
• ?DKA treatment forms

120
Other Committees To be Conquered

• Pharmacy and Therapeutics
• Formulary issues
• Oral agents
• Insulins
• Insulin Forms iv, sq
• Forms
• Insulin forms iv, sq
• Quality Improvement
• Need buy in at this level to achieve
  administrative support

121
Other People To be Conquered

• Smaller Hospitals
• CEO
• Chief of Staff
• Larger Institutions
• Chairs of Medicine, Surgery
• Heads of training programs from Medicine, Surgery
• Chief of Staff, Chief Medical Officer, CEO
• Chairs of other Departments
• Chief Residents
• Dean for Education

122
Implementation

• Smaller Hospitals
• Entire Institution
• Larger Institutions
• ? One unit at a time
• ? One service at a time
• Make certain forms are available
• Unit clerks must be aware!!!!
• If orders written in ER, forms must be in ER
• If forms not available, this will fail.

123
UCSF Implementation

• Committee Endocrinologists, Hospitalist,
  Diabetes Nurse Specialist, Clinical Pharmacists,
  QA administrators, others
• Formulary
• Limited number of insulins now available
• Forms
• IV insulin forms ICU, Floor
• SQ insulin form
• DKA treatment forms

124
UCSF Implementation

• Nursing Education
• Diabetes Nurse Specialist
• Intranet Training
• Physician Training
• Small group sessions
• Internet training

125
Using Glucometrics to assess changes in glycemic
control during hospital admission Improvements
in glucoses measured during hospitalization Melis
sa E. Weinberg and Robert J. Rushakoff
126
Question 1 Transition from IV to SQ Insulin
The IV rate has been changing, what do you use to
base the conversion rate on? The idea is to
take the most recent steady rate and use that as
the rate for the previous 24 hours. Thus for
this patient, for 6 hours it has been at 1.8
units per hours, so that will be the rate used to
calculate a 24 hour dose.
127
Question 1 Transition from IV to SQ Insulin
Take 80 of last 24 h insulin infusion Basal
½ of the value premeal ½ of the value
divided for the meals Example 1.8
units per hour 43.2U 43 x .8 34 Basal
34x.517 premeal 34x.517 6 per meal
128
Transition from IV to SQ Insulin
129
Transition from IV to SQ Insulin
130
Case 2 SQ Insulin Adjustments
Breakfast 179 Lunch 202, Dinner 105
bedtime 143
Change for next day Breakfast 12A, 46 G Lunch
12A Dinner 15A
Insulin 11 A(92) 16 A(124) 15 A(150) 42
glargine
131
Case 3 Patient Starting Insulin
57, 270 lb, glucose 279, HgA1c 8.9
132
Case 3 Patient Starting Insulin
There is no perfect formula, the idea is to start
with a reasonable choice and make quick
adjustments This patient is sick, obese, insulin
resistant to begin with. Would be reasonable to
use .5 U/kg and give ½ as basal and ½ split for
premeal. Thus   279/2.2 122.7 kg
122x .5 61   So about 30units basal and 10 units
premeal.
133
Case 3 Patient Starting Insulin
134
Case 4 Patient NPO for short time
Glucose 240 Insulin 6 A(06) 55 glargine
135
Glucocorticoids and Diabetes
Glucose 151 220 340 360 Insulin 6 A(51) 7
A(52) 9 A(54) 3A(3) 20 glargine
Change for next day would be increase
Aspart Breakfast 10units Lunch 10 units
Dinner 9 units
136
Case 6 Tube Feeds
Patient is being started on Tube feeding. It
would be easiest to titrate insulin using in IV
drip, but you decide to just use SQ insulin. You
are starting continuous feedings of ensure at 60
ml/hour. Ensure has .175 g CHO/ml (hint
10.5 g/hour, 252g/24 hours). Write some orders
137
Tube Feeds
If no IV just use 1 unit per 6-10g CHO to
start 1U/10g X U/256 g (basically
256/10 for those of you sleeping by now)- for 26
units of insulin in 24 hours.
Use 26 units for 24 hours Basal 24 hour
total/2 Aspart 24 hour total/10
given q4h Example Basal 26/213U
glargine aspart 26/102.6 (3 U aspart q4h)
138
Case 6 Tube Feeds