Hyperglycemia in Hospitalized Patients

1
Hyperglycemia in Hospitalized Patients

• Strategies For Implementing Change
• Nuts and bolts of management

• Robert J. Rushakoff, MD
• Associate Clinical 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

3
"Each blind man perceived the elephant as
something different a rope, a wall, tree trunks,
a fan, a snake, a spear..."
4
Coordination of Outpatient Care Home care
services Outpatient diabetes classes
Medical Errors JCAHO
Jargon CQI
ICU Protocols
5
What is inpatient diabetes care?
X
Primary Diabetes Education
RARE
Diabetes as Primary Diagnosis
X
Diabetes Metabolic Floors
6
Benefits of Improved Diabetes Management

• Outpatient
• DCCT
• UKPDS (United Kingdom Prospective Diabetes
  Study)
• Blood pressure control
• Lipids
• Inpatient/perioperative - ????????

7
Target Glucose Levels
Alive
8
Target Glucose Levels
No DKA or Hyperosmolar Coma
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

• Length of Stay

University Healthsystem ConsortiumDiabetes
ManagementFinal Data Analysis Report 6/4/1999
IN-CONTROL glucose 60-250 mg/dlFLUCTUATING
glucose lt60 or gt250 mg/dl
Primary Diagnosis AMI Length of
Stay In-control (N26) 4.1 Fluctuating
(N59) 6.7 (plt0.05)
17

• Length of Stay

University Healthsystem ConsortiumDiabetes
ManagementFinal Data Analysis Report 6/4/1999
IN-CONTROL glucose 60-250 mg/dlFLUCTUATING
glucose lt60 or gt250 mg/dl
Primary Diagnosis CABG Length of
Stay In-control (N18) 6.3 Fluctuating
(N143) 8.2 NS
18

• Length of Stay

University Healthsystem ConsortiumDiabetes
ManagementFinal Data Analysis Report 6/4/1999
IN-CONTROL glucose 60-250 mg/dlFLUCTUATING
glucose lt60 or gt250 mg/dl
Primary Diagnosis CAP Length of
Stay In-control (N19) 4.5 Fluctuating
(N56) 6.3 (plt0.05)
19
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.
20

• 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
OR (95 CI) P

Any infection 1.40 (1.081.82) 0.01
Septicemia 1.36 (1.001.86) 0.05
Acute renal failure 1.47 (1.002.17) 0.05
Cardiac complications 1.61 (1.092.37) 0.02
Death 1.77 (1.232.52) lt0.01
Any complication 1.58 (1.202.07) lt0.01

21
Risk of Complications by glucose level quartile
after adjusting for age, sex and presence of
preexisting diabetes
lt124mg/dl lt6.9 mmol/l (OR) 124-140 6.9-7.8 124-140 6.9-7.8 140-164 7.9-9.1 140-164 7.9-9.1 gt164 gt9.1 gt164 gt9.1
lt124mg/dl lt6.9 mmol/l (OR) OR P OR P OR P

Any infection 1 1.3 0.71 2.8 0.08 3.9 0.02
Septicemia 1 0.8 0.73 1.0 1.0 2.5 0.17
Acute renal failure 1 14.8 0.02 10.9 0.03
Cardiac complications 1 1.1 1.0 4.9 0.17 6.2 0.11
Death 1 1.0 1.0 3.4 0.18 10.9 lt0.01
Any complication 1 1.2 0.76 4.1 0.01 4.3 lt0.01
Cheung et al Diabetes Care, 282367-2371, 2005
22
Intervention Studies
23

• 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
24

• 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
25
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
26

• 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
27

• 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
28

• 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
29

• 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
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.)
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.)

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

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.)

• Unresolved Questions
• Application in medical ICU patients
• Application in children in ICU
• Application in surgical patients in regular wards

33
Kaplan-Meier Curves for In-Hospital Survival
Van den Berghe, G. et al. N Engl J Med
2006354449-461
34
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.
35
Hawthorne Effect
Initial improvement in a process of production
caused by the obtrusive observation of that
process.
36
Hawthorne Effect

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

37
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

38
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

39
How to Obtain Tight Control

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

40
INSULIN SLIDING SCALE
41
INSULIN SLIDING SCALE
42
Roller Coaster Effect of Insulin Sliding Scale
43
Mr. And Mrs. XXXXX are admitted for Sweet
Sixteenitis. 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 NPH at night.
44
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
45
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.
46
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

47
INSULIN SLIDING SCALE
48
Postoperative Problems

• Stress induced counterregulatory hormones
• Varying rates of IV dextrose
• Unpredictable eating patterns
• Lack of established predictors of insulin needs

49
Optimal Regimen

• Target glucose range that would minimize risk of
  hypoglycemia and avoid undesirable effects of
  hyperglycemia
• Fixed dextrose infusion to reduce chances of
  hypoglycemia
• Simple algorithm for individualizing the rate of
  the insulin infusion

50
Postoperative Management of Diabetes
Mellitus(Diabetes Care 10722, 1987)

• Protocol
• 1. D5 1/2 NS with 20 meq KCl/l at 100 cc/h
• 2. Insulin 1.5 U/h IV
• 3. BS checked q2h
• 4. --- lt80 mg/dl decrease insulin by 0.5 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 8 U IV
  bolus

51
Postoperative Management of Diabetes Mellitus
Insulin Rate(U/h)
Insulin Rate(U/h)
Diabetes Care 10722, 1987
52
Postoperative Management of Diabetes Mellitus
Glucose (mg/dl)
Glucose (mg/dl)
Diabetes Care 10722, 1987
53
Postoperative Management of Diabetes
Mellitus(Diabetes Care 10722, 1987)

• Control Group vs. Protocol Group
• Same initial glucose
• Final glucose
• 30-369 in Control
• 80-220 in Protocol
• Average final glucose
• 208 20 in Control
• 136 15 in Protocol
• No Protocol patients with glucose lt 80
• 5 of 20 Control patients had glucose lt80

54
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

55
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

56
Problems with Insulin Algorithms

• Changes in D5 with no change in IV insulin
• IV fluid stopped during transfusion
• IV fluid change by MD not aware of ongoing
  insulin algorithm
• Large insulin adjustment needed secondary to
  change in underlying condition
• decreasing steroids
• general improvement with stress reduction
• Not priming tubing

57
Diabetes 2572, 1976
58
Subcutaneous Insulin Order Sheet

• Introduction

59
Subcutaneous Insulin Order Sheet Glucose
Monitoring
On the very top of the insulin form are the
orders for bedside glucose monitoring. There are
two sets of standard times. If the patient is
eating, then the box for patient eating should
be checked. If the person is NPO, on tube
feedings or TPN, then those boxes should should
be checked.
1. BLOOD GLUCOSE (BG) MONITORING ? Patient
EatingBEFORE meals, at bedtime, and 2 a.m.
? NPOEvery 4 hours ? Tube Feeds/TPNEvery
4 hours
60
Subcutaneous Insulin Order Sheet Scheduled Dose
2. BASAL AND NUTRITION INSULIN DOSE (IN UNITS) Hold nutritional dose of Aspart if patient becomes NPO or tube feed held but give correctional insulin if required 2. BASAL AND NUTRITION INSULIN DOSE (IN UNITS) Hold nutritional dose of Aspart if patient becomes NPO or tube feed held but give correctional insulin if required 2. BASAL AND NUTRITION INSULIN DOSE (IN UNITS) Hold nutritional dose of Aspart if patient becomes NPO or tube feed held but give correctional insulin if required 2. BASAL AND NUTRITION INSULIN DOSE (IN UNITS) Hold nutritional dose of Aspart if patient becomes NPO or tube feed held but give correctional insulin if required 2. BASAL AND NUTRITION INSULIN DOSE (IN UNITS) Hold nutritional dose of Aspart if patient becomes NPO or tube feed held but give correctional insulin if required 2. BASAL AND NUTRITION INSULIN DOSE (IN UNITS) Hold nutritional dose of Aspart if patient becomes NPO or tube feed held but give correctional insulin if required 2. BASAL AND NUTRITION INSULIN DOSE (IN UNITS) Hold nutritional dose of Aspart if patient becomes NPO or tube feed held but give correctional insulin if required
Tube Feeds TIME 8 a.m. 12 p.m. 4 p.m. 8 p.m. 12 a.m. 4 a.m.
Patient Eating TIME Breakfast Lunch Dinner Bedtime
Aspart (Novolog) 10 8 5

NPH
Glargine (Lantus) 20
Novolog Mix 70/30
61
Premixed Insulins
Insulin Name First Component Second Component Component Ratio   FirstSecond
Novolin 70/30 Human NPH Human Regular 7030
Novolog 70/30 aspart protamine aspart 7030
Humulin 70/30 Human NPH Human Regular 7030
Humulog 50/50 Aspart protamine aspart 5050
Humalog 75/25 lispro protamine lispro 7525
62
Subcutaneous Insulin Order Sheet Meal time (or
q4h) insulin adjustments
3. CORRECTIONAL INSULIN with Aspart Choose ?
Meals OR ? Every 4 hrs (Tube feed,TPN, NPO)
BG Range Default Value to add or subtract from nutritional dose of Aspart Insulin (Use unless numbers are entered in next column as individualized Dose.) Or Individualized Dose
lt70 mg/dl Treat for hypoglycemia per protocol (see 6 below). Once BG 100 mg/dl, give insulin, 2 units less when patient eats.
70-100 mg/dl - 1 unit -
101-150 mg/dl Give nutritional dose of Aspart as in 2 above
151-200 mg/dl 1 unit
201-250 mg/dl 2 units
251-300 mg/dl 3 units
301-350 mg/dl 4 units
351-400 mg/dl 5 units
Over 400 mg/dl 6 units
MEALS OR EVERY 4 HOURS
63
Correctional Aspart or Regular Insulin
Blood Glucose Normal, BMIlt25 Overweight BMI 25-30 Obese  BMIgt30
PREMEAL      
150-200 1 unit 2 units 3 units
201-250 2 units 4 units 6 units
251-300 3 units 6 units 9 units
301-350 4 units 8 units 12 units
351-400 5 units 10 units 15 units
gt400 6 units 12 units 18 units
Bedtime, 2AM      
201-250 1 units 2 units 3 units
251-300 2 units 3 units 4 units
gt300 3 units 4 units 5units
64
Subcutaneous Insulin Order Sheet Meal time
insulin adjustments
x
3. CORRECTIONAL INSULIN with Aspart Choose ?
Meals OR ? Every 4 hrs (Tube feed,TPN, NPO)
BG Range Default Value to add or subtract from nutritional dose of Aspart Insulin (Use unless numbers are entered in next column as individualized Dose.) Or Individualized Dose
lt70 mg/dl Treat for hypoglycemia per protocol (see 6 below). Once BG 100 mg/dl, give insulin, 2 units less when patient eats.
70-100 mg/dl - 1 unit -
101-150 mg/dl Give nutritional dose of Aspart as in 2 above
151-200 mg/dl 1 unit 3
201-250 mg/dl 2 units 6
251-300 mg/dl 3 units 9
301-350 mg/dl 4 units 12
351-400 mg/dl 5 units 15
Over 400 mg/dl 6 units 18
MEALS OR EVERY 4 HOURS
65
Subcutaneous Insulin Order Sheet Bed time and
2am insulin adjustments
Shown below is the section 4 of the form. 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.
4. Bedtime and 2am high blood glucose correction with Aspart. (Not for tube feed, TPN or NPO. Patients on tube feed, TPN or NPO follow orders number 2 and 3 as above). 4. Bedtime and 2am high blood glucose correction with Aspart. (Not for tube feed, TPN or NPO. Patients on tube feed, TPN or NPO follow orders number 2 and 3 as above). 4. Bedtime and 2am high blood glucose correction with Aspart. (Not for tube feed, TPN or NPO. Patients on tube feed, TPN or NPO follow orders number 2 and 3 as above). 4. Bedtime and 2am high blood glucose correction with Aspart. (Not for tube feed, TPN or NPO. Patients on tube feed, TPN or NPO follow orders number 2 and 3 as above).
BG Range Default Value (use unless numbers are centered in next column as individualized dose) Or Individualized Dose
200-250 mg/dL 1 unit. ________
251-300 mg/dL 2 units.. ________
gt300 mg/dL 3 units... ________
BEDTIME And 2AM
66
Low Glucose Reading
The final section of the order sheet 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.

• 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.

67
Transition from IV to SQ Insulin
x
1. BLOOD GLUCOSE (BG) MONITORING ? Patient
EatingBEFORE meals, at bedtime, and 2 a.m.
? NPOEvery 4 hours ? Tube Feeds/TPNEvery
4 hours
Method 1 Take the last 24 hour insulin
infusion Basal 24 hour total/2.5 premeal
24 hour total/7 Example 1.5 units per hour
36U Basal 36/2.514U premeal 36/75
Method 2 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
68
Transition from IV to SQ Insulin
2. BASAL AND NUTRITION INSULIN DOSE (IN UNITS) Hold nutritional dose of Aspart if patient becomes NPO or tube feed held but give correctional insulin if required 2. BASAL AND NUTRITION INSULIN DOSE (IN UNITS) Hold nutritional dose of Aspart if patient becomes NPO or tube feed held but give correctional insulin if required 2. BASAL AND NUTRITION INSULIN DOSE (IN UNITS) Hold nutritional dose of Aspart if patient becomes NPO or tube feed held but give correctional insulin if required 2. BASAL AND NUTRITION INSULIN DOSE (IN UNITS) Hold nutritional dose of Aspart if patient becomes NPO or tube feed held but give correctional insulin if required 2. BASAL AND NUTRITION INSULIN DOSE (IN UNITS) Hold nutritional dose of Aspart if patient becomes NPO or tube feed held but give correctional insulin if required 2. BASAL AND NUTRITION INSULIN DOSE (IN UNITS) Hold nutritional dose of Aspart if patient becomes NPO or tube feed held but give correctional insulin if required 2. BASAL AND NUTRITION INSULIN DOSE (IN UNITS) Hold nutritional dose of Aspart if patient becomes NPO or tube feed held but give correctional insulin if required
Tube Feeds TIME 8 a.m. 12 p.m. 4 p.m. 8 p.m. 12 a.m. 4 a.m.
Patient Eating TIME Breakfast Lunch Dinner Bedtime
Aspart (Novolog) 5 5 5

NPH
Glargine (Lantus) 15
Novolog Mix 70/30
69
Transition from IV to SQ Insulin
x
3. CORRECTIONAL INSULIN with Aspart Choose ?
Meals OR ? Every 4 hrs (Tube feed,TPN, NPO)
BG Range Default Value to add or subtract from nutritional dose of Aspart Insulin (Use unless numbers are entered in next column as individualized Dose.) Or Individualized Dose
lt70 mg/dl Treat for hypoglycemia per protocol (see 6 below). Once BG 100 mg/dl, give insulin, 2 units less when patient eats.
70-100 mg/dl - 1 unit -
101-150 mg/dl Give nutritional dose of Aspart as in 2 above
151-200 mg/dl 1 unit
201-250 mg/dl 2 units
251-300 mg/dl 3 units
301-350 mg/dl 4 units
351-400 mg/dl 5 units
Over 400 mg/dl 6 units
MEALS OR EVERY 4 HOURS
70
Transition from IV to SQ Insulin
Glucose 140 255 180 150 Insulin 5 A(50) 8
A(53) 5 A(51) 15 glargine
2. BASAL AND NUTRITION INSULIN DOSE (IN UNITS) Hold nutritional dose of Aspart if patient becomes NPO or tube feed held but give correctional insulin if required 2. BASAL AND NUTRITION INSULIN DOSE (IN UNITS) Hold nutritional dose of Aspart if patient becomes NPO or tube feed held but give correctional insulin if required 2. BASAL AND NUTRITION INSULIN DOSE (IN UNITS) Hold nutritional dose of Aspart if patient becomes NPO or tube feed held but give correctional insulin if required 2. BASAL AND NUTRITION INSULIN DOSE (IN UNITS) Hold nutritional dose of Aspart if patient becomes NPO or tube feed held but give correctional insulin if required 2. BASAL AND NUTRITION INSULIN DOSE (IN UNITS) Hold nutritional dose of Aspart if patient becomes NPO or tube feed held but give correctional insulin if required 2. BASAL AND NUTRITION INSULIN DOSE (IN UNITS) Hold nutritional dose of Aspart if patient becomes NPO or tube feed held but give correctional insulin if required 2. BASAL AND NUTRITION INSULIN DOSE (IN UNITS) Hold nutritional dose of Aspart if patient becomes NPO or tube feed held but give correctional insulin if required
Tube Feeds TIME 8 a.m. 12 p.m. 4 p.m. 8 p.m. 12 a.m. 4 a.m.
Patient Eating TIME Breakfast Lunch Dinner Bedtime
Aspart (Novolog) 5 5 5

NPH
Glargine (Lantus) 15
Novolog Mix 70/30
Change for next day would be increase in
Breakfast and lunch Aspart
71
Patient on Insulin who is Eating

• In general - continue patient's normal outpatient
  insulin regimen
• Do not stop the outpatient insulin and use a
  sliding scale
• If outpatient glucoses have been poorly
  controlled on current insulin regimen, consider
  starting more appropriate insulin regimen

72
Patient on Insulin who is Eating
x
1. BLOOD GLUCOSE (BG) MONITORING ? Patient
EatingBEFORE meals, at bedtime, and 2 a.m.
? NPOEvery 4 hours ? Tube Feeds/TPNEvery
4 hours
Basal Insulin the insulin required for when the
patient is not eating Nutritional the insulin
required for meals (.1-.4 U/kg/d)
Easy method Choose the 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
73
Patient on Insulin who is Eating
x
1. BLOOD GLUCOSE (BG) MONITORING ? Patient
EatingBEFORE meals, at bedtime, and 2 a.m.
? NPOEvery 4 hours ? Tube Feeds/TPNEvery
4 hours
Patient on 40Uam,30Upm of 70/30 Poorly
controlled, 80kg 30 U glargine 10U aspart/humalog
premeal
Easy method Choose the 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
74
Patient on Insulin who is Eating
2. BASAL AND NUTRITION INSULIN DOSE (IN UNITS) Hold nutritional dose of Aspart if patient becomes NPO or tube feed held but give correctional insulin if required 2. BASAL AND NUTRITION INSULIN DOSE (IN UNITS) Hold nutritional dose of Aspart if patient becomes NPO or tube feed held but give correctional insulin if required 2. BASAL AND NUTRITION INSULIN DOSE (IN UNITS) Hold nutritional dose of Aspart if patient becomes NPO or tube feed held but give correctional insulin if required 2. BASAL AND NUTRITION INSULIN DOSE (IN UNITS) Hold nutritional dose of Aspart if patient becomes NPO or tube feed held but give correctional insulin if required 2. BASAL AND NUTRITION INSULIN DOSE (IN UNITS) Hold nutritional dose of Aspart if patient becomes NPO or tube feed held but give correctional insulin if required 2. BASAL AND NUTRITION INSULIN DOSE (IN UNITS) Hold nutritional dose of Aspart if patient becomes NPO or tube feed held but give correctional insulin if required 2. BASAL AND NUTRITION INSULIN DOSE (IN UNITS) Hold nutritional dose of Aspart if patient becomes NPO or tube feed held but give correctional insulin if required
Tube Feeds TIME 8 a.m. 12 p.m. 4 p.m. 8 p.m. 12 a.m. 4 a.m.
Patient Eating TIME Breakfast Lunch Dinner Bedtime
Aspart (Novolog) 10 10 10

NPH
Glargine (Lantus) 30
Novolog Mix 70/30
75
Patient on Insulin who is Eating
x
3. CORRECTIONAL INSULIN with Aspart Choose ?
Meals OR ? Every 4 hrs (Tube feed,TPN, NPO)
BG Range Default Value to add or subtract from nutritional dose of Aspart Insulin (Use unless numbers are entered in next column as individualized Dose.) Or Individualized Dose
lt70 mg/dl Treat for hypoglycemia per protocol (see 6 below). Once BG 100 mg/dl, give insulin, 2 units less when patient eats.
70-100 mg/dl - 1 unit -
101-150 mg/dl Give nutritional dose of Aspart as in 2 above
151-200 mg/dl 1 unit 2
201-250 mg/dl 2 units 4
251-300 mg/dl 3 units 6
301-350 mg/dl 4 units 8
351-400 mg/dl 5 units 10
Over 400 mg/dl 6 units 12
MEALS OR EVERY 4 HOURS
76
Patient on Insulin who is Eating
Glucose 140 255 180 150 Insulin 10 A(100) 10
A(106) 10 A(102) 30 glargine
2. BASAL AND NUTRITION INSULIN DOSE (IN UNITS) Hold nutritional dose of Aspart if patient becomes NPO or tube feed held but give correctional insulin if required 2. BASAL AND NUTRITION INSULIN DOSE (IN UNITS) Hold nutritional dose of Aspart if patient becomes NPO or tube feed held but give correctional insulin if required 2. BASAL AND NUTRITION INSULIN DOSE (IN UNITS) Hold nutritional dose of Aspart if patient becomes NPO or tube feed held but give correctional insulin if required 2. BASAL AND NUTRITION INSULIN DOSE (IN UNITS) Hold nutritional dose of Aspart if patient becomes NPO or tube feed held but give correctional insulin if required 2. BASAL AND NUTRITION INSULIN DOSE (IN UNITS) Hold nutritional dose of Aspart if patient becomes NPO or tube feed held but give correctional insulin if required 2. BASAL AND NUTRITION INSULIN DOSE (IN UNITS) Hold nutritional dose of Aspart if patient becomes NPO or tube feed held but give correctional insulin if required 2. BASAL AND NUTRITION INSULIN DOSE (IN UNITS) Hold nutritional dose of Aspart if patient becomes NPO or tube feed held but give correctional insulin if required
Tube Feeds TIME 8 a.m. 12 p.m. 4 p.m. 8 p.m. 12 a.m. 4 a.m.
Patient Eating TIME Breakfast Lunch Dinner Bedtime
Aspart (Novolog) 10 10 10

NPH
Glargine (Lantus) 30
Novolog Mix 70/30
Change for next day would be increase in
Breakfast and lunch Aspart
77
Tube Feeds
1. BLOOD GLUCOSE (BG) MONITORING ? Patient
EatingBEFORE meals, at bedtime, and 2 a.m.
? NPOEvery 4 hours ? Tube Feeds/TPNEvery
4 hours
x
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
78
Tube Feeds
2. BASAL AND NUTRITION INSULIN DOSE (IN UNITS) Hold nutritional dose of Aspart if patient becomes NPO or tube feed held but give correctional insulin if required 2. BASAL AND NUTRITION INSULIN DOSE (IN UNITS) Hold nutritional dose of Aspart if patient becomes NPO or tube feed held but give correctional insulin if required 2. BASAL AND NUTRITION INSULIN DOSE (IN UNITS) Hold nutritional dose of Aspart if patient becomes NPO or tube feed held but give correctional insulin if required 2. BASAL AND NUTRITION INSULIN DOSE (IN UNITS) Hold nutritional dose of Aspart if patient becomes NPO or tube feed held but give correctional insulin if required 2. BASAL AND NUTRITION INSULIN DOSE (IN UNITS) Hold nutritional dose of Aspart if patient becomes NPO or tube feed held but give correctional insulin if required 2. BASAL AND NUTRITION INSULIN DOSE (IN UNITS) Hold nutritional dose of Aspart if patient becomes NPO or tube feed held but give correctional insulin if required 2. BASAL AND NUTRITION INSULIN DOSE (IN UNITS) Hold nutritional dose of Aspart if patient becomes NPO or tube feed held but give correctional insulin if required
Tube Feeds TIME 8 a.m. 12 p.m. 4 p.m. 8 p.m. 12 a.m. 4 a.m.
Patient Eating TIME Breakfast Lunch Dinner Bedtime
Aspart (Novolog) 5 5 5 5 5 5

NPH
Glargine (Lantus) 24
Novolog Mix 70/30
79
Tube Feeds
x
3. CORRECTIONAL INSULIN with Aspart Choose ?
Meals OR ? Every 4 hrs (Tube feed,TPN, NPO)
BG Range Default Value to add or subtract from nutritional dose of Aspart Insulin (Use unless numbers are entered in next column as individualized Dose.) Or Individualized Dose
lt70 mg/dl Treat for hypoglycemia per protocol (see 6 below). Once BG 100 mg/dl, give insulin, 2 units less when patient eats.
70-100 mg/dl - 1 unit -
101-150 mg/dl Give nutritional dose of Aspart as in 2 above
151-200 mg/dl 1 unit
201-250 mg/dl 2 units
251-300 mg/dl 3 units
301-350 mg/dl 4 units
351-400 mg/dl 5 units
Over 400 mg/dl 6 units
MEALS OR EVERY 4 HOURS
80
Tube Feeds
Glucose 140 255 180 260 Insulin 5 A(50) 8
A(53) 5 A(51) 8 A(53) 24 glargine
2. BASAL AND NUTRITION INSULIN DOSE (IN UNITS) Hold nutritional dose of Aspart if patient becomes NPO or tube feed held but give correctional insulin if required 2. BASAL AND NUTRITION INSULIN DOSE (IN UNITS) Hold nutritional dose of Aspart if patient becomes NPO or tube feed held but give correctional insulin if required 2. BASAL AND NUTRITION INSULIN DOSE (IN UNITS) Hold nutritional dose of Aspart if patient becomes NPO or tube feed held but give correctional insulin if required 2. BASAL AND NUTRITION INSULIN DOSE (IN UNITS) Hold nutritional dose of Aspart if patient becomes NPO or tube feed held but give correctional insulin if required 2. BASAL AND NUTRITION INSULIN DOSE (IN UNITS) Hold nutritional dose of Aspart if patient becomes NPO or tube feed held but give correctional insulin if required 2. BASAL AND NUTRITION INSULIN DOSE (IN UNITS) Hold nutritional dose of Aspart if patient becomes NPO or tube feed held but give correctional insulin if required 2. BASAL AND NUTRITION INSULIN DOSE (IN UNITS) Hold nutritional dose of Aspart if patient becomes NPO or tube feed held but give correctional insulin if required
Tube Feeds TIME 8 a.m. 12 p.m. 4 p.m. 8 p.m. 12 a.m. 4 a.m.
Patient Eating TIME Breakfast Lunch Dinner Bedtime
Aspart (Novolog) 5 5 5 5 5 5

NPH
Glargine (Lantus) 24
Novolog Mix 70/30
Change for next day would be increase in glargine
81
Hyperalimentation and Diabetes

• Use separate IV insulin drip with NPO protocol
• As glucose controlled change to q12 hour NPH or
  qd glargine based on the IV insulin drip
• In hospital, remember to hang D10 if the feedings
  interrupted

82
TPN and Diabetes

• Use separate IV insulin drip with NPO protocol
• As glucose controlled add insulin to the TPN
  solution based on the IV insulin drip
• Allows reduction in TPN solution waste
• Use SQ form for correctional insulin doses

83
General Issues in Management of Diabetes

• Use forms
• If patient on stable outpatient regimen, continue
  this as inpatient
• If glucoses not controlled as outpatient,
  consider glargine/short acting insulin regimen
• Remember, patients need basal insulin

84
Fine Tuning Hospital Management of Diabetes

• Use forms
• Use lispro insulin when unsure of PO intake
• Give insulin after meal
• Give insulin after meal based on amount eaten

85
Short Procedures

• First procedure of the day
• Can just take meds after procedure
• Patients who are using insulin glargine as their
  basal insulin should be handled like a patient on
  an insulin pump. They should continue the
  glargine (or basal insulin by pump) as basal
  insulin and only take their short acting insulin
  when they are ready to resume eating.

86
Short Procedures

• Late Morning
• Oral Agents
• Most will be ok just waiting and taking after
  procedure
• Insulin
• Best is to use insulin drip
• Glargine continue and give short acting insulin
  when ready to eat
• Insulin pump just leave on basal rate
• NPH, 70/30 Give 1/3 to ½ of usual am dose

87
Short Procedures

• Afternoon
• Move to AM
• Oral Agents
• Most will be ok just waiting and taking after
  procedure
• Insulin
• Best is to use insulin drip or at least a sq
  protocol
• Insulin pump just leave on basal rate
• Could give intermediate acting insulin in am, but
  does not allow adjustments
• Glargine just use the basal dose (can use SQ
  form)

88
Pathophysiology of Type 2 Diabetes
Peripheral Tissues (Muscle and Fat)
Receptor postreceptor defect
Insulin resistance
Glucose
Liver
Increased glucose production
Pancreas
Impaired insulin secretion
89
Glucocorticoids and Diabetes
Peripheral Tissues (Muscle)
postreceptor defect
Insulin resistance
Glucose
Liver
Increased glucose production
Pancreas
Impaired insulin secretion
90
Glucocorticoids and Diabetes
Glucose
Breakfast
Lunch
Bedtime
Dinner
Breakfast
91
Glucocorticoids and Diabetes
Typical sliding scale insulin
Glucose
Breakfast
Lunch
Bedtime
Dinner
Breakfast
92
Glucocorticoids and Diabetes
Typical sliding scale insulin
Glucose
Breakfast
Lunch
Bedtime
Dinner
Breakfast
93
Glucocorticoids and Diabetes
Revved Up sliding scale insulin
Glucose
Breakfast
Lunch
Bedtime
Dinner
Breakfast
94
Glucocorticoids and Diabetes
Revved Up sliding scale insulin
Glucose
Breakfast
Lunch
Bedtime
Dinner
Breakfast
95
Glucocorticoids and Diabetes
NPH andRegular
Glucose
Breakfast
Lunch
Bedtime
Dinner
Breakfast
96
Glucocorticoids and Diabetes
NPH andRegular
Glucose
Breakfast
Lunch
Bedtime
Dinner
Breakfast
97
Glucocorticoids and Diabetes
Increase NPH andRegular
Glucose
Breakfast
Lunch
Bedtime
Dinner
Breakfast
98
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
99
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
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
100
What does it take to Implement Change?

• Physicians
• Administration

101
RESIDENT
102
Eliminating Inpatient Sliding Scale Insulin A
reeducation project with medical housestaff

• Patient with DM or glucose gt140
• Length of stay gt2 days
• 2 general medicine teams
• For each 24 hour period, 2 HS responsible for all
  glucose management on their teams
• Thiazolidinediones DC if new or if heart failure
• Sulfonylureas discontinued if patient unable to
  eat
• If glucose gt 200 oral agents stopped and insulin
  started
• Insulin was bid NPH and regular, no premixed
• No sliding scale insulin permitted
• A teaching endocrinologist rounded twice daily at
  7am and 6pm with house staff. (nurse and student
  for each patient also rounded)

Diabetes Care 281008-1011,2005
103
Eliminating Inpatient Sliding Scale Insulin A
reeducation project with medical housestaff
Study patients (n 88) Control patients (n 98)

Mean age years (range) 57 (1986) 59 (2487)
Female sex () 63 58
Type 2 diabetic () 95 93
Mean duration of diabetes (years) 10.4 14.6
Newly diagnosed diabetes () 10 9
Inpatient therapy
No diabetic therapy () 2 16
Oral agent () 30 37
NPH and regular insulin () 68 32
Combination NPH/Regular and oral agent () 0 15
Sliding-scale regular () 0 100

Diabetes Care 281008-1011,2005
104
Eliminating Inpatient Sliding Scale Insulin A
reeducation project with medical housestaff
Study patients Control patients Significance

Mean glucose SD (mg/dl) 150 37 200 51 P lt 0.01
Glucose lt60 mG/dl () 3.60 1.40 P 0.01
Low glucose levels requiring i.v. D-50 () 26 30 NS

Glucose gt250 mg/dl () 6.50 20.50 P lt 0.01
Glucose 80140 mg/dl () 43.80 22 P lt 0.01
Glucose 80180 mg/dl () 65.10 43.10 P lt 0.01


Diabetes Care 281008-1011,2005
105
Eliminating Inpatient Sliding Scale Insulin A
reeducation project with medical housestaff

• Have continued educating their 44 1st year HS in
  program
• As of 2003, sliding scale insulin no longer
  allowed on medical patients
• 1st year HS continue to be trained in groups of 4
  usually 4 months of intensive training per
  year.
• Surgical house staff decreased use of sliding
  scale by 60 (cross-pollination).
• In current climate of reduced work hours for
  interns, success described is not easy to
  maintain. Difficult for on call interns. Some
  regression has been inevitable and addition of
  additional resources may be necessary.

Diabetes Care 281008-1011,2005
106
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.

107
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

108
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

109
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

110
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.

111
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

112
SQ Insulin Form Completion Rates 2005 Med
Surg Department 7/14 7/29 8/5 8/19 8/26 9/9
10/6 11/22 8L 67 67 67 75 75
76 89 100 10L 79 81 81 88 89
92 98 100 11L 60 60 60 60 60
64 69 85 12L 59 65 65 73 75
75 88 98 GCRC 81 81 81 81 86
100 100 100 Dialysis 81 81 81 81 81
81 81 81 5N MZ 50 50 50 51 51
57 70 96 4E MZ 46 58 67 71 71
71 76 100
Critical Care ED 0 8 14 30 30
37 61 87 PACU 50 76 85 88 92
98 100 100 PACU MZ 24 24 29 35 41
41 82 100 8S 0 15 55 85 89 93 96 100 8
NICU 0 0 0 0 0 72 94 100 9
ICU 7 17 30 50 57 70 76 90 10S 46 5
9 64 64 67 67 77 86 10
ICC 41 53 64 67 72 76 83 94 ICU
MZ 0 5 10 20 48 52 88 88 NICU 58 78
79 89 89 89 96 99
113
UCSF Implementation

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