Workshop 1: Inpatient Management of Hyperglycemia · Workshop 1: Inpatient Management of...
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Workshop 1:Inpatient Management of
Hyperglycemia
Osama Hamdy, MD, PhD, FACEMedical Director, Inpatient Diabetes Program
Director of Obesity Clinical Program
Joslin Diabetes Center
Harvard Medical School, Boston, MA
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Disclosures
◼ Sports: Patriots and Celtics fan
◼ Advisory Board: Astra Zeneca, Sanofi Aventis
◼ Research Support: National Dairy Council
◼ Consultant: Abbott Nutrition, Merck
◼ Shares: Healthimation
◼ Speaker bureau: None
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Objectives
1- Magnitude of the Inpatient Diabetes Problem
2- Hyperglycemia and Hospital Outcomes
3- Potential Benefits of Glycemic Control
4- Recommendations from Professional Societies
5- Protocols for Inpatient Diabetes Management
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Objectives
1- Magnitude of the Inpatient Diabetes Problem
2- Hyperglycemia and Hospital Outcomes
3- Potential Benefits of Glycemic Control
4- Recommendations from Professional Societies
5- Protocols for Inpatient Diabetes Management
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– Total estimated cost of diabetes in 2012 was $245 billion (41% up from 2007), with $176 billion direct cost and 69 billion reduced productivity
– Largest component of medical expenditures attributed to diabetes was hospital inpatient care(~43%% of costs)
Diabetes Care. 2013; 36(4): 1033-1046
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The management of diabetes in the hospital was generally considered to be of secondary
importance versus the condition that prompted the patient’s admission
ADA. Diabetes Care. 2009;32(suppl 1):S13-S61.
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Cook CE et al. J Hosp Med 2009; 4:E7-E14
Blood Glucose >180 mg/dL
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Umpierrez GE et al. J Clin Endocrinol Metab 2002; 87:978-982
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Robbins JM & Webb DA. Med Care 2006; 44:292-296
Failure to identify diabetes is an independent predictor of rehospitalization
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Based on 2030 consecutive hospitalized patients whose charts were reviewed
NormoglycemiaKnown
DiabetesNew
Hyperglycemia
62% 26% 12%
Admission BG 108 mg/dL 230 mg/dL 189 mg/dL
Length of Stay 4.5 days 5.5 days 9 days
Mortality 1.7% 3.0% 16%
Medical, Surgical, and ICU Patients
Umpierrez GE et al. J Clin Endocrinol Metab. 2002;87(3):978-982.
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Objectives
1- Magnitude of the Inpatient Diabetes Problem
2- Hyperglycemia and Hospital Outcomes
3- Potential Benefits of Glycemic Control
4- Recommendations from Professional Societies
5- Protocols for Inpatient Diabetes Management
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*P < 0.001; †NS; ‡P < 0.017.
n= 3,184Source: Emory University Hospital (Atlanta, GA) between January 1st, 2007 and June 30th, 2007
Frisch A et al. Diabetes Care 2010; 33:1783-1788
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There is an association between postoperative blood glucose levels and the rate of deep sternal wound infections
Zerr KJ et al. Ann Thorac Surg. 1997;63(2):356-361.
n=1585
Cardiac Surgery Patients
70
60
50
40
30
20
10
0
P=0.002
Dee
p s
tern
al w
ou
nd
infe
ctio
n r
ate
(%)
100-150 150-200 200-250 250-300
Day 1 blood glucose (mg/dL)
13 16
25
67*
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Umpierrez GE et al. J Clin Endocrinol Metab 2002; 87:978-982
* p<0.01
*
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Krinsley et al. Crit Care Med 2008; 36: 3008-3013.
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Falciglia et al. Crit Care Med 2009;37:3001-3009
Documented *
PneumoniaSepsisUnstable angina Congestive heart failureArrhythmiaStroke Gastrointestinal bleedingAcute renal failureRespiratory failure
No association
COPDDKAGastrointestinal neoplasmMusculoskeletal diseaseHip fractureLiver failureProstate surgery
* High risk patients: Recommended better glycemic control
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Objectives
1- Magnitude of the Inpatient Diabetes Problem
2- Hyperglycemia and Hospital Outcomes
3- Potential Benefits of Glycemic Control
4- Recommendations from Professional Societies
5- Protocols for Inpatient Diabetes Management
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Van Den Berghe G et al. N Engl J Med. 2001;345(19):1359-1367.
Critically Ill Patients
-60
-50
-40
-30
-20
-10
0
46%41%
50%
45%
Sepsis Dialysis
Blood transfusionper patient Polyneuropathy
Perc
ent
red
uct
ion
(%
)
N=1548
P=0.003
P=0.007
P<0.001
P<0.001
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Nutrition Support in the ICU
• Target 20-25 kcal/kg/d> 25 increases risk of overfeeding and hepatopathy
< 20 increases risk of underfeeding and starvation-induced catabolism
• Protein targets are generally 1.2 – 1.5 g/kg/d
• Prevent critical energy debt by ICU day 3-5
• Positive nitrogen balance is generally not possible
• Early combined enteral and parenteral nutrition to meet these evidence-based requirements
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Differences in Resource Utilization Between Diabetic Patients Receiving Diabetes-Specific Nutrition Formula Versus Standard Nutrition
Formula In US Hospitals
Hamdy O et al. JPEN J Parenter Enteral Nutr. 2014; 38(2 Suppl):86S-91S.
$
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Results
Per patient Tube Fed PWD
Average Length of Hospital Stay 0.9 days
Total Hospital Costs $2,586
* Average LOS and hospital cost statistically significant at P < 0.001
Savings from feeding DSF rather than STD formula
• Feeding DSF to patients with diabetes results in significant* improvement in patient efficiency and cost of care
Hamdy O et al. JPEN J Parenter Enteral Nutr. 2014; 38(2 Suppl):86S-91S.
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When caring for hospitalized patients with diabetes, consider consulting with a specialized diabetes or glucose management team where possible
ADA. Diabetes Care. 2019;42 (suppl 1):S173-S181
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Resource Utilization for Inpatient Diabetes Management and its Impact on 30-day
Readmission and Overall Cost
$
Hospitalist Specialist
n= 262 (131 in each group)
Bansal V, Hamdy O et al. BMJ Open Diabetes Res Care. 2018;6(1):e000460
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Primary Service Team (PST)
- House staff
- General Discharge plan
- Follow up
Diabetes Team (DT)
- Endocrinologist
- Basic Diabetes Education
- Diabetes Discharge plan
- Transition of care
n= 262 (131 in each group)
Bansal V, Hamdy O et al. BMJ Open Diabetes Res Care. 2018;6(1):e000460
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*p<0.05n= 262 (131 in each group)
Bansal V, Hamdy O et al. BMJ Open Diabetes Res Care. 2018;6(1):e000460
16.613.915.1
9.7
32.4
21.722.5
26.7
0
5
10
15
20
25
30
35
40
Medical Service Surgical Service
All Readmission 2011
All Readmission 2012
BST
DT
Perc
enta
ge o
f to
tal r
ead
mis
sio
n (
%)
30.5% Reduction *
2011 2012
Medicine 6695 5567
Surgery 1080 880
Total Diabetes Admissions to non-ICU
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Objectives
1- Magnitude of the Inpatient Diabetes Problem
2- Hyperglycemia and Hospital Outcomes
3- Potential Benefits of Glycemic Control
4- Recommendations from Professional Societies
5- Protocols for Inpatient Diabetes Management
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ADA / AACE Guidelines
Perform A1C for all patients with diabetes or hyperglycemia (blood glucose >140 mg/dL on admission or during hospitalization) if not performed within 3 months
Measuring A1c for differentiation
<6.5%(? Stress hyperglycemia)Does not exclude diabetes
>6.5%(preceded diabetes)
Sensitivity 44-66%Specificity 76-99%
OGTT after dischargeADA. Diabetes Care. 2019;42 (suppl 1):S173-S181
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– In one report, about 60% of patients who had hyperglycemia during hospitalization were likely to have diabetes at follow-up testing 1 month after discharge
Clement S et al. Diabetes Care. 2004;27(2):553-591.
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– While an association between hyperglycemia and poor outcomes has been reported, the optimal target BG that would provide maximum outcome improvement is unknown
– Several clinical studies suggest that it is reasonable to aim to reduce BG levels to <180 mg/dL
ADA. Diabetes Care. 2019;42 (suppl 1):S173-S181
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Plasma Glucose (mg/dL)
Organization ICU Medical/Surgical Units
AACE/ADA 140-180 mg/dLPremeal: <140 mg/dLa
Random: <180 mg/dLa
ADA. Diabetes Care. 2019;42 (suppl 1):S173-S181
• More stringent goals such as 110-140 mg/dL may be appropriate for selected patients if this can be achieved without significant hypoglycemia
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– Insulin should be administered using validated written or computerized protocols that allow for predefined adjustments in the insulin dosage based on glycemic fluctuations. (CPOE= computerized physician order entry)
– In the ICU, IV infusion is the preferred route of insulin administration. Outside of critical care units, subcutaneous administration is frequently used
– Safety and efficacy of non-insulin antihyperglycemic therapy is an area of active research
ADA. Diabetes Care. 2019;42 (suppl 1):S173-S181
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Objectives
1- Magnitude of the Inpatient Diabetes Problem
2- Hyperglycemia and Hospital Outcomes
3- Potential Benefits of Glycemic Control
4- Recommendations from Professional Societies
5- Protocols for Inpatient Diabetes Management
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Protocols for Hospital Management
• ICU unit (IV insulin infusion)
• Non-Critical Care unit (Basal-Bolus Insulin)
• Hypoglycemia
• Pre-operative and NPO
• Parenteral Nutrition
• Enteral Nutrition
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100 units Regular Insulin into 100 cc NS (1.0 unit/ml)
Test blood glucose every hour
Starting Rate Units / hour = (Current BG – 60) x 0.02 (Where 0.02 is the multiplier)
Example: Current BG is 210 mg/dl (210 - 60) X 0.02 = 3 units/hour (3 ml/hour)
2. Adjust Multiplier to keep in desired glucose target range (140 to 180 mg/dl)If BG 140 - 180 mg/dl, no change in Multiplier If BG > 180 mg/dl, increase by 0.01If BG < 140 mg/dl, decrease by 0.01
Example: Current BG is 120 mg/dl, last multiplier 0.02 units/hr and last rate 2 units/hr(120 - 60) X 0.01 = 0.6 units/hour (0.6 ml/hour)
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Starting dose = Body weight (kg) x 0.2 • Glargine insulin: One dose at bedtime • Detemir insulin : One dose at bedtime (Type 2) or split to 2 equal doses
AM and bedtime (Type 1)• NPH insulin: 2/3 AM and 1/3 bedtime
Example: Type 2 and body weight 100 kg: Glargine or Detemir 20 units at bedtime or NPH 14 units AM and 6 units BEDTIME
(A multiplier of 0.2 to 0.5 may be considered based on the home insulin regimen and the degree of insulin resistance)
1. If fasting blood glucose >140 mg/dl, increase bedtime dose by 2 units (an increase of 1-4 units may be considered)
2- If pre-supper >140 mg/dl, increase the AM dose by 2 units (an increase of 1-4 units may be considered)
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Starting dose = Body weight (kg) x 0.2 divided equally for the 3 meals (for a blood glucose >80 mg and eating a meal)
Calculate Correction Factor1. For previously known total daily dose (TDD): 1700/TDD2. For unknown total daily dose: 3000/Body weight (Kg)3- Build the scale by increasing insulin dose by 1-2 units for every correction factor
Example: 75 Kg person with unknown previous insulin dose. Starting insulin 75 X 0.2 = 15 (5 units for each meal). Correction 3000/75= 40 mg/dl
Scale: 80-120 mg/dl = 5 units120-160 mg/dl = 6 units160-200 mg/dl = 7 units.....etc
STAT Dose(Current blood glucose - 100) / CF
Example: Current BG 340 and CF 40: (340-100)/40 = 6 units of short acting insulin
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ICU: >140 mg/dl Regular ward and postpartum: >100 mg/dlLabor: >80 mg/dl
Every 15-30 min
If patient is conscious and on oral feeding give15-20 grams of sugars or carbohydrates
Example: - Glucose tablets - 4 oz (1/2 cup) of juice or regular soda- 4 or 5 saltine crackers - 4 teaspoons of sugar
ICU patients on insulin infusion:1. Stop insulin infusion2. Give a bolus of D50 cc = (100 – BG) x 0.4 followed by IV infusion of D10W 50 cc/hr3. After reaching the target blood glucose, resume IV insulin at 1/2 previous rate
Patients on SC insulin and NPO1. Give a bolus of D50 cc = (100 – BG) x 0.4 followed by IV infusion of D10W 50cc/hr2. After reaching the target blood glucose, resume insulin regimen after appropriate
insulin adjustment if needed
Glucagon 1mg SC if unconscious and no IV line
Hypoglycemia Management
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Day Before the surgery
Maintain usual meal plan and insulin dose, insulin via pump (CSII), or oral anti-diabetes medications.
Day of the Surgery Aim for Early Morning Schedule
Insulin management
• If fasting after midnight:• 75-80% of the usual dose of long-acting (glargine/detemir)• 50% of the usual dose of intermediate (NPH)• If on pre-mixed insulin (70/30, 75/25, 50/50) give 50% of the NPH component of the usual dose.• Continue same basal rate by the pump (CSII)
• Omit short-acting insulin, OAD, exenatide, liraglutide, or pramlintide
Frequency of testing and Action
Check BG every 2 hours before and during surgeryInsulin pump patients (CSII) can maintain basal rate during surgery or change to IV or SC insulin to maintain blood glucose target.
Pre-Operative and NPO
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• Regular insulin at a dose of 0.1 unit/gram of carbohydrates in TPN• Correction dose of regular insulin q6 hr or rapid acting analog insulin q4 hr
• Insulin dose in TPN can be adjusted daily by adding 80% of the previous day's correctional insulin• If blood glucose is severely elevated, use IV insulin• Once IV insulin dose is stable, add 75% of the insulin dose to the TPN• Alternative method for patients with pre-existing diabetes: 40% of known TDD as basal and 60% added to TPN
Example: • Patient in the ICU with TPN of 1600 cal, 60% carbohydrates, weigh 75 Kg• Amount of carbs in grams = 1600 * 0.6 / 4= 240 grams• Regular insulin in TPN = 240 * 0.1 = 24 units• Correction dose = 3000/75 = 40 (1 units for every 40 mg above target q4-6 hrs)
Transition to oral feedingPrevious TDD divided into 50% basal and 50% as boluses before meals
Parenteral Nutrition
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Continuous tube feeding
•TDD = 0.3-0.6 unit/kg body weight as basal insulin (2 doses of Glargine or Detemir or 2-3 doses of NPH)•Correction dose of regular insulin q6 hr or rapid acting analog insulin q4 hr•Basal insulin is adjusted by adding 80% of the previous day's correctional insulin
Example: • Patient in the ICU on entetral nutrition, weigh 75 Kg• Basal insulin dose = 0.4 * 75 = 30 units (15 unit of glargine or Detemir q12 hours or 10 units of NPH q8 hours)
Cyclic overnight tube feeding
• TDD = 0.3-0.6 unit/kg body weight as NPH insulin given 3-4 hours before the start of the feeding • If patients on nocturnal tube feedings are eating meals, they may require mealtime bolus insulin
Bolus tube feedings
Covered the same as ingested meals with basal insulin and a dose of rapid-acting analog insulin for each bolus feeding
Enteral Nutrition
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Interruption of tube feedings
• Insulin should be adjusted appropriately if there is a planned withholding of feedings.
• If the enteral feeding is unexpectedly interrupted for more than 2 hours, stop all insulins and give DW10% IV at the same rate as that of the enteral feedings to prevent hypoglycemia.
• Monitoring electrolytes and providing adequate free water to prevent dehydration
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SUMMARY
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– New hyperglycemia in hospital is associated with high 30-day readmission rate and, if missed, significantly increased mortality
– There is a strong association between the degree on hyperglycemia and in-hospital complications and mortality
– Wide glucose variability is associated with increased mortality at all ranges of blood glucose level
– Using protocols for inpatient diabetes management by specialized diabetes team is recommended
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Thank You