diabetes management in the hospital bruce w. bode, md, face atlanta diabetes associates atlanta,...

Diabetes Management in the Hospital

Bruce W. Bode, MD, FACE

Atlanta Diabetes Associates

Atlanta, Georgia

Diabetes in Hospitalized Patients1997

• 3.5 Million US Hospitalizations

15% of Admissions

• 14 Million Hospital Days

20% of All Hospital Days

• 36% First Diagnosed in Hospital 66% No Documentation by Physician 27% Labeled Hyperglycemia 2% Diagnosed on Chart

Diabetes in Hospitalized Patients1997 Costs

•$$23,500 Each Diabetes Patient vs.23,500 Each Diabetes Patient vs. $12,200 for Non-Diabetes Patient$12,200 for Non-Diabetes Patient

•60% of All Diabetes-Related Costs60% of All Diabetes-Related Costs

•Only 5% DKA, HHNKCOnly 5% DKA, HHNKC

•48% Diabetes Complications48% Diabetes Complications

•52% Other Conditions52% Other Conditions

Diabetes in Hospitalized PatientsDiabetes in Hospitalized PatientsReason for Higher CostsReason for Higher Costs

Higher Rate of HospitalizationHigher Rate of Hospitalization

Longer StaysLonger Stays

More Procedures, MedicationsMore Procedures, Medications

Chronic ComplicationsChronic Complications

More Arteriosclerotic DiseaseMore Arteriosclerotic Disease

More InfectionsMore Infections

Complicated PregnanciesComplicated Pregnancies

Diabetes in Hospitalized PatientsDiabetes in Hospitalized Patients

• High-risk for Bacterial Infection– Surgery– Catheters– Intravenous Access– Anaesthesia

Problems with wound healing

Problems with tissue and organ perfusion

InfectionsInfections in Diabetesin Diabetes

More FrequentMore Frequent

Bacteremia Bacteremia

Septic ShockSeptic Shock

PyelonephritisPyelonephritis

CandidaCandida

TPNTPN

UniqueUnique

Necrotizing FasciitisNecrotizing Fasciitis

Fournier’s GangreneFournier’s Gangrene

MucoromycosisMucoromycosis

Emphysematous GB Emphysematous GB

Malignant External OtitisMalignant External Otitis

Infections in Diabetes

One BG >220 mg/dl results in 5.8 times increase in nosocomial infection rate

Two hours hyperglycemia results in impaired WBC function for weeks

Pomposelli, New England Deaconess,

J Parenteral and Enteral Nutrition 22:77-81,1998

TPN In DiabetesTPN In DiabetesVA Cooperative TrialVA Cooperative Trial

Benefit NegatedBenefit Negated

Increased InfectionsIncreased Infections

Related to HyperglycemiaRelated to Hyperglycemia

Buzby et al. NEJM 325:525-531, 1991Buzby et al. NEJM 325:525-531, 1991

Side Effects of BG >200 mg/dl Side Effects of BG >200 mg/dl

Reduced Intravascular VolumeReduced Intravascular Volume

DehydrationDehydration

Electrolyte FluxesElectrolyte Fluxes

Impaired WBC FunctionImpaired WBC Function

Immunoglobulin InactivationImmunoglobulin Inactivation

Complement DisablingComplement Disabling

Increased Collagenase, Decreased Wound Increased Collagenase, Decreased Wound CollagenCollagen

Psychology of Diabetes in HospitalPsychology of Diabetes in Hospital

Patients expect good glycemic control as part of Patients expect good glycemic control as part of hospital carehospital care

They strive for recommended goals at homeThey strive for recommended goals at home

Difficult to understand staff’s casual approach to BG’s Difficult to understand staff’s casual approach to BG’s >150>150

Evidence for Immediate Benefit of Evidence for Immediate Benefit of Normoglycemia in Hospitalized PatientsNormoglycemia in Hospitalized Patients

Numerous Publications on in Vitro EvidenceNumerous Publications on in Vitro Evidence

– Neutrophil DysfunctionNeutrophil Dysfunction

– Complement InhibitionComplement Inhibition

– Altered Redox State (Pseudohypoxia)Altered Redox State (Pseudohypoxia)

– Glucose Rich Edema as Culture MediaGlucose Rich Edema as Culture Media

Six Recent Clinical Publications supporting good glucose Six Recent Clinical Publications supporting good glucose control in the hospital settingcontrol in the hospital setting

Open Heart Surgery in DiabetesPortland St. Vincent Medical Center

Control Group

N=968

1987-1991

SubQ Insulin q 4 h

Goal 200 mg/dl

Standard Deviation 36

All Mean BG’s <200 47%

Study Group

N=1499

1991-1997

IV Insulin

Goal 150-200 mg/dl

Standard Deviation 26

All Mean BG’s <200 84%

Furnary et al, The 34th Meeting of The Society of Thoracic Surgeons New Orleans, LA January 26, 1998

Open Heart Surgery in DiabetesOpen Heart Surgery in DiabetesPortland CII ProtocolPortland CII Protocol

DemographicsDemographics

Total Open Heart Surgery Patients 14,468Total Open Heart Surgery Patients 14,468

Diabetes at Admission 2467 (17%)Diabetes at Admission 2467 (17%)

Age 65 SD 10Age 65 SD 10

Males 62%Males 62%

Insulin Rx 36%Insulin Rx 36%

OHA 48%OHA 48%

170

190

210

230

250

DOS POD 1 POD 2 POD 3

SQI

CII

Open Heart Surgery in DiabetesPortland St. Vincent Medical Center Perioperative Blood Glucose

Furnary et al, The 34th Meeting of The Society of Thoracic Surgeons New Orleans, LA January 26, 1998

Incidence of DSWI: 1987-1997

0.0%

1.0%

2.0%

3.0%

4.0%

87 88 89 90 91 92 93 94 95 96 97

Year

DS

WI DM Pts.

Non-DM

CII

Furnary, et al, The 34th Meeting of The Society of Thoracic Surgeons New Orleans, LA January 26, 1998


Infectious ComplicationsInfectious Complications

DiabetesDiabetes

31/2467 (1.3%) Deep Sternal Wound Infection (DSWI)31/2467 (1.3%) Deep Sternal Wound Infection (DSWI)

23/31 Required Second Admission23/31 Required Second Admission

22 Micrococcus22 Micrococcus

0 Anaerobes, fungal, yeast0 Anaerobes, fungal, yeast

Non-DiabetesNon-Diabetes

40/12,005 (0.3%)40/12,005 (0.3%)


MortalityMortality AllAll (99/2467) 4.0%(99/2467) 4.0%

SQI SQI 6.1% 6.1%

CIICII 3.0% 3.0%

DSWIDSWI 19.0% 19.0%

No DSWI 3.8%No DSWI 3.8%

Recent ExperienceRecent Experience

1994-1997 DSWI as in non-diabetics1994-1997 DSWI as in non-diabetics

1996-7 No DSWI in last 15 mo.1996-7 No DSWI in last 15 mo.


Comparison of GroupsComparison of GroupsHigher Risk Patients in CII GroupHigher Risk Patients in CII Group

SQI CII P Value

Hypertension (% ) 54 67 0.0001

BMI 28.4 29.6 0.0001

Urgent Status (% ) 51 75 0.0001

ITA /CABG (% ) 64 71 0.001

LOS (Days ) 10.7 8.5 0.0001

Mortality (% ) 6.1 3.0 0.03


Univariate Analysis of DSWIUnivariate Analysis of DSWI

No DSW I

DSW I P value

POD #1 >200 mg/d l (% )

34 42 0.04

LOS (Days) 9.5 25 0.001

Mortality (% ) 3.8 19 0.001

Variable SQI CII Savings# DSWI 2,968 1009 1,959

Additional LOS 47,488 16,416 31,342

Additional $ $78.4M $26.6M $51.7M

# Deaths 564 192 372

Estimated USA Socioeconomic Savings

Assumes 742K cases*, 20% prevalence of DM& 2% DSWI with SQI

*1998 Heart & Stroke Statistical update, AHA


Weakness of StudyWeakness of Study

Not RandomizedNot Randomized

Temporal Sequential NatureTemporal Sequential Nature

Subtle Cumulative Improvements in TechniquesSubtle Cumulative Improvements in Techniques


ConclusionsConclusions

Magnitude and Strength of Study is CompellingMagnitude and Strength of Study is Compelling

Ethics of Confirming Study Would be QuestionableEthics of Confirming Study Would be Questionable

Application of CII is Simple and SafeApplication of CII is Simple and Safe

Hyperglycemia Predicts DSWIHyperglycemia Predicts DSWI

CII Prevents DSWICII Prevents DSWI

Open Heart Surgery in DiabetesJohn Hopkins

Prospective Cohort Study of 411 OHS pts with Diabetes 1990 – 1995

Diabetes based on history (42% insulin treated, 45% oral agents)

SMBG 4x/day with sliding scale

Measured relationship between peri-operative control and risk of all infections

Open Heart Surgery in DiabetesJohn Hopkins

24.3% with infections

BG divided into quartiles Relative Odds

Q1 121-206 20.1%

Q2 207-229 21.6% 1.17

Q3 230-252 29.8% 1.86*

Q4 252-352 25.7% 1.72*

Golden SH Diabetes Care 22: 1408, 1999 * P < 0.01

DIGAMI StudyDiabetes, Insulin Glucose Infusion in Acute Myocardial Infarction(1997)

Acute MI With BG > 200 mg/dl Intensive Insulin Treatment IV Insulin For > 24 Hours Four Insulin Injections/Day For > 3 Months Reduced Risk of Mortality By:

28% Over 3.4 Years

51% in Those Not Previous Diagnosed

Malmberg BMJ 1997;314:1512Malmberg BMJ 1997;314:1512

Cardiovascular RiskMortality After MI Reduced by Insulin Therapy in the DIGAMI Study

Malmberg, et al. BMJ. 1997;314:1512-1515.

All Subjects

(N = 620)Risk reduction (28%)

P = .011

Standard treatment

0

.3

.2

.4

.7

.1

.5

.6

0 1Years of Follow-up

2 3 4 5

Low-risk and Not Previously on Insulin

(N = 272)Risk reduction (51%)

P = .0004

IV Insulin 48 hours, then 4 injections daily

0

.3

.2

.4

.7

.1

.5

.6

0 1Years of Follow-up

2 3 4 5

6-11

ICU Survival

1548 Patients (mostly OHS pts.)

All with BG >200 mg/dl

Randomized into two groups

– Maintained on IV insulin

– Conventional group (BG 180-200)

– Intensive group (BG 80-110)

Conventional Group had 1.74 X mortality

Van den Berghe et al, NEJM 2001;345(19):1359

ICU IV Insulin Protocol

If > 100 mg/dl, 2 U/h If > 200 mg/dl, 4 U/h

If > 140 mg/dl, increase by 1 – 2 U/h

If 121 to 140 mg/dl, increase by 0.5 – 1 U/h

If 111 to 120 mg/dl, increase by 0.1 – 0.5 U/h

If 81 to 110 mg/dl, no change

If 61 to 80 mg/dl, change back to prior rate


ICU Survival

Blood glucose control:

Convetional Intensive

Mean AM BG 153 103

% Receiving Insulin 39% 100%

BG < 40 mg/dl 6 39


In no instance was hypoglycemia considered to be a serious event

ICU Survival

Intensive Therapy (80 to 110 mg/dL) resulted in:

34% reduction in mortality

46% reduction in sepsis

41% reduction in dialysis

50% reduction in blood transfusion

44% reduction in polyneuropathy


Conclusion

All hospital patients should have normal glucose

Insulin

The agent we have

to control glucose

only

most powerfulpowerful

Comparison of Human Insulins / Analogues

Insulin Onset of Duration ofpreparations action Peak action

Regular 30–60 min 2–4 h 6–10 h

Lispro/aspart 5–15 min 1–2 h 4–6 h

NPH/Lente 1–2 h 4–8 h 10–20 h

Ultralente 2–4 h Unpredictable 16–20 h

Glargine 1–2 h Flat ~24 h

4:004:00

2525

5050

7575

8:008:00 12:0012:00 16:0016:00 20:00 20:00 24:0024:00 4:004:00

BreakfastBreakfast LunchLunch DinnerDinner

Pla

sma

insu

lin

(P

lasm

a in

suli

n (µ U

/ml)

U

/ml)

TimeTime

8:008:00

Physiological Serum Insulin Secretion Profile

4:00 16:00 20:00 24:00 4:00

Breakfast Lunch Dinner

8:0012:008:00

Time

Glargineor

Detemir

Lispro Lispro Lispro

Aspart Aspart Aspartor oror

Pla

sma

insu

lin

Basal/Bolus Treatment Program withRapid-acting and Long-acting Analogs

Methods For Managing Hospitalized Persons with Diabetes

Continuous Variable Rate IV Insulin Drip

Major Surgery, NPO, Unstable, MI, DKA, Hyperglycemia, Steroids, Gastroparesis, Delivery, etc

Basal / Bolus Therapy (MDI) when eating


Mix Drip with 125 units Regular Insulin into

250 cc NS Starting Rate Units / hour = (BG – 60) x 0.02

where BG is current Blood Glucose

and 0.02 is the multiplier Check glucose every hour and adjust drip Adjust Multiplier to keep in desired glucose

target range (100 to 140 mg/dl)


Adjust Multiplier (initially 0.02) to obtain glucose in target range 100 to 140 mg/dL

If BG > 140 mg/dL, increase by 0.01

If BG < 100 mg/dL, decrease by 0.01

If BG 100 to 140 mg/dL, no change in Multiplier

If BG is < 80 mg/dL, Give D50 cc = (100 – BG) x 0.3

Give continuous rate of Glucose in IVF’s

Once eating, continue drip till 1 hour post SQ insulin

Glucose Management System

Glucommander

Based on 15 Year Experience with a Computer Based Algorithm for the Administration of IV Insulin

Developed for Marketing by MiniMed and Roche

GMS System

Shelved Pending FDA Approval of IV Use of Insulin

Useful and Safe for Any Application of IV Insulin

Glucommander Effectiveness

Initial blood glucose

– Median 292 mg/dl

– Range 181-1,568 Time to achieve glucose < 180 mg/dl

– Median 3 hours

– Range 0.3 - 19.7 Time to achieve three consecutive glucose results between 60 - 180

mg/dL

– Median 3. 1 hours

– Range 0.3 - 22.5

Converting to SQ insulin Establish Daily Insulin Requirement

– IV Insulin First Night

– (BG - 60) x Multiplier = Ins/hr Targeted to 120

– 60 x Multiplier x 24 = Daily Insulin Requirement

Give One-Half Amount As Basal

Give p.c. Boluses Based on CHO Intake

– Start at CHO/Ins 1 CHO = 1.5 units Rapid-acting

Monitor a.c. tid, hs, and 3 am

Supplement All BG >150

– (BG-100)/(1700/Daily Insulin Requirement)

Protocol for SQ Insulin in Hospitalized Patient

Bedtime: Wt (kg) x 0.2 = Units of Glargine Meals Eaten: 1.5 units per 15 Gm CHO eaten BG >150: (BG-100) / CF

CF = 3000 / Wt (kg) Do Not Use Sliding Scale Only Any BG <80: D50 = (100-BG) x 0.3 ml

Maintain INT Do Not Hold Insulin When BG Normal

How to Initiate MDI Starting dose = 0.4 to 0.5 x weight in kilograms

Bolus dose (aspart/lispro) = 20% of starting dose at each meal

Basal dose (glargine) = 40% of starting dose given at bedtime or anytime

Correction bolus = (BG - 100)/ Correction Factor, where CF = 1700/total daily dose

How to Initiate MDI

starting dose = 0.45 x wgt. in kg

Wt. is 80 kg; 0.45 x 80 = 36 units

Bolus dose (aspart / lispro) = 20% of starting dose at each meal; 0.2 x 36 = 7 units ac (tid)

Basal dose (glargine) = 40% of starting dose at HS; 0.4 x 36 = 14 units at HS

Correction bolus = (BG - 100)/ CF, where CF = 1700/total daily dose; CF = 50

Correction Bolus Formula

Example:

–Current BG: 250 mg/dl

– Ideal BG: 100 mg/dl

–Glucose Correction Factor: 50 mg/dl

Current BG - Ideal BGGlucose Correction factor

250 - 100 50

=3.0u

Piedmont Diabetes PlanPiedmont Diabetes PlanWhat Can We Do For Patients Admitted To Hospital?What Can We Do For Patients Admitted To Hospital?

NPO Pathway For All Diabetes PatientsNPO Pathway For All Diabetes Patients

Finger Stick BG ac qid on ALL AdmissionsFinger Stick BG ac qid on ALL Admissions

Check All Steroid Treated PatientsCheck All Steroid Treated Patients

Diagnose DiabetesDiagnose Diabetes

FBG >126 mg/dlFBG >126 mg/dl

Any BG >200 mg/dlAny BG >200 mg/dl


Document Diagnosis in ChartDocument Diagnosis in Chart

Hyperglycemia Is Diabetes Until Proven Hyperglycemia Is Diabetes Until Proven

Bring to All Physician’s AttentionBring to All Physician’s Attention

Note on Problem List and Face SheetNote on Problem List and Face Sheet

Check Hemoglobin A1CCheck Hemoglobin A1C

Hold Metformin; Hold TZD with CHF, Liver DysfunctionHold Metformin; Hold TZD with CHF, Liver Dysfunction

Start Insulin in All Hospitalized Patients Not Start Insulin in All Hospitalized Patients Not Already on InsulinAlready on Insulin


Get Diabetes Education ConsultGet Diabetes Education Consult

Instruct Patient in Monitoring and RecordingInstruct Patient in Monitoring and Recording

See That Patient Has Meter on DischargeSee That Patient Has Meter on Discharge

Decide on Case Specific Program for DischargeDecide on Case Specific Program for Discharge

Arrange Early F/U with PCPArrange Early F/U with PCP


Follow Guidelines For Endocrinology ConsultFollow Guidelines For Endocrinology Consult

Any Hypoglycemia Requiring InterventionAny Hypoglycemia Requiring Intervention

DKA or HHNCDKA or HHNC

Patient on Insulin PumpPatient on Insulin Pump

Diabetes in PregnancyDiabetes in Pregnancy

Glucocorticoid Therapy in DiabetesGlucocorticoid Therapy in Diabetes

Progressive Diabetes ComplicationsProgressive Diabetes Complications

A1C >8%, Microalbuminuria >30 mgA1C >8%, Microalbuminuria >30 mg

Treat Any Patient With BG > 150 With InsulinTreat Any Patient With BG > 150 With Insulin

– Treat Any BG >150 with Rapid-acting Insulin Treat Any BG >150 with Rapid-acting Insulin (BG-100) / (5000 / wt #) or (3000 / wt kg) (BG-100) / (5000 / wt #) or (3000 / wt kg)

– Treat Any Recurrent BG >200 with IV InsulinTreat Any Recurrent BG >200 with IV Insulin

If More than 0.5 u/hr IV Insulin Required with Normal If More than 0.5 u/hr IV Insulin Required with Normal BG Start Long Acting InsulinBG Start Long Acting Insulin

Protocol for Insulin in Hospitalized PatientProtocol for Insulin in Hospitalized Patient


Daily Total: Pre-Admission or Weight (#) x 0.2 uDaily Total: Pre-Admission or Weight (#) x 0.2 u

– 40 % as Glargine (Basal)40 % as Glargine (Basal)

– 60% as Rapid-acting insulin (Bolus)60% as Rapid-acting insulin (Bolus)

• Give in Proportion to Meal’s CHO EatenGive in Proportion to Meal’s CHO Eaten

BG >150: (BG-100) / CFBG >150: (BG-100) / CF

CF = 5000 / Wt(#) or 3000 / Wt(kg)CF = 5000 / Wt(#) or 3000 / Wt(kg)

Do Not Use Sliding Scale As Only Diabetes Do Not Use Sliding Scale As Only Diabetes ManagementManagement


Treatment of HypoglycemiaTreatment of Hypoglycemia

Any BG <80 mg/dl: D50 = (100-BG) x 0.3 ml IVAny BG <80 mg/dl: D50 = (100-BG) x 0.3 ml IV

Do Not Hold Insulin When BG NormalDo Not Hold Insulin When BG Normal

Diabetes at Piedmont HospitalDiabetes at Piedmont Hospital

ConclusionsConclusions

Any BG >200 mg/dl Is Diabetes (Fasting >126 mg/dl)Any BG >200 mg/dl Is Diabetes (Fasting >126 mg/dl)

Most Diabetes Is Type 2Most Diabetes Is Type 2

All DM patients Must Self-Monitor BG’s and RecordAll DM patients Must Self-Monitor BG’s and Record

No BG >150 mg/dl Should Go UntreatedNo BG >150 mg/dl Should Go Untreated

Most Hospitalized DM [atients Should Be on InsulinMost Hospitalized DM [atients Should Be on Insulin

IV Insulin is Most Effective, Efficient, Safest Rx in Acute Illness IV Insulin is Most Effective, Efficient, Safest Rx in Acute Illness (Glucommander)(Glucommander)

Diabetes at Piedmont HospitalDiabetes at Piedmont HospitalConclusions 2Conclusions 2

Type 2 Diabetics Are Resistant to Insulin ReactionsType 2 Diabetics Are Resistant to Insulin Reactions

Treat Insulin Reactions in Hospital With IV GlucoseTreat Insulin Reactions in Hospital With IV Glucose

Do Not Be Hold Insulin for Normal BG, i.e. 80-120 mg/dlDo Not Be Hold Insulin for Normal BG, i.e. 80-120 mg/dl

A1C Values A1C Values >>7% Indicates Sub-optimal Care7% Indicates Sub-optimal Care

Diabetes at Piedmont HospitalDiabetes at Piedmont HospitalConclusions 3Conclusions 3

Discharge Plan For BG ControlDischarge Plan For BG Control

You Are the Link Between the Best You Are the Link Between the Best Diabetes Care and the PatientDiabetes Care and the Patient

Use Your Diabetes ResourcesUse Your Diabetes Resources

Diabetes Education Center Diabetes Education Center EndocrinologistsEndocrinologists

The Paradigm for the MilleniumThe Paradigm for the MilleniumHyperglycemia: A Mortal SinHyperglycemia: A Mortal Sin

A blood glucose over 200 in a hospitalized patient A blood glucose over 200 in a hospitalized patient causes increased morbidity and mortality.causes increased morbidity and mortality.

In the 21st Century Neglecting a BG >200 Will Be In the 21st Century Neglecting a BG >200 Will Be MalpracticeMalpractice

Conclusion

Intensive therapy is

the best way to treat

patients with diabetes

QUESTIONS

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diabetes management in the hospital bruce w. bode, md, face atlanta diabetes associates atlanta,...

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