final_ipd dm version 2012
DESCRIPTION
DMTRANSCRIPT
-
0
Clinical Practice Guidelines for In-patients with Diabetes Mellitus,
Department of Medicine Maharat Nakhon Ratchasima Hospital
.. 2555
-
1
(DIABETES MELLITUS)
(Diabetes mellitus, DM) 4 1 2 2 1 (diabetic ketoacidosis, DKA) (hypoglycemia) (hyperosmolar hyperglycemic syndrome, HHS) (diabetic ketoacidosis, DKA)
-
2
2553 1,880 re-admit 28 604 16.8 612 2.3 sepsis myocardial infarction
2553 (hypoglycemia at admission) 77 (in-hospital hypoglycemia) 989 DM type 1 with DKA 15 DM type 2 with DKA 36 DM type 2 with coma (HHS) 134
2554 3,588 764 21.3 re-admit 28 604 16.8
2554 (hypoglycemia at admission) 77 (in-hospital hypoglycemia) 1,083 DM type 1 with DKA 22 DM type 2 with DKA 86 DM type 2 with coma (HHS) 143
-
3
1. (mortality rate) 2. (morbidity rate) 3. 4. (re-admission) 1. (capillary blood sugar) (non-critical care setting) 2. (Hypoglycemia)
3. 4. (Hyperosmolar hyperglycemic syndrome, HHS) (Diabetic ketoacidosis, DKA) 5. 6.
-
4
( 26 .. 2555)
CPG for In-patients with Diabetes Mellitus ( 1)
DKA = Diabetic Ketoacidosis HHS = Hyperosmolar Hyperglycemic Syndrome
.. ..
Hypoglycemia (3, 4)
DKA (5)
HHS (5)
(6, 7)
Yes
Yes
Yes
(2) BS non-critical care
-
5
CPG for Blood Sugar Assessment and Monitoring in In-patients with Non-critical Care Setting ( 2)
Hyperglycemia 1. Plasma Glucose at Admission
1 in-hospital hyperglycemia 140 mg/dl
2. capillary blood sugar (CBS) ( 3 - 7)
3. CBS corticosteroids, enteral nutrition parenteral nutrition CBS 24-48
4. CBS > 140 mg/dl CBS 24-48
5. CBS >140 mg/dl HbA1c 3
Capillary Blood Sugar (CBS) 1. CBS (accuracy)
plasma glucose 2. CBS
3. (NPO) continuous enteral feeding
CBS 6 4.
- 140 mg/dl - 180 mg/dl
Adapted from J Clin Endocrinol Metab. 2012; 97:1638.
-
6
(Hypoglycemia)
Treatment of In-patients with Hypoglycemia ( 3)
Hospitalized patient PAPPAPpatient
PG < 70 mg/dl with Symptoms sweating, palpitation, blurred vision, confusion, slurred speech, tired weakness, drowsiness, headache, hunger, irritability or coma
Start Treatment CBS < 70 - + 1 15-30 g
CHO - + 50% glucose 20 . IV
5-10% Dextrose 100 ml/hr - 50% glucose 25 . IV
5-10% dextrose 100 ml/hr Monitor CBS 1/2 - 1 . CBS > 100 mg/dl 2
DM hypoglycemia plasma glucose < 50 mg/dl
Clot blood 5 . insulin,
cortisol, GH hypoglycemia
Monitor CBS 2 6 keep CBS 100 180 mg/dl Hypoglycemia
- hypoglycemia - * - ** -
Follow up Education 1
* ** hypoglycemia
hypoglycemia plasma glucose
PG = Plasma Glucose CBS = Capillary blood sugar
Adapted from J Clin Endocrinol Metab. 2012; 97:1638.
-
7
1
-
8
- o o ward
- / o (repeated hypoglycemia)
o 5
- o
(hypoglycemia at admission)
- o
(drug induced hypoglycemia)
-
9
Nutritional Assessment for In-patients ( 4)
4
1. Body Mass Index (BMI) * - BMI 18.5 22.5 Normal = 0
- BMI 17.5 18.4 Thin = 1 - BMI < 17.4 = 2
2. Weight loss - < 5 % = 0 - 5-10 % = 1 - > 10% = 2
3. Apetite - < 50% = 1 - NPO > 5 = 2
4. Serum albumin - serum albumin 2.6 3.0 g/dL = 1 - serum albumin < 2.5 g/dL = 2
*BMI = body weight (kg)/ height 2 (m2)
- 2
- < 2 1
-
10
2
* ** drip < 50% TPN
- > 65 , BMI < 17.5 kg/m2, alcoholism Serum electrolyte, BUN, Magnesium phosphate 24-48
-
11
Hyperosmolar Hyperglycemic Syndrome (HHS) Diabetic Ketoacidosis (DKA)
Treatment of In-patients with DKA and HHS ( 5)
DKA HHS
Start IV Fluid - NSS 1000 cc/hr 1 - NSS NSS/2 250- 500 cc/hr
IV fluid degree of dehydration serum Na
Start IV Insulin therapy - RI 0.1 U/kg IV bolus RI 0.1 U/kg/hr
rate RI IV fluid PG 50-75 mg/dl/hr
- Add 5-10% Dextrose PG level 200-300 mg/dl rate RI IV fluid maintain PG 150-200 mg/dl
Initiate Potassium Replacement - Normokalemia (3.3-5.2) : Add KCl 20-30
mEq in IV 1000 cc. - Hypokalemia ( 3.3
- K > 5.0 mEq/L or no urine output : Not need K replacement
- DKA / HHS
- consult Endocrine consult
DKA : most common in DM type 1 - Serum glucose > 250 mg/dl - Positive serum ketone* - Wide gap metabolic acidosis
( arterial pH < 7.3, serum HCO3 < 15 meq/L and anion gap** > 12 )
HHS : most common in DM type 2 - Serum glucose > 600 mg/dl - Effective serum osmolarity #>320
mOsm/L
Monitoring : Check PG CBS 1 . PG CBS ~ 200-300 mg/dl then check CBS 2-4 .
: Check Electrolyte 2-4 . hypokalemia
Additional Electrolyte Replacement - Bicarbonate : in severe acidosis
pH < 6.9 : NaHCO3 100 cc IV in 2 hr
- not need NaHCO3 if pH 6.9
* Positive serum ketone = Serum beta hydroxybutyrate > 3 mg/dL, Moderate positive the nitroprusside test (dilute sample 1:1) ** Anion gap = serum Na (Cl + HCO3) # Effective serum osmolarity = 2 [serum Na] + glucose/18 PG = Plasma Glucose CBS = Capillary blood sugar
Adapted from ADA 2009
-
12
Treatment of DM In-patients with Illness ( 6) (Not Diabetic Emergency)
PG = Plasma Glucose CBS = Capillary blood sugar
..
NPO ?
5% D/N/2 RI ( 7) Add RI IV fluid RI IV drip RI SC q 6 h Supplemental insulin scale
- CBS - FPG 80-180
mg/dl
- insulin
CBS q 1 hr until stable (keep PG 80-180 mg/dl)
BS < 100 mg/dl BS 100-180(200) mg/dl BS > 180(200) mg/dl
- Insulin - BS < 70 mg/dl insulin
+ 50% glucose IV - CBS q -1 hr until CBS > 100
CBS q 6 hr
1. RI IV fluid drip
2. RI intravenous drip 3. Supplemental
insulin scale
CBS q 2-6 hr
No
Yes
Adapted from J Clin Endocrinol Metab. 2012; 97:1638.
-
13
Insulin ( 7)
A. (NPO) insulin
1. RI IV fluid with Dextrose
- CBS 200 mg/dl add RI 5% D/N/2 1,000 cc 201 250 mg/dl add RI 5 unit 5% D/N/2 1,000 cc 251 300 mg/dl add RI 10 unit 5% D/N/2 1,000 cc > 300 mg/dl RI 5 unit intravenous
- CBS IV fluid 1 . CBS 201 250 mg/dl add RI 2 unit 5% D/N/2 1,000 cc 251 300 mg/dl add RI 4 unit 5% D/N/2 1,000 cc > 300 mg/dl RI intravenous
- CBS 100 180(200) mg/dl CBS q 6 hr
2. RI intravenous drip IV fluid with Dextrose
- RI intravenous drip 0.5 1 unit/hr RI : NSS 1:1 1: 25 RI 20 unit NSS/2 500 cc (25 cc = RI 1 unit 1 cc = RI 0.04 unit)
- drip RI intravenously infusion pump
- CBS RI intravenous drip rate insulin CBS 120-200 mg/dl
3. RI subcutaneuos injection Supplemental insulin scale CBS
Adapted from J Clin Endocrinol Metab. 2012; 97:1638.
-
14
1 Supplemental insulin scale (RI rapid acting insulin)
Blood Glucose (mg/dl) Insulin-sensitive Usual Insulin-resistant
>141- 180 2 4 6
181- 220 4 6 8
221- 260 6 8 10
261- 300 8 10 12
301 350 10 12 14
351 400 12 14 16
>400 14 16 18
- sliding scale Schedule insulin regimens (Basal Bolus Insulin Injection)
- RI (2-4 unit 10-20 % ) ,
- RI 2-4 unit 80 unit .
- Schedule insulin regimens (Basal Bolus subcutaneous insulin injection) overlapping period 2 Subcutaneuos insulin injection RI intravenous drip 1-2
Adapted from J Clin Endocrinol Metab. 2012; 97:1638.
-
15
B. insulin
1. Scheduled insulin regimen (Basal Bolus subcutaneous insulin injection) - Total insulin dosage
- RI 1 ( intravenous insulin drip rate ) - 0.2-0.3 U/kg/day 70 / GFR < 60 ml/min - 0.4 U/kg/day
140-200 mg/dl - 0.5 U/kg/day 201-400 mg/dl
- 1/2 total insulin Basal insulin NPH () glargine/determir insulin 1
- 1/2 total insulin Prandial insulin RI ( rapid acting insulin)
- insulin CBS 80-180 (200) mg/dl CBS - renal/liver insufficiency Basal insulin NPH ac prandial insulin
2. Supplemental subcutaneous insulin injection - supplemental insulin injection scheduled insulin regimen supplemental insulin scale ** > 300 mg/dl ()
Adapted from J Clin Endocrinol Metab. 2012; 97:1638.
-
16
Care Map
CARE MAP OF HYPOGLYCEMIA
Day Assessment Specimen/test Medication Activity / diet Planning discharge
1. /
Hemodynamic assessment
VS. q 1-2 hrs / 4-6 hrs
**
CBS q - 1 hr stable
hypoglycemia CBC, UA, Urine C/S Hemoculture, BUN, Cr. Electrolyte etc.
50% glucose IV*
IV fluid*
precipitating causes
NPO/soft diet hypoglycemia
Education ../ hypoglycemia
2.
VS. q 4-6 hrs
CBS q 4-6 hr Follow up Labs
IV fluid* NPO/soft diet ***
Education .. / hypoglycemia
follow up 3.
VS. q 4-6 hrs
CBS tid ac & hs Antidiabetic drugs
Soft / regular diabetic diet
Education .. / hypoglycemia
follow up
* glucose IV fluid 3 ** 4 *** 1
-
17
CARE MAP FOR DKA / HHS
Day Assessment Specimen/test Medication Activity / diet
Planning discharge
1. /
Hemodynamic assessment
VS. q 1-2 hrs / 4-6 hrs
CBS q 1 hr BUN, Cr Electrolyte q 2-4 hr Serum ketone ABG EKG, CXR
CBC, UA, Urine C/S Hemoculture, etc.
RI* IV fluid* K, HCO3
* RX precipitating
causes
NPO Consult Endocrine
Education
2.
VS. q 4-6 hrs
CBS q 4-6 hr BUN, Cr, electrolyte Follow up Labs
RI* IV fluid* RX precipitating
causes
NPO/soft diet
Education .. /
follow up 3.
VS. q 4-6 hrs
CBS tid ac & hs NPH/RI Pre-mixed insulin
RX precipitating causes
Soft / regular diabetic diet
Education .. /
follow up
* RI & IV fluid 5
-
18
CARE MAP FOR DM IN-PATIENTS WITH ILLNESS
Day Assessment Specimen/test Medication Activity / diet
Planning discharge
1. /
Hemodynamic assessment
VS. q 1-2 hrs / 4-6 hrs
CBS q 1 hr BUN, Cr Electrolyte Investigate cause of
illness CBC, UA, Urine C/S Hemoculture, etc.
Insulin (NPH/RI)*
IV fluid* RX / support Rx
of causes of illness
NPO/diabetic diet
Education
2.
VS. q 4-6 hrs
CBS q 4-6 hr Follow up Labs
Insulin (NPH/RI)*
IV fluid* RX / support Rx
of causes of illness
NPO/diabetic diet
Education .. / ..
follow up
3.
VS. q 4-6 hrs
CBS tid ac & hs Antidiabetic drugs*
NPH/RI* IV fluid* Rx / support Rx
of causes of illness
diabetic diet
Education .. / ..
follow up
* Insulin & IV fluid 6 7
-
19
1. . 2. . 3. . 4. . 5. . 6. .. 7. .. 8. 8 9.
10. 11. 12. 13. 14. 15. 16.
-
20
1. American Diabetes Association. Diagnosis and Classification of Diabetes Mellitus. Diabetes Care 2012; 35 supp 1: s64-71.
2. . . 2546 15 28.
3. 2553-2554.
4. . . 2546 359 385.
5. Umpierrez GE, Hellman R, Korytkowski MT, Kosiborod M, Maynard GA, Montori VM, et al. Management of hyperglycemia in hospitalized patients in non-critical care setting: an endocrine society clinical practice guideline. J Clin Endocrinol Metab. 2012; 97: 16-38.
6. Kitabchi AE, Umpierrez GE, Miles JM, Fisher JN. Hyperglycemic crises in adult patients with diabetes. Diabetes Care. 2009; 32: 1335-43.
7. Gordon C. Weir. Insulin Therapy and Its Complications. In : Kenneth L. Becker. Principles and Practice of Endocrinology and Metabolism 3rd Edition. LWW. Philadelphia 2001: p 1348-59.
8. . . 2546 133 152.
-
21
- insulin
- hypoglycemia
- DKA chart
- Diabetic chart
-
-
22
Insulin
-
23
HYPOGLYCEMIA
- ..................................................................................HN......................... hypoglycemia .................................................................................... Diagnosis..
1) Capillary blood sugarmg/dl and/or Plasma glucose..mg/dl ()
2) [ ] Hypoglycemia at Admission [ ] In-hospital Hypoglycemia, one episode [ ] In-hospital Hypoglycemia, recurrent (> 2 episodes)
3) Cause of hypoglycemia [ ] Oral hypoglycemic drug induced hypoglycemia [ ] Insulin induced hypoglycemia [ ] Poor intake (< 50%) or NPO [ ] Sepsis [ ] Others (specify)....
4) [ ] Consult Endocrine [ ] Consult Nutrition [ ] Consult ( Doctor Order) [ ] Consult ( Doctor Order)
[ ] [ ] ...................................................................................................................................
-
24
-
25
-
26
-
27
Nutrition Alert Form:
1. // 2 (Arm span) : :
( )
2. [ (BMI) = (.) ( (.) (.))] : 3 : Albumin Albumin Total Lymphocyte Count (TLC) [TLC = (Total WBC Lymphocyte) 100]
3. :
4. 4 :
5. 2 : (Clear liquid diet: ) (Full liquid diet: )
(Soft diet: )
(Regular diet: ) - :
6. > 2 ( 1 ):
7. :
8. / ( 1 ) CKD-ESRD :
rejection Solid cancer : Lymphoma (Leukemia)
(Tumor)