Sara Meltzer, MD, FRCPC, FACP2010

In-Hospital ManagementIn-Hospital Managementof Patients of Patients

with Diabeteswith Diabetes

In-Patient Diabetes In-Patient Diabetes ManagementManagementObjectives:Objectives: Importance of Diabetes

as a risk factor in hospital outcomes

Review physiology of stress and insulin needs

Aspects of glucose control in hospital Diet and Testing, Oral agents Insulin use Peri-operative care

Emergency Room management Pump therapy – basics in case admitted

Scope of the problem…Scope of the problem…Common and Increasing

Overall: > 8% Individuals 65+: > 15% 1 in 3 individuals born in 2000 will develop

diabetes in their lifetime 25% of DM1 & 30% of DM2 admitted each year 49% of DM in discharge diagnoses from 1980

to 2001

Costly: Medical expenditures/patient 2.4x > non-

diabetics 4.6 million DM-associated admissions costs in

2001; 17 million hospital days at > $ 40 billion (US)

May, 2008

Vascular Disease Outcomes in Patients with or without DM: OACIS RegistryOACIS Registry

8,013 patients with unstable angina or non-Q wave MI

95 hospitals in 6 countries (incl. Canada)

Overall mortality increased 57% in presence of DM

May, 2008

Figure 1. Long-term clinical outcomes amongNon-diabetic and diabetic patients in the OACIS registry

Malmberg, Circulation,2000

% o

f p

ati

en

ts

Canadian Acute Coronary Syndrome Canadian Acute Coronary Syndrome RegistryRegistry

May, 2008

• 4,578 patients with acute coronary syndromes

• 9 Canadian provinces 1999-2001

Yan, JACC, 2004

Digami Trial - SwedenDigami Trial - Sweden 620 patients with DM & MI; mean follow-up 3.4 y. ◦ 306 intensive insulin; 314 controls

May, 2008

Malmberg, BMJ, 1997

Death Rate: 138 (44%) in controls; 102 (33%) in the int. tx group (RR 0.72, P=0.011)

One life saved for every 9 treated patients

Stoke patients…Stoke patients…2 - 4 x risk of CVA compared to non-diabetics (Framingham Study, Paris Prospective Study, Whitehall Study, MRFIT, Rancho Bernardo Study)Hyperglycemia present in 40% of CVA admissions Both ischemic and hemorrhagic CVA have 3X 30-

day mortality risk when admission glucose>6-8 mM (Capes, Stroke, 2001, 32-Study Meta-Analysis)

Return to work post-CVA 76% if normal admission glucose, vs. 43% if glucose > 6.7 mM (Pulsinelli, Am J Med, 1983)

Persistent in-hospital glucose > 7 infarct expansion and functional recovery

May, 2008

In-Patient Diabetes In-Patient Diabetes ManagementManagement: Objectives: Objectives Importance of Diabetes

as a risk factor in hospital outcomes

Review physiology of stress and insulin needs

Aspects of glucose control in hospital Diet and Testing, Oral agents Insulin use Peri-operative care Emergency Room management Pump therapy – basic concepts in case

admitted

Hyperglycaemia in the Hyperglycaemia in the Hospital SettingHospital Setting

May, 2008

GlucoseGlucose

Growth hormoneCortisolCatecholaminesGlucagon

Insulin

Pathophysiology

May, 2008

Considerations in Assessment of

Peri-operative Stress

Clement, NEJM 2004

Metabolic stress response

Stress hormones & peptides

Glucose Insulin

FFAKetonesLactate

Reactive O2 species

Transcription factors

Secondary mediators

Immune dysfunction

Infection dissemination

Cellular injury/apoptosisInflammation / Tissue damageAltered tissue/wound repair

Acidosis / Infarction/ischemia

Prolonged hospital stayDisability

Death

Optimal Insulin replacement Optimal Insulin replacement – Why bother? – Why bother?

May, 2008

Surgical or illness related stress causes insulin needs to increase

Insulin is the BEST ANABOLIC HORMONE we have and if the amount available is inadequate for metabolic needs…

CATABOLISM occurs.

Hyperglycemia increases chances of infections

In patients severely ill in ICU, even glucose values > 6mmol/L can be associated with poorer outcomes.

Insulin secretionInsulin secretionProinsulin

May, 2008

Insulin released in equimolaramounts with C - peptide (90-97%)

Pro-insulin & conversion products (3 -10 %) Released into

portal circulation

Basal secretion is approximately 1 unit / hourIn response to food, increases 5 - 10 foldAverage insulin release about 40 units/day

Insulin Needs in HospitalInsulin Needs in Hospital

May, 2008

Surgical Site InfectionsSurgical Site Infections Correlation with peri-operative Correlation with peri-operative glucoseglucose

May, 2008Ata et al Arch Surg Sept. 2010 p858

Surgical Site Infection without DM – 5.3%Surgical Site Infection with DM – 11.2% Adjusted OR 1.80

Adj OR 12.1

In-Patient Diabetes In-Patient Diabetes Management: Management: ObjectivesObjectives

Importance of Diabetes as a risk factor in hospital outcomes

Review physiology of stress and insulin needs

Aspects of glucose control in hospital Diet and Testing, Oral agents Insulin use Peri-operative care

Emergency Room management Pump therapy – basic concepts in case

admitted

Before the ORBefore the OREvaluate for concurrent illness

and risks related to them e.g. Silent cardiovascular disease (women and

men) Autonomic and/or peripheral neuropathy Hypertension/ renal disease Co-existent other autoimmune disease in

type 1’s (hypothyroid, Addisons?)

Adjust diet to provide optimal nutrition

May, 2008

Concept of Diet for Concept of Diet for DiabetesDiabetes

Adequate for caloric and nutritional needs

Spread carbohydrate (CHO) intake from food throughout day

Balance sources from fruits/vegetables and starches with needed protein & fat

Insulin must match carbohydrate intake

May, 2008

Not equal to “ Don’t eat sugar”!

Diet orders…Diet orders…Clarity is very important! Clarity is very important! Order ‘diabetic diet’ once eating Clear fluids will often put sugars up

as well… try to have it given in 30g servings at meal & snack times…

eg. 6 oz apple juice or ginger ale (15g) + 1 jello (15g)

Full fluids also better served Q3H and as 30g feeds, if possible...

e.g. 1c cream soup (15g) + 1c eggnog (15g)

May, 2008

Carbohydrate Intake Peri-Carbohydrate Intake Peri-operativelyoperatively

If eating, must consider timing of insulin with meals, size and frequency

If on tube feeds – continuous or interrupted? – must plan insulin appropriately

If on IV fluids, must provide adequate calories to avoid catabolism and ketone formation, roughly 5g per houri.e. D5W or D5NS or ½ NS@100cc/h;

D10W@50cc/h (~ 2 oz of orange juice only!)

If on Total Parental Nutrition – requirements for insulin increase as calories are continuous and similar to when eating

May, 2008

Capillary Blood Glucose Capillary Blood Glucose TestingTesting

Clinical Status of Patients

Options for CBGM

Patients actively treated, often with changes in dietary or CHO intake

Q1-4h for patients on IV insulinQ 2-6h for patients on continuous feedsAC meals and HS for patients eatingAC and PC meals, HS and 03h for patients requiring excellent control e.g. pregnancy

Patients with stable diabetes on insulin or oral agents eating consistent meals with minimal changes in diet plan

Routinely AC breakfast and AC supperOnce or twice weekly, AC meals and HS

Long-term care patients with diabetes which is unstable or DM1

AC meals and HS in order to adjust insulin dose

Long-term care patients on insulin or oral agents who are stable

AC bkft daily; PC breakfast, lunch, supper in rotation if on oral agentsAC meals and HS in rotation: once weekly

AC (ante-cebum ) = before meal and PC (post-cebum ) = after meal in Latin

May, 2008

Humulin R

Humulin N

7.2 5.4 9.32.7

8u 6-24u

16u

10u 10.5 16h 2.7 OJ given

Humulin R

Nov. 15

Nov. 16

Humulin N

8+210u

11.4

Diet & Sulfonylureas Metformin -Glucosidase TZD Insulin Exercise and Glitinides Inhibitors

1° mech ↓ insulin resist ↑ insulin secretion ↓ hepatic output ↓ CH2O absorpt ↑ insulin sens ↑[insulin]

HgbA1c↓ 0.5-2.0 1.0-2.0 1.0-2.0 0.5-1.0 0.5-1.0 1.5-2.5

Agents Avoiding McD Glyburide Metformin Acarbose Rosiglitazone

Gliclazide Miglitol Pioglitzone

Glimepiride

Repaglinide

Nateglinide

Adverse Injury Hypoglycemia GI upset GI upset Edema ↓ glucose

Effects Wt gain Lactic acidosis

Wt gain

Oral Agents: Effects and Mechanisms of Action

The Stable Hospitalized The Stable Hospitalized Diabetic PatientDiabetic Patient

May, 2008

Can sometimes continue home regimen, including oral agents, as long as:

1. Stable or improving medical status

2. Predictable nutritional intake

3. Frequent CBG monitoring

4. Sufficient glycemic control

Insulin Routes of AdministrationInsulin Routes of AdministrationSubcutaneous

◦ variable absorption◦ variable duration of action◦ all formulations may be given this route

Intramuscular◦ all can be given, hurts more, faster action

Intravenous◦ faster action (T 1/2 = < 5 min.)◦ very consistent action◦ high levels of circulating insulin can be established

Intra-peritoneal ◦ used in peritoneal dialysis◦ portal levels >> systemic - more physiologic◦ used in implanted pumps… trouble with omental

blockingMay, 2008

Regular insulin - half Regular insulin - half lifelifeIf given IV…. T ½ = 4 - 5 min.

If given IM… T ½ = 1 - 2 hours

If given IP… T ½ = 2 - 3 hours

If given SC … T ½ = 6 hours

May, 2008

Insulin Types & Action Insulin Types & Action Profiles: Profiles: Short-actingShort-actingType Name

Onset (min)

Peak action(h)

Duration action(h)

Rapid Analog

Humalog - lispro Novorapid - aspart Apidra

- glulisine

10 – 15 1- 3 3 - 5

Regular Human

Novolin Toronto Humulin R

30 - 60 2 - 3 4 - 8

May, 2008

Insulin Types & Action Profiles: Insulin Types & Action Profiles: Intermediate and Long-actingIntermediate and Long-acting

Type Name Onset

(h)

Peak action (h)

Duration of action

(h)

NPHHuman

Novolin NPH

Humulin NPH

1 – 3 5 – 10 16 – 18

Glargine Lantus 4 – 6 8 – 16 20 – 36

Detemir Levemir 2 – 4 6 – 12 12 - 24

May, 2008

Insulin orders... Clarity Insulin orders... Clarity counts!counts!

For patient on IV’s◦ Best option = iv insulin with adjustment◦ 2nd best option is Q6H regular SC or R ac meals

and NPH at HSFor patients who are eating but unstable:

◦ NPH @ HS and Regular pre-meal … both with adjustment scale

For patients who are eating but unstable amounts:◦ NPH @ HS and Regular pre-meal if needed ◦ + Rapid acting post-meal … only adjust pre-meal

regular with sliding scaleFor patients who are eating and stable:

◦ Regular AC meals and NPH at HS, adjusted with sliding scale… may be able to reduce testing frequency but should still cover all parts of the day

May, 2008

Insulin Therapy: Insulin Therapy: Temporary Temporary use...use...Pregnancy… can’t use pills!Surgery … increased need.Medication such as steroids which

dramatically increase insulin needs.Concurrent illness … eg. MI or CVA…

better peri-event sugar control improves morbidity and mortality.

May, 2008

Good sugar control helps patients recover and leave hospital faster!

Concept of Concept of BASAL insulin needsBASAL insulin needsAny person, eating or not requires

insulin to live… 24 hours a day!Basal needs (no food):

◦ often lower levels between 12 am and 4 am, an increase prior to awaking until about 8 am, then often about 0.4-0.8 u/hr.

In response to food, ◦ proportion of insulin release closely relates to

CHO content of the meal +/- presence of protein & fat in it.

May, 2008

Insulin replacement Insulin replacement for Type 1for Type 1

In type 1… no insulin of their own without injections… never leave them without insulin coverage!

May, 2008

Insulin replacement for Insulin replacement for Type 2Type 2Type 2 on diet: if not eating, can

often keep fasting glucose normal… may not need basal

Type 2 on oral agents: if not eating… usually needs additional amounts of insulin to keep normal sugars, even without eating.

Type 2 on insulin: often some remaining basal insulin but needs coverage even if not eating to have good glucose entry into cells.

May, 2008

Establishing “basal” needs – Establishing “basal” needs – i.e. amount needed if no significant i.e. amount needed if no significant carbohydrate intakecarbohydrate intake

Establish known total daily dose (TDD) i.e. sum of all insulin taken in a normal day

Determine what ½ of that amount is… approximate amount of insulin needed if no CHO intake

Determine the necessary hourly rate of this “base need”

[i.e. [(TDD/2)] 24 = X u/h

Set up an IV insulin infusion with this hourly rate as a starting point and allow adjustment up or down until target range is reached

May, 2008

May, 2008

Patients taking insulin who Patients taking insulin who are NPO or Pre-op:are NPO or Pre-op:Items of the order sheet are based on the following premises…Patients should receive glucose IV at ~ 5g/h in order to provide essential minimum calories to avoid ketosis of fasting. Can be done using D10W at 50cc/h if fluid status is a problem, or D5W or D5NS @100cc/h for most patients.Capillary blood glucose should be measured frequently initially Q1H and subsequently decreasing frequency depending on stability of blood sugar, with a minimum frequency of Q4H.Intravenous insulin should always be REGULAR insulin (either Humulin R or Novolin Toronto – be precise to avoid confusion).

May, 2008

Patients taking insulin who Patients taking insulin who are NPO or Pre-op:are NPO or Pre-op:

May, 2008

Premise which permits determination of the initial insulin infusion rate:

This is usually based on a simple calculation of the basal insulin requirements. Approximately half of the insulin given every day covers the meals – the other half covers the basal needs. Therefore, calculate ½ of the total daily dose (TDD) of insulin to allow coverage of basal needs, converted to units/hour. i.e. ½ TDD ÷ 24 = starting insulin infusion rate.

If the infusion rate is < 1.0units/h – use 10units/250ml NS (1unit = 25ml.)If the infusion rate is ≥ 1.0 units/h – use 25units/250ml NS (1unit / 10ml)

Establishment of basal Establishment of basal infusion rate:infusion rate:

May, 2008

Adjustments to Insulin Infusion Adjustments to Insulin Infusion Rate:Rate:

May, 2008

If CBG (mmol/L) is:

≤ 4.0 Stop insulin infusion temporarily; continue glucose infusion at previous rate and give 20ml of D50W IV push over 2-3 minutes. Inform MD. Recheck CBG in10 min. & repeat D50W until CBG ≥6mmol/L, then resume the insulin infusion at ½ previous rate.

4.1 – 7.0 Decrease insulin infusion rate by (indicate with checkmark)□ half of current rate (for fractions of a ml.,

decrease to nearest whole number)□ ______ units/hr. (i.e. _______ ml/hr).

7.1 – 10.0 Continue the current insulin infusion rate.10.1 – 14 Increase current infusion rate by ____units/hr (i.e. ___ml/hr).14.1 – 18 Increase current infusion rate by ____units/hr. (i.e. ___ml/hr).> 18 Increase current infusion rate by ____units/hr. (i.e. ___ml/hr).

and inform MD.

Post-operative orders Post-operative orders once ready to resume full fluidsonce ready to resume full fluids

May, 2008

Re-order “diabetic diet …X….Kcal/day”

In patients normally on oral agents, re-order once patient is eating may need lower doses as intake may be

poor may need “insulin adjustment scale” or

“sliding scale” for values above 8 or 10 mmol/L

In patients normally on insulin, restart subcutaneous insulin dose at least 20-30 minutes prior to the discontinuation of the IV, even if at a lower dose than prior to admission…

Returning to eatingReturning to eatingOnce patient ready to return to meals, likely not

eating well, so work in reverse…i.e. Hourly dose given X 24 = approximate present “basal

needs” which can be distributed to be given prior to meals and HS in the proportion of:

Use insulin adjustment scale to correct for food and relative proportion errors

Adjust base dose daily based on previous day’s needs until control achieved and on normal diet

May, 2008

Time Breakfast Lunch Supper HS

NPH or basal 0 - 0 - 0 - 40%

Regular/rapid 25% - 15% - 20% - 0

Insulin orders – patient Insulin orders – patient eatingeatingOrdered baseline dose(Indicate clearly type and brand of insulin)

Breakfast or

0600h

Lunch or 12h

Supper or 18h

HS or 22h

NPH/glargine/detemir 0% 0% 0% 40%

Regular/lispro/aspart/glusine

25% 15% 20% 0%

Example of insulin adjustment scale for pre-meal or HS insulin adjustment

If capillary blood glucose is:

≤ 4 mmol/L Treat for low blood sugar; decrease ordered dose by 4units

4.1 – 6.0 mmol/L Decrease ordered dose by 2 units

6.1 – 10.0 mmol/L Give ordered baseline dose

10.1 – 12.0 mmol/L Increase ordered dose by 2 units

12.1 – 14.0 mmol/L Increase ordered dose by 4 units

14.1 – 16.0 mmol/L Increase ordered dose by 6 units

16.1 – 18.0 mmol/L Increase ordered dose by 8 units

> 18.0 mmol/L Increase ordered dose by 10 units; inform MD

November, 2010

Additional considerations once Additional considerations once eating:eating:

IV insulin – Regular is preferred, as analogues have no advantage if not SC and are more expensive. Once eating, if previously on analog insulins, can re-start.

Monitor glucose at least every 4 - 6 h; ideally, pre-meals.

In situation where changes of need may occur rapidly, use of aspart (Novorapid®) or lispro (Humalog®) SC may be easier, since it can be given with the meal. Rapid acting analogs, however, only lasts 4-6h, not 6-8h as “regular” does.

Initially CBG testing would be ordered as 0600, 1200, 1800 and 2400 but, if switched to eating, adjust timing to meal delivery & 2200 hr.

May, 2008

Patients going for testsPatients going for tests

Adjust timing of tests to facilitate insulin and diet needs whenever possible.

If patient likely to be gone at a snack time or may have lunch delays by waiting times in X-ray, etc… send juice and a snack with them.

Reassess patient on return from test with capillary blood glucose & adjust therapy as needed.

May, 2008

““Sliding Scales” Sliding Scales” – why such a bad – why such a bad reputation?reputation?Inappropriately, they are used

alone….as the only insulin ordered…

To work, the sliding scale should only help fix the “ordered dose”

The information from the adjustments used in the sliding scale should be used to help correct the “base dose” the next day.

May, 2008

Sliding scale in hospitalSliding scale in hospitalif glucose is: (mmol/L)

R/RA beforemeals

N/L/UL @ hs

< 4.0 - 4 units - 4 units

4.1 - 6 - 2 units - 2 units

6.1 - 10 Base dose Base dose

10.1 - 12 + 2 units + 1 u. R/RA

12.1 - 14 + 4 units + 2 u. R/RA

14.1 - 18 + 6 units + 3 u. R/RA

> 18 + 8 units + 4 u. R/RA

if glucose above 20, give 10 units & call MDif glucose above 20, give 10 units & call MD

May, 2008

Insulin adjustment scale for Insulin adjustment scale for patients at home or for insulin patients at home or for insulin sensitive type 1sensitive type 1 if glucose is: (mmol/L)

R/RA beforemeals

N/L/UL @ hs

< 3.0 - 3 units - 3 units

3.1 - 4 - 2 units - 2 units

4.1 - 5 - 1 unit - 1 unit

5.1 - 8 Base dose Base dose

8.1 - 10 + 1 unit + 1 unit

10.1 - 12 + 2 units + 2 units

12.1 - 14 + 3 units + 3 units

14.1 - 18 + 4 units + 4 units

> 18 + 5 units + 5 units

May, 2008

In-Patient Diabetes In-Patient Diabetes ManagementManagement:Objectives:Objectives

Importance of Diabetes as a risk factor in hospital outcomes

Review physiology of stress and insulin needs

Aspects of glucose control in hospital Diet and Testing, Oral agents Insulin use Peri-operative care Emergency Room management Pump therapy – basic in case admitted

ER or Hospital Management ER or Hospital Management - Challenges to Care:- Challenges to Care:

Meals are : ◦ irregular, or missed completely◦ rarely the same as normal diet or on time

Capillary Blood Glucose Monitoring is:◦ Done irregularly, not always in relation to meals ◦ Difficult to arrange hourly for IV infusions due to

nursing staff limitations on occasion.Staff changes are frequent, thus less continuity of

care.Patient’s participation in self care may be severely

limited.Patient, by definition, will be ill and inter-current

illness often substantially changes insulin requirements… often increasing them due to the psychological and physiological stresses.

May, 2008

Evaluation in the Emergency Evaluation in the Emergency Room….Room….

May, 2008

Usual treatment often gives valuable insight into how patient’s care should be done

Is patient able to eat normally?

Is patient NPO or on IV infusion?

Does patient normally take insulin? - If so, need to know: what kinds of insulin, type and exact namehow much, and at what times?

DETAILED EXACT INFO needed!!!

ER IV insulin infusions – pros and ER IV insulin infusions – pros and conscons

In some ER situations, due to staffing issues, hourly CPG to adjust an IV protocol initially may not be possible.

Use an insulin adjustment scale as one would use normally pre-meal using ¼ of total daily dose [TDD] as top limit of sliding scale for highest glucose values.

May, 2008

To calculate dosage to use for basal needs if not eating…

Calculate Total Daily Dose (TDD) divide by 2 (since ½ insulin for food)Divide this amount over the day - 40 % overnight and the rest split in 3 with a bit more at breakfast than lunch as regular or analogue pre-meal or 0600, 1200, 1800 hours and NPH at HS.

e.g. 25% - 15% - 20% - 0 can be given pre-meal regular or RA

0 - 0 - 0 - 40% as longer acting evening insulinspre

May, 2008

Continue usual diet and pillsContinue usual diet and pills

Give consistent glucose load by IV (~ 5 g/h) to avoid

ketosisEg. IV D5 W or D5NS @ 100cc/h

orD10 W @ 50 cc/h if fluid an

issue.

Give consistent glucose load by IV (~ 5 g/h) to avoid

ketosisEg. IV D5 W or D5NS @ 100cc/h

orD10 W @ 50 cc/h if fluid an

issue.Is glucose stable and well

controlled?

Is glucose stable and well

controlled?

YESYES NONO

Monitor glucose q 4-6 h as needed, no other therapy for DM likely

needed.

Monitor glucose q 4-6 h as needed, no other therapy for DM likely

needed.

Initiate an IV insulin infusion with concept of giving 10 – 12 u/24 h. (or presumption of potential total insulin dose as 20 u/day) Ie. IV insulin to start @ 0.4 u/h orBase dose ac meals & HS of :N 0 - 0 - 0 - 4R/RA 4 - 5 - 4 - 0 with insulin adjustment scale. Monitor glucose as needed.

Initiate an IV insulin infusion with concept of giving 10 – 12 u/24 h. (or presumption of potential total insulin dose as 20 u/day) Ie. IV insulin to start @ 0.4 u/h orBase dose ac meals & HS of :N 0 - 0 - 0 - 4R/RA 4 - 5 - 4 - 0 with insulin adjustment scale. Monitor glucose as needed.

Patient with DM in ERPatient with DM in ERNormally on diet ± oral agentsNormally on diet ± oral agents

Patient with DM in ERPatient with DM in ERNormally on diet ± oral agentsNormally on diet ± oral agents

Able to eatAble to eat Not able to eatNot able to eat

May, 2008

Able to eatAble to eat Not able to eatNot able to eat

Continue usual diet and insulin if

possible

Continue usual diet and insulin if

possible

Give consistent glucose load by IV (~ 5 g/h) to avoid

ketosisEg. IV D5 W or D5NS @

100cc/h or D10 W @ 50 cc/h if fluid volume is an issue.

Give consistent glucose load by IV (~ 5 g/h) to avoid

ketosisEg. IV D5 W or D5NS @

100cc/h or D10 W @ 50 cc/h if fluid volume is an issue.

Is glucose stable and well

controlled (ie < 10mmol/L)?

Is glucose stable and well

controlled (ie < 10mmol/L)?

YESYES NONOMonitor glucose q 4-6 h as needed,

continuing therapy as planned.

Monitor glucose q 4-6 h as needed,

continuing therapy as planned.

Initiate insulin …either as an IV insulin infusion of base dose [total daily dose / 2] distributed over 24 hour as starting insulin dose for infusion… ie. IV insulin to start …

@ (TDD/2) = X u/h (initial rate) & adjustorBase dose ac meals & HS of :N 0 - 0 - 0 - 40%R/RA 25% - 15% - 20% - 0 with insulin adjustment scale. Monitor glucose as needed.

Initiate insulin …either as an IV insulin infusion of base dose [total daily dose / 2] distributed over 24 hour as starting insulin dose for infusion… ie. IV insulin to start …

@ (TDD/2) = X u/h (initial rate) & adjustorBase dose ac meals & HS of :N 0 - 0 - 0 - 40%R/RA 25% - 15% - 20% - 0 with insulin adjustment scale. Monitor glucose as needed.

If type 1If type 1, initiate IV or Q4-6 SC insulin regimen once glucose above 6 mmol/L and check for ketones.

If type 1If type 1, initiate IV or Q4-6 SC insulin regimen once glucose above 6 mmol/L and check for ketones.

Ordered dose: Breakfastor 0600

Lunchor 1200

Supper or 1800

HSor 2400

NPH/lente/ultralente(source, brand)

0 0 0 X

Regular / Rapid acting(source, brand)

X X X 0

EG. Insulin adjustment scale for rapid acting insulin before each meal: If capillary blood glucose is:

≤4.0 mmol/L Treat for low blood sugar; decrease ordered dose by 4 units

4.1–6.0 mmol/L Decrease ordered dose by 2 units

6.1–10.0 mmol/L Give ordered dose

10.1–12.0 mmol/L Increase ordered dose by 2 units

12.1–14.0 mmol/L Increase ordered dose by 4 units

14.1–18.0 mmol/L Increase ordered dose by 6 units

>18.0 mmol/L Increase ordered dose by 8 units and inform physician

Patient with DM in ERPatient with DM in ERNormally on insulin

Patient with DM in ERPatient with DM in ERNormally on insulin

In-Patient Diabetes In-Patient Diabetes ManagementManagementObjectives:Objectives: Importance of Diabetes as a risk factor in hospital outcomes

Review physiology of stress and insulin needs Aspects of glucose control in hospital Diet and Testing, Oral agents Insulin use Peri-operative care Emergency Room management Pump therapy – basic concepts in case

admitted

The dilemma of pump The dilemma of pump patients…patients…

May, 2008

That patient in Bed 3 is on an insulin pump – you take her!

No, I can’t… I don’t know anything about pump therapy…

Well neither does the doctor who’s on tonight – so what do we tell the patient?

Core Concepts of Insulin Pump Core Concepts of Insulin Pump PrescriptionsPrescriptions((~25% of type 1’s now on pumps!)~25% of type 1’s now on pumps!)

“Basal” = Basal dose – units per hour

24 – 04h …0.6u

04–07h …1.0u

07–12h …0.8u

12–18 …0.6u 18–24h …0.7u

Bolus doses: Ratio of grams CHO covered by 1 unit of insulin

24–07h 1u/20g

07–11h 1u/8g 11–15h 1u/12g

15–20h 1u/10g

20-24h 1/15g

Correction factor – the amount of glucose lowered by 1 u (in mmols)

24–07h 1u/3 07–11h 1u/1.5

11–15h 1u/2 15–20h 1u/2 20-24h 1/3

May, 2008

Basal = baseline dose = insulin amount given over 24 hours without food Bolus = dose given to cover food intake Total daily dose = insulin amount used as basal + bolus given for meals Insulin Sensitivity Factor (ISF) or Correction factor indicates

mmol increments for sliding scale (often must be doubled if ill or stressed e.g. hospital i.e. mmol denominator must be decreased)

The Type 1 on pump or who “carb The Type 1 on pump or who “carb counts”…counts”…

In order to order IV or alternative subcutaneous insulin doses … need to know the total daily dose (TDD) – pumps have that info in their minicomputers… ask the patient!

For Patients who don’t know/can’t tell you their Total Daily Dose

To determine basal total: Ask them (or review basal on the pump) to find basal rates by hour… calculate: [basal rates X numbers of hours at each] = total basal rate

To determine meal amounts if carbohydrate counting:

1. Ask them what their “normal” meal carbohydrate intake is, then ask them what they usually take to cover that… will often get relative doses for breakfast, lunch and dinner that way.

2. If they are not able to tell you their usual meal CHO intake, assume 40g at breakfast and 50g for lunch and supper – multiply by ratio found under bolus wizard or EZ carbs eg 1u/8g at bkft = 5units

May, 2008

Total Daily Dose = sum of basal rates + usual amount for each meal…

Search for “micro” Search for “micro” complications!complications!Nephropathy:

◦ Check albumin/creatinine ratio (> 2.0 men or 2.8 women = trouble)

◦ creatinine clearance by Cockcroft-Gault equation◦ Urinalysis – for cells, protein, or signs of infection

Retinopathy◦ Be sure patient has been seen by competent

ophthalmologist and eyes assessed within last year

Neuropathy - Test ankle jerks + 10g monofilament on toes- Ask about erectile dysfunction, bowel problems,

excess sense of fullness post-meal, postural hypotensive symptoms

May, 2008

Search for “macro” risk factors Search for “macro” risk factors or complicationsor complications

Lipid profile at least yearly ◦ evaluation of LDL and HDL cholesterols,

Triglycerides, apo-B.Cardiac assessment

◦ ECG + / - stress test◦ Hypertension – assess and control to < 130/85

Peripheral Vascular Disease… ◦ Vascular flow assessments with doppler PRN ◦ Assess for bruits or intimal media thickening

Foot care…◦ Look at the foot – reflexes, monofilament,

ulcers, redness, callouses and general state of care

May, 2008

Make sure outpatient Make sure outpatient follow-up follow-up well establishedwell establishedRemember to use entire team… nursing, dietitian, family MD, social worker and community services, if needed.

Plan appropriate steps long before day of discharge.

Survival booklets available in English & French – order via Endocrinology office…

May, 2008

Thank you for your Thank you for your attention… Questions ???attention… Questions ???