Transcript Strategies_to_Reduce_Hypoglycemia

Strategies to Reduce
Hypoglycemia
Presented by:
Hennie Garza, M.S., R.Ph., C.D.E,
Director of Pharmacy Utilization and Outcomes
Senior Care Centers
http://www.seniorcarecentersltc.com/
September 18, 2012
Goals & Objectives
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Define Hypoglycemia
Identify Risk Factors for Hypoglycemia
Identify signs and symptoms of Hypoglycemia
Discuss elements of a hypoglycemia
management protocol
• Review insulin characteristics and discuss
strategies to improve patient safety when
administering insulin
• Discuss strategies to reduce hypoglycemia
A really good reference:
 Journal Clinical Endocrinology & Metabolism
 January 2012, 97(1):16-38
 “MANAGEMENT OF HYPERGLYCEMIA IN
HOSPITALIZED PATIENTS IN NONCRITICAL CARE SETTING: AN
ENDOCRINE SOCIETY CLINICAL
PRACTICE GUIDELINE”
Definition
 Hypoglycemia = Plasma glucose less than
70mg/dL
 Severe Hypoglycemia = when an individual
requires the assistance of another person
and cannot be treated with oral carbohydrate
due to confusion or unconsciousness.
 Cognitive impairment can occur with plasma
blood glucoses less than 50mg/dL
Risk factors for hypoglycemia
 Older age
 Greater illness severity
(septic shock, mech.
Ventilation, renal
failure, malignancy,
malnutrition
 Diabetes
 Use of oral glucose
lowering agents &
insulin
 Cessation of nutrition
for procedures
 Adjustment in amount
of nutritional support
 Interruption of the
routine for glucose
monitoring
 Failure to adjust
therapy when glucose
is trending down
Signs & symptoms
 Perspiring or sweating

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excessively
Weakness, dizziness,
faintness
Hunger or excessive
eating
Nervousness, irritability,
changes in personality
Blurred/impaired vision
 Numbness in tongue
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and lips
Tachycardia or
palpitations
Tremors
Headaches
Altered level of
consciousness
Does your facility have a protocol?
Nurse Strategies for Treatment
Recommendations
New Beers List 2012
Hypoglycemia Case
Insulin Time-Action Profiles
Human 70/30 mix BID
Analog mix 70/30 or 75/25 BID
Basal-Bolus with Glargine and RapidActing Analog AC
Hypoglycemia Case
Problems with Sliding Scale
• COSTLY
– Nursing time, Test strips, lancets, Insulin waste
– Hypoglycemia risk
• We have better options
• Reactive instead of proactive
• Basal insulin can help reduce reliance on
sliding scale and reduce hypoglycemia
• Move to “correctional” or “supplemental”
dosing if needed
Starting Basal Insulin
Supplemental Insulin
Insulin-common mistakes
• New types of insulin and similar drug names make
order-entry problematic
– Know your different types of insulin
– Use “Tall Man” lettering: NovoLOG, NovoLIN
– Do not use the abbreviation “u” for units
– Spell out numbers i.e. “give two units”
• Similar drug packaging contributes to errors (case of
missing Novolog but Novolog 70/30)
• Methods of storage can impact errors
Insulin – common mistakes cont’d
 Communication of Insulin orders problematic
– Dangerous Abbreviations will get “U” in trouble
– Unclear orders on MAR
– Sliding scale insulin orders BIGGEST culprit for
errors and bad outcomes—HYPOGLYCEMIA
– Multiple sliding scale orders for same resident
(morning scale and bedtime scale)
Insulin--hypoglycemia
 Insulin has few actual drug interactions, but
hypoglycemia is biggest concern
 All facilities should have a HYPOGLYCEMIC
protocol to follow
 A word about Glucagon
 Majority of cases of hypoglycemia are result of
sliding scale insulin use
 Sliding scale is now on the Beers list!
Transitions of care
 Care transitions can be challenging
 Within the hospital
 From acute to post-acute
 Medication reconciliation is critical
 As patients get better, their insulin needs change
 Please work with your post-acute care providers
closely
Summary
 Strategies to reduce hypoglycemia
– Identify patients at risk
– Set targets for blood glucose
– Move to basal insulin instead of solely using
sliding scale insulin
– Many elderly patients do well with just 1 or 2 basal
injections daily
– Bedtime sliding scale most problematic in elderly
– Don’t forget to adjust based on patient progress
Questions/Discussion
THANK YOU!!!
Hennie Garza, M.S., R.Ph., C.D.E
Email address: [email protected]