Management of the hospitalized type I DM patient
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Transcript Management of the hospitalized type I DM patient
MANAGEMENT OF THE
HOSPITALIZED TYPE I DIABETIC
PATIENT
Riverside Methodist Hospital
January 23, 2014
Rundsarah Tahboub, MD
CASE
A 44 year old male is transferred from an outside hospital with low back
pain and hyperglycemia after recent spinal surgery. The patient uses an
insulin pump at home and it is unclear if he has Type I or II Diabetes . He
was initiated on an intravenous insulin infusion at the outside facility for
glucose of 300 and his pump was removed.
On admission the patient was not able to state how much insulin he gets
through pump on a daily bases
The admitting hospitalist discontinued the insulin drip and began sliding
scale insulin.
The patient became severely hyperglycemic shortly afterward and
developed ketoacidosis
He was found to have an epidural abscess
QUESTIONS I
What is the best insulin regimen for this patient ?
1.
Aggressive corrective sliding scale insulin since he has a severe infection
2.
Glargine insulin and standard corrective sliding scale insulin
3.
Variable intravenous insulin infusion
4.
Have him put his pump back on
QUESTION II
What would you do if patient became hypoglycemic while NPO on your
insulin regimen?
1.
Discontinue insulin altogether
2.
Reduce insulin doses
3.
Correct hypoglycemia with IV dextrose 50 once
4.
Initiate IV dextrose infusion
QUESTION III
All the following are appropriate criteria for reinitiating of insulin pump
except one:
1.
Will only resume at home after discharge
2.
Hemodynamically stable and AOX3
3.
Able to tolerate diet
4.
Has insulin pump supplies and able to fill pump and administer boluses
HOSPITALIZED TYPE I DM PATIENT
High risk patient
Completely dependent on exogenous insulin
Insulin sensitive usually requires <0.5 units/kg/day
Frequent use of insulin pumps
Will develop ketoacidosis in absence of sufficient basal insulin:
SSI monotherapy
Holding basal insulin when NPO
Delay in responding to stress hyperglycemia
DKA occurring after admission in
a hospitalized patient is
a result of medical error until proven otherwise
COMMON ERRORS IN MANAGEMENT
OF INPATIENT TYPE I DM
Holding basal insulin for NPO status or hypoglycemia
severe
hyperglycemia or DKA
Omitting mealtime insulin for low premeal BG (60-80 )
Using SSI only
Assuming Type I patient is as insulin resistant as Type II patients when
correcting hyperglycemia
RECOMMENDED GLYCEMIC TARGETS
Targets Must be:
Achievable
Reasonable
Safe
Critically Ill
Non critically Ill
140-180 mg/dL
Premeal <140 mg/dL
Random <180 mg/dL
NOT recommended
BG <110 mg/dL
Consider changing regimen for
BG <100 mg/dL
NON CRITICALLY ILL TYPE I DM
Continue to require an insulin regimen similar to home regimen but
modified for being inpatient with potential less PO intake
Regimen consists of:
Basal insulin
long acting glargine or detemir
intermediate acting NPH
Mealtime insulin (analog) must be scheduled if patient is eating
Corrective insulin for premeal glucose above target of 150 typically
NON CRITICALLY ILL TYPE I DM & NPO
STATUS
Must always continue exogenous basal insulin
Long or intermediate acting insulin
Basal rate of insulin pump if suitable
Initiation of IV insulin especially in critical care setting
May use corrective insulin in addition to basal
PERIOPERATIVE MANAGEMENT OF TYPE I
DM
Basal insulin should always be continued
Using glargine or detemir
If well controlled give 80% of dose
Uncontrolled may give the full dose
Using NPH
Give full evening dose
Give 50% of AM dose
Avoid use of mixed insulin 70/30, 75/25
Hold scheduled mealtime insulin but may continue to use corrective doses
If undergoing high risk surgery such as CABG or prolonged procedures
initiate IV insulin infusion the night before
Insulin Pump Therapy
Electronic device that delivers insulin through
a SC catheter
Can be programmed to deliver variable basal
rates throughout the day
Delivers bolus /mealtime coverage based on
•
carbohydrate intake with meals :
insulin to carbohydrate ratio
programmed into pump.
•
Example 1 unit per 15 gm of carb
per meal
•
correction factor : example 1 unit of
insulin drops BG by 50mg/dl
CHALLENGES OF INSULIN PUMP
THERAPY IN HOSPITAL SETTING
Patient may be unfamiliar with the pump settings but know how to use
pump otherwise ( fill with insulin , insert SC catheter, bolus for meals
and give correction doses )
Hospital Staff usually unfamiliar with pumps
Safety issues with pumps (kinked catheter, overbolused, discontinued by
staff without alternate insulin orders)
Technical concerns (safety with radiological testing, intraopertively)
REQUIREMENTS FOR SAFE INPATIENT
USE OF INSULIN PUMP THERAPY
Insulin pump order set
Patient contract
Nursing documentation of basal rates and boluses
administered by patient & evaluation of insertion site
Pharmacy overview of pump & patients insulin supply
Endocrine consult
INPATIENT INSULIN PUMP THERAPY
Criteria for maintaining pump
The patient is alert and oriented
Not critically ill
Able to administer boluses and suspend pump when needed
Cooperation with staff and signs patient contract
Patient has own supplies
INSULIN PUMP THERAPY IN
PERIOPERTAIVE PERIOD
May continue use of pump for short procedures <2 hours and insulin
insertion site away from surgical site
Reduce basal rate by 20% of usual
For procedures >2 hours
Initiate IV insulin infusion the night before at same rate as the insulin pump infusion
rate
Discontinue insulin pump
CRITICALLY ILL TYPE I DM & NPO STATUS
IV insulin infusion is the method of choice until condition is stabilized
Often need D5 IVF initiated also if
expected to be NPO for prolonged periods
BGs trending <150
IV insulin infusion rates may be titrated down as low as 0.1 units/hour
to avoid hypoglycemia while still providing IV insulin without
interruption
CRITICALLY ILL TYPE I DM & NPO STATUS
If enteral nutrition is going to be initiated IV insulin infusion is the safest
and most flexible method of achieving control
IV insulin should be maintained until the patient is tolerating enteral
nutrition and at goal rate
WHEN IS PATIENT READY TO BE
TRANSITIONED FROM IV TO SC INSULIN?
Hemodynamically stable
DKA or HHS resolved
Insulin infusion rate has been stable for 6-8 hours
Insulin infusion rate < 5 units/hour
Insulin infusion rates are similar to patient prior insulin requirements
Medications that effect BG have not been recently changed
Inotropes
Glucocorticoids
CONSIDERATIONS WHEN
TRANSITIONING FROM IV TO SQ INSULIN
Continue IV insulin until patient is able to tolerate PO intake (diabetic clear
liquids) if not on EN or PN
Continue IV insulin at least 2 h after the first SC basal insulin injection is
given or pump is started (Overlap is essential)
Is patient receiving Dextrose in IVF or have they eaten on Insulin Infusion?
Do not use the total insulin IV amount given in previous 24 hours
Don’t switch to SSI only !
FEEDING WHILE ON INSULIN INFUSION
The insulin infusion will not prevent hyperglycemia associated with ingestion
of carbohydrates
Insulin infusion is reactive
Interferes with our ability to calculate insulin requirements when
transitioning off of infusion
If you are going to feed on insulin give a SC dose of short acting insulin
before the meal
Giving a IV bolus is not going to cover the meal ..its effect only lasts 5-
10mins
HOW TO TRANSITION FROM IV TO SQ
INSULIN
Type I DM on IV insulin and D5 IVF (such as DKA)
Use stable insulin infusion rate in past 6 hours to calculate total daily
dose (TDD)
Example:
Stable average infusion rate 2 units/hour
2 units/hour x 24 hours =48 units (TDD)
HOW TO TRANSITION FROM IV TO SQ
INSULIN
Type I DM on IV insulin and D5 IVF (DKA)
Divide the new TDD as follows:
50% Basal ( to be given 2-3 hours before discontinuation of insulin
IV)
50% as premeal divided into 3 doses
Example : TDD 48 units calculated from IV insulin
24 units glargine
24/3 units as premeal analog insulin = Lispro 8 units with each meal
HOW TO TRANSITION FROM IV TO SQ
INSULIN
Type I on TPN or continuous tube feeds
Use stable insulin infusion rate in past 6 hours to calculate TDD
Divide the new TDD as follows:
50% Basal either glargine every 24 hours or equal dose of NPH q 12 hours
50% as nutritional given as regular insulin scheduled Q 6 hours
HOW TO TRANSITION FROM IV TO SQ
INSULIN
Type I on TPN or continuous tube feeds
Example average hourly rate over previous 6 hours while on goal tube feeds = 3.5
units/hour
3.5 x 24 hours = 84 units
Give 50% as basal = 42 units of glargine
even if TF discontinued this dose should be continued
Give 50% as nutritional = 42 units ÷ 4 ~ 10 units q 6 hours while on TF
this is to be held if TF interrupted
Also start correctional SSI
HOW TO TRANSITION FROM IV TO SQ
INSULIN
Type I DM (Not receiving dextrose , TPN or Tube feed)
Use stable insulin infusion rate in past 6 hours to calculate total basal dose
Example:
infusion rate 2 units/hour
2 x 24 hours =48 units
Give 80% as the Total basal dose for next 24 hours
0.8 x 48=40 units
Give all of this as basal insulin
Give premeal insulin roughly 0.05 - 0.1 unit/kg with each meal when patient
starts eating
TRANSITIONING FROM IV TO INSULIN
PUMP
Insulin pump should be placed and started at least 1-2 hours before IV
infusion is discontinued
QUESTIONS ??
REFERENCES
Umpierrez GE, Hellman R, Korytkowski MT, 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.
American Diabetes Association. Standards of medical care in diabetes—
2013. Diabetes Care. 2013;36(suppl 1):S11-S66.
Moghissi ES, Korytkowski MT, DiNardo M, et al. American Association of
Clinical Endocrinologists and American Diabetes Association consensus
statement on inpatient glycemic control. Endocr Pract. 2009;15:353-369.