GET TO GOAL: INPATIENT GLYCEMIC CONTROL Melanie E. Mabrey DNP, BC-ADM, FAANP Acute Care Nurse Practitioner
GET TO GOAL:
INPATIENT GLYCEMIC CONTROL
Melanie E. Mabrey
DNP, BC-ADM, FAANP
Acute Care Nurse Practitioner
Three Best Resources I Know…
Practical Management of DKA, HHS,
Hyperglycemia and Diabetes in the Hospital
Why? Key Points
◦ Epidemiologic studies show - glucose control
in hospitals is woefully inadequate
◦ As glucose levels rise, so does mortality risk, as
well as the risk of dehydration, hypotension,
eventual renal shutdown, poor healing, and
impaired immune system function.
◦ 6% to 7% of patients have experience
hypoglycemia.
Clinical Trials Summary
5
Hyperglycemia is associated with poor clinical outcomes across many disease states in the hospital setting
Despite the inconsistencies in clinical trial results, good glucose management remains important in hospitalized patients
More conservative glucose targets should result in lower rates of hypoglycemia while maintaining outcome benefits
Content from AACE
What Should We Take AwayFrom These
Trials?
Good glucose control, as opposed to near-normal control, is likely sufficient to improve clinical outcomes in the ICU setting
Hyperglycemia and hypoglycemia are markers of poor outcome in critically and noncritically ill patients
Importantly, the recent studies do not endorse a laissez-faire attitude toward inpatient hyperglycemia that was prevalent a decade ago
Content from AACE
Hyperglycemia in Patients
With Undiagnosed
Diabetes
• 26% had known history of diabetes• 12% had no history of diabetes
Hyperglycemia occurred in 38% of patients admitted
• Higher in-hospital mortality rate (16%) compared with patients with a history of diabetes (3%) and patients with normoglycemia (1.7%; both P<.01)
• Longer hospital stays; higher admission rates to intensive care units (ICUs)
• Less likely to be discharged to home (required more transitional or nursing home care)
Newly discovered hyperglycemia was associated with:
Umpierrez GE et al. J Clin Endocrinol Metab. 2002;87:978–982.
Glycemic Goals – ADA
“Insulin therapy should be initiated for treatment of persistent hyper-glycemia starting at a threshold 180 mg/dL. Once insulin therapy is started, a target glucose range of 140– 180 mg/dL is recommended for the majority of critically ill patients and non- critically ill patients.”
“More stringent goals, such as 110–140 mg/dL, may be appropriate for selected patients, if this can be achieved without significant hypoglycemia.”
POCT in the Hospital
◦ FDA - separate category for POC glucose
meters; guidance on in-hospital use with
stricter standards
◦ Significant discrepancies have been
observed with low or high hemoglobin
concentrations and with hypoperfusion
◦ Any POC glucose that does not correlate
with the patient’s clinical status should be confirmed by laboratory glucose test.
HOW???
In most instances in the hospital setting, insulin is the preferred treatment for hyperglycemia
Indications for IV insulin
DKA and HHS
Stroke
Cardiac Surgery
Critical Illness
Glucocorticoids
Organ transplantation
MI or Cardiogenic Shock
Labor and Delivery
Prompt glycemic control critical to
recovery
Transitioning from to Readiness
◦ Resolution of hyperglycemia1
◦ Low variability of insulin infusion rate2
◦ Glucose toxicity (evidenced by high insulin infusion rates) has resolved2
◦ Anion gap closed1
◦ No significant edema (may affect absorption of subcutaneous insulin)3
◦ Resolution of critical illness3
◦ Not requiring ventilator support4
◦ Vasopressors (inotropic support) d/c’d or weaned to physiologic doses3
1Kubacka, B. 2019. Acute hyperglycemic emergencies: Diabetic Ketoacidosis and Hyperosmolar Hyperglycemic State. Nursing2019 Critical Care, 14(2). 2Lien LL. et al. 2016. Transitioning from intravenous to subcutaneous insulin. In B. Draznin (Ed.), Managing diabetes and hyperglycemia in the hospital setting (pp. 115-28).3Jacobi J. et al. 2012. Guidelines for the use of an insulin infusion for the management of hyperglycemia in critically ill patients. Critical Care Medicine, 40(12):3251–76.4O’Malley CW. Et al. 2008. Bridge over troubled waters: Safe and effective transitions of the inpatient with hyperglycemia. Journal of Hospital Medicine, 3(5):S55-65.
Tips for Transitioning IV to Subq
Insulin
◦ IV insulin has a short half-life
◦ Do not stop until subcutaneous onboard
◦ Timing of administration of subcutaneous
insulin before discontinuation of IV insulin
◦ 1 to 2 hours in advance for short acting insulins
◦ 2 to 3 hours in advance for NPH or basal
insulins
◦ Consider continuing IV
◦ Consider starting basal insulin the night before
transitioning
◦ Patients on an insulin gtt may eat but will need
insulin for meal coverage
Current Recommendations
for Inpatient Diabetes Care
AACE/ADA recommendations
• “Outside of critical care units, subcutaneous administration of insulin is used much more frequently. Orally administered agents have a limited role in the inpatient setting.”
Endocrine Society Clinical Practice Guideline
• “We recommend insulin therapy as the preferred method for achieving glycemic control...
• We suggest the discontinuation of oral hypoglycemic agents and initiation of insulin therapy for the majority of patients…”
Endocrine Practice. May/June 2009
J Clin Endocrinol Metab. January 2012, 97(1):16 –38
Question◦ My patient takes oral agents at home to treat his
diabetes at home. He is now NPO, I’m just
going to put him on “sliding scale insulin”.◦ Diabetes exists even when patients are NPO
◦ In a pt with HTN, would you order medications
to be given only when BP > 180/90…..or◦ In a pt with infection, would you order Antibx
only if temp > 38.5….◦ Hmmm – why order insulin only when BG >
150.
Limitations Associated With Sliding Scale Insulin (SSI) Delivery◦ It is reactive rather than proactive 1
◦ Treats hyperglycemia after it happens 1-3
◦ Patients do not receive insulin if their glucose level is normal3
◦ If glucose increases, insulin is given—regardless of basal or prandial needs 1-3
1.Clement S et al. Diabetes Care. 2004;27:553-591.2.Queale WS et al. Arch Intern Med. 1997;157:545-552.3.Browning LA, Dumo P. Am J Health-Syst Pharm. 2004;61:1611-1614.
Theoretical glucose levels with SSI
Sliding Scale Insulin (SSI)
Insulin
Insulin Insulin
Insulin
BG
(m
g/d
L)
Target range
ASSESS THE EFFICACY
OF THE HOME
REGIMEN
A1c (%) Mean plasma glucose (mg/dL)
6 135
7 170
8 205
9 240
10 275
11 310
12 345
There is little point in sending
a patient home on a regimen
that has not been effective
Basal – Bolus Insulin Therapy
• Basal Insulin – Long acting; regulates BG overnight and between meals
• Bolus Insulin – Rapid acting; given with each meal to prevent glucose spike from carbohydrate consumption
• Correction Insulin – Rapid acting; given to bring an elevated BG back into target range
Basal Insulin Review
• Administered regardless of meal intake
• May be given once or twice daily
• Long-acting Insulin
• Glargine (Lantus)
• Detemir (Levemir)
• Intermediate-acting Insulin
• NPH
NEVER discontinue basal insulin in a
patient with Type 1 Diabetes unless on an IV
insulin infusion or an insulin pump. Holding
even a single dose can result in DKA.
• SCHEDULED insulin that accompanies each meal to prevent glucose
spikes with carbohydrate intake
• May be administered 15 minutes before the meal or up to 15 minutes
after completion of the meal for those with variable meal intake
• Rapid-acting Insulin
• Aspart (Novolog)
• Lispro (Humalog)
• Glulisine (Apidra)
Meal Bolus Insulin should be held for patients who are NPO or will not eat.
Bolus Insulin Review
Determining Initial Insulin Dosing
0.1 – 0.3 units/kg/day
divided into 4 shotsInsulin naïve
Low insulin resistance
(thin, frail elder, diet controlled)
0.5 – 1.0 units/kg/day
divided into 4 shotsHigher insulin resistance
(High stress, Obese)
Long-standing, or poorly controlled DM
Point system:
Add 0.1 unit/kg/day
Each 30 kg >100 kg
> 5 years of DM
multiple oral medications
steroids
Subtract 0.1 unit/kg/day
CKD, ARF, frail elder, hepatic failure, hypoglycemia unaware
Determine Insulin Administration Pattern
Basal insulin or a basal plus bolus correction insulin regimen with poor oral intake or NPO
Basal, prandial, and correction components is the preferred treatment for noncritically ill patients with good nutritional intake.
Rapid- or short- acting insulin to correct hyperglycemia (before meals or every 4-6 hours if NPO or continuous nutrition)
Obtain Blood Glucose
Insulin Administration
Meal Tray Delivery
Timing of Meal Bolus Insulin
30-45 MINUTES
Insulin Dosing
Basal Bolus insulin is usually 50/50 split of Total Daily Dose (TDD)
Regular and NPH is usually 25% of TDD
• Regular 30 minutes before each meal
• NPH at hs
Example: Pt wt = 120 kg, DM-2 on metformin only as outpatient
• Consider 0.5 units/kg for TDD
• TDD = 60 units
• 30 units basal and 30/3 = 10 units with each meal
• 15 units Regular before each meal and 15 units of NPH at hs
How do you adjust
insulin daily?
Breakfast Lunch Supper Bedtime
BG 198 213 243 222
Scheduled
Insulin
10 units RA 10 units RA 10 units RA 30 units
basal
Correction 3 units 6 units 6 units
BG 191
Scheduled
Insulin
10 units RA
Correction 3 units
Yesterday’s total insulin = 75 units 60 (scheduled) + 15 (correction)
= 75 X 20% = 15 units
= 75 + 15 = 90 units
Today’s regimen = 15 units bolus tidac and 45 units basal qhs
Adjusting SQ insulin
Assess the total amount of insulin the patient received on the previous day
Assess overall glucose control previous day
Did the patient require correction dose or have a low BG. ALWAYS look at fasting BG
If close to goal increase TDD by 10% over the previous days total
If BGs significantly elevated (>180) increase by 20%
Adjusting Insulin Example
Yesterday’s total insulin = 19 (scheduled) + 2 (correction) = 21 units
= 21 X 20% = 4 units
= 21 + 4 = 25 units
Today’s new regimen = 4 units bolus tidac and 12 units basal qhs
Breakfast Lunch Supper Bedtime
BG 198 253 264 222
Insulin 3 units RA 3 units RA 3 units RA 10 units basal
Correction 0 units 1 units 1 units
BG 191
Insulin 3 units RA
Correction 0 units
Correction
therapy
Day 1 Day 3
Scheduled Correction
Units
Correction insulin
signals the need to
change scheduled dose
of insulin in order to
prevent ongoing
hyperglycemia
Mel’s tips
◦ FOLLOW UP, be available and ready to adjust insulin frequently after
transitioning, initiating, or adjusting
◦ Talk with nursing staff, provide education and let them know you are
a resource
◦ Call orders if BG elevated (don’t wait until BG > 350 to be notified)Renal failure, elderly, Type 1,
and hypoglycemic unaware
Condition Blood Glucose Monitoring
IV insulin q1hour – may Δ to q2h when BG within 100-150 mg/dl for 4
consecutive hours. If BG < 100 mg/dl or >150 mg/dl monitoring
MUST return to q1h.
New TPN or tube feeding (when blood
glucose monitoring not already ordered)
q4-6 hours X 72hrs. If all glucoses <140 x72h, then d/c BG
monitoring; otherwise continue monitoring until TF d/c’d.
If glucose >180mg/dl, call provider for insulin orders. Consider
diabetes consult.
TPN or tube feeding receiving insulin q4-6 hours: if TF held, obtain BG q3hours X 2 (from last check),
then resume q6hour monitoring (provided BG ≥70); notify provider if BG <70 while TF held.
NPO or q6hour Regular insulin q4-6 hours
Regular, NPH, 70/30, 75/25 or any other
combination insulin
ac, hs, and 0300
Glargine (Lantus) insulin and/or rapid
acting insulins (aspart, glulisine, or lispro)
ac and hs
Safety with insulin
◦ Subcutaneous Insulin orders usually include:
◦ Decrease Regular insulin usually by ½ when NPO
◦ Give full dose of NPH at hs even if NPO
◦ Always give full dose Lantus or Levemir and hold rapid acting insulins (aspart, lispro, apidra) if NPO
◦ Give correction scale even when NPO
◦ Protocol for treating hypoglycemia:
◦ 15 g CHO (1 juice or ½ amp D50) recheck in 30 min.
◦ Rarely appropriate to hold insulin dose
◦ Rebound hyperglycemia
◦ When in doubt – monitor more frequently