CGM in the Hospital

Dee Sawyer, MS, APRN, MLDE, AGCNS-BC, BC-ADM, CDE

Diabetes Clinical Nurse Specialist

Objective

• Upon completion of this activity, participants will be able identify the emerging roles of continuous glucose monitoring in hospitalized diabetes patients.

• Conflict of interest: Stock shareholder - Dexcom

Diabetes and Hospitalizations

• Threefold greater chance for hospitalization• 40.3 million hospital inpatient days• $237 billion direct medical care cost• $4966 annual per capita health care

expenditure for inpatient

1. CDC, National Diabetes Statistics Report, 2017 2. ADA, Economic Costs of Diabetes in the US in 2017. Diab Care. 2018 Mar: 14: 917- 928.

Hospital Glycemic Control

Control Hyperglycemia

Minimize hypoglycemia

Both independent risks factors for poor clinical outcome and increased mortality.

Hospital Goals for Glycemic Control

Target BG 140-180 mg/dL

ICU

IV Insulin

Non ICU

Sub Q Basal, bolus,

correction

Glycemic Challenges During Hospitalization

• Patients with pre-existing diabetes

• Patients without diabetes

• Stress hyperglycemia• Systemic

glucocorticoids• Infections• Poor PO nutrition intake• PN and EN nutrition• Acute/chronic kidney

injury

Monitoring BG in the Hospital• Point of Care glucose testing

– Measure blood glucose one point in time– Accuracy FDA standards: +/- 15% Bg < 75 mg/dL; +/- 20% > 75

mg/dL

• Nova StatStrip hospital meter- approved for arterial, venous, capillary, neonatal blood glucose testing– Only system approved for use in critically ill patients– Corrects for interferences- Hematocrit, Ascorbic Acid, Uric Acid,

Acetaminophen (Paracetamol), Bilirubin, Maltose, Galactose, Oxygen

Early Model

• Used for research and glucose clamp studies

• Came on market 1984• Early continuous

glucose monitoring + insulin/dextrose to regulate blood glucose

CGM in the Hospital

• NOT approved for hospital use by FDA• Must use continue to use glucose monitoring • Policy to address use and limits in hospital

setting.

1 Gomez and Umpierrez, Continuous Glucose

CGM Use in Hospitalized PatientsBenefits• Allows for frequent measurement of interstitial

glucose every 5-15 minutes • Trends glucose direction and magnitude Limitations• Warm up period• Interference from diagnostic testing• Patient’s alertness to self manage• Maintaining staff competency

Personal CGM Devices

• Dexcom® G6• Medtronic™ Guardian• Abbott FreeStyle Libre• Senseonics Eversense CGM system

Dexcom G6

From User GuideAcetaminophen > 1g every 6 hrs may affect sensor

readings“Because we haven’t tested every x-ray and scanner, we don’t know if they damage the G6.”

Medtronic GUARDIAN™ CONNECT SMART CGM

Do not expose your sensor or transmitter to MRIequipment, diathermy devices, or other devices (for example, x-ray, CT scan, or other types of radiation) that generate strong magnetic fields

Always remove your sensor and transmitter before entering a room that has x-ray, MRI, diathermy, or CT scan equipment.

FreeStyle Libre Flash Glucose Monitoring System

Warning: Remove the sensor before MRI, CT scan, X-ray, or diathermy treatment

Limitation: The built-in blood glucose meter is not for use on dehydrated, hypotensive, in shock, hyperglycemic-hyperosmolar state, with or without ketosis, neonates, critically-ill patients, pregnant women, persons on dialysis or for diagnosis or screening of diabetes.

Eversense CGM SystemImplanted Sensor

Warning:MRI: The Smart Transmitter MUST BE REMOVED before

undergoing an MRI procedure.Lithotripsy: Lithotripsy to break up masses like kidney

stones or gallstones is not recommended. Diathermy: Energy from diathermy therapy can transfer

through the sensor and cause tissue damage in the insertion area.

Electrocautery: Electrocautery near an inserted sensor may damage the device.

Research Findings forInpatient CGM Use

• General wards– Comparison of CGM vs POC testing – Results found CGM detected more hypoglycemia and hyperglycemia

events.

• ICU– 88 critically ill patients, 929 paired sample OptiScanner® central

venous catheter was adequate for ICU patients but still recommended another method of glucose monitoring be used.

– Computerized simulation demonstrated increased frequency of BG monitoring reduced occurrence of hypo-, hyper-glycemia and glucose variability.

1. Gomez and Umpierrez, Continuous Glucose Monitoring in Insulin Treated Patients in Non-ICU Settings, J Diab Sci n Technol, 2014, vol 8, pp 930-036. 2. Shinotsuka et al., Manual vs Automated monitoring Accuracy of GlucosE II (MANAGE II), Critical Care . 2016. 20:380. 3. Krinsley et al., The impact of measurement frequency on the domains of glycemic control in critically ill- a Monte Carlo simulation. J Diab Sci Technol. 2915L 9: 237-45. 4. Umpierrez & Klonoff, Diab TechologyUpdate: Use of Insulin Pumps and Continuous Glucose Monitoring in Hospital. Diab Care 2018. 41:1579-1589.

Beside Continuous Monitoring for Critical Care

• OptiScanner® 5000– Approved by FDA– Trends plasma glucose every

15 minutes– No calibration– 0.15 mL per draw

• In Europe, approved for IV monitoring– GlucoClear – Edwards Life

Science– Glysure System – Glysure– Eirus by Maquet Getinge

Group

Bedside Monitoring for Critical CareMicroEye®/ContinuMon®• Available in Europe only• Easy-to-use device inserted using

common peripheral venous catheters.

• Delivers dialysate to an external sensor system.

• Provides real-time data to standalone monitors or hospital information systems.

• Use with ContinuMon® for accurate monitoring of glucose.

• Concurrent collection of samples for offline analysis.

CGM Inpatient Studies Needed

Wallia et al. Consensus Statement on Inpatient Use of Continuous Glucose Monitoring. J of Diab Sci Technol. 2017, Vol 1: 1036-1044.