住院患者的血糖控制

台大雲林分院 代謝內分泌科

賴瑩純醫師

Outline

1. Frequency of hyperglycemia in non-critical care setting

2. The association between hyperglycemia and outcome

3. Diagnosis and Recognition of Hyperglycemia and Diabetes

4. Glycemia Target

5. Management of Hyperglycemia

6. Hypoglycemia

Umpierrez et al. J Clin Endocrinol Metabol. 97(1): 16-38, 2012

Hyperglycemia is common in patients with and without diabetes

Kosiborod M et al. J Am Coll Cardiol 49(9): 1018-183, 2007: 283A-284A

Hyperglycemia: A common Comorbidity in Medical-

Surgical P’t

[百分

比]

[百分

比]

[百分

比]

2

Normoglycemia

Known Diabetes

New Hyperglycemia

Umpierrez G et al, J Clin Endocrinol Metabol 87:978, 2002

New hyperglycemia: FPG≥ 126 mg/dl random blood glucose level ≥ 200 mg/dl X2N=2,020

Hyperglycemia and Pneumonia Outcomes

McAllisteret al. Diabetes Care 28: 810-815, 2005

In-hospital mortality In-hospital complications

OR (95% CI) P value OR (95% CI) P value

6.11–11.0 compared with ≤6.1

1.20 (0.88–1.65) 0.25 1.10 (0.89–1.36) 0.37

11.01–13.99 compared with ≤6.1

1.79 (1.01–3.16) 0.05 1.53 (1.01–2.32) 0.04

≥14 compared with ≤6.1

1.69 (0.97–2.94) 0.07 1.52 (1.02–2.25) 0.04

Thirty-day mortality and in-hospital complication rates in patients with and without diabetes:

blood infection (combined bacteriemia and sepsis); urinary tract infection (UTI), acute

myocardial infarction (AMI), and ARF. *P < 0.001; †NS; ‡P < 0.017.

Frisch A et al. Dia Care 2010;33:1783-1788

Copyright © 2011 American Diabetes Association, Inc.

Hospital Mortality and Mean Glucose in Patient with AMI

Kosiborod M al. al CIrculation 117:1018, 2008

What diagnosis criteria should we used?

Umpierrez et al. J Clin Endocrinol Metabol. 97(1): 16-38, 2012

Factors influencing HbA1c

• Hemoglobinopathies

• High-dose salicylates

• Hemodialysis

• Blood transfusion

• Iron deficiency anemia

• Analysis : National GlycohemoglobinStandardization Program

J Clin Endocrinol Metabol. 97(7): 2447-2453, 2008

Glycemic Targets in Non-ICU P’t

AACE/ADA guideline• Premeal glucose < 140 mg/dL• Random blood glucose (BG) <180 mg/dL• To avoid of hypoglycemia, reassess insulin

regimen if BG levels fall below 100 mg/dL

Achieving Glycemic Goal in Non-ICU setting

Management of Hyperglycemia in Non-Critical setting

Insulin Therapy:•Sliding scale short-acting insulin•Basal/bolus therapy

•NPH and regular insulin•Long-acting and rapid acting insulin analogs

Randomized study of basal-bolus insulin therapy in the inpatient management of patients with type 2

diabetes (RABBIT 2 trial).• DC oral antidiabetic drugs on admission

• Starting total daily dose (TDD):

0.4 U/kg/d x BG between 140-200 mg/dL

0.5 U/kg/d X BG between 201-400 mg/dL

• Half of TDD as insulin glargine and half as rapid-acting insulin (glulisine)

Insulin glargine- once daily, at the same timeday

Glulisine- three equally divided dose (AC)

Umpierrez G E et al. Dia Care 2007;30:2181-2186

Clinical Diabetes Volume 29, Number1, 2011

Sliding Scale Insulin Regimen

BG (mg/dl) Insulin-sensitive

Usual Insulin resistance

>141-180 2 4 6

181-220 4 6 8

221-261 6 8 10

261-300 8 10 12

301-350 10 12 14

351-400 12 14 16

>400 14 16 18

Premeal: add to scheduled insulin doseBedtime: give half of SSI

glargine plus glulisine (•)

SSI (○). *P < 0.01; ¶P < 0.05.

Umpierrez G E et al. Dia Care 2007;30:2181-2186

Copyright © 2011 American Diabetes Association, Inc.

Umpierrez G E et al. Dia Care 2007;30:2181-2186

Copyright © 2011 American Diabetes Association, Inc.

Insulin Dose and Hypoglycemia

Basal bolus Group

SSI group

Glargine 22 ± 2 units/d -

Glulisine/RI 20 ± 1 units/d 12.5 ± 2 units/d

BG< 60 0.4 % 0.2%

BG<40 0 0

RABBIT Surgery

Umpierrez G E et al. Dia Care 2011, 34(2):1-6

Medical Nutrition Therapy (MNT)

Most patients receive 1500-2000 calories/day, with range of 12-15 carbohydrate servings

Special Situations

1. Transition from Intravenous Continuous Insulin Infusion (CII) to Subcutaneous Insulin Therapy

2. Patients Receiving Enteral or Parenteral Nutrition

3. Perioperative Blood Glucose Control4. Glucocorticoid-induced Diabetes

Hypoglycemia

• Definition: BG< 70 mg/dL

• Frequency: 3-30 % (serious events: 4%)

• Risk factors: older age, illness, BW loss, renal failure, Insulin or OAD treatment, missed meal, failure to adjust therapy..

Suggested Nurse-Initiated Strategies for Treating

Hypoglycemi• BG<70 mg/dL, P’t alert and able to eat

15-20 g rapid acting carbohydrate

• BG<70 mg/dL, P’t alsert but NPO

20ml 50% dextrose iv , then 5% dextrose 100ml/h

• BG<70 mg/dL, conscious change

25ml 50% dextrose iv , then 5% dextrose 100ml/h

• BG<70 mg/dL, conscious change, no IV cath

IM 1mg glucagon, two times

Repeat treat every 15 min until BG> 80 mg/dL

Discharge Insulin Algorithm

Discharge Treatment

A1C <7 % A1C 7-9 % A1C >9 %

Re-Start outpatient

treatment (OAD and/or insulin

Re-Start outpatient oral agent and on

glaargine once daily 50-80 % of

hospital dose

Basal bolus at same hospital dose

Alternative: Re-Start outpatient oral agent and on

glaargine once daily 50-80 % of

hospital dose

Patient Education

• Survival skills:

1. Basic meal planning

2. Medication administration

3. BG monitor

4. Hypoglycemia and hyperglycemia detection, treatment and prevention

Thank you for your attention