final_ipd dm version 2012

0

Clinical Practice Guidelines for In-patients with Diabetes Mellitus,

Department of Medicine Maharat Nakhon Ratchasima Hospital

.. 2555

1

(DIABETES MELLITUS)

(Diabetes mellitus, DM) 4 1 2 2 1 (diabetic ketoacidosis, DKA) (hypoglycemia) (hyperosmolar hyperglycemic syndrome, HHS) (diabetic ketoacidosis, DKA)

2

2553 1,880 re-admit 28 604 16.8 612 2.3 sepsis myocardial infarction

2553 (hypoglycemia at admission) 77 (in-hospital hypoglycemia) 989 DM type 1 with DKA 15 DM type 2 with DKA 36 DM type 2 with coma (HHS) 134

2554 3,588 764 21.3 re-admit 28 604 16.8

2554 (hypoglycemia at admission) 77 (in-hospital hypoglycemia) 1,083 DM type 1 with DKA 22 DM type 2 with DKA 86 DM type 2 with coma (HHS) 143

3

1. (mortality rate) 2. (morbidity rate) 3. 4. (re-admission) 1. (capillary blood sugar) (non-critical care setting) 2. (Hypoglycemia)

3. 4. (Hyperosmolar hyperglycemic syndrome, HHS) (Diabetic ketoacidosis, DKA) 5. 6.

4

( 26 .. 2555)

CPG for In-patients with Diabetes Mellitus ( 1)

DKA = Diabetic Ketoacidosis HHS = Hyperosmolar Hyperglycemic Syndrome

.. ..

Hypoglycemia (3, 4)

DKA (5)

HHS (5)

(6, 7)

Yes

Yes

Yes

(2) BS non-critical care

5

CPG for Blood Sugar Assessment and Monitoring in In-patients with Non-critical Care Setting ( 2)

Hyperglycemia 1. Plasma Glucose at Admission

1 in-hospital hyperglycemia 140 mg/dl

2. capillary blood sugar (CBS) ( 3 - 7)

3. CBS corticosteroids, enteral nutrition parenteral nutrition CBS 24-48

4. CBS > 140 mg/dl CBS 24-48

5. CBS >140 mg/dl HbA1c 3

Capillary Blood Sugar (CBS) 1. CBS (accuracy)

plasma glucose 2. CBS

3. (NPO) continuous enteral feeding

CBS 6 4.

- 140 mg/dl - 180 mg/dl

Adapted from J Clin Endocrinol Metab. 2012; 97:1638.

6

(Hypoglycemia)

Treatment of In-patients with Hypoglycemia ( 3)

Hospitalized patient PAPPAPpatient

PG < 70 mg/dl with Symptoms sweating, palpitation, blurred vision, confusion, slurred speech, tired weakness, drowsiness, headache, hunger, irritability or coma

Start Treatment CBS < 70 - + 1 15-30 g

CHO - + 50% glucose 20 . IV

5-10% Dextrose 100 ml/hr - 50% glucose 25 . IV

5-10% dextrose 100 ml/hr Monitor CBS 1/2 - 1 . CBS > 100 mg/dl 2

DM hypoglycemia plasma glucose < 50 mg/dl

Clot blood 5 . insulin,

cortisol, GH hypoglycemia

Monitor CBS 2 6 keep CBS 100 180 mg/dl Hypoglycemia

- hypoglycemia - * - ** -

Follow up Education 1

* ** hypoglycemia

hypoglycemia plasma glucose

PG = Plasma Glucose CBS = Capillary blood sugar


8

- o o ward

- / o (repeated hypoglycemia)

o 5

- o

(hypoglycemia at admission)

- o

(drug induced hypoglycemia)

9

Nutritional Assessment for In-patients ( 4)

4

1. Body Mass Index (BMI) * - BMI 18.5 22.5 Normal = 0

- BMI 17.5 18.4 Thin = 1 - BMI < 17.4 = 2

2. Weight loss - < 5 % = 0 - 5-10 % = 1 - > 10% = 2

3. Apetite - < 50% = 1 - NPO > 5 = 2

4. Serum albumin - serum albumin 2.6 3.0 g/dL = 1 - serum albumin < 2.5 g/dL = 2

*BMI = body weight (kg)/ height 2 (m2)

- 2

- < 2 1

10

2

* ** drip < 50% TPN

- > 65 , BMI < 17.5 kg/m2, alcoholism Serum electrolyte, BUN, Magnesium phosphate 24-48

11

Hyperosmolar Hyperglycemic Syndrome (HHS) Diabetic Ketoacidosis (DKA)

Treatment of In-patients with DKA and HHS ( 5)

DKA HHS

Start IV Fluid - NSS 1000 cc/hr 1 - NSS NSS/2 250- 500 cc/hr

IV fluid degree of dehydration serum Na

Start IV Insulin therapy - RI 0.1 U/kg IV bolus RI 0.1 U/kg/hr

rate RI IV fluid PG 50-75 mg/dl/hr

- Add 5-10% Dextrose PG level 200-300 mg/dl rate RI IV fluid maintain PG 150-200 mg/dl

Initiate Potassium Replacement - Normokalemia (3.3-5.2) : Add KCl 20-30

mEq in IV 1000 cc. - Hypokalemia ( 3.3

- K > 5.0 mEq/L or no urine output : Not need K replacement

- DKA / HHS

- consult Endocrine consult

DKA : most common in DM type 1 - Serum glucose > 250 mg/dl - Positive serum ketone* - Wide gap metabolic acidosis

( arterial pH < 7.3, serum HCO3 < 15 meq/L and anion gap** > 12 )

HHS : most common in DM type 2 - Serum glucose > 600 mg/dl - Effective serum osmolarity #>320

mOsm/L

Monitoring : Check PG CBS 1 . PG CBS ~ 200-300 mg/dl then check CBS 2-4 .

: Check Electrolyte 2-4 . hypokalemia

Additional Electrolyte Replacement - Bicarbonate : in severe acidosis

pH < 6.9 : NaHCO3 100 cc IV in 2 hr

- not need NaHCO3 if pH 6.9

* Positive serum ketone = Serum beta hydroxybutyrate > 3 mg/dL, Moderate positive the nitroprusside test (dilute sample 1:1) ** Anion gap = serum Na (Cl + HCO3) # Effective serum osmolarity = 2 [serum Na] + glucose/18 PG = Plasma Glucose CBS = Capillary blood sugar

Adapted from ADA 2009

12

Treatment of DM In-patients with Illness ( 6) (Not Diabetic Emergency)

PG = Plasma Glucose CBS = Capillary blood sugar

..

NPO ?

5% D/N/2 RI ( 7) Add RI IV fluid RI IV drip RI SC q 6 h Supplemental insulin scale

- CBS - FPG 80-180

mg/dl

- insulin

CBS q 1 hr until stable (keep PG 80-180 mg/dl)

BS < 100 mg/dl BS 100-180(200) mg/dl BS > 180(200) mg/dl

- Insulin - BS < 70 mg/dl insulin

+ 50% glucose IV - CBS q -1 hr until CBS > 100

CBS q 6 hr

1. RI IV fluid drip

2. RI intravenous drip 3. Supplemental

insulin scale

CBS q 2-6 hr

No

Yes


13

Insulin ( 7)

A. (NPO) insulin

1. RI IV fluid with Dextrose

- CBS 200 mg/dl add RI 5% D/N/2 1,000 cc 201 250 mg/dl add RI 5 unit 5% D/N/2 1,000 cc 251 300 mg/dl add RI 10 unit 5% D/N/2 1,000 cc > 300 mg/dl RI 5 unit intravenous

- CBS IV fluid 1 . CBS 201 250 mg/dl add RI 2 unit 5% D/N/2 1,000 cc 251 300 mg/dl add RI 4 unit 5% D/N/2 1,000 cc > 300 mg/dl RI intravenous

- CBS 100 180(200) mg/dl CBS q 6 hr

2. RI intravenous drip IV fluid with Dextrose

- RI intravenous drip 0.5 1 unit/hr RI : NSS 1:1 1: 25 RI 20 unit NSS/2 500 cc (25 cc = RI 1 unit 1 cc = RI 0.04 unit)

- drip RI intravenously infusion pump

- CBS RI intravenous drip rate insulin CBS 120-200 mg/dl

3. RI subcutaneuos injection Supplemental insulin scale CBS


14

1 Supplemental insulin scale (RI rapid acting insulin)

Blood Glucose (mg/dl) Insulin-sensitive Usual Insulin-resistant

>141- 180 2 4 6

181- 220 4 6 8

221- 260 6 8 10

261- 300 8 10 12

301 350 10 12 14

351 400 12 14 16

>400 14 16 18

- sliding scale Schedule insulin regimens (Basal Bolus Insulin Injection)

- RI (2-4 unit 10-20 % ) ,

- RI 2-4 unit 80 unit .

- Schedule insulin regimens (Basal Bolus subcutaneous insulin injection) overlapping period 2 Subcutaneuos insulin injection RI intravenous drip 1-2


15

B. insulin

1. Scheduled insulin regimen (Basal Bolus subcutaneous insulin injection) - Total insulin dosage

- RI 1 ( intravenous insulin drip rate ) - 0.2-0.3 U/kg/day 70 / GFR < 60 ml/min - 0.4 U/kg/day

140-200 mg/dl - 0.5 U/kg/day 201-400 mg/dl

- 1/2 total insulin Basal insulin NPH () glargine/determir insulin 1

- 1/2 total insulin Prandial insulin RI ( rapid acting insulin)

- insulin CBS 80-180 (200) mg/dl CBS - renal/liver insufficiency Basal insulin NPH ac prandial insulin

2. Supplemental subcutaneous insulin injection - supplemental insulin injection scheduled insulin regimen supplemental insulin scale ** > 300 mg/dl ()


16

Care Map

CARE MAP OF HYPOGLYCEMIA

Day Assessment Specimen/test Medication Activity / diet Planning discharge

1. /

Hemodynamic assessment

VS. q 1-2 hrs / 4-6 hrs

**

CBS q - 1 hr stable

hypoglycemia CBC, UA, Urine C/S Hemoculture, BUN, Cr. Electrolyte etc.

50% glucose IV*

IV fluid*

precipitating causes

NPO/soft diet hypoglycemia

Education ../ hypoglycemia

2.

VS. q 4-6 hrs

CBS q 4-6 hr Follow up Labs

IV fluid* NPO/soft diet ***

Education .. / hypoglycemia

follow up 3.

VS. q 4-6 hrs

CBS tid ac & hs Antidiabetic drugs

Soft / regular diabetic diet

Education .. / hypoglycemia

follow up

* glucose IV fluid 3 ** 4 *** 1

17

CARE MAP FOR DKA / HHS

Day Assessment Specimen/test Medication Activity / diet

Planning discharge

1. /


VS. q 1-2 hrs / 4-6 hrs

CBS q 1 hr BUN, Cr Electrolyte q 2-4 hr Serum ketone ABG EKG, CXR

CBC, UA, Urine C/S Hemoculture, etc.

RI* IV fluid* K, HCO3

* RX precipitating

causes

NPO Consult Endocrine

Education

2.

VS. q 4-6 hrs

CBS q 4-6 hr BUN, Cr, electrolyte Follow up Labs

RI* IV fluid* RX precipitating

causes

NPO/soft diet

Education .. /

follow up 3.

VS. q 4-6 hrs

CBS tid ac & hs NPH/RI Pre-mixed insulin

RX precipitating causes

Soft / regular diabetic diet

Education .. /

follow up

* RI & IV fluid 5

18

CARE MAP FOR DM IN-PATIENTS WITH ILLNESS

Day Assessment Specimen/test Medication Activity / diet

Planning discharge

1. /


VS. q 1-2 hrs / 4-6 hrs

CBS q 1 hr BUN, Cr Electrolyte Investigate cause of

illness CBC, UA, Urine C/S Hemoculture, etc.

Insulin (NPH/RI)*

IV fluid* RX / support Rx

of causes of illness

NPO/diabetic diet

Education

2.

VS. q 4-6 hrs

CBS q 4-6 hr Follow up Labs

Insulin (NPH/RI)*

IV fluid* RX / support Rx


NPO/diabetic diet

Education .. / ..

follow up

3.

VS. q 4-6 hrs

CBS tid ac & hs Antidiabetic drugs*

NPH/RI* IV fluid* Rx / support Rx


diabetic diet

Education .. / ..

follow up

* Insulin & IV fluid 6 7

19

1. . 2. . 3. . 4. . 5. . 6. .. 7. .. 8. 8 9.

10. 11. 12. 13. 14. 15. 16.

20

1. American Diabetes Association. Diagnosis and Classification of Diabetes Mellitus. Diabetes Care 2012; 35 supp 1: s64-71.

2. . . 2546 15 28.

3. 2553-2554.

4. . . 2546 359 385.

5. Umpierrez GE, Hellman R, Korytkowski MT, Kosiborod M, Maynard GA, Montori VM, 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.

6. Kitabchi AE, Umpierrez GE, Miles JM, Fisher JN. Hyperglycemic crises in adult patients with diabetes. Diabetes Care. 2009; 32: 1335-43.

7. Gordon C. Weir. Insulin Therapy and Its Complications. In : Kenneth L. Becker. Principles and Practice of Endocrinology and Metabolism 3rd Edition. LWW. Philadelphia 2001: p 1348-59.

8. . . 2546 133 152.

21

- insulin

- hypoglycemia

- DKA chart

- Diabetic chart

-

22

Insulin

23

HYPOGLYCEMIA

- ..................................................................................HN......................... hypoglycemia .................................................................................... Diagnosis..

1) Capillary blood sugarmg/dl and/or Plasma glucose..mg/dl ()

2) [ ] Hypoglycemia at Admission [ ] In-hospital Hypoglycemia, one episode [ ] In-hospital Hypoglycemia, recurrent (> 2 episodes)

3) Cause of hypoglycemia [ ] Oral hypoglycemic drug induced hypoglycemia [ ] Insulin induced hypoglycemia [ ] Poor intake (< 50%) or NPO [ ] Sepsis [ ] Others (specify)....

4) [ ] Consult Endocrine [ ] Consult Nutrition [ ] Consult ( Doctor Order) [ ] Consult ( Doctor Order)

[ ] [ ] ...................................................................................................................................

27

Nutrition Alert Form:

1. // 2 (Arm span) : :

( )

2. [ (BMI) = (.) ( (.) (.))] : 3 : Albumin Albumin Total Lymphocyte Count (TLC) [TLC = (Total WBC Lymphocyte) 100]

3. :

4. 4 :

5. 2 : (Clear liquid diet: ) (Full liquid diet: )

(Soft diet: )

(Regular diet: ) - :

6. > 2 ( 1 ):

7. :

8. / ( 1 ) CKD-ESRD :

rejection Solid cancer : Lymphoma (Leukemia)

(Tumor)

final_ipd dm version 2012

Documents