insulin therapy and nutritional management in patients with diabetes mellitus in the perioperative...

INSULIN THERAPY AND INSULIN THERAPY AND NUTRITIONAL MANAGEMENT NUTRITIONAL MANAGEMENT IN PATIENTS WITH DIABETES IN PATIENTS WITH DIABETES

MELLITUS IN THE MELLITUS IN THE PERIOPERATIVE PERIODPERIOPERATIVE PERIOD

Josephine Carlos-Raboca MD FPCP Josephine Carlos-Raboca MD FPCP Gabriel V. Jasul MD FPCP FPSEMGabriel V. Jasul MD FPCP FPSEMRosa Allyn G. Sy MD FPCP FPSEMRosa Allyn G. Sy MD FPCP FPSEM

Leilani B. Mercado-Asis, M.D., Ph.D.FPCP Leilani B. Mercado-Asis, M.D., Ph.D.FPCP FPSEMFPSEM FPSEMFPSEM

Insulin Therapy Insulin Therapy and and

Hyperglycemia in Hyperglycemia in Hospitalized Hospitalized

PatientsPatients

Dr. Josephine Carlos-Dr. Josephine Carlos-RabocaRaboca

Dr. Leilani B. Mercado-AsisDr. Leilani B. Mercado-Asis

GENERAL OBJECTIVES:GENERAL OBJECTIVES: To review general guidelines and treatment To review general guidelines and treatment

approaches in diabetes management in approaches in diabetes management in surgical patients, including in-hospital surgical patients, including in-hospital glycemic targets and intravenous and glycemic targets and intravenous and subcutaneous insulin regimens.subcutaneous insulin regimens.

To review treatment guidelines on To review treatment guidelines on nutritional management of diabetic nutritional management of diabetic patients in the perioperative period, in patients in the perioperative period, in particular, routes of feeding and insulin particular, routes of feeding and insulin therapy adjustments in relation to therapy adjustments in relation to nutritional provision.nutritional provision.

To apply these guidelines through case-To apply these guidelines through case-based discussion and to formulate practical based discussion and to formulate practical treatment plans in the management of treatment plans in the management of diabetic patients undergoing surgery.diabetic patients undergoing surgery.

CaseCase

VS, 62M VS, 62M Type 2 DM X3 yrsType 2 DM X3 yrs

– Rx: Glibenclamide 5 mg OD Rx: Glibenclamide 5 mg OD

Metformin 500 mg BID Metformin 500 mg BID

admitted due to abdominal admitted due to abdominal painpain

HistoryHistory

2 days PTA 2 days PTA crampy LLQ paincrampy LLQ pain

increasing in severity increasing in severity

anorexia and vomitinganorexia and vomiting

(-)fever(-)fever

(-)diarrhea,constipation (-)diarrhea,constipation ADMISSION

CASE

Physical ExaminationPhysical Examination

Conscious, coherentConscious, coherent BP: 130/70; CR: 89: RR: 23/min; T: 36.8CBP: 130/70; CR: 89: RR: 23/min; T: 36.8C Wt: 80kg, Ht: 178cm BMI: 25Wt: 80kg, Ht: 178cm BMI: 25 Neck: (+)curvilinear scar, no palpable Neck: (+)curvilinear scar, no palpable

thyroidthyroid Heart and lungs were unremarkableHeart and lungs were unremarkable Abdomen: flabby, normoactive bowel Abdomen: flabby, normoactive bowel

sounds, no organomegaly, (+) direct sounds, no organomegaly, (+) direct tenderness on the left lower quadrant tenderness on the left lower quadrant area.area.

Extremities: (-)edema nor cyanosisExtremities: (-)edema nor cyanosis

CASE

Course at the ERCourse at the ER

Stat CBGStat CBG 357mg/dl357mg/dl Serum ketonesSerum ketones NegativeNegative ABGABG Compensated Compensated

metabolic acidosismetabolic acidosis

Repeat CBGRepeat CBG 260mg/dl260mg/dl

IVF: Plain NSS at 30gtts/min

Regular Insulin 10u/SC

CASE

11stst Hospital Day Hospital Day

Scout film of the abdomenScout film of the abdomen– localized ileuslocalized ileus– rule out a localized fluid collection or an rule out a localized fluid collection or an

inflammatory process. inflammatory process. CBC CBC

– leukocytosis with predominance of segmenters leukocytosis with predominance of segmenters (WBC: 20.90, seg: 0.96). (WBC: 20.90, seg: 0.96).

Urinalysis Urinalysis – (+1) albumin.(+1) albumin.

Ultrasound of the abdomen Ultrasound of the abdomen – hyperechoic lesion (2.0X1.8X2.2cm) right lobe of hyperechoic lesion (2.0X1.8X2.2cm) right lobe of

the liverthe liver HbA1c: 7%; FBS: 345 mg/dlHbA1c: 7%; FBS: 345 mg/dl Creatinine: 0.98; Na:131mg/dl; K:3.2; SGPT: Creatinine: 0.98; Na:131mg/dl; K:3.2; SGPT:

28.1.28.1.

CASE

Initial OrdersInitial Orders

Keep on NPOKeep on NPO Serial abdomen exam Serial abdomen exam IVF: D5 NM1L + 20meqs KCl X IVF: D5 NM1L + 20meqs KCl X

30gtts/min30gtts/min Refer to Endocrine serviceRefer to Endocrine service

CASE

11stst Hospital Day Hospital Day

Persistent abdominal painPersistent abdominal pain (+) Rebound tenderness, LLQ (+) Rebound tenderness, LLQ

areaarea Surgery consult: Surgery consult:

– For exploratory LaparotomyFor exploratory Laparotomy– Endocrine clearanceEndocrine clearance

CASE

Endocrine ConsultEndocrine Consult D5NSS X 100cc/hrD5NSS X 100cc/hr Stat CBG: 245mg/dlStat CBG: 245mg/dl 6units Regular Insulin/SC stat6units Regular Insulin/SC stat CBG monitoring q4hCBG monitoring q4h Standing insulin: Glargine Insulin10u SC Standing insulin: Glargine Insulin10u SC

ODOD Supplemental scale: Supplemental scale:

CBGCBG Regular Insulin/SCRegular Insulin/SC

180 – 250180 – 250 4u4u

251 – 350251 – 350 6u6u

>350>350 8u 8u

CASE

CBG MONITORING CBG MONITORING SHEETSHEET

2AM (ER)2AM (ER) 3am (ER)3am (ER) 8am (Ward)8am (Ward) 12nn 12nn

(Ward)(Ward)

BGBG Insulin/Insulin/

routerouteBGBG Insulin/Insulin/



routeroute

357357 10u/10u/

SCSC260260 ---- 245245

GlarginGlargine 10 u e 10 u SC +SC +

4u HR/4u HR/

SCSC

301301 ??

CASE

Admission To OR

REVIEW GENERAL PRINCIPLES OF REVIEW GENERAL PRINCIPLES OF PERIOPERATIVE MANAGEMENT OF DIABETES PERIOPERATIVE MANAGEMENT OF DIABETES MELLITUS, INCLUDING NUTRITION SUPPORT, MELLITUS, INCLUDING NUTRITION SUPPORT, CHOICE OF TYPE AND ROUTE OF INSULIN CHOICE OF TYPE AND ROUTE OF INSULIN ADMINISTRATION, FREQUENCY OF ADMINISTRATION, FREQUENCY OF MONITORING AND FLUID MANAGEMENTMONITORING AND FLUID MANAGEMENT

REVIEW GENERAL PRINCIPLES OF PERIOPERATIVE REVIEW GENERAL PRINCIPLES OF PERIOPERATIVE MANAGEMENT OF DIABETES MELLITUS, INCLUDING MANAGEMENT OF DIABETES MELLITUS, INCLUDING CHOICE OF, TYPE AND ROUTE OF INSULIN CHOICE OF, TYPE AND ROUTE OF INSULIN ADMINISTRATION, FREQUENCY OF MONITORING ADMINISTRATION, FREQUENCY OF MONITORING AND FLUID MANAGEMENTAND FLUID MANAGEMENT

Objective # 3

GENERAL PRINCIPLES OF GENERAL PRINCIPLES OF PERIOPERATIVE MANAGEMENT OF PERIOPERATIVE MANAGEMENT OF DIABETES MELLITUSDIABETES MELLITUS Oral agents may be contraindicatedOral agents may be contraindicated Dose adjustment of oral agents may Dose adjustment of oral agents may

require time and may be ineffectiverequire time and may be ineffective Stress, intravenous dextrose, and Stress, intravenous dextrose, and

enteral feedings, may increase dose enteral feedings, may increase dose requirements for exogenous insulinrequirements for exogenous insulin

Pattern of carbohydrate exposure may Pattern of carbohydrate exposure may change, necessitating pattern change, necessitating pattern adjustment of insulin therapyadjustment of insulin therapy

Nutritional assessment is importantNutritional assessment is important

SLIDING SCALE IS NOT SLIDING SCALE IS NOT RECOMMENDEDRECOMMENDED

..

6 12 6 12

NPH

6 12 6 12

Regular at least 50 % - - - -

Glargine not more than 50 %

Regular ~ 33 % (hold if low) - - -

NPH ~ 67 % —

q 6 – 8 h

Prolonged NPO Status

CHOICE OF TYPE AND ROUTE OF CHOICE OF TYPE AND ROUTE OF INSULIN ADMINISTRATIONINSULIN ADMINISTRATION

Established basal therapy with peakless long-acting insulin analog

6 am 12 pm 6 pm 12 am

Glargine Doses

yesterday’s today’s

Procedures, brief NPO status, or anesthesia < 1hr

8 12 6 10

Lispro or Aspart

Glargine

Endocrine Follow upEndocrine Follow up

Patient cleared for surgeryPatient cleared for surgery Perioperative orders:Perioperative orders:

– Hold standing and supplemental insulinHold standing and supplemental insulin– Give 10u Regular insulin/IV now thenGive 10u Regular insulin/IV now then– Insulin drip: Plain NSS 100cc + 50 units Insulin drip: Plain NSS 100cc + 50 units

Regular Insulin – flush 20cc thru the Regular Insulin – flush 20cc thru the tubings before hooking to patient. Start tubings before hooking to patient. Start at 10cc/hr via infusion pump (5u/hr)at 10cc/hr via infusion pump (5u/hr)

– CBG monitoring q1hCBG monitoring q1h

CASE

Review rationale for intensive Review rationale for intensive glucose control in hospitalized glucose control in hospitalized patients and in particular, in patients and in particular, in surgical patientssurgical patients

Objective # 1

1.What is the rationale for 1.What is the rationale for intensive glucose control in intensive glucose control in hospitalized patients?hospitalized patients?

Insulin is anti-inflammatory, anti-Insulin is anti-inflammatory, anti-oxidant, profibrinolytic, anti-platelet, oxidant, profibrinolytic, anti-platelet, vasodilatory, anti-apoptotic and vasodilatory, anti-apoptotic and cardioprotective.cardioprotective.

Glucose is pro-inflammatory, pro-Glucose is pro-inflammatory, pro-oxidant, prothrombotic, platelet pro-oxidant, prothrombotic, platelet pro-aggregatory, worsens prognosis in aggregatory, worsens prognosis in AMIAMI

Proposed Mechanisms of Poor Proposed Mechanisms of Poor Outcomes in Patients with Outcomes in Patients with Uncontrolled HyperglycemiaUncontrolled Hyperglycemia

Immune systemImmune system– Glucose >200mg/dl impairs leukocyte functionGlucose >200mg/dl impairs leukocyte function

ThrombosisThrombosis– Reduced fibrinolytic activity, increased platelet Reduced fibrinolytic activity, increased platelet

reactivityreactivity Vascular endothelial dysfunctionVascular endothelial dysfunction

– Increased permeability, inflammation and Increased permeability, inflammation and thrombosisthrombosis

Oxidative stressOxidative stress– Cell and tissue injuryCell and tissue injury

Poor wound healingPoor wound healing– Glycation of collagen, increased collagenase Glycation of collagen, increased collagenase

activityactivity Insulin deficiency per seInsulin deficiency per seClement S., Braithwaite SS, Magee MF, et al (ADA Diabetes in

Hospitals Writing Committee). Management of diabetes and yperglycemia in hospitals. Diabetes Care. 2004;27:533-591

Benefits of Intensive Blood Benefits of Intensive Blood Glucose Control in Critically Ill Glucose Control in Critically Ill PatientsPatients Whole blood glucose levels at 80-Whole blood glucose levels at 80-

100%100%mortality by 34%mortality by 34%

sepsis by 46%sepsis by 46%

renal failure necessitating dialysis by renal failure necessitating dialysis by 41%41%

need for blood transfusion by 50%need for blood transfusion by 50%

critical illness related polyneuropathy critical illness related polyneuropathy by 41%by 41%

Van den Bergh G, Wouters F, et al. Intensive therapy in the critically ill patients. NEJM 2001;345:1359-1367

Increased Increased hormoneshormones– CortisolCortisol– CathecolaminesCathecolamines– GlucagonGlucagon– Growth hormoneGrowth hormone

Metabolic effectsMetabolic effects– GluconeogenesisGluconeogenesis– GlycogenolysisGlycogenolysis– LipolysisLipolysis– KetogenesisKetogenesis

Metabolic Consequences Metabolic Consequences of Surgery and of Surgery and AnesthesiaAnesthesia

DEFINE INTENSIVE GLUCOSE DEFINE INTENSIVE GLUCOSE CONTROL IN HOSPITALIZED CONTROL IN HOSPITALIZED PATIENTS AND SET GLYCEMIC PATIENTS AND SET GLYCEMIC TARGETS IN THE SURGICAL PATIENTSTARGETS IN THE SURGICAL PATIENTS

Objective # 2

Target Blood Glucose LevelsTarget Blood Glucose LevelsADA 2006ADA 2006

Critically illCritically ill– BG as close to 110mg/dl as possible BG as close to 110mg/dl as possible

and generally <180mg/dland generally <180mg/dl Noncritically illNoncritically ill

– Premeal: 90 – 130mg/dlPremeal: 90 – 130mg/dl– Postprandial: <180mg/dlPostprandial: <180mg/dl

Glycemic TargetsGlycemic Targets AACE 80-110 mg/dlAACE 80-110 mg/dl

ADA as close to 110 mg/dl as possible, and generally <180 ADA as close to 110 mg/dl as possible, and generally <180 mg/dlmg/dl

Yale New Haven Hospital 90-120 mg/dlYale New Haven Hospital 90-120 mg/dl

ACC/AHA ST elevation MI(STEMI) guidelineACC/AHA ST elevation MI(STEMI) guideline Class I recommendation ”an insulin infusion to normalize BG Class I recommendation ”an insulin infusion to normalize BG

for patients with STEMI and complicated course for patients with STEMI and complicated course “(level evidence “(level evidence B)B)

Class IIa recommendation; :During the acute phase (first 24-48 Class IIa recommendation; :During the acute phase (first 24-48 hours) of management of STEMI inpatients with hours) of management of STEMI inpatients with hyperglycemia, it is reasonable to administer an insulin hyperglycemia, it is reasonable to administer an insulin infusion to normalize BG in paitents with an uncomplicated infusion to normalize BG in paitents with an uncomplicated course course “(level evidence B)“(level evidence B)

Garber AJ et al Endocr Pract 2004,10.77-82ADA Diabetes Care 2006:29 (Suppl 1) 575-77

REVIEW INTRAVENOUS INSULIN REVIEW INTRAVENOUS INSULIN PROTOCOLS CURRENTLY IN USE PROTOCOLS CURRENTLY IN USE AND DETERMINE THEIR AND DETERMINE THEIR FEASIBILITY FOR USE IN OUR FEASIBILITY FOR USE IN OUR SETTINGSETTING

Objective # 4

Atlanta Multiplier methodAtlanta Multiplier method Van den Berghe (studied in critical care Van den Berghe (studied in critical care

setting)setting) Portland Protocol (used in surgical Portland Protocol (used in surgical

setting)setting) Markovitz (studied in post op heart Markovitz (studied in post op heart

surgery patients)surgery patients) Yale protocol (studied in medical Yale protocol (studied in medical

intensive care setting)intensive care setting)

Various protocolsVarious protocols

Insulin (units per hour) = multiplier × (BG - 60)

With use of this algorithm manually, the initial multiplier is set at 0.02, and a BG value is determined every hour in conjunction with calculation of the units of IV insulin therapy per hour. The multiplier is adjusted every hour by 0.01 to obtain the target BG level—if the result is less than the target, decrease by 0.01; if within target range, no change is needed; if more than the target and the BG level has not decreased by 25%, increase by 0.01. The BG is always determined hourly until stable results are achieved; then it is measured every 2 hours.

Portland Protocol for Continuous Portland Protocol for Continuous IV Insulin Infusion -- FLOOR IV Insulin Infusion -- FLOOR patientspatients Target: 80 - 120Target: 80 - 120

1.1. Surgical Patients:Surgical Patients: Start “Portland Protocol” during surgery. Continue through Start “Portland Protocol” during surgery. Continue through 7 AM of the 37 AM of the 3rdrd POD; patients who are not taking enteral nutrition on the 3 POD; patients who are not taking enteral nutrition on the 3rdrd POD POD should remain on this protocol until taking at least 50% of a soft ADA diet.should remain on this protocol until taking at least 50% of a soft ADA diet. Medical PatientsMedical Patients: Continue Portland Protocol throughout until taking soft ADA : Continue Portland Protocol throughout until taking soft ADA diet.diet.

2.2. For patients previously undiagnosed diabetes (DM) who present with For patients previously undiagnosed diabetes (DM) who present with hyperglycemia: start PDX protocol if blood glucose (BG) level > 150 mg/dl X 2 hyperglycemia: start PDX protocol if blood glucose (BG) level > 150 mg/dl X 2 consecutive readings consecutive readings OROR >175 at any one time. Consult endocrinologist for DM >175 at any one time. Consult endocrinologist for DM workup and follow-up orders.workup and follow-up orders.

3.3. Start insulin infusion via pump “piggybacked” to normal saline IV as follows:Start insulin infusion via pump “piggybacked” to normal saline IV as follows:

Furnary AP, et al. Endocr Pract. 2004;10:21–33.

Portland Protocol for Continuous Portland Protocol for Continuous IV Insulin Infusion -- FLOOR IV Insulin Infusion -- FLOOR patientspatients Target: 80 - 120Target: 80 - 120


Blood Glucose Blood Glucose (mg/dL)(mg/dL)

Intravenous Intravenous Insulin Bolus (U)Insulin Bolus (U)

Initial Insulin Rate (Units/h) (circle Initial Insulin Rate (Units/h) (circle one)one)

Type 2 DMType 2 DM Preoperatively Preoperatively

Type 1 DMType 1 DMPreoperativelyPreoperatively

80–12080–120 00 0.50.5 11

121–180121–180 00 11 22

181–240181–240 44 22 3.53.5

241–300241–300 88 3.53.5 55

301–360301–360 1212 55 6.56.5

> 360> 360 1616 6.56.5 88

Portland Protocol for Continuous Portland Protocol for Continuous IV Insulin Infusion -- FLOOR IV Insulin Infusion -- FLOOR patients Target: 80 - 120patients Target: 80 - 120


4.4. Test BG level by finger-stick or venous line drop Test BG level by finger-stick or venous line drop sample. sample. The frequency of BG testing is as follows:The frequency of BG testing is as follows:

a.a. If BG ≥180 or < 80 : check BG every If BG ≥180 or < 80 : check BG every 30 30 minutesminutes

b.b. If BG 80 - 179: check BG every hour.If BG 80 - 179: check BG every hour.c.c. When BG 80 – 120, with <15 mg/dl change When BG 80 – 120, with <15 mg/dl change andand

insulin rate remains unchanged x insulin rate remains unchanged x 44hr., = “stable hr., = “stable infusion rate” -- then may test q. 2 hrsinfusion rate” -- then may test q. 2 hrs

d.d. May stop q. 2 hr testing on May stop q. 2 hr testing on POD #3POD #3 in surgery in surgery patients or as noted in #1 (see items #1 & #8).patients or as noted in #1 (see items #1 & #8).

e.e. At nightAt night: Test q. 2 hr : Test q. 2 hr if BG 120 - 150if BG 120 - 150; Test q4 hr ; Test q4 hr if if BS 80 - 120 and BS 80 - 120 and “stable infusion rate” exists.“stable infusion rate” exists.


Blood Glucose Blood Glucose (mg/dL)(mg/dL) ActionAction

< 60< 60

Stop insulin; give 25 mL D50; Stop insulin; give 25 mL D50; Recheck BG in 30 Recheck BG in 30 minutesminutes. . When blood glucose > 70, restart with rate 50% of When blood glucose > 70, restart with rate 50% of previous rate. previous rate.

60–69 60–69 Stop insulin; if previous BG >100, give 25 mL D50. Stop insulin; if previous BG >100, give 25 mL D50. Recheck BG in 30 minutesRecheck BG in 30 minutes When BG > 70, restart with rate 50% of previous rate.When BG > 70, restart with rate 50% of previous rate.

70–7970–79

If greater than last BG, continue current rate. If greater than last BG, continue current rate. If lower than last BG by 20 mg/dl or more, decrease rate If lower than last BG by 20 mg/dl or more, decrease rate by 50%by 50%If within 20 mg/dL of last BG, decrease rate by 0.5 If within 20 mg/dL of last BG, decrease rate by 0.5 units/hour. units/hour. Recheck BG in 30 minutesRecheck BG in 30 minutes

80–12080–120Same rate -- EXCELLENT! You are in the Target Range!Same rate -- EXCELLENT! You are in the Target Range!TITRATE DRIP AT WILL TO MAINTAIN BG in TITRATE DRIP AT WILL TO MAINTAIN BG in TARGET RANGETARGET RANGE

ALL Remaining ALL Remaining TitrationTitration SAME AS ICU PROTOCOLSAME AS ICU PROTOCOL

5. Insulin titration:5. Insulin titration:

Furnary AP, et al. Endocr Pract. 2004;10:21–33. 59


6.7. -- Diet and SQ Humalog orders and titration:SAME AS IN ICU PROTOCOL

8. At protocol cessation: Restart preadmission glycemic control medication. If receiving insulin, wait 1hr after injection of short-acting insulin or 2hr after long-acting insulin before stopping IV insulin drip.Long-acting insulin: type Schedule/dose Short-acting insulin: type Schedule/dose Oral agents:

Check BG (circle)….. qAC; qHS; 90minutes PCOR……….. q ___ hours

GIK SolutionGIK Solution

500ml10% dextrose solution500ml10% dextrose solution+15u short – acting insulin+15u short – acting insulin

+ 10mmol KCl+ 10mmol KCl Infuse over 5 hours(100ml/h)Infuse over 5 hours(100ml/h)

CBG MONITORING SHEETCBG MONITORING SHEET

BGBG Insulin/Insulin/




routeroute

1pm1pm 2pm2pm 3pm3pm 4pm4pm

Post opPost op

250250 5uR/5uR/

dripdrip247247 7uR/7uR/



dripdrip

CASE

Post opIntraoperative

WHEN AND HOW DO WHEN AND HOW DO YOU INITIATE YOU INITIATE NUTRITIONAL NUTRITIONAL

SUPPORT ?SUPPORT ?

The time arrives to begin eating discrete meals

8 12 6 10

Insulin requirement

Patients who are eating

Consistent carbohydrate diet order

8 12 6 10

Lispro / aspart ( ~ 50 % )Glargine ( ~ 50 % )

8 12 6 10

Lispro or aspartGlargine

( ~ 50 % )

Advanced carbohydrate counting

4. How do you shift 4. How do you shift from IV to SC insulin?from IV to SC insulin? Establish 24 hour insulin Establish 24 hour insulin

requirementrequirement Extrapolated from average over Extrapolated from average over

last 4 hours of stablelast 4 hours of stable Give 50% as basal and 50% as Give 50% as basal and 50% as

total bolustotal bolus Correction bolus for BG>140Correction bolus for BG>140

Shifting Insulin from IV to Shifting Insulin from IV to Subcutaneous RouteSubcutaneous Route

Establish 24 hour insulin requirementEstablish 24 hour insulin requirement Extrapolated from average over last Extrapolated from average over last

4 hours of stable4 hours of stable Give 50% as basal and 50% as total Give 50% as basal and 50% as total

bolusbolus Correction bolus for BG>140Correction bolus for BG>140 There should be an overlap between There should be an overlap between

IV to SQ insulin TxIV to SQ insulin Tx

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