management of the hospitalized type i diabetic patient riverside methodist hospital january 23, 2014...
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Management of the hospitalized type I DIABETIC patient Riverside Methodist Hospital
January 23, 2014
Rundsarah Tahboub, MD
Case
A 44 year old male is transferred from an outside hospital with low back pain and hyperglycemia after recent spinal surgery. The patient uses an insulin pump at home and it is unclear if he has Type I or II Diabetes . He was initiated on an intravenous insulin infusion at the outside facility for glucose of 300 and his pump was removed.
On admission the patient was not able to state how much insulin he gets through pump on a daily bases
The admitting hospitalist discontinued the insulin drip and began sliding scale insulin.
The patient became severely hyperglycemic shortly afterward and developed ketoacidosis
He was found to have an epidural abscess
Questions I
What is the best insulin regimen for this patient ?1. Aggressive corrective sliding scale insulin since he has a severe
infection
2. Glargine insulin and standard corrective sliding scale insulin
3. Variable intravenous insulin infusion
4. Have him put his pump back on
Question II
What would you do if patient became hypoglycemic while NPO on your insulin regimen?1. Discontinue insulin altogether
2. Reduce insulin doses
3. Correct hypoglycemia with IV dextrose 50 once
4. Initiate IV dextrose infusion
Question III
All the following are appropriate criteria for reinitiating of insulin pump except one:
1. Will only resume at home after discharge
2. Hemodynamically stable and AOX3
3. Able to tolerate diet
4. Has insulin pump supplies and able to fill pump and administer boluses
Hospitalized Type I DM Patient
High risk patient Completely dependent on exogenous insulin Insulin sensitive usually requires <0.5 units/kg/day Frequent use of insulin pumps Will develop ketoacidosis in absence of sufficient basal
insulin: SSI monotherapy Holding basal insulin when NPO Delay in responding to stress hyperglycemia
DKA occurring after admission in a hospitalized patient is
a result of medical error until proven otherwise
Common Errors in Management of Inpatient Type I DM Holding basal insulin for NPO status or hypoglycemia
severe hyperglycemia or DKA
Omitting mealtime insulin for low premeal BG (60-80 )
Using SSI only
Assuming Type I patient is as insulin resistant as Type II patients when correcting hyperglycemia
Recommended Glycemic Targets
Targets Must be:
Achievable Reasonable Safe
Critically Ill Non critically Ill
140-180 mg/dL Premeal <140 mg/dLRandom <180 mg/dL
NOT recommendedBG <110 mg/dL
Consider changing regimen for BG <100
mg/dL
Non Critically Ill Type I DM
Continue to require an insulin regimen similar to home regimen but modified for being inpatient with potential less PO intake
Regimen consists of: Basal insulin
long acting glargine or detemir
intermediate acting NPH
Mealtime insulin (analog) must be scheduled if patient is eating Corrective insulin for premeal glucose above target of 150 typically
Non Critically Ill Type I DM & NPO Status
Must always continue exogenous basal insulin Long or intermediate acting insulin Basal rate of insulin pump if suitable Initiation of IV insulin especially in critical care setting
May use corrective insulin in addition to basal
Perioperative Management of Type I DM Basal insulin should always be continued
Using glargine or detemir If well controlled give 80% of dose Uncontrolled may give the full dose
Using NPH Give full evening dose Give 50% of AM dose
Avoid use of mixed insulin 70/30, 75/25
Hold scheduled mealtime insulin but may continue to use corrective doses
If undergoing high risk surgery such as CABG or prolonged procedures initiate IV insulin infusion the night before
Insulin Pump Therapy
Electronic device that delivers insulin through a SC catheter
Can be programmed to deliver variable basal rates throughout the day
Delivers bolus /mealtime coverage based on
• carbohydrate intake with meals : insulin to carbohydrate ratio programmed into pump.
• Example 1 unit per 15 gm of carb per meal
• correction factor : example 1 unit of insulin drops BG by 50mg/dl
Challenges of Insulin Pump Therapy in Hospital Setting Patient may be unfamiliar with the pump settings but know
how to use pump otherwise ( fill with insulin , insert SC catheter, bolus for meals and give correction doses )
Hospital Staff usually unfamiliar with pumps
Safety issues with pumps (kinked catheter, overbolused, discontinued by staff without alternate insulin orders)
Technical concerns (safety with radiological testing, intraopertively)
Requirements for Safe Inpatient use of Insulin Pump Therapy Insulin pump order set Patient contract Nursing documentation of basal rates and
boluses administered by patient & evaluation of insertion site
Pharmacy overview of pump & patients insulin supply
Endocrine consult
Inpatient Insulin Pump Therapy
Criteria for maintaining pump The patient is alert and oriented Not critically ill Able to administer boluses and suspend pump when
needed Cooperation with staff and signs patient contract Patient has own supplies
Insulin Pump Therapy in Periopertaive Period
May continue use of pump for short procedures <2 hours and insulin insertion site away from surgical site
Reduce basal rate by 20% of usual
For procedures >2 hours Initiate IV insulin infusion the night before at same rate as the
insulin pump infusion rate Discontinue insulin pump
Critically Ill Type I DM & NPO Status
IV insulin infusion is the method of choice until condition is stabilized
Often need D5 IVF initiated also if expected to be NPO for prolonged periods BGs trending <150
IV insulin infusion rates may be titrated down as low as 0.1 units/hour to avoid hypoglycemia while still providing IV insulin without interruption
Critically Ill Type I DM & NPO Status
If enteral nutrition is going to be initiated IV insulin infusion is the safest and most flexible method of achieving control
IV insulin should be maintained until the patient is tolerating enteral nutrition and at goal rate
When is patient ready to be transitioned from IV to SC Insulin?
Hemodynamically stable DKA or HHS resolved Insulin infusion rate has been stable for 6-8 hours Insulin infusion rate < 5 units/hour Insulin infusion rates are similar to patient prior insulin
requirements Medications that effect BG have not been recently changed
Inotropes Glucocorticoids
Considerations when Transitioning from IV to SQ Insulin
Continue IV insulin until patient is able to tolerate PO intake (diabetic clear liquids) if not on EN or PN
Continue IV insulin at least 2 h after the first SC basal insulin injection is given or pump is started (Overlap is essential)
Is patient receiving Dextrose in IVF or have they eaten on Insulin Infusion?
Do not use the total insulin IV amount given in previous 24 hours
Don’t switch to SSI only !
Feeding while on Insulin Infusion The insulin infusion will not prevent hyperglycemia
associated with ingestion of carbohydrates
Insulin infusion is reactive
Interferes with our ability to calculate insulin requirements when transitioning off of infusion
If you are going to feed on insulin give a SC dose of short acting insulin before the meal
Giving a IV bolus is not going to cover the meal ..its effect only lasts 5-10mins
How to Transition from IV to SQ Insulin
Type I DM on IV insulin and D5 IVF (such as DKA)
Use stable insulin infusion rate in past 6 hours to calculate total daily dose (TDD)
Example: Stable average infusion rate 2 units/hour 2 units/hour x 24 hours =48 units (TDD)
How to Transition from IV to SQ Insulin
Type I DM on IV insulin and D5 IVF (DKA) Divide the new TDD as follows:
50% Basal ( to be given 2-3 hours before discontinuation of insulin IV)
50% as premeal divided into 3 doses
Example : TDD 48 units calculated from IV insulin 24 units glargine 24/3 units as premeal analog insulin = Lispro 8 units
with each meal
How to Transition from IV to SQ Insulin
Type I on TPN or continuous tube feeds Use stable insulin infusion rate in past 6 hours to calculate TDD
Divide the new TDD as follows: 50% Basal either glargine every 24 hours or equal dose of
NPH q 12 hours 50% as nutritional given as regular insulin scheduled Q 6
hours
How to Transition from IV to SQ Insulin
Type I on TPN or continuous tube feeds Example average hourly rate over previous 6 hours while on goal tube
feeds = 3.5 units/hour 3.5 x 24 hours = 84 units Give 50% as basal = 42 units of glargine
even if TF discontinued this dose should be continued
Give 50% as nutritional = 42 units ÷ 4 ~ 10 units q 6 hours while on TF this is to be held if TF interrupted
Also start correctional SSI
How to Transition from IV to SQ Insulin
Type I DM (Not receiving dextrose , TPN or Tube feed) Use stable insulin infusion rate in past 6 hours to calculate total
basal dose Example:
infusion rate 2 units/hour 2 x 24 hours =48 units Give 80% as the Total basal dose for next 24 hours 0.8 x 48=40 units
Give all of this as basal insulin Give premeal insulin roughly 0.05 - 0.1 unit/kg with each meal
when patient starts eating
Transitioning from IV to insulin pump
Insulin pump should be placed and started at least 1-2 hours before IV infusion is discontinued
References
Umpierrez GE, Hellman R, Korytkowski MT, 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.
American Diabetes Association. Standards of medical care in diabetes—2013. Diabetes Care. 2013;36(suppl 1):S11-S66.
Moghissi ES, Korytkowski MT, DiNardo M, et al. American Association of Clinical Endocrinologists and American Diabetes Association consensus statement on inpatient glycemic control. Endocr Pract. 2009;15:353-369.