A Children’s Bedtime Story - Mayo Clinic School of ... A Children’s Bedtime Story ... – Regular

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  • A Childrens Bedtime Story Setting:UniversityMedicalCenter,BigTown,USA Scenario:0500,lastadmissionofthenight,10previousadmissions,alltuckedinforthenight

    Patient:75yearoldmalewithpastmedicalhistoryofdiabetesmellituson70/30insulin15unitsBID,chronickidneydisease(CKD),whopresentswithalteredmentalstatusandacutekidneyinjuryonCKD.Youadmitthepatient,puttingordersinforhishomeinsulindose(15unitsBID70/30)witha

    nowdose.

  • TurnedHorrorStory 0700:Dayteamarrives. 0700:RNcalltoNightPAC,interruptingsignout:Igavethepatienthis15unitsuponarrivaltothefloorat0530.HisAMdoseisdueat0730.Doyouwantmetogiveit?Hisbloodsugariscurrently179.Also,hewillgetSSIcorrectiontooperprotocol.

    NightPAC:Yes,giveit. RN:Errr,areyousure?Thatis2dosesofinsulininashorttimeperiod.

    NightPAC:Yes,Imsure,givetheinsulin.

  • FromGoldilocks toAmerican Horror Story

    0830:DayPAChearsrapidresponsecalledoverhead

    Arrivestofindhernewpatientunresponsive Bloodsugaronarrivalis35.

    This story is real. It happened 3 months ago on my service.

    WHY?

  • DiabetesMellitus,Hyperglycemia&HypoglycemiaforHospitalized

    Patientsin2017

    5thAnnualAcuteCareoftheComplexHospitalizedPatientforNPs&PAs

    KrystalMRenszel,DO,MSHospitalInternalMedicine

    MayoClinicArizona

  • Objectives

    Reviewcurrentliteratureregardingglycemictargets&insulindosingwithfocusonnonICUhospitalizedpatients

    Managespecialpopulations(corticosteroids,ESRD/CKD,ICU)

    Discusshypoglycemiaandimpactonmortality Choosedosingregimensbasedonpatientpopulation&nutritionalstatus

  • 180

    140

    110

    200

  • DiabetesisanAmbulatoryCareProblem,notmine.

    25.8millionpeopleintheUShaveDMor8.3% 7th leadingcauseofdeathand4th leadingcomorbidconditionamonghospitaldischarges

    30% ofpatientswithDMrequire2ormorehospitalizationsinanygivenyear

    Observationalstudieshaveshownhyperglycemiaisa/w prolongedhospitalstay,increasedinfectionincidence,moredisabilityafterd/canddeath

  • Admission:WheredoIstart? Allpatients:bloodglucose(BG)testuponadmission&A1C*

    *Ifhyperglycemicandnotcheckedinthelast23months Discontinue oralagentsandinitiate insulinifDM2 Useastandardizedsubcutaneousinsulinorderset

    Scheduledbasal&nutritionalinsulintherapy Nurseinitiatedhypoglycemiatreatmentprotocol (BG140mg/dlusing

    bedsidePOCtestingforatleast2448h IfBG>140,continuePOCtesting

    Avoid solelyslidingscaleinsulin(SSI)therapy POCschedules:

    Beforemealsandbedtimeinpatientswhoareeating q46hinpatientswhoareNPOorgettingcontinuousenteralfeeding

  • ForNonICUHospitalizedPatients:Isthereagoal?

    InhospitalhyperglycemiaisdefinedanyBG>140mg/dl

    NonICUmaximum:BS=180 Glycemictargetsshouldbemodifiedaccordingtoclinicalstatus:Forpatientsw/terminalillness,orlimitedlifeexpectancy,orathighriskforhypoglycemia,ahighertargetrange

  • ForNonICUhospitalizedpatients:HowshouldIdoseinsulin?

    AllDM1&mostDM2=scheduledbasalinsulin Estimatetotaldailydose(TDD)insulin*:

    Malnourished,elderly,CKD,ESRD,ESLD 0.20.3units/kg

    Normalweightpatients,incl.TypeIDM 0.4units/kg

    Overweight 0.5units/kg

    Obese,highdosesteroids,insulinresistance 0.6units/kg

    *Ifpatientoninsulinathome,canuseasstartingpoint*

  • ForNonICUhospitalizedpatients:HowshouldIdoseinsulin?

    NPOorclearliquids Basal:50%TDD,nutritional:none

    Eatingmeals Basal:50%,nutritional:50%

    ContinuousTFs Basal:40%,nutritional:60%

    Parenteralnutrition Regularinsulingivenparenterally,cont SSI

    *Adjustq12daysbasedonglucosetrends;decreaseby20%ifhypoglycemia*

  • HowdoItransitionfromContinuousInsulinInfusiontoSC

    Insulin? Calculateaveragehourlyrateoncedripdeliveryratehasstabilized

    Multiplyby20togetconservativeTDDestimate IspatientNPOoreating?

    i.e.,doesmyTDDestimaterepresentsolelybasalorbasalbolus?

    Continueinsulininfusion: Foratleast1hourafterSCrapidactingorregularinsulin Foratleast23hoursafterSCintermediateactingorlongactinginsulin.

  • ForNonICUhospitalizedpatients:WhatshouldIkeepinmind?

  • SpecialPopulations

    Steroidinducedhyperglycemia MonitorwithbedsidePOCtestingforatleast2448hafterinitiationofsteroids;ifBG>140mg/dl,continuePOCtesting

    Initiateinsulinifpersistenthyperglycemia(BG>140)

    CKD Perioperative IntensiveCare

  • SpecialPopulations

    Steroidinducedhyperglycemia CKD

    Highriskforhypoglycemia A1Cvaluesareoftenunreliable ManypatientsstopneedinginsulinasCKDprogresses Doseinsulinat0.20.3units/kg

    Perioperative IntensiveCare

  • SpecialPopulations Steroidinducedhyperglycemia CKD Perioperative

    Allpatientsw/DM1undergoingmajororminorsurgeryreceiveeitherIVcontinuousinsulininfusionorsc basal/bolusinsulin

    D/coralandnoninsulininjectables beforesurgery BasalforNPOpatientsandbasal/bolusforpatientswhoareeating

    IntensiveCare

  • SpecialPopulations

    Steroidinducedhyperglycemia CKD Perioperative IntensiveCare

    Intensiveinsulintherapy(BGatorbelow110mg/dl)reducesmorbidityandmortalityamongcriticallyillpatientsinthesurgicalintensivecareunit(2001)

    NICESUGAR:intensiveglucosecontrolincreasedmortalityamongadultsintheICU:abloodglucosetargetof180mg/dlorlessresultedinlowermortalitythandidatargetof81108mg/dl(2009)

  • ForBetterorWorse:Hyper vsHypoGlycemia

    Inaretrospectivestudyfrom2009,hypoglycemiawasseenin7.7%ofhospitalizedpatients

    Episodesofseverehypoglycemiaconstituteanindependentcardiovascularriskfactor,increasedLOS,&highermortalitybothduringandafteradmission

  • SmallGroupCases(10min) Ingroupsof34people,workthroughthecasesatyourtables

    Pickatablespokesperson Wewilldiscussanswersasalargegroup

  • References1. Guillermo,E.,etal.ManagementofHyperglycemiainHospitalizedPatientsinnoncriticalcare

    setting:AnEndocrineSocietyClinicalPracticeGuideline.JClin Endocrinol Metab,January2012,97(1):1638.

    2. Iyer,S.H.andTanenberg,R.J.Managingdiabetesinhospitalizedpatientswithchronickidneydisease.ClevelandClinicJournalofMedicine.April2016,83(4):301310.

    3. TheNICESUGARStudyInvestigators.IntensivevsConventionalGlucoseControlinCriticallyIllPatientsNEngl JMed2009;360:12831297.

    4. vandenBerghe etal Intensiveinsulintherapyincriticallyillpatients.NEngl JMed2001;345:13591367.

    5. SocietyofHospitalMedicine,StepwiseApproachtoManagingInpatientHyperglycemia.https://www.hospitalmedicine.org/.../GC_Supp_Appdx1_ins_protocol_final_(2).pdf.

    6. Schnipper,JL,etal.SocietyofHospitalMedicineGlycemicControlTaskForceSummary:PracticalRecommendationsforAssessingtheImpactofGlycemicControlEfforts.JournalofHospitalMedicine.2008Sept/Oct.Vol3(5)Supplement5:S6675.

    7. Wesorick,D.etal.ManagementofDiabetesandHyperglycemiaintheHospital:APracticalGuidetoSubcutaneousInsulinUseintheNonCriticallyIll,AdultPatient.JournalofHospitalMedicine.2008Sept/Oct.Vol3(5):Supplement5:S1728.

    8. Turchin,A.,etal.HypoglycemiaandClinicalOutcomesinPatientsWithDiabetesHospitalizedintheGeneralWard.DiabetesCare2009Jul;32(7):11531157.

    9. Christensen,MB,etal.Efficacyofbasalbolusinsulinregimensintheinpatientmanagementofnoncriticallyillpatientswithtype2diabetes:asystematicreviewandmetaanalysis.Diabetes/MetabolismResearchandReview.Acceptedmanuscriptonline:9January2017.

  • THANKYOU!

    Questions?