Critical care ppt

MANAGEMENT OF DIABETESIN THE ICU

DR A P Naveen KumarChief Specialist ( Gen. Med. )

Visakha Steel General Hospital

Reasons for Deteriorated Glucose Control During Hospital Admissions

Hyperglycemia

“Stress hyperglycemia” Corticosteroid Therapy Hyperalimentation solutions Medication/insulin omission Insulin errors

Netchick LN, Am J Med 113:317, 2003

Counterregulatory hormones• Cortisol• Catecholamines• Glucagon• Growth Hormone

Glucose utilization

Glucose production

Glucose FFAs

LipolysisFFAs

(-)

(-)

Stress HyperglycemiaStress Hyperglycemia

Metchick LN et al, Am J Med 113:317, 2003Kitabchi AE, Diabetes Care 24:131, 2001

(-)

The Increasing Rate of Diabetes Among Hospitalized Patients

Hospitalizations for Diabetes as a Listed Diagnosis

0

1

2

3

4

5

1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001

Hospital Discharges (millions)

48%

Available at: http://www.cdc.gov/diabetes/statistics/dmany/fig1.htm. Accessed June 15, 2004.

Hyperglycemia: An Independent Marker of In-Hospital Mortality in Patients with Undiagnosed Diabetes

Total In-patient Mortality

Normoglycemia Known New Diabetes Hyperglycemia

1.7% 3.0%

16.0% *

Mor

talit

y (%

)

* P < 0.01Umpierrez GE et al, J Clin Endocrinol Metabol 87:978, 2002

0

10

20

30

Hyperglycemia and Pneumonia Outcomes

BG (mg/dl) < 110 110 - <198 198 - <250 ≥250

* *

* *

* p: < 0.05 vs BG < 198 mg/dl (11 mmol/L)

Admission glucose (mg/dl)

%

McAllister et al, Diabetes Care 28:810-815, 2005

N= 2,471 patients with CAP

0

5

10

15

20

25

30

Mortality

HospitalComplications

Hyperglycemia*: A Common Comorbidity in Medical-Surgical Patients in a Community Hospital

62%62%

12%12%

26%26%

NormoglycemiaKnown DiabetesKnown DiabetesNew Hyperglycemia

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

n = 2,020

* Hyperglycemia: Fasting BG 126 mg/dl or Random BG 200 mg/dl X 2

Hyperglycemia in Hospitalized Patients• Hyperglycemia (>200 mg/dL x 2) occurred in 38% of

hospitalized patients

– 26% had known history of diabetes

– 12% had no history of diabetes

• Newly discovered hyperglycemia was associated with:– Longer hospital stays– higher admission rates to intensive care units– Less chance to be discharged to home (required more

transitional or nursing home care)

Umpierrez GE, et al. J Clin Endocrinol Metab. 2002;87:978–982.

Hyperglycemia in Hospitalized PatientsHyperglycemia in Hospitalized Patients

– Surgery– Catheters– Intravenous Access

Problems with wound healing

Problems with tissue and organ perfusion

High-risk for bacterial infection

02468

10121416

<150 150-175 175-200 200-225 225-50 >250

Average Post-operative glucose (mg/dl)

Mor

talit

y

Cardiac-related mortalityNoncardiac-related mortality

Mortality of DM Patients Undergoing CABG

Furnary et al J Thorac Cardiovasc Surg 2003;123:1007-21

How do we know that hyperglycemia is bad?

• Hyperglycemia associated with morbidity and mortality in various epidemiologic studiesMyocardial infarctionStrokeTraumaSurgeryMedical ICUBurnsPediatric ICU

IS IT DIFFERENT FROM OUTPATIENT MANAGEMENT

Acute illness results in number of physiological changes

increase in circulating stress hormones

sepsis and infection and hypotension and shock

therapeutic usage of glucocorticoids

Nutritional and clinical instability

Diagnosis of diabetes and hyperglycemia in hospital setting

• Patients with known history of diabetes can be admitted in hospital

• Hyperglycemia detected in the hospital it could be newly detected diabetes it could be stress hyperglycemia

• Above two can be differentiated by the measurement of HBA1C

Normoglycemia in Intensive Care Evaluation–Survival Using Glucose Algorithm Regulation (NICE-SUGAR)

• Nice sugar study the largest trial to date intensive insulin therapy is associated with increased hypoglycemia and increased mortality

• Therefore it is recommended to maintain blood glucose level between 140 - 180 mgs

• A lower blood glucose target (not less than 100mgs) may be appropriate in selected patients

NICE-SUGAR Study Outcomes

Outcome Measure

Intensive Group

Conventional Group

Morning BG (mg/dL) 118 + 25 145 + 26

Hypoglycemia(≤ 40mg/dL)

206/3016 (6.8%)

15/3014(0.5%)

28 Day Mortality (p=0.17) 22.3% 20.8%

90 Day Mortality (p=0.02) 27.5% 24.9%

The NICE-SUGAR Study Investigators. N Engl J Med. 360:1283-1297, 2009.

Diabetes Mellitus Insulin-Glucose Infusion in Acute Myocardial Infarction (DIGAMI) trial

• People with diabetes who suffer an acute myocardial infarction (MI) are at markedly increased risk of future cardiovascular morbidity and mortality.

• The DIGAMI study compared "conventional" anti-diabetic therapy to intensive insulin therapy consisting of acute insulin infusion during the early hours of MI and thrice-daily subcutaneous insulin injection for the remainder of the hospital stay and a minimum of 3 months thereafter.

• 1-year mortality was statistically significant.

Glycemic Threshold in Acute MI and Intervention (PTCA)

DIGAMI supports BG < 180 mg/dlMinimal other data: - PTCA reflow better with BG 159 than

209 mg/dl

Iwakura K: JACC 2003; 41:1-7

Malmberg BMJ 1997;314:1512Malmberg BMJ 1997;314:1512

AACE-ADA Consensus Statement onInpatient Glycaemic Targets

Recommends using insulin therapy if blood glucose levels exceed 180 mg/dL

Moghissi E, et al. Diabetes Care 2009; 32 (6):1119-1131

Moghissi et al. Endocr Pract 2009;15:353–69

Inpatient glycaemic targets

• Insulin infusion to control hyperglycaemia

• Starting threshold no higher than 180 mg/dL

• Maintain BG between 140 and 180 mg/dL– Possible greater benefit at lower end of range

• Somewhat lower targets may be appropriate in selected patients

• Targets <110 mg/dL are not recommended

Recommended140–180 mg/dL

May be appropriate110–140 mg/dL

Not recommended<110 mg/dL

Not recommended>180 mg/dL

Insulin

The most powerful agent we haveto control glucose

only

IV Insulin Protocol

In all NMH Surgical ICU’s glucose levels are checked every hour upon admission. If glucose is greater then 110mg/dL X 2 or >200mgdL X 1, insulin drip is started.

Hyperglycemia is treated in all patients, even in the absence of a diabetes diagnosis.

Suggested protocol for insulin infusion in icu

A preparation 50 units of regular insulin dissolved in 50 ml normal saline in a 50 ml disposable syringes

B. Mode of administration

IV infusion with an electronic syringe pump/infusion pumps

C. Primary target

To maintain blood sugar level with a predefined target 140 mg/dl

D. Control methodology

Blood sugar to be controlled gradually in case of severe hyperglycemia by titrating the dose of IV insulin

Suggested protocol for insulin infusion in icu continued

E. Pre-requisites Initially 15–20mL of solution should be flushed through plastic tubing to saturate the insulin binding sites in the tubing

F. Targets Dose should be adjusted as per the levels of blood sugar

G. Monitoring Either by capillary blood glucose or from the venous site/central line

Portland Protocol• Start insulin infusion as follows:

http://www.hospitalmedicine.org/AM/Template.cfm?Section=Home&Template=/CM/ContentDisplay.cfm&ContentID=11490 . Accessed on 11/11/2011

24

Blood Glucose (mg/dL)

Intravenous Insulin Bolus

(IU)

Initial Insulin Rate (IU/hour)

Type 2 DM Type 1 DM

80–120 0 0.5 1121–180 0 1 2181–240 4 2 3.5

241–300 8 3.5 5

301–360 12 5 6.5> 360 16 6.5 8

Portland Protocol (contd…)• Insulin titration:

Furnary AP et al, Ann Thorac Surg 1999;67:352-62 25

BG (mg/dL) Instructions

>250 If > 10% lower than prior BG, no changeIf < 10% lower or higher BG, ↓ by 1 IU/hr

201-250 If lower BG, no changeIf higher, ↓ by 0.5 IU/hr

151-200 No change in drip rate

101-150 If < 10% lower BG, ↓ by 0.5 IU/hrIf > 10% lower BG, ↓ rate by 50%

< 100Hold insulin (25 ml of 50% dextrose if BG < 75). When BG >150 mg/dl, restart at 50% of previous rate

Yale Insulin Infusion Protocol• Insulin infusion:

– Mix 1 U regular human insulin per 1 mL 0.9% NaCl. Administer via infusion pump in increments of 0.5 U/h

• Bolus and initial infusion rate:

– Divide initial BG by 100, round to nearest 0.5 U for bolus and initial infusion rates

• Example: Initial BG = 325 mg/dL: 325/100 = 3.25, round up to 3.5, IV bolus = 3.5 U + start infusion at 3.5 U/h

• Subsequent rate adjustments:

– Changes in infusion rate are determined by the current infusion rate and the hourly rate of change from the prior BG level

Goldberg PA, et al. Diabetes Care. 2004;27:461-467. 26

Titration of insulin dose according to blood glucose level

Blood glucose levels(mg/dl) Dosage of insulin infusion

<100 No insulin to be given

100-149 1-1.5 units/hour

150-199 2 units/hour

200-249 2.5 units/hour


300-349 3.5 units/hour


Algorithm 1: Start with most patientsAlgorithm 2: Patients with post coronary bypass surgery, or solid organ transplantation, or receiving glucocorticoid therapy, or diabetes receiving more than 80 units of insulin/day

Patient Age Weight Kg

Blood glucose Initial Insulin Infusion rate Units/hour

Level (mg/dl)

Algorithm 1 Algorithm 2 Other

Less than 6061-109

Call AnesthesiologistHold insulin infusion, check glucose in 1 hourAnd follow the schedule

110-119 0.5 1_________

120-149 1 1.5________

150-179 1.5 2________

180-209 2 3_________

210-239 2 4_________

240-269 3 5_________

270-299 3 6_________

300-329 4 7_________

330-359 4 8_________

360-399 6 10________

400 or Greater 8 12________

65 yo Male without a previous hx of DM, s/p CABG x3 and MVRNPO, BS= 162. BG q 1 hour

Using the Insulin DripUsing the Insulin Drip

Titration of Insulin Drip

One hour later, BG=230. Previous BG 162One hour later, BG=230. Previous BG 162 An increase of 68An increase of 68

Give a Bolus of Give a Bolus of 3 3 unit(s) unit(s)

Increase Drip Rate by Increase Drip Rate by 1 1 unit(s) to unit(s) to 3 3 unit(s) unit(s)

KRINSLEY PROTOCOL

Diet Monitoring

NPO Q6 hours. 6AM, Noon, 6PM, Midnight

PO Diet 1 Hour Before Meals, QHS

Tube Feedings Q6 hours. 6AM, Noon, 6PM, Midnight

Glucose Value Action (SubQ insulin)

<140 No Treatment

140-169 3 units Regular Insulin

170-199 4 units Regular insulin; Recheck glucose value in 3 hours



300+ 10 units Regular insulin; Recheck glucose value in 3 hours

Basal Insulin

32

Nutritional Insulin

• Given as rapid-acting analogue or regular insulin, for those patients who are eating meals

• Must be matched to the patient’s nutrition

• Should not be given to patients who are not receiving nutrition (e.g., NPO)

• Can be estimated to be about ½ of the total daily dose of insulin

33

Correctional Insulin

• Extra insulin given to correct hyperglycaemia, in addition to basal and nutritional insulin

• Rapid-acting or regular insulin is generally used

• Customized to the patient using an estimate of the patient’s insulin sensitivity

• If correctional insulin is required consistently, or in high doses, basal and/or nutritional insulin doses need to be modified

34

Physiologic Subcutaneous Insulin Guidelines

Step Action Comments

1

• Measure blood glucose before meals and at bedtime, or every six hours if nothing by mouth

• Stop oral agents

• Order A1C if none obtained in past 30 days

Initiate protocol for:

•Patients with known DM

•Anyone with:• ≥ 2 random BG readings

> 180 mg/dL or• Fasting glucose > 126

mg/dL

Nau KC, et al. Am Fam Physician. 2010 May 1;81(9):1130-1135 35

Physiologic Subcutaneous Insulin Guidelines (contd…)


2Calculate initial total daily dose of insulin

• 0.3 IU/kg: underweight; older age; hemodialysis

• 0.4 IU/kg: normal weight

• 0.5 IU/kg: overweight

• ≥ 0.6 IU/kg: obese; glucocorticoids; insulin resistance




3 50 % of the total daily dose as long-acting basal insulin

Insulin glargine or NPH insulin used

4

50 % of the total daily dose as short-acting nutritional insulin given in three divided doses zero to 15 minutes before meals (if eating) or before bolus tube feeds

If continuous tube or parenteral feeds, consider every six hour dosing of short-acting or regular insulin; hold if nothing by mouth




5Select a scale of short-acting correctional insulin given zero to 15 minutes before meals

Use patient's insulin sensitivity as a guide for initial scale selection

6

Subsequent daily adjustment of total daily dose based on previous day's total units given

--

Nau KC, et al. Am Fam Physician. 2010 May 1;81(9):1130-113538

Correctional Insulin Dosing

Blood glucose level (mg/dL)

Insulin-sensitive dosing

(units of insulin)*

Standard dosing (units of

insulin)†

Insulin-resistant dosing

(units of insulin)‡

150 to 199 1 1 2200 to 249 2 3 4250 to 299 3 5 7300 to 349 4 7 10

> 349 5 + call 8 + call 12 + call

Nau KC, et al. Am Fam Physician. 2010 May 1;81(9):1130-113539

*— Total daily dose: less than 40 units.†— Total daily dose: 40 to 80 units.‡— Total daily dose: greater than 80 units.

CASE SCENARIO

• A 60 kg. male on OHA

• What are you going to do

• Basal insulin - 12 units

• Nutritional insulin - 4 units

40

CASE SCENARIO

• Overweight female aged 65 using human mixtard morning 32 and evening 24 units

• Basal insulin - 26 units

• Nutritional insulin - 10 units

• Correctional insulin - standard dosing

41

Case scenario56 year old woman with DM2 admitted with a diabetes-related foot infection which may require surgical debridement in the near future, eating regular meals.

- Weight: 100 kg- Home medical regimen: Glipizide 10 mg po qd, Metformin

1000 mg po bid, and 20 units of NPH q HS- Control: A recent HbA1c is 10%, POC glucose in ED 240 mg/dL

What are your initial orders for basal and nutritional insulin?How would you manage the oral agents?

Case scenario

• Discontinue oral agents

• Total daily dose 100 kg x 0.6 units/kg/day = 60

• Basal: Glargine 30 units q HS

• Nutritional: Rapid-acting analogue 10 units q ac at the first bite of each meal

• Correction: Rapid-acting analogue per scale q ac and HS (Note: Use correctional insulin with caution at HS, reduce the daytime correction by up to 50% to avoid nocturnal hypoglycemia)

Case scenario

The patient is made NPO after midnight for a test, but is expected to be able to resume her diet at lunch or dinner the next day. What changes would you make to her management program regarding glucose monitoring and her insulin program? Would you provide dextrose in her IV fluids?

Case scenario

• Change bedside glucose checks to q 6 hours, as the patient will not be eating meals

• Continue basal insulin: If using glargine, continue as is. If using NPH, continue in equal twice daily doses with a dose reduction of 1/3-1/2 while NPO.

• Hold nutritional insulin while NPO

• Provide a low level of intravenous dextrose (e.g. 75-125 cc/hr of a D5 containing solution)

• Continue appropriate correctional insulin for hyperglycemia

Case scenario

56 year old woman with type 1 diabetes admitted with a diabetes-related foot infection. The wound is an infected ulcer on the fifth digit with necrosis. The plan is for amputation first thing in the morning, so the patient will be NPO after midnight. However, she is expected to resume a regular diet at lunch the following day after surgery.

- Weight: 70 kg - Home medical regimen: 70/30 insulin 14 units BID- Control: A recent HbA1c is 9%, POC glucose in ED is 240 mg/dL

It is now dinner time, and the patient took her last dose of insulin before breakfast. What insulin would you give her now (before dinner) and how would you modify her regimen given the plan for NPO after midnight?

Case scenario

• TDD by weight = 70 kg x 0.4 units/kg/day = 28 units

• Her home TDD is 28, but patient has very poor control on this regimen, so increase (arbitrarily) by 20% = 34 units

• IV dextrose infusion while NPO (e.g. D5 at 75-150 cc/hr)

• Basal: Glargine 17 units q HS

• Nutritional: Rapid-acting insulin 6 units q ac at the first bite of each meal

• Correction: Rapid-acting insulin per scale q ac and HS

Post Operative Management: Goals

• In patients who are eating– Use regular/ rapid acting insulin before meals– 1 U insulin S.C for every 10-15 gm of

carbohydrate or by “Miami 4/12 rule”

Meneghini L, Perioperative management of diabetes: Translating evidence into

practice. Cleve Clin J Med. 2009 Nov; 76 Suppl 4:S53-9

48

Basal replacementWeight (kg) / 4

Prandial coverageWeight (kg) / 12

Example: 60 kg patientBasal: 60/4 = 15 U daily

Example: 60 kg patientPrandial: 60/12 = 5 U

before each meal

“Miami 4/12 rule”

Treatment of Hypoglycaemia in Hospitalized Patients

• Any BG <80 mg/dl:– Administer IV 50% dextrose = (100-BG) x 0.4 ml

• If eating, may use 15 g of rapidly absorbed carbohydrate (prefer glucose tablets)

• Do not hold insulin when BG is normal

Advice at Hospital Discharge

Umpierrez GE. Cleveland Clinic Journal Of Medicine 2011; 78 (6):379-384

strategies for preventing Hypoglycemia

• Less aggressive blood glucose targets (AACE/ADA guidelines blood sugar between 140-180mgs)

• Improved glucose monitoring• If Blood glucose level <100mgs reassess the

insulin protocol• If blood sugar <70mgs modify therapy • We should be very careful patients with altered

nutritional state heart failure renal or liver disease .malignancy, sepsis

• While reducing corticosteroid dose

Recommendations:Recommendations:Diabetes Care in the Hospital Diabetes Care in the Hospital

Goals for blood glucose levelsCritically ill patients• Initiate insulin therapy for persistent hyperglycemia starting no

greater than 180 mg/dL (10 mmol/L); once started, glucose range of 140–180 mg/dL (7.8–10 mmol/L) is recommended A

• More stringent goals, 110–140 mg/dL (6.1–7.8 mmol/L) may be appropriate for selected patients if achievable without significant hypoglycemia C

• Critically ill patients require an IV insulin protocol with demonstrated efficacy, safety in achieving desired glucose range without increasing risk for severe hypoglycemia E

ADA. 13. Diabetes Care in the Hospital, Nursing Home, and Skilled Nursing Facility. Diabetes Care 2015;38(suppl 1):S80

Recommendations:Recommendations:Diabetes Care in the Hospital Diabetes Care in the Hospital

Goals for blood glucose levelsNon-Critically ill patients• If treated with insulin, generally premeal blood glucose targets of

<140 mg/dL (7.8 mmol/L) with random blood glucose <180 mg/dL (10.0 mmol/L) are reasonable, provided these targets can be safely achieved. C– More stringent targets may be appropriate in stable patients with previous tight

glycemic control. – Less stringent targets may be appropriate in those with severe

• A basal plus correction insulin regimen is the preferred treatment for patients with poor oral intake or who are taking nothing by mouth (NPO). An insulin regimen with basal, nutritional, and correction components is the preferred treatment for patients with good nutritional intake. A

ADA. 13. Diabetes Care in the Hospital, Nursing Home, and Skilled Nursing Facility. Diabetes Care 2015;38(suppl 1):S80

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Critical care ppt

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