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- 1. MANAGEMENT OF DIABETES IN THE ICU DR A P Naveen Kumar Chief Specialist ( Gen. Med. ) Visakha Steel General Hospital
- 2. 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
- 3. Counterregulatory hormones • Cortisol • Catecholamines • Glucagon • Growth Hormone Glucose utilization Glucose production Glucose FFAs Lipolysis FFAs (-) (-) Stress HyperglycemiaStress Hyperglycemia Metchick LN et al, Am J Med 113:317, 2003 Kitabchi AE, Diabetes Care 24:131, 2001 (-)
- 4. 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.
- 5. 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% * Mortality(%) * P < 0.01 Umpierrez GE et al, J Clin Endocrinol Metabol 87:978, 2002 0 10 20 30
- 6. 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 Hospital Complications
- 7. Hyperglycemia*: A Common Comorbidity in Medical-Surgical Patients in a Community Hospital 62%62% 12%12% 26%26% Normoglycemia Known DiabetesKnown Diabetes New 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
- 8. 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.
- 9. 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
- 10. 0 2 4 6 8 10 12 14 16 <150 150-175 175-200 200-225 225-50 >250 Average Post-operative glucose (mg/dl) Mortality Cardiac-related mortality Noncardiac-related mortality Mortality of DM Patients Undergoing CABG Furnary et al J Thorac Cardiovasc Surg 2003;123:1007-21
- 11. How do we know that hyperglycemia is bad? • Hyperglycemia associated with morbidity and mortality in various epidemiologic studies Myocardial infarction Stroke Trauma Surgery Medical ICU Burns Pediatric ICU
- 12. 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
- 13. 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
- 14. 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
- 15. 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.
- 16. 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.
- 17. Glycemic Threshold in Acute MI and Intervention (PTCA) DIGAMI supports BG < 180 mg/dl Minimal 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
- 18. AACE-ADA Consensus Statement on Inpatient 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
- 19. 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 Recommended 140–180 mg/dL May be appropriate 110–140 mg/dL Not recommended <110 mg/dL Not recommended >180 mg/dL
- 20. Insulin The most powerful agent we have to control glucose only
- 21. 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.
- 22. 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
- 23. 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
- 24. 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 1 121–180 0 1 2 181–240 4 2 3.5 241–300 8 3.5 5 301–360 12 5 6.5 > 360 16 6.5 8
- 25. 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 change If < 10% lower or higher BG, ↓ by 1 IU/hr 201-250 If lower BG, no change If higher, ↓ by 0.5 IU/hr 151-200 No change in drip rate 101-150 If < 10% lower BG, ↓ by 0.5 IU/hr If > 10% lower BG, ↓ rate by 50% < 100 Hold insulin (25 ml of 50% dextrose if BG < 75). When BG >150 mg/dl, restart at 50% of previous rate
- 26. 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
- 27. 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 250-299 3 units/hour 300-349 3.5 units/hour 350-399 4 units/hour
- 28. Algorithm 1: Start with most patients Algorithm 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 60 61-109 Call Anesthesiologist Hold insulin infusion, check glucose in 1 hour And 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________
- 29. 65 yo Male without a previous hx of DM, s/p CABG x3 and MVR NPO, BS= 162. BG q 1 hour Using the Insulin DripUsing the Insulin Drip
- 30. 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 ofGive a Bolus of 33 unit(s)unit(s) Increase Drip Rate byIncrease Drip Rate by 11 unit(s) tounit(s) to 33 unit(s)unit(s)
- 31. 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 200-249 6 units Regular insulin; Recheck glucose value in 3 hours 250-299 8 units Regular insulin; Recheck glucose value in 3 hours 300+ 10 units Regular insulin; Recheck glucose value in 3 hours
- 32. Basal Insulin 32
- 33. 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
- 34. 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
- 35. 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
- 36. Physiologic Subcutaneous Insulin Guidelines (contd…) Step Action Comments 2 Calculate 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 Nau KC, et al. Am Fam Physician. 2010 May 1;81(9):1130-1135 36
- 37. Physiologic Subcutaneous Insulin Guidelines (contd…) Step Action Comments 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 Nau KC, et al. Am Fam Physician. 2010 May 1;81(9):1130-1135 37
- 38. Physiologic Subcutaneous Insulin Guidelines (contd…) Step Action Comments 5 Select 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):1130-1135 38
- 39. 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 2 200 to 249 2 3 4 250 to 299 3 5 7 300 to 349 4 7 10 > 349 5 + call 8 + call 12 + call Nau KC, et al. Am Fam Physician. 2010 May 1;81(9):1130-1135 39 *— Total daily dose: less than 40 units. †— Total daily dose: 40 to 80 units. ‡— Total daily dose: greater than 80 units.
- 40. CASE SCENARIO • A 60 kg. male on OHA • What are you going to do • Basal insulin - 12 units • Nutritional insulin - 4 units 40
- 41. 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
- 42. Case scenario 56 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?
- 43. 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)
- 44. 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?
- 45. 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
- 46. 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?
- 47. 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
- 48. 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 48 Basal replacement Weight (kg) / 4 Basal replacement Weight (kg) / 4 Prandial coverage Weight (kg) / 12 Prandial coverage Weight (kg) / 12 Example: 60 kg patient Basal: 60/4 = 15 U daily Example: 60 kg patient Basal: 60/4 = 15 U daily Example: 60 kg patient Prandial: 60/12 = 5 U before each meal Example: 60 kg patient Prandial: 60/12 = 5 U before each meal “Miami 4/12 rule” “Miami 4/12 rule”
- 49. 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
- 50. Advice at Hospital Discharge Umpierrez GE. Cleveland Clinic Journal Of Medicine 2011; 78 (6):379-384
- 51. 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
- 52. Recommendations:Recommendations: Diabetes Care in the HospitalDiabetes Care in the Hospital Goals for blood glucose levels Critically 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
- 53. Recommendations:Recommendations: Diabetes Care in the HospitalDiabetes Care in the Hospital Goals for blood glucose levels Non-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
- 54. THANK YOU
Editor's Notes
- UMPIERREZ
- UMPIERREZ
- The Increasing Rate of Diabetes Among Hospitalized Patients Data regarding the burden of diabetes among hospitalized patients is somewhat difficult to determine because diabetes is reflected in multiple codes in the International Classification of Diseases, Ninth Revision. In the 1990s the number of hospital discharges with diabetes as the first-listed diagnosis began increasing. http://www.cdc.gov/diabetes/statistics/dmany/fig1.htm. Accessed June 15, 2004.
- UMPIERREZ
- UMPIERREZ
- UMPIERREZ In a more recent study that involved 2020 consecutive patients admitted to a community hospital in Atlanta, we found that 64% of patients had normal glucose values, 26% had a prior history of diabetes, and that 12% of patients with hyperglycemia, as determined by 2 or more FBG &gt; 126 or RBG &gt; 200, did not had a know history of diabetes prior to admission.
- Hyperglycemia in Patients With Undiagnosed Diabetes New hyperglycemia was defined as an admission or in-hospital fasting glucose level of 126 mg/dL (7 mmol/L) or more or a random blood glucose level of 200 mg/dL (11.1 mmol/L) or more on 2 or more determinations. Hyperglycemia was present in 38% of patients admitted to the hospital, of whom 26% had a known history of diabetes, and 12% had no history of diabetes before admission. Newly discovered hyperglycemia was associated with a higher in-hospital mortality rate (16%) compared with patients with a history of diabetes (3%) and patients with normoglycemia (1.7%; both P &lt; 0.01). In addition, new hyperglycemic patients had longer hospital stays and a higher admission rate to an intensive care unit, and were less likely to be discharged to home, frequently requiring transfer to a transitional care unit or nursing home facility. The results indicate that in-hospital hyperglycemia is a common finding and represents an important marker of poor clinical outcome and mortality in patients with and without a history of diabetes. Patients with newly diagnosed hyperglycemia had a significantly higher mortality rate and a lower functional outcome than patients with a known history of diabetes or normoglycemia. 1. Umpierrez GE, Isaacs SD, Bazargan N, et al. Hyperglycemia: an independent marker of in-hospital mortality in patients with undiagnosed diabetes. J Clin Endocrinol Metab. 2002;87:978-982.
- Due to the critical gaps in our understanding of the relationship between hyperglycemia and poor outcomes, these recommendations should be viewed by clinicians only as a general reference.
- Recommendations
- SCHMIDT
- SCHMIDT
- SCHMIDT
- The best way to provide nutritional insulin depends on the type of nutrition the patient is receiving. When patients are eating discrete meals, a rapid-acting or regular insulin best mirrors the glycemic peak that is caused by the meal. One of the advantages to providing a physiologic insulin regimen with separate basal and nutritional insulin is that, when a patient is not receiving any nutrition (which commonly occurs in the hospital setting), the nutritional insulin can be held without upsetting the basal insulin regimen. Ideally, the amount of nutritional insulin provided at any time would be derived from the exact amount of carbohydrate that a patient will consume. However, in real practice this can be difficult to do. As a general rule, 1/2 of the TDD can be provided as nutritional insulin (divided equally among the meals or tube feed boluses) if a patient is consuming a “normal” amount of carbohydrates. If nutrition is reduced, however, the amount of nutritional insulin must be reduced proportionately.
- Correctional insulin is the name for the small amounts of insulin that are given to patients, in addition to basal and nutritional insulin, when hyperglycemia results despite the use of the a physiologic insulin regimen. Hyperglycemia often results because of imperfect calculations of insulin needs, and imperfect intake and timing of nutrition. Correctional insulin is usually provided as relatively small doses of rapid-acting or regular insulin, given in a dose that is specifically designed to reduce the patient’s blood glucose back into the target range. For patients receiving nutritional insulin, the correctional insulin is usually the same type of insulin as the nutritional insulin. Correctional insulin is often written in a “stepped” format, to provide the appropriate amount of insulin for a given blood glucose value. Correctional insulin is often given with meals in patients who are eating, or every 4-6 hours in patients who are not. It differs from the traditional sliding-scale in that it is not used alone, and in that it should be customized for each patient. Most standardized order sets for subcutaneous insulin provide several choices of different scales to choose from, depending on the patient’s weight or TDD. Perhaps the most important point regarding the use of correctional insulin is this: If correctional insulin is required consistently, or in high doses, it suggests a need to modify the basal and/or nutritional insulin. Remember, a well designed, physiologic insulin regimen should provide good glycemic control, without having to constantly add correctional boluses.
- Note that the HbA1c is available on this patient, and can be used to help you estimate both the immediate and long-term (e.g. discharge) insulin requirements of the patient. We recommend that providers order HbA1c in inpatients with hyperglycemia if a recent value is not already available in the medical record. (Note: HbA1c values may be inaccurate in patients who have been recently transfused red blood cells.)
- Eating hospitalized patients should have fingerstick glucose measurements at least q AC and HS. If eating discrete meals, one might have been tempted to continue the patient on the home diabetes regimen. In this case the arguments for converting to a physiologic, basal-bolus insulin regimen are: The patient will never achieve adequate glucose control without a better insulin program (i.e. she needs it anyway). Her HbA1c is well above the target range despite treatment with high doses of oral agents and night-time NPH, and A basal-bolus insulin program will provide flexible control for her in the rapidly changing hospital environment (e.g. if she needs to be NPO for a procedure, which is a real possibility). A sulfonylurea would increase the patient’s risk for hypoglycemia in the hospital. Although metformin could be continued along with the insulin, the disadvantages to using metformin in the hospital (discussed above) make it reasonable to discontinue it as well, at least for now. Step 1: Estimate the amount of insulin the patient would need, if getting adequate nutrition = total daily dose (TDD) Because the patient is obese and very poorly controlled on 2 oral hypoglycemic agents in addition to 20 units of NPH, 0.6 units/kg/day is a safe and reasonable starting point in this patient. Starting with 0.5 units/kg/day would have also been reasonable. For an insulin naïve patient, or a patient on a low dose of an oral hypoglycemic agent with a glucose measurement near the target range, it would be safer to start with a lower starting estimate, such as 0.3 units/kg/day x 100 kg = 30 units, or to use correctional insulin alone for 24 hours to assess her insulin needs. Step 2: Assess the patient’s nutritional situation This patient is eating, so insulin is provided in nutritional boluses, timed with meals. Step 3: Decide which components of insulin the patient will require, and which percentage of the TDD each should represent. In this case, 50% of the TDD would be given as basal insulin. As mentioned above, glargine (or detemir) is preferred over NPH, as it most closely mimics physiologic basal insulin secretion. However, if necessary, NPH insulin can be used. If NPH insulin is used to provide basal insulin, some experts would recommend giving 2/3 of the NPH in the morning, and 1/3 at night, if the patient is eating meals. In this way, part of the morning NPH would actually act as nutritional insulin covering the lunch intake, and the lower dose of NPH at night would be less likely to cause hypoglycemia. However, a conservative estimate of basal insulin can also be split into two equal daily doses of NPH. The dose of rapid-acting analogue shown in this solution would presume that the patient is taking in 100% of each meal. Medical judgment is always needed in selecting a dose. A patient eating only half of the projected carbohydrate load should take only half of the above nutritional insulin.
- Step 1: Estimate the amount of insulin the patient would need, if getting adequate nutrition = total daily dose (TDD) We have already estimated her TDD to be 60 units/day. Step 2: Assess the patient’s nutritional situation The patient’s nutritional situation is changing, mandating a change in her insulin regimen. She will now be receiving no significant calories, as she will not be eating meals. Step 3: Decide which components of insulin the patient will require, and which percentage of the TDD each should represent.Since the patient is on a physiologic insulin regimen already, it is easy to manage her during this time of NPO by simply eliminating her nutritional insulin. Her basal insulin needs will not change, and therefore we can continue this component of her treatment. If glargine insulin had been chosen as her basal insulin, it could be continued without change. If NPH insulin were chosen as her basal insulin, then the dose should reduced by 1/3-1/2 and it should be provided in equal twice daily doses. If the patient were not on a physiologic insulin program, the management of her NPO status could become much more difficult. For example, if she were on a twice a day 70/30 insulin program, the clinician would need to change her insulin completely to provide basal insulin (which she needs) without nutritional insulin (which she does not need), by calculating the amount of basal insulin contained in the mixed doses. Since the patient is being given basal insulin, and no other nutritional source, we favor a low rate of intravenous dextrose to provide a buffer to hypoglycemia (e.g. 75-125 cc/hr of a 5% dextrose solution). It is also reasonable to continue to provide correctional insulin, as discussed above.
- As in the previous case, there is a temptation to continue the patient on her outpatient insulin regimen. It would be easy to simply give her home 70/30 dose. In some situations, continuing the patient’s home insulin regimen may be a reasonable starting point at the time of admission (e.g. patient is eating normally, illness is not severe, control is adequate). In this case, reinventing her insulin program is a better options for two reasons: The patient’s current TDD is totally inadequate, as evidenced by her elevated HbA1c, and In the hospital, her home 70/30 regimen will be somewhat difficult to manage, not offering the flexibility of a physiologic insulin regimen with separate basal and nutritional components. In this patient’s case, this is a particularly important point. This patient has type 1 diabetes and needs exogenous basal insulin provided 100% of the time. Even short periods without insulin have the potential to lead to diabetic ketoacidosis. However, after her next meal, she will no longer need nutritional insulin until she resumes her diet postoperatively (which is likely to be lunch the next day). So, the clinician needs to provide her with the appropriate nutritional insulin for her dinner (now) and then the appropriate basal insulin to get her through much of the day (tomorrow). The simplest way to do all this is to resort to the principles of physiologic insulin dosing discussed here. Step 1: Estimate the amount of insulin the patient would need, if getting adequate nutrition = total daily dose (TDD) In this case, the weight-based TDD calculation using 0.4 units/kg/day gives you a result of 28 units, which happens to be her current outpatient TDD. However, you should also recognize that her current dose is inadequate, so this TDD should be adjusted accordingly (e.g. upwards by 10-20%). Step 2: Assess the patient’s nutritional situation This patient is about to eat, so it would be appropriate to give her a dose of nutritional insulin now, in addition to the appropriate correctional dose of the same insulin. However, after this meal, beginning at midnight, the patient will be made NPO, and will not need further nutritional insulin until she resumes her diet. Step 3: Decide which components of insulin the patient will require, and which percentage of the TDD each should represent. In this case, as in the last example, 50% of the TDD is given as basal insulin. In this case, the best option would be to use glargine (or detemir), with the first dose given either now or at bedtime. This will provide an appropriate amount of basal insulin for the next 24 hours. NPH could be substituted if necessary, but this insulin would be losing its effect by morning, and would require redosing in the morning. In either case, it would be prudent to start a low rate of a D5 containing solution at midnight, and to check a 2 a.m. or 3 a.m. glucose over night. An arguably better alternative in this case would be to start an intravenous insulin infusion, which could then be continued through the surgery and until the patient resumed a diet.
- Whenever there is hypoglycaemia in a patient who is NPO , use 50% dextrose. Amount of dextrose to be given is arrived at by the formula (100-BG) x 0.4 ml IV, where BG is the current glucose level. If the patient is on oral feeds 15 Gm of glucose is a good choice. When the blood glucose returns to normal, it is recommended that insulin is continued.