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In-patient & Perioperative

Management of Hyperglycemia

Luigi Meneghini, MD, MBA

Professor, Internal Medicine (Endocrinology), UT Southwestern Medical Center

Executive Director, Global Diabetes Program, Parkland Health & Hospital System

Novo Nordisk – advisory board & consultant

Sanofi Aventis – advisory board & consultant

Dyaeli Kunkel – wife, mother of my children & rock of my life

Testing Kahoot

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Test Question

Where would you rather be this very moment?• On a beach in the Virgin Islands soaking up some rays• Teeing off on the Master’s course in Augusta• Having a three star Michelin meal in Paris• Right here baby, this is the only place I want to be!!!

In-patient glycemic targets & strategies

Physiologic insulin replacement

Initiating basal/bolus insulin therapy in the hospital

Addressing in-patient variables

–Enteral feeds

–Steroids

Perioperative management

In-Patient Glycemic Targets &

Strategies

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Moghissi ES, et al; AACE/ADA Inpatient Glycemic Control Consensus Panel. Endocr Pract. 2009;15(4). http://www.aace.com/pub/pdf/guidelines/InpatientGlycemicControlConsensusStatement.pdf.

AACE/ADA Recommended Target

Glucose Levels in ICU Patients

ICU setting:

–Starting threshold of no higher than 180 mg/dL

–Once IV insulin is started, the glucose level should be

maintained between 140 and 180 mg/dL

–Lower glucose targets (110-140 mg/dL) may be appropriate in

selected patients

–Targets <110 mg/dL or >180 mg/dL are not recommended Recommended140-180

Acceptable110-140

Not recommended<110

Not recommended>180

What About Glycemia Management for

Non-Acute Care Patients?

AACE/ADA Target Glucose Levels

in Non–ICU PatientsNon–ICU setting:

–Premeal glucose targets <140 mg/dL

–Random BG <180 mg/dL

–To avoid hypoglycemia, reassess insulin regimen if

BG levels fall below 100 mg/dL

–Occasional patients may be maintained with a glucose range below and/or above

these cut-points

Hypoglycemia = BG <70 mg/dLSevere hypoglycemia = BG <40 mg/dL

Moghissi ES, et al; AACE/ADA Inpatient Glycemic Control Consensus Panel. Endocr Pract. 2009;15(4). http://www.aace.com/pub/pdf/guidelines/InpatientGlycemicControlConsensusStatement.pdf

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2012 Recommendations:

Pharmacologic Therapy in the Hospital

“We suggest discontinuation of oral agents and initiation of insulin therapy for the

majority of patients with type 2 diabetes at the time of hospital admission”

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“We recommend scheduled SC insulin therapy consisting of basal or intermediate-

acting insulin given once or twice daily in combination of rapid or short-acting

insulin administered before meals in patients who are eating.”

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JCEM 2012;97:16-38

Physiologic Insulin Replacement

Physiologic insulin replacement

[in any patient]

325

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Physiologic insulin secretion & replacement

Basal

Mealtime

Corrective

Concept of basal bolus insulin Rx

325

BID optionsNPH

LevemirQD options

Glargine U100Degludec

Glargine U300

RegularAspart/Lispro/Glulisine

RegularAspart/Lispro/Glulisine

Initial basal/bolus prescription…

…Start with Total Daily Dose (TDD)

Weight-based calculation

Based on prior insulin Rx

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Estimating Basal & Prandial Insulin Doses

Total Daily Dose (TDD)0.5 or 0.3 u/kg/day

Total BASAL dose

50% of TDD

Total PRANDIAL dose

50% of TDD

NPH twice dailyGlargine once daily

Distribute with mealsRegular, aspart, lispro 3 times daily

Take into account age, weight & renal function

56 y/o T2DWeight 96kg

eGFR > 60 cc/min

TDD0.5 u/kg/d x 96kg

48 units

Basal50% of 48

24 units daily

Prandial50% of 48 3 meals

8 units QAC

Basal-Bolus Calculator for Inpatient Insulin

Initiation

Conditions

Basal & Prandial Insulin Replacement*

Pla

sm

a In

su

lin

(µ

U/m

l)

Prandial (8 u)

Basal(24 u)

4:00 16:00 20:00 24:00 4:00 8:0012:008:00

Basal

Prandial (bolus)Prandial

(8 u) Prandial

(8 u)

* Note: Total Daily Dose (TDD) of insulin is 48 units a day

+ Correction scale

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Correction Scales Based on TDD

Pre-meal BG (mg/dl) Additional insulin

150-199 1 unit

200-249 2 units

250-299 3 units

300-349 4 units

>349 5 units

Low Dose: TDD < 40 units/day

Pre-meal BG (mg/dl) Additional insulin

150-199 2 units

200-249 4 units

250-299 7 units

300-349 10 units

>349 12 units

High Dose: TDD > 80 units/day

Pre-meal BG (mg/dl) Additional insulin

150-199 1 unit

200-249 3 units

250-299 5 units

300-349 7 units

>349 8 units

Medium Dose: TDD 40-80 units/day

Pre-meal BG (mg/dl) Additional insulin

150-199 ___ unit(s)

200-249 ___ units

250-299 ___ units

300-349 ___ units

>349 ___ units

Individualized Algorithm

Case Presentation

52 y/o T2D x 18 yrs admitted w/ TIAMeds: metformin, glyburide, NPH 48 u at HSAdmission A1C: 8.9%FPG (mg/dl): 142, 165, 133Weight 132kgeGFR > 60 cc/min

Question 1

What would you do with his outpatient medications?• Discontinue all outpatient meds & start correction scale• Stop the oral anti-diabetic meds and continue NPH insulin• Stop all meds and start basal-bolus insulin replacement• Call the diabetes consultation team

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Case Presentation

Meds

–Hold metformin & glyburide

–Switch NPH to BID or use basal insulin analog (i.e. glargine)

Insulin

–Continue basal insulin replacement (current or re-calculate)

–Start prandial (mealtime) insulin replacement

–Add rapid-acting insulin correction scale

Monitoring

–Pre-meal and bedtime or q4-6 hrs if NPO

Question 2

What is the correct weight-based TDD (Total Daily Dose) of insulin?• 40 units• 48 units• 66 units• Who cares, I already called a diabetes consult

Age 52Weight 132kg

eGFR > 60 cc/min

Case Presentation

Insulin

–TDD = 132 kg x 0.5 units/kg/day = 66 units

–Continue basal insulin replacement

–66 units 2 = 33 units daily

–Start prandial insulin coverage

–33 units 3 = 11 units QAC

–Rapid-acting insulin correction scale

–Consider medium SS

Monitoring

–Before meals & at bedtime

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Question 3

What is the correct insulin dose adjustment based on the CBG values?• Increase breakfast Aspart dose• Increase lunch Aspart dose• Increase breakfast & dinner Aspart and reduce Glargine dose• Really, I did call the diabetes consult service, so stop asking!

Breakfast Lunch Dinner Bedtime 3AM

89 239 146 275 227

122 311 124 237 209

109 197 203 282 201

Glargine 33u QPMAspart 11u QACAspart MOD scale

℞

Addressing Inpatient VariablesEnteral (Tube) Feeds

Enteral (tube) feeds

Enteral feeds: continuous

–Use Regular insulin (Q6 hrs) or rapid-acting insulin analog (Q 4hrs)

–Start 1 unit of insulin SQ to cover 10-15 grams of carbohydrates

Enteral feeds: bolus

–Start 1 unit of insulin SQ per 10-15 grams of carbohydrates (inject 15-20 min prior to bolus)

Enteral feeds: nocturnal

–Consider NPH insulin SQ 1 u per 10-15 gram of carbohydrates

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Estimating Insulin-to-Carbohydrate (CHO)

Ratio

Estimate TDD

Rule of 500 (analogs)

–500 ÷ TDD = grams of CHO covered by 1 unit insulin

Rule of 450 (Regular insulin)

–450 ÷ TDD = grams of CHO covered by 1 unit insulin

Case Presentation

59 y/o admitted w/ dysphagia & swallowing difficultiesInpatient insulin: Glargine (basal) 18 units QD plus Regular insulin MOD correction scaleAdmission A1C: 8.3%Weight 64kgTo start tube feeds between 8PM 8AM with Peptamen(0.128 g of CHO per ml) & increase to 80 cc/hr ~ 10 grams CHO per hour

Question 4

Approximately what amount of carbohydrates (CHO) will the patient get between 8PM 8AM?• 10 grams of CHO• 123 grams of CHO• 246 grams of CHO• Sorry, I don’t have a calculator on me

Age 59Weight 64kg

eGFR > 60 cc/minPeptamen: 0.128g CHO/ml

at 80 ml/hr

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Question 5

What insulin do you order for nutritional coverage?(assume we will use 1u insulin per 10g CHO)• NPH 6u Q12 hours• Regular insulin 6u at 8PM and 6u at 2AM• Aspart 4u at 12AM, 4AM & 8AM• Can I call a dietitian consult instead?

Age 59Weight 64kg

eGFR > 60 cc/minPeptamen: 123g CHO over

12 hours

Case Presentation

Continue prior basal insulin replacement & correction scale

Add nutritional insulin coverage

–For enteral feeds assume Insulin:CHO of 1:10

–Patient receiving 10 grams CHO per hour

–10g/hr x 12 hrs = 120 g/12 hrs = 12 units insulin

–Regular insulin 6 units Q6 hrs (8PM, 2AM)

–Rapid-acting analog (lispro, aspart or glulisine) 4 units Q4 hrs (8PM, MN, 4AM)

Glucose monitoring & supplements–Every 6 (regular) to 4 (lispro, aspart, glulisine) hours for correction

Insulin adjustment Regular insulin dose to 8-10 units at 8PM and 2AMNo change to basal or SS for now

Case Presentation

8AM Noon 4PM 8PM MN 4AM

272 133 120 144 231 286

299 142 103 103 269 324

286 111 96 129 305 297

Insulin prescription

–Basal: Insulin glargine 9 units BID

–Nutritional: Regular insulin 6 units at 8PM and 2AM

–Correctional: Regular insulin LOW correction scaleNGT feeds

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Addressing Inpatient VariablesCorticosteroids

Effect of corticosteroids of plasma glucoseProfiles following Hydrocortisone 100 mg = Prednisone 25 mg

Plat, et al. Am J Physiol 1996 Jan;270(1 Pt 1):E36-42. Hwang, et al. DMRR 2014; 30(2): 96

CO

RTI

SOL

(nm

ol/

L)

cortisolinsulin

appearance of insulin resistance Increased free fatty acid release in bloodstream

PEPCK: phosphoenylpyruvate carboxykinase

Coverage for corticosteroid-induced

hyperglycemia

New to glucocorticoid therapy

–Monitor BG for 24-48 h with correction scale to identify those who will

need extra coverage

History/persistent glucocorticoid-induced hyperglycemia

–Start NPH administered at same time as steroids

Seggelke SA et al. J Hosp Med 2011; 6: 175-176. Clore JN et al. Endocrine Practice. 2009. 15:469-474.

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NPH Coverage for Steroid-Induced

Hyperglycemia

Clore JN et al. Endocrine Practice. 2009. 15:469-474.

Perioperative Diabetes Management

0

2

4

6

8

10

12

14

16

< 150 150–175 175–200 200–225 225–250 > 250

Average Postoperative Glucose (mg/dL)

Mort

alit

y %

Furnary et al. J Thorac Cardiovasc Surg. 2003;125:1007-1021.

Cardiac-related mortality

Noncardiac-related mortality

Post-CABG

Increased mortality with increasing mean BG

after CABG (coronary artery bypass)

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Lower mortality after CABG using IV

insulin for BG control

Furnary AP et al. J Thorac Cardiovasc Surg. 2003;125:1007-1021.

10

8

6

4

0

Mort

alit

y (%

)

87 88 89 90 91 92 93 94 98 99 00

Year

Patients with diabetes

Patients without diabetes

2

95 96 97 01

IV Insulin Protocol

More complication in patients with

diabetes after non-cardiac surgery

0%

2%

4%

6%

8%

10%

12%

14%

Death Pneumonia* Woundinfection*

Sepsis/bact* UTI* AMI* ARF*

Diabetes Non-DM

Frisch, et al. Diabetes Care 2010; 33: 1783-1788

* P < 0.05

What is an acceptable A1C in patients planning elective surgeries?

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What A1C level is acceptable for

elective surgeries?

< 8.5%if it is safe to do so

What is an acceptable intra-operative blood glucose range?

Perioperative target blood glucose

should be…

Dhatariya, et al. Diabetic Medicine 2012; 29: 420-433. ADA Standards. Diabetes Care 2017; 40: S1-S136

106 – 180 mg/dlup to 216 mg/dl acceptable

80 – 180 mg/dl

“Beyond avoidance of marked hyperglycemia and hypoglycemia, the optimal perioperative glucose targets are unclear”

Anywhere between 100 – 220 mg/dl should be appropriate

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Which diabetic therapies should you omit the day of surgery?

Outpatient pre-operative glycemic

management: patient instructions

Hold oral anti-diabetic agents the morning of surgery

Hold non-insulin injectables the morning of surgery

Hold rapid-acting (prandial) insulin the morning of surgery

Adjust the basal insulin

Basal insulin adjustments pre-operatively

Night/evening before surgery

Morning/day of surgery

Intermediate-acting(NPH)

20% 50%

Long-acting(Glargine, Detemir,

Degludec)

20%

Premix(70/30, 75/25)

50%

Society of Hospital Medicine. 2015

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What criteria should you use for using IV (intravenous) insulin versus SQ (subcutaneous)

insulin perioperatively?

Intra-operative insulin management: IV or

SQ?

Duration of surgery Complexity of surgery:CABG, organ transplant, prolonged neurosurgical

Perioperative and intraoperative blood

glucose monitoring

Subcutaneous Intravenous

Q 2-4 hours Q 1-2 hours

Use rapid-acting analog for correction

Use Regular insulinfor correction

Parkland Intraoperative insulin protocol

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Transitioning to post-op glycemic

management

Subcutaneous Intravenous

325

Parkland perioperative insulin protocol

Global Diabetes Program

Quality Improvement Initiative with Hospitalist U Team

(Limb Salvage Team)

Perioperative Insulin Management Protocol

Inpatient Podiatry Service

ANESTHESIASURGERY NURSINGPHARMACYHOSPITAL MEDICINE

INFORMATION TECHNOLOGY

For copy of insulin dose calculator or perioperative protocol, please e-mail luigi.meneghini@utsouthwestern.edu