management of hyperglycemia in hospitalized patients-esc-2012

7/27/2019 Management of Hyperglycemia in Hospitalized Patients-ESC-2012

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MANAGEMENT OF HYPERGLYCEMIA IN HOSPITALIZEDPATIENTS IN NON-CRITICAL CARE SETTING:

AN ENDOCRINE SOCIETY CLINICAL PRACTICE

GUIDELINE

(J Clin Endocrinol Metab 97: 16 –38, 2012)



Introduction

• Stress hyperglycaemia generally refers to transient hyperglycaemiaduring illness and is usually restricted to patients without previousevidence of diabetes.

• No guidelines specifically define stress hyperglycaemia.

• In a technical review written by the Diabetes in Hospitals WritingCommittee of the American Diabetes Association (ADA), (Clement S, Diabetes Care

2004; 27 : 553 –91) patients are classified into one of three groups—

• known diabetes,

• newly diagnosed diabetes, and

• hospital-related hyperglycaemia.



Defining Stress Hyperglycemia

• According to the ADA consensus definition (fasting

glucose >125 mg% or random glucose >200 mg% without

evidence of previous diabetes)

• Also pre-existing diabetes with deterioration of pre-illness

glycaemic control.

• The most appropriate cut off point for stresshyperglycaemia in patients with pre-existing diabetes

needs to be established.



ESC guidelines 2012

• In-hospital hyperglycemia is defined as any glucose value greater than 7.8 mmol/liter

(140 mg/dl)

• Observational studies report that hyperglycemia is present in 32 to 38% of patients in

community hospitals

• 41% of critically ill patients with acute coronary syndromes

• 44% of patients with heart failure

• 80% of patients after cardiac surgery

• Hyperglycemia was found in 1/3 of non-intensive care unit (ICU) patients and

approximately 80% of ICU patients had no history of diabetes before admission



Glycemic Targets and Approaches to Management

of the Patient with Critical Illness

The statistical association in observational studies between blood glucose level andrisk of death follows a J-shaped curve, with normal, fasting blood levels associatedwith lowest risk of death. In patients with diabetes mellitus this curve is blunted andshifted toward higher blood glucose level

Dieter Mesotten & Greet Van den Berghe Curr Diab Rep (2012) 12:101 –107



The NICE-SUGAR (Normoglycemia in Intensive Care Evaluation and Survival Using Glucose Algorithm

Regulation) trial was not a true confirmation study of the Leuven surgical intensive care unit (SICU)

study. Despite using similar blood glucose targets for the intervention group, the Leuven SICU and

NICE-SUGAR differed in the targets for the control group. Whereas in the Leuven SICU study

hyperglycemia up to the renal threshold was accepted, NICESUGAR, already affected by the results

from the Leuven SICU study, used an intermediate blood glucose target for the control group



Kansagara et al.

• Meta-analysis of 21 RCTs in ICU, myocardial infarction, perioperative care,

stroke or brain injury.

• 14,768 hospitalized patients.

• Results of this analysis showed that IIT (intensive insulin therapy) did not

affect short-term mortality or the need for renal replacement therapy, infection

rates, or hospital LOS.

• Moreover, a high risk for severe hypoglycemia was identified in all hospital

settings.

Kansagara, D., R. Fu, M. Freeman, et al., Intensive insulin therapy in hospitalized patients: a systematic

review. Ann Intern Med, 2011; 154(4): p. 268 –82.



ACP recommendations

• The American College of Physicians (ACP) recently published recommendationsfor the management of inpatient hyperglycemia based on the systematic review byKansagara et al. sponsored by the Department of Veterans Affairs.

• The ACP advocates for target blood glucose level of 7.8 –11.1 mmol/L (140 –200

mg/dL) when insulin therapy is used in SICU/ MICU patients.

• Their recommendations are based on current evidence demonstrating noreductions in mortality with target blood glucose levels of 4.4 –6.1 mmol/L (80 –110mg/dL) when compared with higher targets.

• These tight targets are associated with a higher risk for hypoglycemia.

• They also recommend allowing blood glucose levels to rise above 10.0 –11.1mmol/L (180 –200 mg/dL) before initiating therapy

Qaseem, A., L.L. Humphrey, R. Chou, et al., Use of intensive insulin therapy for the management of glycemic control in hospitalizedpatients: a clinical practice guideline from the American College of Physicians. Ann Intern Med, 2011; 154(4):

p. 260 –7.



SUMMARY OFRECOMMENDATIONSESC 2012



Diagnosis and recognition of hyperglycemia

and diabetes in the hospital setting

• Recommend that clinicians assess all patients

admitted to the hospital for a history of diabetes.

• All patients, independent of a prior diagnosis of diabetes, have laboratory blood glucose (BG)

testing on admission.

• Non Diabetic with BG>140MG% be monitored

bedside for 24-48 hrs. Sustained elevation

requires treatment.



Diagnosis and recognition of hyperglycemia

and diabetes in the hospital setting

• Previously normoglycemic patients receiving therapies

associated with hyperglycemia, such as corticosteroids or

octreotide, enteral nutrition (EN) and parenteral nutrition

(PN) be monitored with bedside POC testing for at least

24 to 48 h after initiation of these therapies.

• Recommended that all inpatients with known diabetes or

with hyperglycemia (>140mg%) be assessed with a

hemoglobin A1C (HbA1C) level if this has not been

performed in the preceding 2 –3 months.



Monitoring glycemia in the non-critical care

setting

• Bedside capillary POC testing as the preferred method.

• Timing of glucose measures match the patient’s nutritional

intake and medication regimen.

• Before meals and at bedtime in patients who are eating.

• Every 4 –6 h in patients who are NPO or receivingcontinuous enteral feeding.



Glycemic targets in the non-critical

care setting • Premeal glucose target of <140 mg/d and a random BG of

< 180 mg/dl for the majority of hospitalized patients withnon-critical illness.

• Modified according to clinical status and condition.

• For patients who are able to achieve and maintainglycemic control without hypoglycemia, a lower target

range may be reasonable.

• For avoidance of hypoglycemia, antidiabetic therapy bereassessed when BG values fall below 100 mg/dl.



Management of hyperglycemia in the

non-critical care setting • MNT (medical nutrition therapy) be included as a

component of the glycemic management program for all.

• Providing meals with a consistent amount of carbohydrateat each meal can be useful in coordinating doses of rapid-

acting insulin



Transition from home to hospital

• Insulin therapy as the preferred method for achieving

glycemic control in hospitalized patients with

hyperglycemia.

• Discontinuation of oral hypoglycemic agents, and non

insulin injectables in acute illness.

• Patients treated with insulin before admission have their insulin dose modified according to clinical status as a way

of reducing the risk for hypoglycemia and hyperglycemia



Pharmaco log ical therapy

• Prolonged use of sliding scale insulin (SSI) therapy beavoided as the sole method for glycemic control inhyperglycemic patients with history of diabetes duringhospitalization.

• Scheduled sc insulin therapy consist of basal or intermediate-acting insulin given once or twice a day incombination with rapid- or short-acting insulinadministered before meals in patients who are eating.

• Correction insulin be included as a component of ascheduled insulin regimen for treatment of BG valuesabove the desired target



Starting Basal Bolus (1/2 )

Discontinue oral diabetes drugs and non-insulininjectable diabetes medications upon hospital

admission

Starting insulin: calculate the total daily dose as follows

0.2 to 0.3 U/kg of body weight in patients: aged 70 yr and/or glomerular filtration rate less than 60 ml/min.

0.4 U/kg of body weight per day for patients notmeeting the criteria above who have BG concentrations

of 7.8 – 11.1 mmol/liter (140 –200 mg/dl).



Start of Basal Bolus (2/2)

0.5 U/kg of body weight per day for patients not meeting the criteriaabove when BG concentration is 11.2 –22.2 mmol/liter (201 –400

mg/dl).

Distribute total calculated dose as approximately 50% basal insulin

and 50% nutritional insulin.

Give basal insulin once (glargine/detemir) or twice (detemir/ NPH)daily, at the same time each day.

Give rapid-acting (prandial) insulin in three equally divided doses

before each meal. Hold prandial insulin if patient is not able to eat.

Adjust insulin dose(s) according to the results of bedside BGmeasurements.



Supplement Insulin

• If a patient is able and expected to eat all or most of his/ her meals, give regular or rapid-acting insulin before each mealand at bedtime following the usual column

• If a patient is not able to eat, give regular insulin every 6 h (6 –12 –6 –12) or rapid-acting insulin every 4 to 6 h following thesensitive column.



Supplement Insulin

• If fasting and premeal plasma glucose are persistently above7.8 mmol/liter (140 mg/dl) in the absence of hypoglycemia,increase insulin scale of insulin from the insulin-sensitive to theusual or from the usual to the insulin-resistant column.

• If a patient develops hypoglycemia BG 3.8 mmol/liter (70mg/dl), decrease regular or rapid-acting insulin from the insulin-resistant to the usual column or from the usual to the insulin-sensitive column.



Transition from hospital to home

• We suggest reinstitution of preadmission insulin regimen

or oral and non-insulin injectable antidiabetic drugs at

discharge….provided sugars are under control.

• We suggest that initiation of insulin administration be

instituted at least one day before discharge to allow

assessment of the efficacy and safety of this transition.

• Patients and their family or caregivers receive both written

and oral instructions regarding their glycemic

management regimen at the time of hospital discharge.



SPECIAL SITUATIONS



Transition from iv continuous insulin infusion (CII)

to sc insulin therapy

• All patients with type 1 and type 2 diabetes be

transitioned to scheduled sc insulin therapy at least 1 –2 h

before discontinuation of CII.

• Specially for hyperglycemia requiring more than 2 U/h.

• Close monitoring and regular adjustments are needed.



Transition from ICU to Ward 1/3

• Calculate total IV insulin dose over last 6 hrs

• For e.g if Insulin dose is stable per hour of 3 iu then 6x3 =

18 units over 6 hrs

• 18 x 4= 72 which is the 24 hr requirement of basal insulin

• 80% of 72 is the basal analogue shot to be given

Schmeltz LR, DeSantis AJ, Schmidt K, et al. Conversion of intravenous insulin infusions to

subcutaneously administered insulin glargine in patients with hyperglycemia. Endocr Pract.

2006;12(6):641 –50.




• If patient has been receiving dextrose solution and it will

be discontinued, consider using 60% instead of 80%.

• If BG is fluctuating, > 1 unit/hour variability between

measurement within last 6 h, consider continuing the drip

and reassess later or calculate TDD based on 6 stable

doses (insulin units/hour) within the last 12 h



2006;12(6):641 –50.




• Divide TDD into basal (half of TDD) and prandial (half of

TDD) for patients eating.

• If glucose level >180 mg/dL and just taking clear liquids,

start 25% of TDD divided equally between meals.

• When full diet is started increment dose by 10 –20% and

adjust on a daily basis



2006;12(6):641 –50.



Patients receiving EN or PN

• POC testing be initiated even in non diabetics

• Can be stopped if sugars are <140 mg% after 48 hrs of

adequate caloric intake in non diabetics

• For all others start insulin therapy if sugars >140mg%



Perioperative BG control

• All patients with type 1 diabetes who undergo minor or major surgical procedures receive either CII or sc basalinsulin with bolus insulin as required to preventhyperglycemia during the perioperative period.

• We recommend discontinuation of oral and noninsulininjectable antidiabetic agents before surgery with initiationof insulin therapy.

• When instituting sc insulin therapy in the postsurgicalsetting, we recommend that basal (for patients who areNPO) or basal bolus (for patients who are eating) insulintherapy be instituted as the preferred approach



Glucocortico id-induced diabetes

• Bedside POC testing be initiated for patients with or

without a history of diabetes receiving glucocorticoid

therapy.

• Can be stopped if sugars are <140 mg% after 48 hrs in

non diabetics

• Insulin is preferred means of control

• Severe uncontrolled sugars may require CSII if basal

bolus not effective.



Recognition and management of hypoglycemia

in the hospital setting

• Must have fixed hospital protocols developed with adequately trained staff.

• Prompt immediate therapy of any recognized hypoglycemia, defined as a BG

below 70 mg/dl.

N u r s e s P r o t o c o l



Other Recommendations

• Proper BG device handling and training of personnel

• Standard protocols be set up regarding Glycemia Mgmt

• Patient counseling and education groups



THANK YOU

management of hyperglycemia in hospitalized patients-esc-2012

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