Managing DKA, HHS, &

Hyperglycemia in Acute Care

Christine Kessler ANP, CNS, BC-ADM, CDTC, FAANP

Metabolic Medicine Associates

King George, VA

,

My Industry Associations

• Novo Nordisk – advisor and speaker (obesity only)

• Astra Zeneca – T2DM advisor

• Medtronic – Insulin pumps and continuous glucose monitoring (outpatient and inpatient)

Case of the “Sweetie-Guy”

54 year old obese male with DM type II is admitted to MICU for

acute nausea, vomiting, epigastric pain and hypotension. Labs

and CT of abdomen demonstrates acute pancreatitis. His home

diabetes Rx is Janumet 50:1000 mg bid (metformin/sitaglipitin

combo), glimperide 4 mg bid. Admission BMP shows a random

glucose of 680 and A1C of 9.1. BUN/Cr 30/1.9.

How should his hyperglycemia be managed?

Objectives

• Discuss how hyperglycemia impacts the patient’s morbidities and hospital stay

• Identify research-supported glycemic goals for patients based on morbidities, Hx of diabetes and age.

• Develop strategies to safely transition patients off an insulin infusion, out of the acute care unit and out of hospital to home.

• Compare DKA & HHS with regard to pathogenesis, presentation and treatment priorities

• Discuss strategies to prevent and treat hypoglycemia.

Major Points to Ponder • Hyperglycemia is “systemic poison” causing

profound endothelial dysfunction (with increased morbidity, mortality and health care cost)

• We’re not just talking about diabetes

• You need to identify safe glycemic targets (& get there safely…e.g. without hypoglycemia)

• The greatest risks when transferring patients

• You can be a “hospital star” if you help develop/improve inpatient hyperglycemia care

Hyperglycemia: Scope of the Problem

Kosiborod M, et al. J Am Coll Cardiol. 2007;49(9):1018-183:283A-284A.

No Diabetes

26%

Diabetes 50

40

30

20

10

0

<110 110-140

50

40

30

20

10

0

<110 110-140 140-170 170-200 >200

78%

140-170 170-200 >200

Mean BG, mg/dL

Pati

en

ts,

%

Courtesy B. Bode MD

Hyperglycemia: An Independent Marker of

Inhospital Mortality

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

10 11

31

0

10

20

30

40

Normoglycemia Known diabetes New hyperglycemia

Mo

rtali

ty (

%)

P < 0.01

ICU mortality

Why Sweet Pts Go Sour

• Metabolic changes in response to stress of illness—make sugar!

• insulin secretion

• stress hormones (cortisol, catecholamines, GH, glucagon)

• Results in gluconeogenesis, glycogenolysis, lipolysis, proteolysis

• cytokines (TNFα , IL-1) oxidative stress, inflammation

• Endothelial damage

Other Causes

• TPN – 50% pts. receiving dextrose >

4mg/kg/min develop hyperglycemia

• Meds in fat emulsions (i.e. Propofol)

• Dextrose-containing dialysis solutions

• Immunosuppressants (steroids,Tacrolimus,

glucocorticoids, catecholamines, tacrolimus,

cyclosporine)

• Vasopressors, dextrose solutions

Why patients get too sweet…

INSULIN

RESISTANCE

• Pressors

• Corticosteroids

• Sepsis

• Uremia

• Cirrhosis

• Obesity

• Bed rest

INSULIN

DEFICIENCY

• Advanced age

• Hypothermia

• Hypoxemia

• DM

• Pancreatitis

Why Is Hyperglycemia So Awful for Hospitalized Patients?

Cellular injury/apoptosis Inflammation Tissue damage

Altered tissue wound repair

So what

blood sugar

levels should

we aim at?

Insulin In Critically Ill Patients

• Initiate insulin starting at ≤180 mg/dL

• Once insulin started, 140-180 mg/dL

recommended glucose range for most patients

• More stringent ONLY if closely monitored and

less risk of hypoglycemia

– 110-140 mg/dL

– May be better outcomes in surgical ICU patients

American Diabetes Association. Standards of medical care in diabetes—2015. Diabetes Care.

2015;38(suppl 1):S1-S93.

In Non-critically Ill Patients

• Sub Q insulin—basal or basal bolus

• Premeal target <140 mg/dL with random blood

glucose <180 mg/dL

• Tighter targets may be appropriate

– Tighter: stable patients with previous tight glycemic

control

– Less tight: severe comorbidities

American Diabetes Association. Standards of medical care in

diabetes—2015. Diabetes Care. 2015;38(suppl 1):S1-S93.

AACE/ADA Consensus Statement on Management of Inpatient Hyperglycemia

BG goals Avoid Tips

MICU •140-180 <110 •If >180, initiate IV short acting insulin

General

Wards

•Pre-meal

<140

•Random

<180

<100 •In glucocorticoid therapy, initiate

accuchecks for 48 hours and then initiate

insulin therapy as appropriate

•Avoid routine use of corrective insulin at

bedtime unless continuous nutrition/TPN

Minimum Accuracy Criteria for BG

Monitors (CLSI standard)

• 95% of glucose results must be:

– Glucose < 100 mg/dl – within 12 mg/dl of

reference

– Glucose >/= 100 mg/dl –within 12.5% of

reference

• And 98% of glucose results must be:

– Glucose < 75 mg/dl – within 15 mg/dl of

reference

– Glucose >/= 75 mg/dl – within 20% of reference

Sources of BG Reading Error

• Before testing: site cleaning, proper lancing

• Strip factors: expired date, heat & humidity,

product defects*, handling the strips,

• Glucometer or sensor malfunction

• Analytical factors: high altitude, cold, anemia,

low oxygen, acetaminophen, L-dopa

Krinsley JS, Grover A. Crit Care Med. 2007;35(10):2262-2267.

Severe hypoglycemia (<40 mg/dL) was associated with an increased risk of

mortality (OR, 2.28; 95% CI, 1.41-3.70; P=.0008)

Severe Hypoglycemia in Critically Ill Patients Associated With Increased Risk of Mortality

0

10

20

30

40

50

60

SH Controls No SH

Mo

rtality

Rate

, %

Events Triggering Hospital Hypoglycemia

• Transportation off ward, causing meal delay

• Failure to measure blood glucose before insulin doses

• Sudden decrease in renal function

• New NPO status

• Drugs…i.e. tramadol

• Interruption of – IV dextrose therapy or TPN

– Enteral feedings

– Continuous venovenous hemodialysis

Hughes S. Pain Med Linked to Hypoglycemia. Medscape Medical News [serial online]. Dec 11 2014;.

http://www.medscape.com/viewarticle/836439.

Features Increasing the Risk of Hypoglycemia in an Inpatient Setting

Advanced age, female gender

Renal failure, liver disease

Autonomic neuropathy (hypoglycema unawareness)

Concurrent illness (cerebral vascular accident, congestive heart failure, shock, sepsis)

Ventilator use

Concurrent medications (-blockers, quinolones, epinephrine, tramadol, ETOH)

D’Hondt NJ. Diabetes Spectrum. 2008;21(4):255-261.

Symptoms for hypoglycemia

• Neurogenic or neuroglycopenic symptoms of hypoglycemia:

• • Neurogenic (adrenergic) symptoms: – Sweating, shakiness, tachycardia, anxiety, and a sensation of hunger

• • Neuroglycopenic symptoms: – Weakness, tiredness, or dizziness; odd behavior, difficulty with

concentration; confusion; blurred vision; and, in extreme cases, coma and death

http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3220253/

Concerns with very low blood sugar

If glucose is under 18 mg/dl:

Affects white matter (most sensitive tissue)

Cerebellum & brainstem less affected

can lead to central pontine myelinolysis

Shih-Hung T. Hypoglycemia Revisited in the Acute Care Setting.Yonsei Med J. 2011

Nov 1; 52(6): 898–908

Hypoglycemia and CV Events

• Tachycardia and high blood pressure

• Myocardial ischemia – Silent ischemia, angina, infarction

• Cardiac arrhythmias – Transiently prolonged corrected QT interval,

– Increased QT dispersion

• Sudden death

Wright RJ, Frier BM, Diabetes Metab Res Rev 2008; 24: 353–363.

Treatment of Hypoglycemia

• Obtain a fingerstick blood glucose

immediately

– If fingerstick glucose not available, begin RX

while waiting for the test to be done.

– Do NOT WAIT for lab serum glucose to

confirm hypoglycemia

Treatment of Hypoglycemia

• Treatment based on patient’s level of consciousness

– Conscious patient with no risk of aspiration

• If glucose 50-70 mg/dl – 6 oz juice

– 6 oz regular soda

– One tube glucose gel

• If glucose below 50 mg/dl – 8 oz juice

– 12 oz regular soda

– Two tubes glucose gel

Hypoglycemia Procedure-Con’t

–Unconscious patients, at risk for aspiration

• 50 ml 50% dextrose IV over 5 minutes {or D50 =

(100-BG) x 0.4 ml IV}

• Stay with patient until you see patient responding

– If there is no IV access

• Glucagon 1 ml (1 mg/ml) IM or SQ

• Stay with patient until responsive

• Note: glucagon can cause nausea and vomiting

• Notify provider and follow protocol

There are 13 types of DM

• Type 1 (autoimmune)

• Type 2 (insulin resistance)

• LADA (latent autoimmune DM in adults)

• Flat bush (ketone-prone T2DM)

• Atypical DM

• Iatrogenic type 1 DM

• Type 3 (bucket dx)

• MODY type 1, 2, 3, 4, 5, 6

Tips to common “Types”

• Type 2 (insulin resistance)

– High TGs

– Strong family hx

– Overweight

– Acanthosis nigrins

• Lada (type 1)

– Pt & family hx of autoimmunity

– Not too overweight

– Less family hx (or DM with insulin use)

TRUE OR FALSE

• An A1C is currently the best way to diagnose

diabetes?

Fast Facts On A1C

• Normal < 5.7% – Prediabetes 5.7 to 6.4%

– Diabetes >6.7%

• Ideally should be done on all patients admitted to hospital (if high on DM meds—not controlled!)

• Provides a 3 month average blood sugar (does not show variability!)

• Not accurate in severe anemia (esp Fe deficiency); or Sickle Cell trait

Fast Facts On A1C

• If not accurate—Fructosamine offers 2 week

average (not use if low albumin)

How Can Diabetes and Hyperglycemia be Controlled in the Hospital?

• Oral agents or GLP1 agonists = often inappropriate for

hospital patients

• IV insulin = most often used in the intensive care unit

setting (or in other defined populations)

• Subcutaneous insulin = the drug of choice for controlling

hyperglycemia in the majority of non-critically ill patients

Oral Hypoglycemic Agents Should

NEVER be Used in ICU?

• Non-insulin hyperglycemia agents only okay in patients with normal nutritional intake, stable blood glucose levels, and stable renal and cardiac function.

• But risks outweigh most benefits: – Concern with fluctuating kidney function – Volume shifts – Delayed onset of action – GI upset – Need to feed some

AACE/ADA Consensus Statement Non-insulin therapies in the hospital?

Sulfonylureas are a major cause of hypoglycemia

Secreatagogue: Glipizide, glimepiride, glyburide

Never in ischemic heart dz—caution in CKD

Glynides: repaglinide (prandin) or nateglinide (starlix)

Prandial, fast,

Metformin (insulin sensititzer) contraindicated in

setting of renal impairment and with use of iodinated

contrast dye

Moghissi ES, et al; AACE/ADA Inpatient Glycemic Control Consensus Panel. Endocr Pract. 2009

Moghissi ES, et al; AACE/ADA Inpatient Glycemic Control Consensus Panel. Endocr Pract. 2009

AACE/ADA Consensus Statement Non-insulin therapies in the hospital?

Thiazolidinediones (insulin sensititizers) associated with

fluid retention, edema, weight gain

Never in CHF or liver dz

α glucosidase inhibitors (starch blockers): Acarbose:

prandial glucose lowering agents…but…

Incretins: (prandial)

GLP1-agonists: can cause nausea and not use in GFR

<45 (Victoza, Byetta, Bydureon)

DPP4 antagonist: Januvia, Trajenta, Onglyza

SGLT2 (basal/prandial) Invokana, Farxiga, Jordiance

Moghissi ES, et al; AACE/ADA Inpatient Glycemic Control Consensus Panel. Endocr Pract. 2009

Moghissi ES, et al; AACE/ADA Inpatient Glycemic Control Consensus Panel. Endocr Pract. 2009

Who Needs An Insulin Infusion

• ALL critically ill with Type 1 diabetes or significant hyperglycemia

• DKA, hyperglycemic hyperosmolar state

• Post op cardiac surgical pt with hyperglycemia

• General perioperative care, intra-abdominal surgery, organ transplantation with hyperglycemia

• Prolonged NPO, parenteral nutrition (T1DM)

• Hyperglycemia on high dose steroids

Who Needs An Insulin Infusion

• Uncontrolled hyperglycemia > 180 (2 episodes

in 24 hours)

• If unsure, then monitor qAC/qHS glucose

monitoring for 24 hours and then continue if BG

> 180

• Labor & delivery hyperglycemic patient

Considerations with the use of

IV Insulin Infusion

• Clarify the concentration from pharmacy

• Prime tubing (20-50 cc)

• Determine if a pre-infusion bolus is needed

• Check glucose hourly and modify drip to protocol

• Tandem line with potassium!

What Needs to be Considered?

• Type 1 or type (IR or not)

• Prior insulin use/dose

• Nutrient intake

• Exercise

• Age

• Kidney function

• And…..

Hmmm?

…weight…Insulin needs are different for

this patient than for a thin, type 1 diabetic

Insulin Infusion Tips

• Bolus or no bolus?—go with your protocol

• Modified Yale Protocol:

– If blood glucose over 180 (or 150) will need a bolus

– How much to give: divide blood glucose by 70 and round to nearest 0.5 unit

• Example: blood glucose 210/70 = 3 units

– If pre-infusion glucose =/> 180 (or 150), give it as bolus and hourly rate

DKA • Occurs in absence or near-absence of insulin

• Presenting symptom for ~25% type 1 DM

• Can be seen in Type 2 variants (Flat Bush or ketone-prone)

• More common in children esp. under 5 years

– 40% under 40

– 20% over 55

• Infectious cause most common

• Mortality

– 5-10%

– Increases with age ( > 65 = 20-40%)%)

Hyperosmolar Hyperglycemic State (HHS)

• An acute metabolic complication of type 2

diabetes mellitus characterized by :

– Profound dehydration

– elevated plasma osmolality in a patient with hyperglycemia

– impaired mental status

– Occurs predominately in Type II Diabetics

– A few reports of cases in type I diabetics (LADA).

• The presenting symptom for 30-40% of Type II

diabetics.

Causes of DKA/HHS

• Stressful precipitating event that results in increased catecholamines, cortisol, glucagon.

– Infection (pneumonia, UTI)

– Alcohol, drugs

– Stroke

– Myocardial Infarction

– Pancreatitis

– Trauma

– Medications (steroids, thiazide diuretics)

– Non-compliance with insulin

Diagnostic Criteria for DKA and HHS

Mild DKA Moderate DKA Severe DKA HHS

Plasma glucose

(mg/dL)

> 250 > 250 > 250 > 600

Arterial pH 7.25-7.30 7.00-7.24 < 7.00 > 7.30

Sodium Bicarbonate

(mEq/L)

15 – 18 10 - <15 < 10 > 15

Urine Ketones Positive Positive Positive Small

Serum Ketones Positive Positive Positive Small

Serum Osmolality

(mOsm/kg)

Variable Variable Variable > 320

Anion Gap > 10 > 12 > 12 variable

Mental Status Alert Alert/Drowsy Stupor/Coma Stupor/Coma

Common Symptoms of DKA/HHS

• Polyuria

• Polydypsia

• Dehydration

• Blurred vision

• Dizziness

• Nausea/Vomiting

• Profound Fatigue

Physical Examination in DKA/HHS

• Hypotension, tachycardia

• Kussmaul breathing (deep, labored breaths)**

• Fruity odor to breath (due to acetone)**

• Adominal tenderness—more in DKA

• ** DKA exclusive

• Obtundation—worse in HHS

DKA - Associated Abnormalities

• Sodium

– variable

– fall by 1.6 for every 100 increase in glucose (over 100)

– falsely low with hypertriglyceridemia

• Chloride

– hyper in ketoacidosis

– hypo associated with severe emesis

DKA - Associated Abnormalities

• Potassium

– high in acidosis (0.6 mEq per 0.1 decrease in K+)

– at high risk for severe hypokalemia when pH is

corrected!!

• Serum acetones – Positive in DKA; Possibly small in HHS

• Urinalysis

– Ketones (for DKA); leukocyte esterase, WBC (for UTI)

Diagnostic Studies in DKA

• Chemistry

– Glucose (>250)

– Bicarbonate (<15)

– Anion gap = (Na+) – (Cl- + HCO3-)

– pH <7.3

– Frequently seen: • BUN/creatinine (dehydration)

• sodium

• potassium

Pseudohypernatremia: to correct,

Diagnostic Studies in DKA/HHS

• CBC

– Leukocytosis (possible infection)

• Amylase/Lipase

– To evaluate for pancreatitis

– BUT, DKA by itself can also increase them!

• EKG

– Evaluate for possible MI

DKA

• Management – Fluid resuscitation

• Normal saline 500-1000 cc/hr with bolus of 1L (LR?)

• If UOP good and NA > 140, slow IVF and change to 0.45 NS (add KCL 20 mEq)

• Add D5 once BS < 300 (or 250) – And add potassium !!!!!!!

• POC Sugar checks hourly: – Every 1 hour initially, then every 2 hours, and so on.

• (LR?)

DKA

• Insulin (novolog, glulisine or regular)********

• 0.4u/kg with 1/2 IV and 1/2 SQ

– Some say 0.05 – 0.1 u/Kg…why not?

– Or just give 10 to 20 units IV

• IV infusion better than hourly IV injections

• continue until ketones in urine resolved, sugars stabilize or pt eating

• Change to SQ once BS< 200, pH > 7.3, Bicarb > 18 (anion gap closed)

DKA

• Management

–Potassium

• K< 3.5 add 40 meq/l

• K > 3.5 and < 5.0 add 20 meq/l

• check q 2 hrs

–Replete hypophosphatemia

–Give bicarbonate if pH < 7.1

–Treat underlying cause

Treatment of HHS

• Hydration!!! – Even more important than in DKA

• Find underlying cause and treat!

• Insulin drip – Should be started only once aggressive hydration

has taken place.

– Switch to subcutaneous regimen once glucose < 200 and patient eating.

• Serial Electrolytes – Potassium replacement.

DKA/HHS

• Complications

– Hypotension and shock

– Thrombosis (HHS)

– Cerebral edema

– Renal failure

– Hypoglycemia

Know Your Insulin Needs

BASAL

vs

BOLUS (prandial &

correction)

Physiologic Insulin Basal Bolus Insulin:

Breakfast Lunch Supper

Insu

lin

(µU

/mL

)

Glu

co

se

(mg

/dL

)

Basal & Prandial Glucose

150

100

50

0 8 9 10 11 12 1 2 3 4 5 6 7 8 9

A.M. P.M.

Time of Day

Basal Insulin

50

25

0

Nutritional Glucose

Nutritional (Prandial) Insulin

Suppresses Glucose

Production Between

Meals & Overnight

The 50/50 Rule

What Main Insulins Do We Have?

• BASAL: – Glargine (Lantus)

– Detemir (Levemir)

– NPH

• PRANDIAL/CORRECTION: – Regular

– Novolog (Aspart) ****

– Humalog

– Glulisine (Apidra) ****

• OTHERS: combos, concentrated (U500, U300)

Tips & Summary of the Insulin Types

• Basal insulin: Use non-peaking, longer acting insulins – Glargine or detemir are preferred

– NPH also possible; but mostly used for single day steroid use or PM enteral feedings

• Prandial/Nutritional insulin: Depends on the type of nutrition – Rapid-acting insulin when patients are eating

– Regular insulin also possible

• Correctional insulin: Use rapid-acting (or regular) insulin

– Usually the same as the nutritional insulin to reduce blood glucose

Rapid (Prandial, Bolus) Short (Prandial, Bolus) Intermediate (Basal) Long (Basal)

Which Insulins are Used?

Insu

lin

Eff

ect

NPH

Glargine (Lantus)

Regular

0 6 12 18 24

Lispro (Humalog)

Aspart (Novolog)

Glulisine (Apidra)

Time (hours)

Detemir (Levemir)

Inhaled insulin

When to Stop Insulin Drip

• Hourly sugars checks until stable sugars for at

least 3 hours at target BG level—then q 2 hours

• If stable for 12-24 hours may stop the drip.

• No change expected re: glucose-impacting

meds or hemodynamic status

Transitioning Off IV Insulin

This is where we

really hurt our

patients!!!!!

IMPORTANT!!!!!

• Must start SC glargine at least 2-3 hours before

stopping IV insulin (always for Type 1 DM)

• Or SC Lispro, Aspart, or Regular 15-30 mins.

before stopping drip

• May start long-acting insulin on initiation of IV

insulin or the night before stopping the drip*

• NEVER use only boluses for T1DM

• Bolus-only coverage rarely gets you to target

Is SC Insulin (MDI) Required off

infusion?

YES-

DM1

DM 2 or A1c ≥ 6 and infusion rate ≥ 1 unit / hour

On high dose steroids and rate ≥ 1 unit / hour

NO-

Type 2 DM with infusion rate < 1 unit / hour

Stress hyperglycemia with HbA1c < 6 Even if high infusion rates

So you have to give SQ insulin….how?

Converting to SC insulin

• If more than 0.5 or 1 u/hr IV insulin required with normal BG, start long-acting “basal”insulin (glargine or detemir).

• Determine hourly rate IV insulin over past 6-8 hours and multiply x 24 to get TDD – Take 80% of that 24 hour dose

– Give 50% as basal insulin & 50% as bolus divided before each meal

• Check sugars ac and hs***

Use Correction Bolus and prandial bolus!

Example

• Patient taking ave 2.5 units an hour

– 2.5 u x 24 hr = 60

• 80% of 60 = 48

• ½ of 48 is 24…so give 24 units of glargine (basal) PM

• Give other half in divided doses for meals

–Thus, 8 units bolus with meals tid

–(adjust for meals eaten and blood glucose)

Correction doses of bolus insulin?

• Determine Insulin Sensitivity Ratio

–Use this to correct high sugar

–Take with dose for carb coverage

• Determine carbohydrate coverage (insulin:carb coverage)

For Prandial Insulin Dosing

Calculate Insulin Sensitivity

Calculate the patient’s Insulin Sensitivity* (IS) by compiling

their Total Daily Dose (TDD) and dividing this total into 1500 or

1800

Type 2: 1500 / TDI = Insulin Sensitivity

Type 1: 1800 /TDI = Insulin Sensitivity

(* The IS is the incremental fall in blood sugar that can be

expected from each unit of insulin)

Use IS to construct a tailored correction

What About Dietary Coverage?

• Type 1 or BMI < 30: give one unit per 15 grams of carbs

• Type 2 Or BMI > 30: give one unit per 10 grams of carbs

• Le Menu —the diabetes friendly hospital menu

– Identify the carbohyhdrate amount in full meal portion

– Marks foods as 10-15 gms CHO3

Give prandial bolus right AFTER

eating

Computer Glucose Programs

• Glucommander

• Endo Tool

• GRIP computer program

• others

Pre-operative Medical Management

• Hold morning oral diabetes medications

• If on NPH or mixed insulin (70/30)…take half in morning

• If on detemir (Levemir) or glargine (Lantus), take FULL dose in morning….a caveat is…..

• Encourage pt to check own BG night of and morning of surgery (if <70, contact physician)

• Use rapid-acting insulin to correct sugar only if needed to keep sugar < 200 prior surgery

Tips on EF Glucose Management

• Continous EF: Check BG at start of EF and every 6 hours

– Can use basal insulin, i.e., glargine (calculated by CHO

loading in continuous feedings—(based on BMI)

• For Nocturnal EF-- NPH is preferable

– Time action best covers TF duration (10-16hrs)

– Dose based on weight/BMI

• BMI <30: 10 units NPH at onset of TF

• BMI >30: 20 units NPH at onset of TF

– Give at start of nocturnal tube feeding

Intermittent Dosing With Short-acting Insulin

• Regular Insulin (preferable) every 6h:

– BMI <30: 1 unit per 15 gm CHO

– BMI >30: 1 unit per 10 gm CHO

• Example:

–1Cal Tube feeding (144 gm/L) @ 50 ml/hr:

»43.5 gm CHO infused q 6h

»BMI <30, 3 units Regular q 6h

»BMI >30, 4 units Regular q 6h

Tips on EF Glucose Management

• If TF to be interrupted for > 1 hour:

–Start IV infusion of 10% dextrose at same rate as EF

–Continue until EF resumed at former rate

– Interruptions, clogging, disconnections can cause a major concern for…….

– HYPOGLYCEMIA!

TPN considerations

• Usual Mix is 0.1 unit Regular per gram of dextrose – Example: TPN 225 gram dextrose x 0.1units regular – = Add 22.5 units regular insulin to TPN bag

• Trend of BG levels over 24 hours – ↑ Regular if BG >150 for standard target:

• Guidelines: Increase by 0.05 units Regular Insulin per gram Dextrose

• Threshold: 0.3 units regular insulin/gm dextrose, bag/day

• Check BG on all TPN patients – Check BG every 6 hours

• SQ insulin or an infusion may be added if BG not at target

When Your Patient Has an Insulin

Pump

• Allow to stay on pump if non critical units

• If surgery is planned—stop the pump and give glargine or levemir equaling their 24 hr basal rate

• The pump can provide you lots of information!!!

Insulin pumps

Where we are now

12:00 AM 6:00 AM 12:00 6:00 PM 12:00 AM

Glu

co

se (

mg

/dL

)

400

300

200

100

0

Glucose

measurement

Insulin

bolus

Target

Range

Fingerstick Blood Glucoses

12:00 AM 6:00 AM 12:00 6:00 PM 12:00 AM

Glu

co

se (

mg

/dL

)

400

300

200

100

0

Glucose

measurement

Insulin

bolus

Target

Range

Continuous Glucose Monitoring Provides More

Comprehensive Picture of Glycemic Patterns

A1C < 7%

Re-start outpatient treatment regimen

(OAD and/or insulin)

A1C 7%-9%

Re-start outpatient oral agents and D/C on glargine once daily at 50-80% of hospital dose

A1C >9%

D/C on basal bolus at same hospital dose.

Alternative: re-start oral agents and D/C

on glargine once daily at 50-80% of

hospital dose

Discharge insulin Algorithm

Discharge Treatment

Remember to Consider Exercise