Inpatient Diabetes Management

hello this is Eric strong and today I will be discussing inpatient diabetes management the learning objectives will be to understand the goals and challenges of inpatient diabetes management to be able to create an initial treatment regimen for a diabetic patient admitted to the hospital and to be familiar with basic principles of adjusting and insulin regimen in response to persistent hyperglycemia or NPO status that is nothing by mouth be aware that the management of diabetes is an an extremely detailed and nuanced topic and this video will just be providing a general overview always consult an experienced healthcare professional when making any adjustments to a diabetic treatment regimen the goals of inpatient diabetes management are first and foremost to avoid hypoglycemia which in the short-term is much more dangerous than hyperglycemia second to avoid hyperglycemia next to assess outpatient glycemic control and consider adjustments in consultation with outpatient providers and finally to assess the need for diabetes education which can be performed in the hospital while the patient is a captive audience with plenty of time the inpatient management of diabetes can be very challenging due to a large number of factors which can disrupt the metabolic processes keeping a patient in you glycaemia balance between hyper and hypoglycemia one of the major factors that contribute to hyperglycemia are many hormones and other mediators that are increased during acute illness these include cortisol catecholamines like epinephrine glucagon and various pro-inflammatory cytokines others are the use of IV dextrose along with carbohydrate-rich enteral and parenteral nutrition hyperglycemia can also be exacerbated by the use of exogenous steroids which can be part of the treatment of a number of conditions such as a COPD exacerbation or elevated intracranial pressure and finally there may be new contraindications to a patient's previous outpatient oral medications for example acute kidney injury and NPO status are contraindications to Stefano ureas volume overload is a contraindication to viola lighting Dione's more commonly known as t cds or glitter zones and kidney injury and reason or anticipated IO donated IV contrast are contraindications to metformin in addition to the contributing factors to hyperglycemia factors contributing to hypoglycemia include poor or unpredictable P o intake while a patient is acutely ill also outpatient non adherence can be problematic as well if a patient appears to be well controlled when he or she is secretly only taking medication some of the time or only taking some of the medications the medical staff believes he or she is taking the consequences of hyper and hypoglycemia can be severe hyperglycemia can lead to an osmotic diuresis and volume depletion electrolyte loss and general immune dysregulation while hypoglycemia can lead to ultra Mental Status seizures and if not immediately corrected permanent CNS injury another factor that complicates inpatient diabetes management is the uncertainty regarding what the appropriate glycemic target should be with the passage of time and accumulation of more scientific data opinion on appropriate target glucose levels has changed up until about 10 years ago the prevailing opinion had been that providers should be attempting to get all diabetic patients to you glycemia while in the hospital however newer and larger trials in a variety of patient populations have demonstrated either no benefit to tight glucose control or in some cases even worse outcomes with tight control thus in 2009 a joint task force with representatives from the American Association of Clinical endocrinologists and the American Diabetes Association released a consensus statement in which they recommended a target glucose in most ICU patients of 140 to 180 milligrams per deciliter in non ICU patients they recommended a target pre prandial glucose of 100 to 140 and they target random glucose of 100 to 180 there remains small subsets of ICU patients who may benefit from tighter control than 140 to 180 such as post cardiac surgery patients keep in mind that these are only guidelines and that in practice targets should be individualized to the patient and to the situation one situation in which this is definitely true is for patients nearing the end of life we're a target glucose range might be whatever keeps the patient asymptomatic a provider might tolerate glucose is up in the 300s or even higher without intervention in this specific circumstance depending upon the patient's goals of care to understand how to decide upon a diabetes regimen for an inpatient I will first need to briefly review the different categories of insulin categorized by pharmacokinetics there are four general types of insulin first is the very short acting insulin into which list bro and as part are placed these have a very quick onset of action of 5 to 15 minutes have a peak effect at 45 to 75 minutes and lasts a total of 2 to 4 hours so called regular insulin is considered short acting takes effect at 30 minutes peaking at 2 to 4 hours and lasting 5 to 8 NPH is an intermediate acting form of insulin with an onset of 2 hours peak at 4 to 12 hours and duration of 18 to 28 hours finally long-acting insulin which includes glargine along with some less common others also as an onset of 2 hours has no particular peak time of action and lasts more than a day insulin can also be categorized based on function that is what role does a particular form of insulin play in a patient's management strategy for example there is basal insulin the function of basal insulin is to cover the body's insulin needs to maintain basal metabolic activity that is it reflects the fact that our bodies need insulin even when we are not eating or doing much of anything common regimens a basal insulin are glargine every 24 hours usually at bedtime or NPH every 12 hours in critically ill patients a continuous IV infusion of regular insulin can also be used for this purpose next is prandial insulin sometimes referred to as bolus or nutritional insulin this prevents the hyperglycemia that would otherwise occur as a consequence of eating a meal in patients who are eating common regimens include regular a sport or lisp row before each meal in patients who are NPO this should obviously be held finally there is corrective insulin which is more commonly referred to as the sliding scale the sliding scale is intended to correct hyperglycemia that is already present before the meal starts this can be done with regular aspirin or listro given before each meal and at bedtime in patients eating and given every six hours in patients who are not eating the insulin sliding-scale itself can be a little confusing at first each Hospital typically has its own scale pre-approved by committee of pharmacists and physicians here is just one example of such the only decisions the ordering physician needs to make for an individual patient is which form of insulin to use and which of the three levels to use the mild scale is generally reserved for insulin sensitive patients such as type 1 diabetics the moderate scale is used for most type 2 diabetics and the aggressive scale is for patients with unusually high levels of insulin resistance which are a minority of type 2 diabetics so how do we use this information about insulin to choose a treatment strategy in a specific patient when a diabetic patient is to be admitted to the hospital the first question to ask is does the patient have an indication for a continuous infusion of insulin well agreed upon indications include septic shock post cardiac surgery moderate to severe diabetic ketoacidosis and the hyperosmolar hyperglycemic syndrome some clinicians prefer to use an insulin infusion in any diabetic who is critically ill insulin infusions are a complicated topic the details of which are beyond the scope of this discussion but most hospitals have well-established protocols in place so a few decisions are needed of the provider once the decision to use the infusion itself has been made in patients who do not have an indication for continuous infusion ask whether the patient meets all of the following is he or she a type-2 diabetic is his or her diabetes well controlled as an outpatient with diet and/or oral medications is it anticipated that the patient will be eating normally and are there are no contraindications to his or her regular outpatient oral medications if all these criteria are met then the most appropriate treatment strategy is to continue the outpatient regimen and a day four times a day fingerstick that is a bedside glucose check along with a sliding scale if the patient is on a sofa no urea such as glipizide or glyburide the provider should consider a modest dose reduction as these meds can lead to hypoglycemia if the patient's pio intake is not equal to that as an outpatient which is common in the hospital if on the other hand the patient is well controlled as an outpatient with insulin including those on an insulin pump and you anticipate that they will be eating normally then continue the outpatient regimen plus the finger sticks and sliding scale as with chiffon or urea is considered a modest dose reduction in either the basal and/or the bowls insulin dose what if the patient does not fit into any of these three categories everyone else which actually ends up being the majority of patients should be placed on what is known as a basal bolus regimen creating the basal bolus regimen is a multi-step process that begins with estimating the total daily insulin requirement abbreviated TDD for total daily dose there are several very simple equations described in literature to do this some of which are more conservative or liberal with insulin and others the following is a rough average of the different approaches that are out there for most type 2 diabetics the estimated total daily dose is about 0.4 units per kilogram of body weight in type 1 diabetics the elderly and in patients with renal insufficiency using a value of 0.3 units per kilogram is safer with less risk of hypoglycemia 50% of this total daily dose will be devoted to basal insulin which can either be further divided into twice daily NPH or as once daily glargine or other long-acting insulin I usually prefer using NPH for hospitalized patients who aren't already on glargine because NPH can be titrated more rapidly in response to changing insulin needs as an acutely ill patient however some clinicians are reasonably concerned that NPH can lead to unfit logic peaks and valleys in blood glucose that can actually make in patients eye tration even more challenging the other 50% of the total daily dose will be for bolus insulin divided into three equal doses for each meal regular a sport or lisp pro insulin can be used with regular given 30 minutes prior to the meal and others given immediately prior finally although not part of the total daily dose distribution patients should also be placed on a corrective sliding scale using the same form of insulin as used in the bolus dosing given the concern over in hospital hypoglycemia whenever rounding a dose of insulin one should always round downwards now how should the provider adjust insulin in response to sub optimal glycemic control first the regimen should be reassessed every 1 to 2 days with glargine adjusted more frequently than once every two days one should generally not react to a single high reading if others are within the target range however even a single hypoglycemic episode should prompt an adjustment what are the specifics for up titration of insulin in persistent hyperglycemia if the glucose levels are above target at all times of the day one should increase the basal insulin if the glucose is above target only at certain times of the day adjust according to this chart if the am fasting glucose is high one should increase the p.m. basal dose of NPH if the pre lunch glucose is high one should increase the a.m. bolus of insulin if the pre-dinner is too high increased the a.m. basal and if the bedtime glucose is too high one should increase the p.m. bolus dose for patients on glargine who only have a consistently elevated glucose in the morning or before dinner or some other very specific time some creativity may be required as glargine does not have peaks and valleys of activity like other forms of insulin do for example imagine a patient on glargine for basal insulin and list bro for bolus insulin whose glucose is are all fine except for persistently elevated pre-dinner glucoses in the 300s the provider may need to increase the glargine dose but in order to decrease the risk that hypoglycemia will develop at other times of the day he or she may need to simultaneously decrease all of the bolus doses such that the total daily dose of insulin is increased very modestly if glucose elevations are at random times with no discernible pattern things to ask include is the patient on a consistent carb diet is the patient eating each meal consistently and is the patient sneaking carbohydrate rich snacks that's a good lead-in to discuss proper nutrition for diabetics this is another huge topic but let me discuss it in extreme brief the previously popular term for the inpatient diabetic diet the so called a da diets never really meant anything specific and at many institutions this referred to a calorie controlled diet low in simple carbohydrates without necessarily paying close attention to consistency in Toba carb content each day for patients taking oral nutrition the recommended diet is now the consistent carb diet the components of this diet include equal total grams of carbohydrate each day equal grams of carbohydrates in the same meal from one day to the next approximately equal grams of carbohydrate each meal compared to others in the same day there is no specific calorie level and surprisingly it does not necessarily restrict the use of sucrose provided it's done in small amounts and in a consistent manner how does the typical basal bolus regimen change if the patient is NPO first consider a dose reduction in basal insulin type 2 diabetics on NPH should have a closer to 50% reduction while in type 1 diabetics and type 2 diabetics on glargine a reduction of 25% is more appropriate next eliminate the bolus insulin finally keep the sliding scale there but change the regimen from before each meal and at bedtime to every six hours and in addition the sliding scale should generally be downgraded for example an aggressive sliding scale should be switched to moderate and a moderate sliding scale should be switched to mild finally there are some considerations before discharging a diabetic patient from the hospital should the hemoglobin a1c be checked should the patient's outpatient regimen be adjusted the decision to adjust should be based on the hemoglobin a1c and not based on inpatient glycemic control generally avoid changing the outpatient regimen if the a1c is less than 8% unless there is a new contraindication to a previously used med occasion and only adjust the outpatient regimen in consultation with the patient's outpatient provider finally does the patient need diabetes education three common misconceptions about inpatient diabetes management which I've already gone over but would like to just highlight here towards the end oral hypoglycemic drugs should never be used as an inpatient the sliding scale as the sole means of glucose control is appropriate for most patients and the patients who are NPO do not need insulin all of these statements are completely false let me conclude this lecture by working through a multi-step example a 68 year old man with type 2 diabetes on metformin and glyburide as an outpatient is admitted to the hospital with pneumonia a recent hemoglobin a1c was 9.3 percent the patient is 105 kilograms in weight what is an appropriate diabetic regimen for him at this time step 1 the side of this patient is appropriate for an insulin infusion or for orals in this case he has no indication for an insulin infusion per se and his poor outpatient control indicates that oral medication is not appropriate step 2 estimate the total daily dose of insulin this is 0.4 times his weight in kilograms which in this case is 42 units step 3 calculate the basal dose as 1/2 the total daily dose which is 21 units this can be provided as 10 units and pH twice a day or alternatively as 20 units glargine once a day usually done at bedtime step 4 calculate the bolus dose also 21 units which is then divided into three equal parts rounding down for convenience and safety this becomes 5 minutes of regular insulin three times a day before meals step 5 don't forget to include corrective insulin so in summary an appropriate initial regimen for this patient would be NPH 10 units sub QB idac which is medical shorthand for twice a day before breakfast and dinner a perfectly fine alternative would be glargine 20 units sub q q HS which is shorthand for bedtime regular insulin 5 units sub q tid AC that's three times a day before each meal and finally a regular insulin sliding-scale I would choose a moderate scale as the patient is type 2 and without evidence of unusually high insulin resistance here are the patient's blood sugars after the first 48 hours in the hospital his oral intake has been poor but consistent what if any changes are appropriate to his insulin regimen you can see that all the blood sugars are within goal or close to goal with the exception of 2 pre-dinner measurements both of which are above 300 therefore the appropriate change to make would be to increase the AM and pH dose there is no magic formula for how much to increase it other than avoiding any changes that are too drastic therefore the only change would be an increase in the a.m. and pH dose from 10 to 15 units continuing on his blood sugars are subsequently well controlled but due to the non resolving nature of his pneumonia a bronchoscopy is planned for the following afternoon and the pulmonologist requests that he be made NPO from midnight how should this regimen be changed here's the current regimen again while NPO remember that the patient should have the basal insulin reduced by 25 to 50% the bolus insulin should be deseed and these sliding-scale should generally be downgraded therefore the patient's regimen while NPO should be NPH 7 units each morning before breakfast and 5 minutes each evening before dinner with a mild regular insulin sliding-scale that concludes the summary of inpatient diabetes management's if you found it interesting please remember to like or comment on the video and please subscribe if you are interested in additional lectures on a variety of inpatient medical topics you

Channel: Strong Medicine

Views: 114,597

Keywords: diabetes, insulin, sliding scale, basal bolus, inpatient, consistent carb, hyperglycemia, hypoglycemia, insulin drip, medical lecture, type 1, type 2, npo

Id: tzn4jGEL87I

Length: 22min 53sec (1373 seconds)

Published: Tue Dec 04 2012