Notes

Outline

When Blood Sugar Goes Sour: The Hyperglycemic Crisis Intensive Insulin Therapy Christine Kessler RN MN CS ANP Department of Endocrinology & Metabolic Medicine Walter Reed Army Medical Center Washington D.C.

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MCVH Conference 2005

Prevalence of Diabetes in U.S. DM kills 1 American every 3 minutes New case diagnosed every 40 second More deaths than AIDS & breast CA combined Average life expectancy: 10-15 years less than non-DM Afflicts over 230 million world wide—nearly triple in 25 years

Diabetes Health Expenditures Total 50+ billion dollars spent in U.S. annually 52% spent on hospitalizations 48% increase rate in hospitalizations for DM 1991-2001 Diabetics comprise 29% of all cardiac surgical patients 66% of AMI pts have IGT or undiagnosed T2DM

Source of Hyperglycemic in ICU Pts Acute stress response (hyperadrenergic) Increased glycogenolysis and gluconeogenesis Insulin antagonism Growth hormone Cortisol Glucagon Epinephrine Various vasopressors

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Intensive Insulin Therapy in Critically Ill Patients—Morbidity and Mortality

Cardiovascular Risk Insulin Therapy and MI Mortality-- DIGAMI Study

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Glycemic Threshold in CABG Portland data suggest BG:      < 150 mg/dl for mortality      < 175 mg/dl for infection      < 125 mg/dl for atrial fibrillation

Diabetes in the CV Surgical Pt High risk for bacterial infection Surgery itself Catheter use Intravenous lines WHY Neutrophil dysfunction Complex inhibition Glucose-rich edema (culture media) *  6 recent clinical trial support good glucose control needs

Infections in Diabetes One BG > 220 mg/dl = 5.8 X increase nosicomial infection Two hours of hyperglycemia results in impaired WBC function for weeks

Other Concerns with the DM Patient Renal insufficiency common—drug clearance issues Strange volume shifts Underlying cardiovascular autonomic neuropathy Poor SC uptake of insulin if hypotensive

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Hospital Targets for Glucose AACE and ADA Guidelines: Dec 2003                  80–110 mg/dl ICU                  110–140 (180) mg/dl other units Treat  any patient with BG > 140 mg/dl

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The Ideal IV Insulin Protocol Easily ordered (signature only) Effective (Gets to goal quickly) Safe (Minimal risk of hypoglycemia) Easily implemented Able to be used hospital wide

Essentials of a Good IV Insulin Algorithm Easily implemented by nursing staff Able to seek BG range via:          - Hourly BG monitoring          - Adjusts to the insulin sensitivity            of the patient

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Continuous Variable Rate IV Insulin Drip Mix Drip with 100 units Regular Insulin into      100cc NS Starting Rate: Units / hour = 0.02 to 0.06 u/kg/hr (BG – 60) x 0.02 -- where BG is current Blood Glucose (0.02 is the multiplier) Check glucose every hour and adjust drip Adjust Multiplier to keep in desired glucose     target range (100 to 140 mg/dl)

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When to Switch to SC Insulin Stable sugars for at least 3 hours at target BG level No change expected re: glucose-impacting meds

Physiological Serum Insulin Secretion Profile

Basal/Bolus Treatment Program with Rapid-acting and Long-acting Analogs

Converting to SC insulin If more than 0.5 u/hr IV insulin required with normal BG, start long-acting insulin (glargine, “Lantus”)—this is a “basal” insulin Must start SC glargine at least 2-4 hours before stopping IV insulin Or SC Lispro, Aspart, or Regular 30 mins. Before stopping May start long-acting insulin on initiation of IV insulin or the night before stopping the drip*

Converting to SC insulin Establish 24 hr Insulin Requirement Extrapolate from average over last 6-8 hours if stable Give One-Half Amount As Basal Monitor a.c. tid, hs, and 3 am Correction Bolus for All BG >140 mg/dl (BG-100)/(1500/Daily Insulin Requirement)*

How to Initiate MDI Starting dose = 0.4 to 0.5 x weight in kilograms Bolus dose (aspart/lispro) = 20% of starting dose at each meal Basal dose (glargine) = 40% of starting dose given at bedtime or anytime Correction bolus = (BG - 100)/ Correction Factor, where CF = 1700/total daily dose

SLIDING  SCALE  INSULIN 171 patients with DM on Sliding Scale Regular Insulin without basal insulin: a 3-fold higher risk of hyperglycemic episodes compared with individuals following no pharmacologic regimen (P < .05) - 40.4% hyperglycemia  (>300 mg/dl) - 22.8% hypoglycemia  (<60 mg/dl)

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When Your Patient Has a Procedure Take no short acting insulin (if NPO) Take ½ NPH dose…may take full glargine dose Use short acting to correct sugar Keep < 200 if going to surgery

Which Oral Hypoglycemic Agents Should NEVER be Used in ICU? Actos (pioglitazone) Avandia (rosiglitazone) Metformin (glucophage) Beware the fluid shifts!!!

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