Transcript Tight Glycemic Control: Avoiding Alpine Sugars

Tight Glycemic Control:
How Sweet It Is!
Virginia Point of Care
Coordinators
April 22, 2005
Disclosures
• State faculty for the Surgical Infection
Prevention Initiative
• No financial or other conflicts of
interest
– Claudette Dalton, M.D.
“What, me worry?”
• Surgical Infection Prevention Initiative
(SIP) /Surgical Care Improvement Project
(SCIP)
• Literature
• JCAHO/ CMS/ ACS/ ASA/ ICU/ POC/
NQF/ IOM/ QI/ PI/ VHQC
• ICU standard of care
• ? General standard of care
Core Knowledge Needed
• Impact on outcomes
• Target BGs/Protocols
• Difference between insulins and how they
are given
• How/when to test consistently
• Treatment and prevention of hypoglycemia
• Documentation pathways
• Terms and definitions
Definitions
• Hyperglycemia is a blood sugar over 110 in a
fasting patient and over 125 in a patient who has
eaten.
• Hypoglycemia—40-70 mg/Dl
• Point of care testing
– Immediate results that alter management
• Diabetes mellitus
– Types I and II, gestational
• Hyperglycemia
– Steroids
– Stress
– Other meds
Conditions that Predispose to
Hypoglycemia
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Advanced age
Decreased oral intake
Chronic renal failure
Liver disease
Use of Beta blockers
Mistiming of meals in
relationship to insulin
dosing
• Infrequent or missed
monitoring
• Lack of coordination with
transportation and floor
• Knowledge deficits by
providers
• Unreadable, unusual or
convoluted orders
• Difficult to follow
protocols
• Physician insisting on
different protocol
What is the evidence?
• Risk of microvascular complications
– Renal and retinal disease
– Diabetes Control and Complications Trial
• Risk of macrovascular complications
– CAD and stroke
– Capes SE. Stroke 2001; 32:2427
– DIGAMI and Malmberg K. Circulation. 1999. 99:26262632
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Risk of mortality
Risk of infections
Cost of care
ACE and AACE recommendations
Unanswered Questions
• What is “optimal control”?
• How long does the patient need to be in
good control?
• Can we take “tight control” too far?
• What is the role of lipids in glucose
control?
• Do we need to aggressively treat other
medical conditions at the same time?
The Role of Blood Sugar in
Infections
• Poor wound healing in general/many already
colonized
• Deoxyglucose inhibits glycolytic metabolism which
generates energy for superoxide production
• No absolute Km identified but glucose level
proportional to neutrophil activity
• Granulocyte functions—improve when glucose
control is good—i.e. <200mg/dL
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Adherence
Delays chemotaxis
Impairs phagocytosis
Decreased bacteriocidal activity
Other DM Complications in Surgery
• Cellular immunity
– Decreased complement fixation
• Collagen—increased collagenase activity
• Role of microvascular damage
• 34% of insulin dependent diabetics are
colonized with s. aureus
• Cardiac cellular function
Vanderbilt Study
Latham R. et.al. Infact Control Hosp Epidemiol.
2001; 22:607-612
• Prospective, 1044 CABG and valve ops
• 6% had undiagnosed diabetes
• SSI pts.—62% of known diabetics had
hyperglycemia/37% of non-DM patients
• Dx of DM associated with 2.7X risk for SSI
• Rate of SSIs correlated with degree of
hyperglycemia
• Hyperglycemia during periop is independent risk
factor
Vanderbilt, con’t
• Similar to other studies, 6% were
undiagnosed diabetics
• 19% in this study had abnormal HgbA1c
and another 11% had glucose >200
• But Hgb A1c did not correlate with SSIs
• Still, suggest that screening with HgbA1c
for diagnosis of DM is cost effective if
therapy is initiated
Perioperative Glucose Control
• 1,000 cardiothoracic surgery patients
• Diabetics and non-diabetics with hyperglycemia
Patients with a blood sugar > 300 mg/dL during or within 48 hours of surgery
had more than 3X the likelihood of a wound infection!
Latham R, et al. Infect Control Hosp Epidemiol. 2001.
What factor makes the
difference?
• Patients may be undiagnosed (4.2%--or higher!)
• Most infections when glucose level is >200 mg/dL
• Risk same if glucose high anytime in first 48
hours
• Hyperglycemia doubles risk—2—2.7X
– 20mg/Dl increase = 30% increase risk of death
• May directly affect cardiac cellular function
• Can be stress or medication induced
– Capes SE. Lancet. 2000. 773-778 and Clement S.
Diabetes Care. 2004. 27:553-591
Ain’t No Mountain High Enough…
• Enormous percentage of our patients are
diabetic
• Another percentage are undiagnosed or
hyperglycemic from other causes
• Adding nutrition and crisis management
• Source of blood
• Timing of testing
• Tests used
Ain’t no Valley Low Enough…
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Hypoglycemia is a blood glucose of 40-70
Institution dependent
Cause seizures, brain death if too low
Anesthesia and sedation block usual
symptoms
• Blood source
• Timing of testing
• Tests used
Is There a River Wide Enough?
• Who is the crew and who is the coxswain?
• Untraditional looking crew
– Nutritionist, Pharmacist, QI/PI, managers
– Lab, nurses, doctors, educators
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Constant educational needs
Policies
Which protocol?
Point of care testing and decision making
Patients go through multiple units while in the
hospital—transitions are trouble points
• Costs/equipment
Protocol, protocol, who has a
protocol?
• Portland, van den Berghe, Yale, home-grown?
• Elements to look for
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While NPO, when feeding, when crisis
Timing of doses/testing
Subcu vs IV—continuous (CII) vs. bolus
Different protocol for night shift, for sicker patients, for iconoclastic
docs?
Start higher to avoid going lower—how low is too low?
How many get hypoglycemic on each protocol?
KISS –or not?
Education, re-education and more education
Requires an IV for most of the protocols
UVA Protocol
• ICU generated
• 95 is ICU target, <175 is SIP target, 125-175 is
general floor target
• No subcu
• Tests q 1h till stable X 2, then q 2h
• Hypoglycemia at 80 mg/Dl--!!! This is very
unusual
• Capillary unless needs checking, then venous—
not sure why we do not use arterial in ICU
UVA SIP Glucose Compliance
70
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% BG < 200
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0
June
Sept
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Portland
Furnary. J Thorac CardiovascSurg, 2003; 125: 1007-21
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http://www.starwood.com
Endocr Pract 2004; 10: 21-33
Tests q .5-2 hrs
Continuous IV only
Avg. 3 day Blood glucose
13,649 patients since 1987—prospective
interventional
• 1.5% hypoglycemia rate (60 mg/Dl)
van den Berghe
NEJM 2001. 345:1359-1367
• 1548 SICU patients. Randomized,
prospective, controlled.
• IV insulin to maintain between 80 and 110
mg/Dl
• Relatively short
• Measures q 2h until goal, then q 4h
• Hypoglycemia at 60
• No additional protocols for adding
nutrition, crises, weaning
Yale
• Goldberg PA, et al. Diabetes Care. 2004;
27:461-467
• Current BG leads you to table. Hourly rate of
change is guide. Nomogram. Complicated.
• Target is 100-139 mg/Dl. Very little hypoglycemia
• Mean time to target is 4.6 hrs. Median is 9 hrs.
• Protocol rated “easy”, no additions for nutrition,
weaning, crises.
Other protocols
• Markovitz—Endocr Pract. 2002; 8:10-16
– Has default algorithm
– Testing frequency lowers as stabilizes
– Hourly rate=hourly maintenance rate +(blood glucose150)/ISF
– Cut off is 100
• UNC—not published yet
– Target of 80-110. Has no hypoglycemia cut-off.
• Florida Hospital—not published, looks like blend
of Markovitz format and Portland amounts
• Glucommander
Free Form Protocols-Basic
Concepts
• Usual start dose is 0.15 u/kg
• Continuous IV weaned to bolus weaned to usual
• Think Basal/Nutritional/Correction (Crisis) as
three distinct levels with different needs
• Basal needs long acting agent like glargine
• Nutritional needs medium acting at 1 unit/10
gms of CHO
• Crisis/correctional needs short acting like Lispro
or Aspartine
More Basics to Keep in Mind
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Use regular insulin or NPH in drips
Regular insulin at doses of 0.5-1 unit/ml
Infuse at 0.1 unit dose increments
Use IV fluids with glucose—usually D5
Monitor potassium
Have D50 available and oral CHO also.
But is CII cheaper than SQ?
• Direct and indirect costs for 3 days of q 4h
SQ=$32/pt
• Costs of 3 days of Cont IV infusion with q
1-2 h test =$170/pt ($138 difference)
• Cost of DSWI =$2613/pt + $2081 for 1.8
additional days
• $4694-138 =$4556/pt or $4,556,000 per
1000 CABGs
• US Hospital savings = 103K CABGs =$469
million/yr
Point of Care Testing
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Essential
Timing is crucial
Which blood source? Urine? Same over time?
Sensitivity vs. specificity
What interferes with the test you use?
No way to get trends at this time
What would you want in a testor that you do not
have now…?
• Who needs to be involved? What skills do they
need or bring to share?
More on POC Testing
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Bedside monitoring vs. central lab
Does the person doing the test matter?
Self-monitoring?
Cost, accuracy, accountability
Will we live long enough to see a noninvasive bedside monitor? Wireless?
• Ketones, albumin, HbA1c, glycated serum
proteins-better than blood glucose?
The Pieces You Need
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Know the literature and other rationales
Have a credible champion
The right protocol
Forms, policies and order sets
The right team
Enough equipment
Strong Quality Improvement department
What to Do with the Pieces
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Start with one unit
Keep all data in one place
Solid communication system
Accurate test administered by trained
professionals
Timely changes in treatment
Start high, move lower
Never stop educating
Have a safety plan
Consider special circumstances
Data that may help you…
• Knowing what percentage of patients are
diabetic—and guesstimating percent of
unrecognized hyperglycemic patients
• Literature
• Knowing what surgical infection rate is
• Estimating cost to your institution in terms
of:
– Mortality
– LOS
– Financial Costs
Thanks…
• Questions, comments,
suggestions?
• [email protected]