Transcript Inpatient Management of Diabetes Mellitus

Inpatient Management of
Diabetes Mellitus
William Harper, MD, FRCPC
Endocrinology & Metabolism
Assistant Professor of Medicine,
McMaster University
DKA
1. Monitored setting if Hi-risk
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2.
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4.
5.
elderly & CAD, pH < 7.0, severe K disturbance,
decreased LOC
IV Fluid Resuscitation (6-8L deficit)
Potassium (“no pee no K”)
IV insulin
Identify & Rx underlying cause
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Noncompliance, infection, MI, etc.
DKA: IV Fluids
• IV NS 1L/h x 2-3h or longer so no more
tachycardia, hypotension, orthostatic changes, low
JVP.
• Then change to 1/2 NS:
• 500 cc/h x 1-3h
• 250 cc/h x 4-6h
• If hypotension recalcitrant to fluids consider AI
(Schmidt PGAS II) and send stat cortisol then give
solucortef 100 mg IV q8h.
DKA: Mortality
• Adults 2-4%
• Hypokalemia
• MI, CVA, etc.
• Kids 0.2-0.4%
• Cerebral edema
DKA: Potassium
• Need K with initial IV fluid & insulin Rx
unless:
• Anuric
• K > 5.5 mEq/L or hyperkalemic ECG changes
Initial [K]
> 5.5 mEq/L
5.2-5.5 mEq/L
4-5.2 mEq/L
3-4 mEq/L
< 3 mEq/L
Replacement
nil (initially)
10 mEq/h
20 mEq/h
30 mEq/h
40 mEq/h
> 20 mEq/h:
Cardiac monitor
> 60 mEq/L:
Central line
DKA: IV Insulin
• Humulin R or Novolin Toronto
• Bolus 0.1-0.2 U/kg IV
• Then IV gtt @ 0.1-0.2 U/kg/h
(50 U of regular insulin in 500cc D5W; 1U/10cc)
• Monitor: CBG q1h
• Monitor: Venous BS, electrolytes, creatinine q2h
• Aim is to demonstrate correction of Anion Gap (AG) and
decrease in BS 4.4 mM/L/h
• Monitoring serial serum ketones NOT useful:
ßHß (not detected) DKA Rx Acetoacetate (detected)
DKA: IV Insulin
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Using insulin to treat 2 different and separate
metabolic disturbances in DKA:
1. Ketoacidosis
2. Hyperglycemia
DKA: IV Insulin
• If AG not correcting and/or BS not decreasing then
increase IV gtt rate 1.5-2X
• If BS < 13 but AG still not corrected do NOT decrease
insulin IV gtt.
• Instead start IV glucose gtt:
• D5W-D10W @ 100-200 cc/h
• Once AG corrected than titrate IV insulin to BS
• When BS < 13 and AG normal: reduce IV insulin gtt to 1-2
U/h and add IV glucose if not already done.
DKA: IV Insulin
• Can consider switch to SC insulin when:
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AG normalized
BS < 15 mM
Insulin IV gtt requirements < 2U/h
Patient able to eat
• Overlap insulin IV gtt with 1st SC insulin by 3-4h
to avoid recurrent ketosis.
DKA: Other Rx
• Bicarbonate
• May exacerbate hypokalemia
• Only give if pH < 6.9 AND evidence of cardiovascualr
instability (arrythmia, CHF, hypotension)
• 1-2 amps bicarb in 1L D5W IV over 2h until pH > 7.1
• Phosphate
• Routine IV not recommended
• Rx symptomatic hypophosphatemia (rhabdo, unexplained CHF
or respiratory failure, severe confusion)
• 10cc K Phos soln (3.0mEq Pi and 4.4 mEq K/cc) in 1L NS IV
over 8-12h
DKA: Other Rx
• Cerebral Edema
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Usually only kids
Persistent decreased LOC despite standard Rx of DKA
CT scan to confirm diagnosis
Decadron 10 mg IV
Mannitol 25 mg IV
HONC
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BS > 55
Serum OSM > 350
Coma 25-50%
Mortality rate 25-70%
HONC
1. Coma Management
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ABCs, O2, narcan, D50W, thiamine, etc.
2. IV Fluid Resusciation (10L free water defecit)
3. Insulin
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IV fluids will decrease BS by 4 mM/L/h by itself
For most patients insulin not absolutely neccesary
Insulin IV bolus 5-10 U, gtt @ 1-2 U/h
4. Potassium (replace as in DKA)
5. Identify & Rx underlying precipitant
BS > 11.1 mmol/L
Renal threshold for glycosuria (normal GFR)
Decreased WBC function
Chemotaxsis
Phagocytosis
Decreased Wound Healing
Goals of Inpatient DM Management
• “Avoid hypoglycemia and marked hyperglycemia”
• Target BS: 7.0 - 11.0 mM
• Avoid Hypoglycemia
• Precipitating arrhythmia or other cardiac events
• Inducing seizure, focal or cognitive defects periop
• Avoid Marked Hyperglycemia (BS > 11.1 mM)
• Treat (and avoid) DKA, HONC
DM Inpatient Management
1. Eating
2. NPO: temporary (for a test)
3. NPO: prolonged
DM Inpatient Management
1. Eating:
OHA (T2DM)
Insulin (T2DM and T1DM)
OHA:
Drug
BG
HbA1c
Side-effects
Sulfonylurea
FBG 20%
1.5-2.0%
Hypoglycemia
Weight gain
Biguanide
FBG 20%
1.5-2.0%
Lactic acidosis
GI intolerance
TZD
FBG 2.2-3.6
mM
FPG 14%
PPG 25%
1.0-1.6%
Edema
Weight gain
0.5%
GI intolerance
FPG 4 mM
PPG 5.6 mM
1.8%
Hypoglycemia
α-glucosidase
Inhibitor
Meglitinide
Insulin
Type
Starts
Peaks
Duration
Humalog
NovoRapid
5-10 min
1-2 hrs
3.5 hrs
Regular
30 min
2-4 hrs
6-8 hrs
NPH
Lente
1-2 hrs
6-10 hrs
16-24 hrs
Ultralente
4-6 hrs
8-24 hrs
24-36 hrs
Glargine
Immediately
None
Up to 24 hrs
BIDS Therapy
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T2DM: “Introduction to insulin”
Keep on OHAs
Start NPH 0.2 U/kg SC qhs
Increase by 2-4 U q4d until FBS 4-7
If dose > 30-40U or if BS high late in day
despite OK FBS than split into 2 injections
with 2/3 acB and 1/3 acD
Starting Insulin Regimen
• TDD = 0.5-0.7 U/kg
• “2/3, 1/3” Regimens
• 2/3 of TDD acB, 1/3 acD
• 2/3 of TDD as Long-acting, 1/3 as short acting
• Pre-mix: acB 30/70 acD 30/70
• MDI Regimens
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2/3, 1/3 Regimen: move acD long acting to qhs
i.e. acB N, H acD H qhs N
ac meals H qhs N (bolus 60%, basal 40%)
ac meals H UL q12h (bolus 50%, basal 50%)
Insulin Regimens
acB
Bedtime NPH (+/-bids)
NPH bid
30/70 bid
MDI (3 injections)
MDI (>4 injections)
MDI (>4 injections)
CSII (Insulin Pump)
N
30/70
H+N
H (+/-N)
H + UL
acL
acD
qhs
N
N
H
H
30/70
H
H
H UL
N
N
Guideline for Insulin Adjustments
1.
Adjust the insulin that accounts for the high or low
reading.
Always compare an abnormal BS reading with the one
previous.
If insulin dose is:
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3.
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4.
Less than 8U, adjust by 1U
8-20U, adjust by 2U
> 20 U, adjust by 10% (increase), 20% (decrease)
Don’t forget to compensate for a successful adjustment
acB
acL
acD
qhs
22
(5R)
9
3.1
(O.J.)
15
acB N20 R10
acD R5
qhs N10
20
15
7
8
acB N20 R10
acD R5
qhs N10
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17
acB N20 R10
(RN calls)
Surgeon:
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Internal Medicine:
Endocrinologist:
Rx
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acB
acL
acD
qhs
Rx
22
(5R)
9
3.1
(O.J.)
15
acB N20 R10
acD R5
qhs N10
20
15
7
8
acB N20 R10
acD R5
qhs N10
22
17
acB N20 R10
(RN calls)
Surgeon:Give 5 U Regular SC now
Internist:
Increase qhs N to 12 tonight and acB R to 12 tomorrow
Endocrine:
Increase qhs N to 12 start tonight
Decrease acB N15 R7 starting tomorrow AM
Check 3AM BS tonight
Guideline for Insulin Adjustments
1.
Adjust the insulin that accounts for the high or low
reading.
Always compare an abnormal BS reading with the one
previous.
If insulin dose is:
2.
3.
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4.
Less than 8U, adjust by 1U
8-20U, adjust by 2U
> 20 U, adjust by 10% (increase), 20% (decrease)
Don’t forget to compensate for a successful adjustment
SC Insulin Supplemental Scale
CBG
Action
< 4.0
Call MD
4.1-11.0
nil
11.1-15.0
Humalog 7U SC (0.1U/kg)
15.1-19.9
Humalog 10U SC (0.15 U/kg)
> 20.0
Call MD
DM Inpatient Management
1. Eating
2. NPO: temporary (for a test)
3. NPO: prolonged
NPO for a test: T2DM on Diet Rx
• Schedule test for the AM
• Hold OHAs on AM of test
• CBG @ 7AM:
< 3.0
Consider postpone test
3.1-4.0
IV D5W gtt @ 75-100 cc/h
4.1-11.0 Proceed with test, no Rx necessary
> 11.1
IV insulin gtt
IV D5W gtt @ 75-100 cc/h
> 20.0
Check urine ketones, consider postpone test
NPO for a test: T1/T2DM on Insulin
• Schedule the test for the AM
• Hold AM Insulin on day of test
• CBG @ 7AM:
< 3.0
Consider postpone test
3.1-11.0
Give ½ of total AM insulin dose as NPH SC
IV D5W gtt @ 75-100 cc/h
> 11.1
IV insulin gtt
IV D5W gtt @ 75-100 cc/h
> 20.0
Check urine ketones, consider postpone test
DM Inpatient Management
1. Eating
2. NPO: temporary (for a test)
3. NPO: prolonged
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Patient put on D5W if not on feeds or TPN
IV insulin gtt
SC NPH or UL q12h (+/- supplemental scale)
Insulin IV gtt
• Add 50 U of Human regular insulin (Humulin
R or Novolin Toronto) to 500cc D5W
(1U/10cc).
• Flush & discard first 50cc.
• Infuse insulin solution by IVAC (intravenous
infusion pump), piggybacked into D5W
running at 100cc/h.
• Start insulin @ 0.9 U/h (9cc/h) or start at a
rate dependent on patient’s insulin dose:
IV insulin gtt rate = ( ½ TDD ) / 24
Insulin IV gtt
CPG q1h x 2, then q2h (if BS stable x 2-3 readings consider q4h):
Adjust Insulin IV infusion rate as per scale below:
<4.0
Call MD
4.1-5.0
0.7 U/h ( 7cc/h)
5.1-6.0
0.9 U/h ( 9cc/h)
6.1-7.0
1.2 U/h (12cc/h)
7.1-9.0
1.5 U/h (15cc/h)
9.1-11.0
2.0 U/h (20cc/h)
11.1-13.0 2.5 U/h (25cc/h)
13.1-15.0 3.0 U/h (30cc/h)
15.1-17.0 3.5 U/h (35cc/h)
17.1-20.0 4.0 U/h (40cc/h)
>20.1
Call MD
Evidence to support Inpatient BS control?
DIGAMI
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AMI, prior dx DM or BS > 11 mM
IV insulin gtt started @ 5 U/h
Titrated to keep BS 7-10.9 mM
Insulin IV > 24h  MDI > 3 months
No in-hospital mortality benefit.
Rx Increased hospitalization by 1.8d
0.5% reduction HbA1c @ 3 months
@ 1 year % on Insulin: 72% Rx Group 49% Cntrl Group
1 year mort: ARR 7.5% NNT 13
3.4 y mort: ARR 11% NNT 9
Evidence to support Inpatient BS control?
Leuven, Belgium Study
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ICU patients (63% CV Sx)
If BS > 6.1 mM: Rx with IV insulin gtt & TPN +/- tube feeds
Start IV insulin @ 2-4 U/h, titrated to BS 4.4-6.1 mM
Ave insulin dose: Rx group 3.0 U/h Cntrl group 1.4 U/h
Once out of ICU relaxed treatment goal to < 11.1 mM
Mortality in ICU:
ARR 3.4% NNT 29
Mortality in-hospital: ARR 3.7% NNT 27
Greatest reduction in mortality was sepsis-related.
Insulin Rx reduced: bacteremia, ARF needing HD, need for PRBC,
critical illness polyneuropathy, duration of ventilation and length of
stay in ICU
• To what extent were benefits nutrition related as opposed to insulin
related?