Sanjeev ghai Income tax C

Information about Sanjeev ghai Income tax C

Published on October 13, 2014

Author: praveen114731

Source: authorstream.com

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Management of Inpatient Hyperglycemia: Management of Inpatient Hyperglycemia Feb 2014 Case Vignette: Case Vignette 45 year old obese female with DM type II is admitted for acute nausea, vomiting, and epigastric pain. CT Abdomen with IV contrast demonstrates acute pancreatitis. Her diabetes is usually controlled on metformin 1000mg BID and glyburide 10mg BID. Admission BMP shows a random glucose of 240. How do you manage her hyperglycemia? A. Continue home regimen Continue home glyburide and discontinue metformin Start sliding scale insulin Start correction insulin Learning Objectives: Learning Objectives Appreciate difference between sliding scale insulin vs correction insulin Understand optimal glycemic control goals in ICU vs non ICU settings Review the pharmacokinetics of different insulin preparations Learn how to use correction insulin and initiate insulin therapy on UCI wards The problem with sliding scale insulin: The problem with sliding scale insulin Time 0700 Break- fast 0800 1200 Lunch 1300 1700 Dinner 1800 2100 Blood Glucose 275 350 400 250 Sliding scale 6 units 10 units 12 units 6 units Sliding Scale Insulin - Treats hyperglycemia with only short/rapid acting insulin without long-acting basal insulin Reactive therapy Treats current hyperglycemia, does not prevent future hyperglycemia Can cause large swings in glucose levels throughout day Typical day battling hyperglycemia Correction Insulin: Correction Insulin Correctional Insulin Results in physiologic subcutaneous insulin administration Treats current hyperglycemia with the goal of preventing further hyperglycemic events during the hospital course Includes initiation of three components: 1. basal insulin (long acting) 2. nutritional insulin (rapid acting, pre-meal) 3. correctional insulin (rapid acting, for real time adjustment) Administer correction scale insulin BEFORE the meal using a rapid or short acting insulin A better day when using correction insulin : A better day when using correction insulin Time 700 EAT 0800 1200 EAT 1300 1700 EAT 1800 2100 Blood Glucose 170 275 210 350 250 400 250 Sliding Scale 6 10 12 6 Correction Scale 2 units 4 units 6 units 6 units Sliding scale: 34 units of rapid/short acting insulin administered Correction scale: 18 units of rapid/short acting insulin Remember, it is the concept of correction insulin we want to practice. If this patient remains hyperglycemic, adjust basal/nutritional insulin therapy AACE/ADA Consensus Statement on Management of Inpatient Hyperglycemia : 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 PowerPoint Presentation: Rapid (Prandial, Bolus) Short (Prandial, Bolus) Intermediate (Basal) Long (Basal) Correction Insulin Tips: Correction Insulin Tips Start with If uncontrolled add On insulin at home (DM I, some DM II) NPO *Home basal insulin *Correctional scale insulin Eating *Home basal insulin (reduce 50%) *Home prandial insulin (reduce doses by 25-50%) *Correctional scale insulin Not on insulin (pre-DM, DM II) NPO Stop all oral anti-hyperglycemics. Start correctional scale *Basal insulin Eating Cautiously use oral anti-hyperglycemics OR Start *basal, *prandial, AND *correctional scale insulin *Basal insulin *Prandial insulin *Correctional scale Current UCI Glycemic Monitoring Protocol: Current UCI Glycemic Monitoring Protocol UCI is aggressively pursuing the concept of correction insulin and preventing hyperglycemia. Many more patients will be initiated on insulin therapy When to pursue insulin therapy All DM I Most DM II receiving medication treatment 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 How to Initiate Insulin Therapy (if not already on insulin OR if uncontrolled diabetes): How to Initiate Insulin Therapy (if not already on insulin OR if uncontrolled diabetes) Regimen Tracts Dose Low (DM I, Lean DM II) Standard (Normal weight DM) Moderate (Overweight DM) Aggressive (Obese DM) Total Daily Dose (TDD) 0.3 units/kg/day 0.4 units/kg/d 0.5unit/kg/d 0.6unit/kg/d Basal ½ TDD Prandial ½ TDD divided into 3 meals Correction Scale Yup, they will also receive this too It should be the same rapid/short acting insulin as used for prandial insulin See next page Correction Scale with Meals: Correction Scale with Meals Regimen Tracts Dose Low (DM I, Lean DM II) Standard (Normal weight DM) Moderate (Overweight DM) Aggressive (Obese DM) Total Daily Dose (TDD) 0.3 units/kg/d 0.4 units/kg/d 0.5unit/kg/d 0.6unit/kg/d 161-200 1 units 2 units 3 units 4 units 201-250 2 units 4 units 5 units 6 units 251-300 3 units 6 units 7 units 8 units Insulin Dose Adjustment for CKD: Insulin Dose Adjustment for CKD No dose adjustment if GFR >50 Use 75% of baseline insulin dose if GFR 10-50 Use 50% of baseline insulin dose if GFR <10 Example: At home takes 40 units of glargine qHS If GFR 30: give 30 units of glargine qHS If GFR <10: give 20 units of glargine qHS Long Beach VA Guidelines on Adjustment of Insulin: Long Beach VA Guidelines on Adjustment of Insulin If glucose above target, increase insulin doses by 10-20% (2-5 units) every 1-2 days Once patient clinically stable on insulin regimen, d/c correctional insulin and check glucose 2 hours after meals (target BS <150 two hours after a meal) How to Adjust: Patient on NPH/Regula r insulin regimen If fasting glucoses elevated, increase evening NPH If pre-lunch or 2 hr post breakfast elevated, increase AM pre-breakfast regular If pre-dinner or 2 hr post lunch elevated, increase AM NPH If bedtime or 2 hr post-dinner elevated, increase pre-dinner regular May need bedtime snack once glucoses are well controlled Long Beach VA Guidelines on Adjustment of Insulin: Long Beach VA Guidelines on Adjustment of Insulin Patient on Lantus with Regular/Aspart insulin : If fasting elevated, increase Lantus If pre-lunch or 2 hr post breakfast elevated, increase pre-breakfast regular/Aspart If pre-dinner or 2 hr post lunch elevated, increase pre-lunch regular/Aspart If bedtime or 2 hr post-dinner elevated, increase pre-dinner regular/Aspart If all glucoses elevated, may need to increase all insulins Case Vignette: Case Vignette 45 year old obese female with DM type II is admitted for acute nausea, vomiting, and epigastric pain. CT Abdomen with IV contrast demonstrates acute pancreatitis. Her diabetes is usually controlled on metformin 1000mg BID and glyburide 10mg BID. Admission BMP shows a random glucose of 240. How do you manage her hyperglycemia? A. Continue home regimen Continue home glyburide and discontinue metformin Start sliding scale insulin Start correctional insulin Case Vignette Answer: D: Case Vignette Answer: D Answers A and B incorrect because patient likely to be NPO Answer C, sliding scale insulin is no longer in favor. CORRECT ANSWER(S) Option 1: Initiate insulin therapy (basal, prandial, corrective scale) on admission Option 2: Start q6 accuchecks with correction scale (regular insulin is commonly used). Correct BS per Aggressive Regimen since is obese DM type II BS 160-200 – 4 units BS 201-250 – 6 units, etc. If BS is still >180 after 1-2 days, then initiate longer insulin therapy (basal, prandial, corrective scale). Note Option 2 less preferable because random BS>180 and requires high doses of PO meds already so odds are she will have uncontrolled hyperglycemia Last Question: Last Question 55 year old male with DM I comes from with cough and fevers. Admitted for treatment of pneumonia. He normally takes 20 units glargine qHS and 6 units aspart with each meal. How would you manage his blood sugar? A. Continue home regimen Give 10 units glargine qHS and 2 units aspart qAC Give home glargine dose only Give home aspart doses only Correct Answer is B: Correct Answer is B Patient likely can eat, albeit he may eat less in setting of illness and restrictive hospital diets. He is DM type I so he needs continuous insulin coverage. The safest option is to decrease his insulin doses by 25-50% and monitor. His goal BS is a FBG <140 and random BS <180. If he continues to experience hyperglycemia, then do the following. Basal insulin: uptitrate the glargine or redose based on a TDD of 0.3units/kg/day Prandial insulin: uptitrate the aspart or re-dose based on a TDD of 0.3 units/kg/day Initiate correction scale: Give additional aspart for BS >160. Take Home Points: Take Home Points Correction insulin is a concept to prevent hyperglycemia. It may include the initiation of insulin therapy (basal insulin, prandial insulin, AND correction scale) Avoid hypoglycemia. A safe inpatient BS goal is no lower than 100 Avoid severe hyperglycemia. A good target is a random BS <180 Reassess insulin needs after any change in nutritional status (NPO, PO, tube feeds) Readjust basal and nutritional insulin if still requiring additional correctional scale insulin or hyperglycemia persists every 1-2 days Easy self-directed learning materials: Easy self-directed learning materials American Association of Clinical Endocrinologists and American Diabetes Association Consensus Statement on Inpatient Glycemic Control. Diabetes Care June 2009 32(6) 1119 Intensive insulin therapy in critically ill patients. NEJM 2001; 345(19): 1359 Management of Hyperglycemia in the Hospital Setting. Inzucci et al. NEJM 2006; 355: 1903-1911 The Nice-Sugar study investigators: Normoglycemia in Intensive Care Evaluation Survival Using Glucose Algorithm Regulation Intensive vs conventional glucose control in critically ill patients. NEJM 2009; 360:1283 UpToDate “Management of DM in hospitalized patients” and “General Principals in Insulin Management.” Accessed on June 11, 2012. UCI Inpatient Glycemic Monitoring and Treatment Guidelines. 2012

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