院内高血糖的处理课件

Hyperglycemia Management in the Hospital,Hyperglycemia has been defined as any blood glucose 140 mg/dl (7.8 mmol/l). Levels that are significantly and persistently above this may require treatment in hospitalized patients. In patients without a previous diagnosis of diabetes, elevated blood glucose may be due to “stress hyperglycemia,” a condition that can be established by a review of prior records or measurement of an A1C. A1C values 6.5% suggest that diabetes preceded hospitalization (359).,a. Definition of glucose abnormalities in the hospital setting,The Increasing Rate of Diabetes Among Hospitalized Patients,48%,Available at: /diabetes/statistics/dmany/fig1.htm. Accessed June 15, 2004.,Hyperglycemia in Hospitalized Patients,Hyperglycemia (200 mg/dL x 2) occurred in 38% of hospitalized patients 26% had known history of diabetes 12% had no history of diabetes Newly discovered hyperglycemia was associated with: Longer hospital stays higher admission rates to intensive care units Less chance to be discharged to home (required more transitional or nursing home care),Umpierrez GE, et al. J Clin Endocrinol Metab. 2002;87:978982.,Prevalence of Hyperglycemia in 181 Cardiac Patients Without Known Diabetes,Norhammar A. Lancet. 2002;359:2140-2144.,Hyperglycemia Is an Independent Marker of Inpatient Mortality in Patients With Undiagnosed Diabetes,Adapted from Umpierrez GE, et al. J Clin Endocrinol Metab. 2002;87:978982.,In-hospital Mortality Rate (%),Newly Discovered Hyperglycemia,Patients With History of Diabetes,Patients With Normoglycemia,P 0.01,P 0.01,Hyperglycemia in Hospitalized Patients,Surgery Catheters Intravenous Access,Problems with wound healing,Problems with tissue and organ perfusion,High-risk for bacterial infection,Hospital Costs Account for Majority of Total Costs of Diabetes,Hogan P, et al. Diabetes Care. 2003;26:917932.,Per Capita Healthcare Expenditures (2002),Diabetes,Without diabetes,Benefits of Improved Glucose Control in the Hospital,Aggressive insulin treatment improves ICU outcomes Outcomes post-MI Cardiac surgery outcomes,Mortality of DM Patients Undergoing CABG,Furnary et al J Thorac Cardiovasc Surg 2003;123:1007-21,Costs of Hyperglycemia in the Hospital,For each 50 mg/dL rise in glucose: Length of Stay increases by 0.76 days Hospital Charges increase by $2824 Hospital Costs increase by $1769,Furnary et al Am Thorac Surg 2003;75:1392-9,Intensive Insulin Therapy in Critically Ill PatientsMorbidity and Mortality Benefits,van den Berghe G, et al. N Engl J Med. 2001;345:13591367.,P=0.0009,P=0.026,BG110,110BG150,BG150,Surgical ICU Mortality Effect of Average BG,Van den Berghe et al (Crit Care Med 2003; 31:359-366),Hyperglycemia and Hospital Mortality 1826 consecutive ICU patients 10/99 thru 4/02, Stamford CT,Krinsley JS: Mayo Clin Proc 78: 1471-1478, 2003,Intensive Insulin Management in Medical-Surgical ICU (n = 1600),Krinsley SK. Mayo Clin Proc. 2004;79(8):992-1000.,Glycemic threshold in ICU Patients,BG 110 mg/dl,Van den Berghe et al Crit Care Med 2003; 31(2):359-66 Finney SJ et al JAMA 2003;290(15):2041-47 Krinsley SK. Mayo Clin Proc. 2004;79(8):992-1000,What About Medical Patients?,Cardiovascular Risk Mortality After MI Reduced by Insulin Therapy in the DIGAMI Study,Malmberg, et al. BMJ. 1997;314:1512-1515.,All Subjects,(N = 620),Risk reduction (28%),P = .011,0,.3,.2,.4,.7,.1,.5,.6,0,1,Years of Follow-up,2,3,4,5,Low-risk and Not Previously on Insulin,(N = 272),Risk reduction (51%),P = .0004,IV Insulin 48 hours, then,4 injections daily,0,.3,.2,.4,.7,.1,.5,.6,0,1,Years of Follow-up,2,3,4,5,6-11,Other Medical Conditions,Infection data supports BG 130 mg/dl Hartford ICU study 125 mg/dl vs 179 mg/dl 10X decrease in infections Stroke data supports BG 130 mg/dl Pregnancy data supports BG 100 mg/dl,Target blood glucose in mg/dL,80 110 in ICU patients 80 140 in other Surgical and Medical Patients 70 100 in Pregnancy,Bode et al Endocrine Practice July 2004, All patients with diabetes admitted to the hospital should have their diabetes clearly identified in the medical record. (E) All patients with diabetes should have an order for blood glucose monitoring, with results available to all members of the health care team. (E),Diabetes care in the hospital,Goals for blood glucose levels, Critically ill patients: Insulin therapy should be initiated for treatment of persistent hyperglycemia starting at a threshold of 180 mg/dl (10 mmol/ l). Once insulin therapy is started, a glucose range of 140 180 mg/dl (7.8 10 mmol/l) is recommended for the majority of critically ill patients. (A) These patients require an intravenous insulin protocol that has demonstrated efficacy and safety in achieving the desired glucose range without increasing risk for severe hypoglycemia. (E), There is no clear evidence for specific blood glucose goals. If treated with insulin, the premeal blood glucose target should generally be140 mg/dl (7.8 mmol/l) with random blood glucose 180 mg/dl (10.0 mmol/l), provided these targets can be safely achieved. More stringent targets may be appropriate in stable patients with previous tight glycemic control. Less stringent targets may be appropriate in those with severe comorbidites. (E),Noncritically ill patients:, Scheduled subcutaneous insulin with basal, nutritional, and correction components is the preferred method for achieving and maintaining glucose control in noncritically ill patients. (C) Using correction dose or “supplemental” insulin to correct premeal hyperglycemia in addition to scheduled prandial and basal insulin is recommended. (E), Glucose monitoring should be initiated in any patient not known to be diabetic who receives therapy associated with high risk for hyperglycemia, including high-dose glucocorticoid therapy, initiation of enteral or parenteral nutrition, other medications such as octreotide or immunosuppressive medications. (B),If hyperglycemia is documented and persistent, treatment is necessary.Such patients should be treated to the same glycemic goals as patients with known diabetes. (E), A plan for treating hypoglycemia should be established for each patient. Episodes of hypoglycemia in the hospital should be tracked. (E),All patients with diabetes admitted to the hospital should have an A1C obtained if the result of testing in the previous 23 months is not available. (E),Patients with hyperglycemia in the hospital who do not have a diagnosis of diabetes should have appropriate plans for follow-up testing and care documented at discharge. (E),Conclusion,All hospital patients should have normal glucose,Insulin,The agent we have to control glucose,only,most,powerful,powerful,Methods For Managing Hospitalized Persons with Diabetes,Continuous Variable Rate IV Insulin Drip Major Surgery, NPO, Unstable, MI, DKA, Hyperglycemia, Steroids, Gastroparesis, Delivery, etc Basal / Bolus Therapy (MDI) when eating,critical care setting, continuous intravenous insulin infusion has been shown to be the most effective method for achieving specific glycemic targets (346). Because of the very short half-life of circulating insulin, intravenous delivery allows rapid dosing adjustments to address alterations in patients status.,Threshold blood glucose in mg/dL for starting IV insulin infusion,Peri-operative care: 140 ICU care: 110 - 140 * Non-surgical illness: 140 - 180 * * Pregnancy 100,* Van den Berghes study supports 110; Finneys study supports 145 * * If drip indication is failure of SQ therapy, use 180 ; if indication is specific condition ( DM 1/ NPO, MI, etc ), use 140,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,Various Protocols Exist,DIGAMI (studied in acute MI setting) van den Berghe (studied in critical care setting) Portland Protocol (used in surgical setting) Markovitz (studied in postoperative heart surgery patients) Yale Protocol (studied in medical intensive care setting),A System for the Maintenance of Overnight Euglycemia and the Calculation of Basal Insulin Requirements in Insulin-Dependent Diabetics,Practical Closed Loop Insulin Delivery,1/slope = Multiplier = 0.02,0,1,2,3,4,5,6,0,100,200,300,400,Glucose (mg/dl),Insulin Rate (U/hr),NEIL H. WHITE, M.D., DONALD SKOR, M.D., JULIO V. SANTIAGO, M.D.; Ann Int Med 1982 ;97:210-214,Continuous Variable Rate IV Insulin Drip,Mix Drip with 125 units Regular Insulin into 250 cc NS (0.5 U/cc) or 1 U/cc Starting Rate Units / hour = (BG 60) x 0.02 where BG is current Blood Glucose and 0.02 is the multiplier Check glucose every hour and adjust drip Adjust Multiplier to keep in desired glucose target range (80 to 110 in ICU; 100 to 140 on floor),Continuous Variable Rate IV Insulin Drip,Adjust Multiplier (initially 0.02) to obtain glucose in target range 100 to 140 mg/dL If BG 140 mg/dL and has not decreased by 15% in the last hour, increase by 0.01 If BG 100 mg/dL, decrease by 0.01 If BG 100 to 140 mg/dL, no change in Multiplier If BG is 80 mg/dL, Give D50 cc = (100 BG) x 0.4 Give continuous rate of Glucose in IVFs Once eating, continue drip till 2 hours post SQ insulin,Multiplier Principles,Insulin Units / Hour,Glucose mg/ dl,Davidson et al, Diabetes Care 28(10): 2418-2423, 2005,Computerized Insulin Delivery,In 1984, R Dennis Steed computerized our insulin drip orders into Glucommander Glucommander used extensively since 1985 in our hospitals as well as 40 plus DTCA hospitals In 1996, Roche and MiniMed purchased the rights to use Glucommander in their combined meter pump system. Multi-center trials done and successful. Product died when IV insulin had not been FDA approved,Glucommander Average and Standard Deviation of of All Runs 1985 to 1998; 5808 runs, 120,618 BGs,Davidson et al, Diabetes Care 28(10): 2418-2423, 2005,Hours,Glucose,Multiplier,Multiplier,Insulin,Insulin,Glucose,Typical Glucommander Run,Hi,Low,Davidson et al, Diabetes Care 28(10): 2418-2423, 2005,1 Center Experience with Glucommander over a 1 year period (2004 to 2005),East Carolina University 750 bed hospital with 7 ICUs Glucommander initiated in all ICU patients with BG 140 mg/dL 7 FTEs hired to implement the program Average BG went from 167 to 126 mg/dl LOS decreased in ICU by 1 day; in Hospital by 0.3 days No central line infections Net savings to hospital 2 million dollars (470% Return on Investment),Personal Communication with Chris Newton, MD FACE,Intravenous Insulin Infusion Under Basal Conditions Correlates Well With Subsequent Subcutaneous Insulin Requirement,Hawkins et al. Endocr Pract. 1995;1:385389.,Units IV,Units SQ,Total Intravenous vs. Subcutaneous 24-hour Insulin Requirements, units,275 250 225 200 175 150 125 100 75 50 25 0,275,250,225,200,175,150,125,100,75,50,25,0,Converting to SC insulin,If More than 0.5 u/hr IV insulin required with normal BG, start long-acting insulin (glargine) Exception: if no prior DM and normal A1C, may not need SC insulin Must start SC insulin at least 1 to 2 hours before stopping IV insulin Some centers start long-acting insulin on initiation of IV insulin or the night before stopping the drip,Patients who receive intravenous insulin infusion will usually require transition to subcutaneous insulin when they begin eating regular meals or are transferred to lower intensity care. Typically, a percentage (usually 7580%) of the total daily intravenous infusion dose is proportionately divided into basal and prandial components (see below). Importantly, ubcutaneous insulin must be given 14 h prior to discontinuation of intravenous insulin to prevent hyperglycemia (367),The Physiological Insulin Profile,Adapted from Polonsky, et al. 1988.,10,20,30,Insulin (mU/l),0,40,50,60,70,Short-lived, rapidly generated prandial insulin peaks,Low, steady, basal insulin profile,Normal free insulin levels from genuine data (mean),0600,0900,1200,1500,1800,2100,2400,0300,0600,Breakfast,Lunch,Dinner,4:00,16:00,20:00,24:00,4:00,Breakfast,Lunch,Dinner,8:00,12:00,8:00,Time,Glargine or Detemir,Lispro Lispro Lispro,Aspart, Aspart, Aspart,or,or,or,Plasma insulin,Basal/Bolus Treatment Program with Rapid-acting and Long-acting Analogs,Glulisine Glulisine Glulisine,Insulin Requirements in Health and Illness,Relative Proportion of Insulin Requirement (%)*,*Estimations for illustrative purposes: requirements may vary widely.,Clement S, et al. Diabetes Care. 2004;27:553591.,Illness-Related,Healthy,Sick/ Eating,Sick/ NPO,Converting from IV to SC insulin,Establish 24 hr Insulin Requirement Extrapolate from average over last 6-8 hr if stable Give One-Half Amount As Basal Give One-Half Amount As Total Bolus Give post meal based on portion of food consumed or Give 1.5 units Rapid-acting for every CHO consumed Monitor a.c. tid, hs, and 3 am Correction Bolus for All BG 140 mg/dl,Correction Bolus (Supplement),Must determine how much glucose is lowered by 1 unit of rapid-acting insulin This number is known as the correction factor (CF) Use the 1700 rule or Weight to estimate the CF CF = 1700 divided by the total daily dose (TDD) ex: if TDD = 50 units, then CF = 1700/50 = 30 meaning 1 unit will lower the BG 30 mg/dl CF = 3000 divided by Weight in kg,Correction Bolus Formula,Example: Current BG: 250 mg/dl Ideal BG: 100 mg/dl Glucose Correction Factor: 30 mg/dl,Current BG - Ideal BG Glucose Correction factor,250 - 100 30,= 5.0u,Initiating SC Basal Bolus,Starting total dose = 0.5 x wgt. in kg Wt. is 100 kg; 0.5 x 100 = 50 units Basal dose (glargine) = 50% of starting dose at HS 0.5 x 50 = 25 units at HS Bolus doses (aspart / lispro) = 50% of starting dose 0.5 x 50 = 25 divided by 3 = 8 units pc (tid) Correction bolus = (BG - 100)/ CF, where CF = 1700/total daily dose; CF = 30,Protocol for Treatment of Hypoglycemia,Any BG 80 mg/dl: D50 = (100-BG) x 0.4 ml IV Recheck in 15 minutes and retreat if needed If eating, may use 15 gm of rapid CHO (prefer glucose tablets) Do Not Hold Insulin When BG Normal,TPN or Enteral Feedings,Determine insulin requirement via IV Insulin needs For TPN, add insulin to TPN bag with correction SC every 4 to 6 hours For enteral feedings, give Glargine every 12 hours or NPH every 8 hours or Regular every 6 hours with correction SC every 4 to 6 hours.,Hospital Diabetes Plan What Can We Do For Patients Admitted To Hospital?,Pathway Protocols For All Hyperglycemia and Diabetes Patients Finger Stick BG ac qid on ALL Admissions with BG 140 mg/dL or history of DM or high risk (ICU, Cardiac, Vascular, CVA, etc) Check All Steroid Treated Patients Diagnose Diabetes FBG 126 mg/dl Any BG 200 mg/dl,Hospital Diabetes Plan What Can We Do For Patients Admitted To Hospital?,Document Diagnosis in Chart Hyperglycemia Is Diabetes Until Proven Bring to All Physicians Attention Note on Problem List and Face Sheet Check Hemoglobin A1C in all hyperglycemic patients Hold Metformin; Hold TZD with CHF Start Insulin in All Hospitalized Patients with BG 140 mg/dl,Treat Any Patient With BG 140 mg/dl With Insulin Treat Any BG 140 mg/dl with Rapid-acting Insulin (BG-100) / (3000 / wt kg) or 1700 / total daily insulin Treat Any Recurrent BG 180 mg/dl with IV Insulin if failing SC therapy or 110 to 140 mg/dl if NPO, acute MI, perioperative, ICU, or 100 mg/dl if pregnant If More than 0.5 u/hr IV Insulin Required with Normal BG Start Long Acting Insulin,Hospital Diabetes Plan Protocol for Insulin in Hospitalized Patient,Hospital Diabetes Plan Protocol for Insulin in Hospitalized Patient,Daily Total: Pre-Admission or Weight (kg) x 0.5 u 50% as Glargine (Basal) 50% as Total Rapid-acting insulin (Bolus) Give in Proportion to Meals CHO Eaten BG 140 mg/dl: (BG-100) / CF CF = 1700 / Total Daily Insulin or 3000 / Wt (kg) Do Not Use Sliding Scale As Only Diabetes Management,Initiating Insulin: Basic Recommendations No set formula,One injection Intermediate-acting insulin or long-acting analog at bedtime Premixed formulation before dinner Two injections Breakfast and dinner: premixed formulation Breakfast and dinner: short-acting or rapid-acting plus NPH or long-acting insulin analog Three injections Add a short- or rapid-acting insulin injection at lunchtime to a 2-injection premixed regimen Add a third premix injection at lunchtime to a 2-injection premixed regimen Move the intermediate- or long-acting insulin analog to bedtime with short-acting or rapid-acting insulin analog at breakfast and dinner Multiple injections Short-acting or rapid-acting insulin analog at each meal with an intermediate- or long-acting at bedtime Insulin pump,Insulin regimes: Multiple options,Hospital Diabetes Plan What Can We Do For Patients Admitted To Hospital?,Get Diabetes Education Consult Instruct Patient in Monitoring and Recording See That Patient Has Meter on Discharge Decide on Case Specific Program for Discharge Arrange Early F/U with PCP,Conclusion,Our journey is not over, it has only begun We must normalize glucose in all hospital patients By implementing, assessing and revising protocols/pathways for hyperglycemic management, we can achieve this ultimate goal of normal glycemia,c. Noninsulin agents.,These agents are inappropriate in the majority of hospitalized patients because they are less titratable than insulin in the short tem and are meant to be used in patients eating on a regular meal schedule. Continuation of these agents may be appropriate in selected stable patients who are expected to consume meals at regu