A Look at Hyperglycemia in the Hospital Setting-Insulin Pump Therapy

Transcription

1 A Look at Hyperglycemia in the Hospital Setting-Insulin Pump Therapy Jeffrey S. Freeman DO FACOI Professor Division of Endocrinology and Metabolism Philadelphia College of Osteopathic Medicine

2 Hyperglycemia Is Prevalent at Hospital Admission 38% of all patients at admission have hyperglycemia Of those patients, nearly one-third have no history of diabetes 31% 69% History of diabetes No history of diabetes Single-center, retrospective chart review of 1886 patients hospitalized over 15 weeks in a community teaching hospital. Hyperglycemia defined as BG 126 mg/dl on admission or while fasting, or random BG 200 mg/dl on 2 occasions. Umpierrez GE et al. J Clin Endocrinol Metab. 2002;87:

3 Hyperglycemia is common in patients with and without diabetes 50 Diabetes 50 No Diabetes 40 78% 40 26% Patients, % < >200 < >200 Mean BG, mg/dl 0 Kosiborod M, et al. J Am Coll Cardiol. 2007;49(9): :283A-284A.

4 Mortality Rate (%) Hyperglycemia and Mortality in the MICU ~2x ~3x ~4x >300 Mean Glucose Value (mg/dl) N=1826 ICU patients. Krinsley JS. Mayo Clin Proc. 2003;78:

5 Mean Glucose & In-Hospital Mortality in 16,871 Patients with AMI Kosiborod M et al. Circulation 2008:117:1018

6 Postop Mortality (%) Hyperglycemia: A Predictor of Mortality Following CABG in Diabetes Patients 10 BG <200 BG >200 P< Postop Mortality n= % n= % * *P< Adjusted for 19 clinical and operation variables First Postop Glucose >200 2x LOS x Vent duration 7x mortality!!! CABG, coronary artery bypass graft. 0 < >250 Furnary AP et al. Circulation. 1999:100 (Suppl I): I-591. Blood Glucose (mg/dl)

7 No History Diabetes History Diabetes Mean BG (mg/dl) > Nondiabetics 153,910 Diabetics 62,868 Odd Ratio Odd Ratio 216,775 consecutive first admission 177 surgical, medical, cardiac ICUs 73 geographically diverse VAMC Falciglia et al, Crit Care Med 2009

8 A1C for Diagnosis of Diabetes in the Hospital HbA1c should be measured in non-diabetic subjects with hyperglycemia (BG>140 mg/dl) and in subjects with diabetes if not done within 2-3 months. In the presence of hyperglycemia, a patient with HbA1c >6.5% can be identified as having diabetes. Implementation of A1C testing can be useful: assess glycemic control prior to admission assist with differentiation of newly diagnosed diabetes from stress hyperglycemia designing an optimal regimen at the time of transition to regular floor and discharge Moghisi et al. D Care 2009; Umpierrez et al, J Clin Endocrinol Metabol, 2012

9 Factors influencing A1c

10 What target glucose should we aim in the hospital? What have intervention studies on glucose control shown?

11 Recommended target blood glucose in the ICU Prior to No recommendation. - Average BG ranged between mg/dl ADA and AACE recommended a BG between mg/dl current - ADA and AACE recommended a BG between mg/dl for most patients, but in cardiac surgery patients Moghissi ES, et al; AACE/ADA Inpatient Glycemic Control Consensus Panel. Endocr Pract. 2009;15(4).

12 Portland Diabetes Project: Insulin Infusion Reduces DSWI SCI CII SCI Group: Day of surgery: 241 mg/dl POD #1: 206 mg/dl DSWI (%) CII Group: Day of surgery: 199 mg/dl POD #1: 176 mg/dl Year Prospective study of 2,467 consecutive diabetics who underwent open heart surgery. DSWI, deep sternal wound infection; SCI, subcutaneous insulin; CII, continuous insulin infusion. Furnary AP, et al. Ann Thorac Surg. 1999;67:

13 Intensive Glucose Management in RCT Trial N Setting Primary Outcome ARR RRR Odds Ratio (95% CI) P-value Van den Berghe 2006 HI MICU Hospital mortality 240 CCU AMI 6-mo mortality 2.7% 7.0% 0.94* ( ) N.S. -1.8%* -30%* NR N.S. Glucontrol 2007 Ghandi 2007 VISEP 2008 De La Rosa ICU ICU mortality -1.5% -10% 1.10* ( ) 399 OR Composite 2% 4.3% 1.0* ( ) 537 ICU 28-d mortality 504 SICU MICU 28-d mortality 1.3% 5.0% 0.89* ( ) N.S. N.S. N.S. -4.2% * -13%* NR N.S. NICE-SUGAR ICU 3-mo mortality -2.6% ( ) < 0.05 *not significant

14 AACE/ADA Recommended Target Glucose Levels in ICU Patients l ICU setting: Starting threshold of no higher than 180 mg/dl Once IV insulin is started, the glucose level should be maintained between 140 and 180 mg/dl Lower glucose targets ( mg/dl) may be appropriate in selected patients Targets <110 mg/dl or >180 mg/dl are not recommended Not recommended Acceptable Recommended Not recommended < >180 Moghissi ES, et al; AACE/ADA Inpatient Glycemic Control Consensus Panel. Endocr Pract. 2009;15(4).

15 Health Information Service Integration ADT CPOE EMR LIS emar

16 Converting to SC insulin If one has known diabetes or A1C above 6%, one should convert to basal bolus insulin if no prior DM and normal A1C, usually do not need SC insulin Must start SC insulin at least 1 to 2 hours before stopping IV insulin Many centers start long-acting insulin the night before stopping the insulin drip

17 Converting from IV to SC insulin Establish 24 hr Insulin Requirement Extrapolate from average over last 4 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 Monitor a.c. tid, hs, and 3 am Correction Bolus for All BG >140 mg/dl

18 Tube Feedings If > 180 mg/dl, establish 24 hr Insulin Requirement via IV insulin Once at goal, - Give total amount IV insulin as basal SC twice daily - Stop IV insulin 12 hrs post 2 nd basal dose - If TF are held, hold basal insulin and hang D10 at 50 ml/hr Monitor q 4hrs and once stable, q 6 hrs Correction Bolus for All BGs >140 mg/dl; correction dose based on BG-100/CF where CF = 1700/TDD

19 TPN If < 180 mg/dl, add 1 unit Regular Insulin per 10 gm Dextrose and then monitor q 4hrs and use correction dose RAI If > 180 mg/dl, establish 24 hr Insulin Requirement via IV insulin Once at goal, - Give total amount IV insulin as regular insulin in TPN daily - Stop IV insulin 2 hrs post new TPN with insulin is started - If TPN is held, no issue regarding hypoglycemia Monitor q 4hrs and once stable, q 6 hrs Correction Bolus for All BGs >140 mg/dl where correction dose based on BG-100/CF where CF = 1700/TDD

20 Discharge insulin Algorithm Discharge Treatment A1C < 7% A1C 7%-9% A1C >9% Re-start outpatient treatment regimen (OAD and/or insulin) D/C on basal plus OHA once daily D/C on basal bolus at same hospital dose. Umpierrez et al, ADA Abstract: 2012

21 General Points About Insulin Pumps Insulin pump is another delivery device for insulin. It is often called CSII Continuous Subcutaneous Insulin Infusion. Through the pump, insulin can be delivered in the 2 rates to closely mimic the normal functioning pancreas: BASAL (units/hour) BOLUS (amount of units give at one time) Fast acting insulin (Novolog, Humalog, Apidra) is ONLY used.

22 INSULIN PUMP EXAMPLES: MEDTRONIC ANIMAS OMNIPOD

23 Insulin Pumps on the Market Accu-Chek Combo System Asante Snap Insulin Pump System MiniMed Paradigm Real-Time Revel System (523/723) MiniMed 530G with Enlite (551/751) OmniPod Insulin Management System OneTouch Ping t:slim Insulin Pump V-Go Disposable Insulin Delivery Device Roche Health Solutions Asante Solutions Medtronic MiniMed Medtronic MiniMed Insulet Corporation Animas Tandem Diabetes Care Valeritas, Inc.

24 MEDTRONIC A = insulin pump B = SQ insertion site with tubing attached to pump C = SQ site for sensor D = Sensor A B ANIMAS

25 KEY PUMP FUNCTION: MEDTRONIC To give a bolus: Press the UP arrow button Keep pressing the UP arrow button until the amount of insulin to be given shows Press ACT (listen for beeps; the number will be flashing); reverify dose Press ACT (again) Bolus is being given Document dose given in MAR UP arrow button

26 KEY PUMP FUNCTION: UP arrow button ANIMAS To give a bolus Press side button Press UP arrow button until amount is listed in units Press OK (GO will be highlighted) (reverify dose) Press OK (again) Bolus is being given Document dose given in MAR Side Button

27 OMNIPOD POD attached to any site on the body delivers basal insulin PDM Personal Data Manager used within 2 feet of POD to deliver extra insulin

28 KEY PUMP FUNCTION: This button is either Enter, Select or Confirm button OMNIPOD To give a bolus: Have PDM within 2 feet of patient Press Power button (read the screen); Press Menu button Make sure Bolus is highlighted (top of the screen) and Press the SELECT button Read the screen; Press NO twice Use little arrow to enter the amount of units needed Press Enter (reverify dose) Press Confirm Bolus has been given Document dose given in MAR Power button Little UP arrow button (is also Power button) New PDM (works same as old PDM)

29 Guidelines for caring for the hospitalized patient with insulin pump Leave pump in place unless otherwise ordered If it is taken off, the patient can not be off insulin longer than an hour If pump is taken off, give to the patient s family and DOCUMENT THAT IV insulin or long acting insulin can be used when patient is off the pump At least AC & HS monitoring is needed for a pump patient; at times ~0300 Insulin pump must be removed during any x-ray, MRI, scan, etc. (not to be in same room; it is not necessary to suspend it) After test, immediately hook up pump If Omnipod, the POD has to be taken off; a new one with new insulin will need to be put on after the test Know how to give a bolus (follow the prompts on the pump screen)

30 Guidelines for caring for the hospitalized patient with insulin pump Patient needs to be alert enough to manage the pump when inpatient. Patient is to bring his own pump supplies; hospital can provide insulin. Patient is to change out the pump, insulin, and site every 3 days Obtain written physician order to use pump while in the hospital. Place Insulin Pump Standing Orders form in the Orders section of the chart. Send a referral to the Diabetes & Nutrition Center to see insulin pump patient. Diabetes Educator will obtain all the rates, check the pump and complete the Insulin Pump Standing Orders. MAR is to have all the rates listed on it.

31 Patient Expectations Inform the patient of the following expectations regarding self-management of the insulin pump: a) Patient must keep detailed written records at bedside, which include FSBS/CBG values, carbohydrate intake, meal bolus, correction bolus, basal rates, and infusion set change. b) Patient will inform nurse of: i. Any insulin given via pump, in addition to basal rates ii. All carbohydrate intake iii. Any concerns he/she has regarding the pump or pump care iv. Any change to set or site

32 Documentation 1. On admission and every shift, document the following: a) Visual inspection of pump including but not limited to; b) LCD screen lit, keypad/buttons functioning and casing of pump intact. c) Infusions set connections are secure. d) Infusion set, including tubing connector and tubing intact without evidence of cracks or damage. 2. Assessment of insertion site; a) Signs and symptoms of infection such as drainage from site, bleeding, swelling, odorous and/or patient complaints of pain/discomfort. b) Site dressing intact without evidence of dislodging of infusion cannula. 3. Basal rate per patient/physician. 4. Description of how patient determines bolus insulin to give as correction/supplemental insulin to cover high FSBS/CBG s and insulin to cover carbohydrate intake (on admission only). 5. Carbohydrate intake. 6. All bolus insulin given by patient via pump to include correction/supplemental insulin and insulin for carbohydrate intake.

33 Special Considerations 1. Insulin used in insulin pumps is rapid-acting. If there is an occlusion in the tubing or the patient s insulin needs drastically change due to acuity in medical condition, the blood sugar can rise quickly 2. The insulin pump may not always alarm when there is a problem with insulin delivery. 3. If one blood glucose is over 250 mg/dl, the following steps must be taken: a) Have patient give a correction bolus of insulin via the pump. b) Recheck blood glucose in 60 minutes. c) If the blood glucose has not decreased, have the patient give a correctional injection of insulin as ordered with an insulin syringe (not through the pump). d) If blood glucose is > 240 mg/dl two consecutive times, have the patient change the set and site.

34 Conclusion Our journey is not over, it has only begun We should near-normalize glucose in all hospital patients By implementing, assessing, and revising protocols / pathways for hyperglycemic management, we can ultimately achieve this goal of euglycemia without hypoglycemia