CSII (CONTINUOUS SUBCUTANEOUS INSULIN INFUSION) AND INPATIENT ADMISSION

CSII (CONTINUOUS SUBCUTANEOUS INSULIN INFUSION) AND INPATIENT ADMISSION

Goals of Inpatient Glucose Management Avoid Hypoglycemia (Serum glucose <70 mg/dl) Dangerous due to the effects of counter-regulatory hormones (i.e. catecholamines), which can induce arrhythmias. Avoid Severe Hyperglycemia Which can lead to volume depletion and electrolyte abnormalities Ensure Adequate Nutrition Inpatients are outside their normal environment. Nutritional routines change and the type of food consumed is outside their norm.

Glycemic Targets Non-Critically Ill The ADA/AACE recommends pre-meal glucose of < 140 mg/dl and random glucose of <180 mg/dl for general hospitalized patients (consensus recommendation only) Critically Ill The ADA/AACE recommends a blood glucose target of 140 to 180 mg/dl. Achieving this goal may take an insulin infusion Acute MI American Heart Association recommends the use of an insulin infusion when glucose values are >180 mg/dl (10 mmol/l) in patients with an MI and a complicated course NICE-SUGAR (Intensive versus Conventional Glucose Control in Critically Ill Patients) In this large, international, randomized trial, we found that intensive glucose control increased mortality among adults in the ICU: a blood glucose target of 180 mg or less per deciliter resulted in lower mortality than did a target of 81 to 108 mg per deciliter. (ClinicalTrials.gov number, NCT00220987.) Well managed glycemic control avoids complications in hospitalized patients, reduced inpatient time, reduced risk of infection, promotes healing.

Models of Glycemic Management Sliding-Scale i.e. if POC glucose is 151-200 mg/dl, give 2u SQ NOVOLOG Not tailored to the individual patient outside of BMI and diet. Does not adjust to increasing or decreasing sensitivity of the patient or changes in condition Corrective Varied doses of short acting and long acting insulin, typical 50/50 rule based on BMI and estimated needs. Tools such as The Glucommander by Glyetec adapt the corrective insulin through data collection and patient surveillance. Highly dependent on the accuracy of nursing staff estimates of choleric intake. Infusion Continuous IV infusion of insulin as used in the treatment of DKA. This has allows for quicker adjustment of based on insulin demands, but requires more frequent monitoring of blood glucose and a higher level of training than what is on the medical floor to maintain.

What about the Insulin Pump?

The Insulin Pump Many advances in the last few years. Highly customizable, self-managed, glucose monitoring, detailed logging, trending, alarms, multiple modes based on activity and dietary intake, highly efficient and becoming more prevalent in the DMII patient.

CSII and the Inpatient Benefits Well controlled diabetics with insulin pumps are able to maintain euglycemia in the inpatient setting through self monitoring and insulin dosing/adjustment. Their insulin routine is not disrupted, insulin is not changed nor the timing of their dosing. Caveats The patient must be fully capable of managing the pump. They can not be intubated, sedated or too sick to think clearly. Nursing needs to have additional training on monitoring a patient who is self-dosing through an insulin pump. Additional charting is mandatory for patient safety. The specific disposable/limited use equipment must be brought by the patient. i.e. infusion sets and specific insulin.

CSII and the Inpatient Few studies have been done. One retrospective analysis was in Journal of Diabetes Science and Technology, Volume 4, Issue 4, July 2010. This analysis included inpatient CSII from 2006-2009, a total of 65 patients and 125 admissions. Mean glucose of 175 mg/dl was observed and found to not be significantly different than those patients where the pump was discontinued or intermittently used. Based on the record review, which included nursing flow sheets, patients can safely operate their insulin pumps. However there appears to be room for optimization of glucose control when pumps are allowed to be patient maintained during hospital admissions.

Surgery and Insulin Pumps One of the criteria for allowing patient managed insulin pumps was ability to monitor and manage. What do you do when your patient needs to go to surgery? Majority of hospitals have specific diabetes protocols regarding surgery, with expected pre-surgical treatments (i.e. specific IVF s), acceptable blood glucose ranges, and post-op diabetic goals. This is one area where insulin pumps can not be continued. Most reviewed protocols have the pumps being discontinued 24 hours prior to surgery to allow for surgical protocols to be implemented. Reinstatement of the pump can occur once the patient meets criteria post-op

Conclusion Insulin pumps with proper management provide an euglycemic state. The technology available provides all the tools necessary for a trained physician to adjust the pump to individual. Pump usage in the inpatient environment has not been shown to significantly improve glucose management but has also not been show to cause harm. Many organizations have elected to allow pump usage to maintain a proved diabetic regimen while inpatient. Additional training of nursing staff is required for the workflow surrounding patient maintained glycemic control. Additional charting and monitoring is required

References Policy: Use of Continuous Subcutaneous Insulin Infusion (Insulin Pump) Therapy in the Hospital: Shore Health System, University of Maryland Medical System Dalton M, Klipfel L, Carmichael K. 2006, Safety Issues: Use of Continuous Subcutaneous Insulin Infusion (CSII) Pumps in Hospitalised Patients, Hospital Pharmacy, vol. 41, no.10, pp956-969. Cook C, Boyle M, Cisar N, Miller-Cage V, Bourgeois P, Roust L, Smith S, Zimmerman R. 2005 Use of Continuous Subcutaneous Insulin Infusion (Insulin Pump) Therapy in the Hospital Setting: Proposed Guidelines and Outcome Measures. The Diabetes Educator, vol 31, pp849-857. Policy: JOSLIN DIABETES CENTER and JOSLIN CLINIC GUIDELINE for INPATIENT MANAGEMENT OF SURGICAL and ICU PATIENTS with DIABETES (Pre, Peri and Postoperative Care) 10/02/09. Outpatient-to-Inpatient Transition of Insulin Pump Therapy: Successes and Continuing Challenges Adrienne A. Nassar, M.D.,1 Brenda J. Partlow, C.N.P., N.P.,2 Mary E. Boyle, C.N.P., N.P.,2 Janna C. Castro, B.S.,3 Peggy B. Bourgeois, A.P.R.N., M.N.,4 and Curtiss B. Cook, M.D.2, Journal of Diabetes Science and Technology Volume 4, Issue 4, July 2010 Continuous Subcutaneous Insulin Infusion (CSII) in Inpatient Setting: Unmet Needs and the Proposal of a CSII Unit, Lelio Morviducci, M.D., Ph.D.,1 Alessandra Di Flaviani, M.D.,2 Angelo Lauria, M.D.,3 Dario Pitocco, M.D., Ph.D.,4 Paolo Pozzilli, M.D., Ph.D.,3 Concetta Suraci, M.D.,5 and Simona Frontoni, M.D., Ph.D.,2 for the CSII Study Group of Lazio Region, Italy, DIABETES TECHNOLOGY & THERAPEUTICS Volume 13, Number 10, 2011 Use of Continuous Subcutaneous Insulin Infusion (Insulin Pump) Therapy in the Hospital: A Review of One Institution s Experience, Brenda J. Leonhardi, M.S.N., FNP-C,1 Mary E. Boyle, C.N.P., C.D.E.,1 Karen A. Beer, P.A., C.D.E.,1 Karen M. Seifert, M.S., C.D.E.,2 Marilyn Bailey, R.N., M.S.,2 Victoria Miller-Cage, M.S., F.N.P.,3 Janna C. Castro, B.S.,4 Peggy B. Bourgeois, A.P.R.N., M.N.,5 and Curtiss B. Cook, M.D.1, Journal of Diabetes Science and Technology SYMPOSIUM Volume 2, Issue 6, November 2008 Intensive versus Conventional Glucose Control in Critically Ill Patients, The NICE-SUGAR Study Investigators, N Engl J Med 2009; 360:1283-1297March 26, 2009DOI: 10.1056/NEJMoa0810625

Questions?