Yazan karim 09032020 Objectives Discuss background amp etiology about acute DM management Differentiate different points of care for ICU vs NonICU patients Identify clinical goals for diabetic patients in an inpatient settingADA guidelines ID: 1033083
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1. Acute Management of Diabetes MellitusYazan karim09/03/2020
2. ObjectivesDiscuss background & etiology about acute DM managementDifferentiate different points of care for ICU vs Non-ICU patientsIdentify clinical goals for diabetic patients in an inpatient setting(ADA guidelines)State the guidelines of UCM in treatment of acute DMIdentify antihyperglycemic treatments and the discontinoutaion of oral agents
3. Meta-analysis study"A meta-analysis of over 26 studies, including the Normoglycemia in Intensive Care Evaluation–Survival Using Glucose Algorithm Regulation (NICE-SUGAR) study, showed increased rates of “severe hypoglycemia” (defined as blood glucose <40 mg/dL)In surgical patients, perioperative BG levels at <180 mg/dL compared to <200 mg/dL is associated with a lower rate of mortality and stroke
4. Background & etiology
5. Actions upon admissionIdentify how patient takes medication and obtain labs listed on the leftUsually, oral medications are held (resume 1-2 days after discharge), and insulin is the drug of choice for hyperglycemiaSelf-management education such monitoring glucose and recognizing and treating hypoglycemia
6. Icu vs non-icu patientsICUNon-ICUBlood Glucose > 180 mg/dLInitiate insulinInitiate insulinGlycemic goal140-180 mg/DL in most patients140-180 mg/DL in most patientsTreatmentsIV insulinScheduled insulin injectionsDo not use premixed insulinMonitoring20-120 minutesBefore meals. If NPO, every 4-6 hours
7. patient treatmentNon-ICU – Scheduled insulin injections- PO: basal, bolus, and correction doses of insulin- NPO: basal/bolus in addition to a correction dose of bolus insulinICU – IV insulin- IV insulin infusions should be administered based on a validated written or computerized protocols that allow for glycemic fluctuations, adjustment in infusion rates, and insulin dose
8. Treatment regimen
9. Type 1 diabetes An insulin regimen that has both basal and correction components is necessaryCannot dose based on pre-prandial glucose levels alone. That will result in increasing both hyperglycemic and hypoglycemic risksBody-weight dosing should be usedIf the patient is eating, a prandial insulin should be added as well
10. Transitioning IV to SCA patient with either type 1 or 2 should receive SC basal insulin 2-4 hours before the IV insulin is discontinued60-80% of the daily infusion dose should be converted to the basal insulin dose, which has shown to be effectiveIn the inpatient setting, concentrated insulin (U-300, U-500, etc.) should be validated with caution to ensure the proper dosing
11. UCM Hypoglycemia management protocol
12. UCM Hypoglycemia management protocol
13. Inpatient recommendationsTriggering events of hypoglycemia include, but are not limited to: emsis, new NPO status, inappropriate timing of rapid or short-acting insulin, reduced infusion rate of IV dextrose, and unexpected interruption of oral, enteral, or parenteral feedingsTJC recommends that all hypoglycemic episodes are evaluated to find what the cause was, and reviewed to assess systemic issues
14. Sliding scale- Not recommended in the inpatient setting
15. Sliding scale inpatient use
16. Nutrition goalsGoals of medical nutrition therapy in the hospital are to provide sufficient calories to optimize glycemic control, meet metabolic demands, and facilitate creation of a discharge planSelf-management can be authorized for patients who have the cognitive and physical skills needed to successfully self-administer insulin and preform self-monitoring of blood glucoseMust also have adequate oral intake, be proficient in carbohydrate estimation, and protocol of the institution that an agreement between the medical staff and the patient has been established
17. Perioperative careTarget glucose range for the perioperative period should be 80–180 mg/dL (4.4–10.0 mmol/L)Perform a preoperative risk assessment for patients at high risk for ischemic heart disease and those with autonomic neuropathy or renal failure Withhold metformin the day of surgeryWithhold any other oral hypoglycemic agents the morning of surgery or procedure and give half of NPH dose or 60–80% doses of long-acting analog or pump basal insulin.Monitor blood glucose at least every 4–6 h while NPO and dose with short- or rapid-acting insulin as needed.
18. Diabetic Ketoacidosis and Hyperosmolar Hyperglycemic StateDKA can occur when the patient is hyperglycemic and can result in a diabetic coma or even death.Clinical goals:- Restoration of circulatory volume, tissue perfusion, restoration from hyperglycemic state, and correction of electrolyte imbalance and ketosisContinuous IV insulin is the standard of care
19. DischargeThe Agency for Healthcare Research and Quality (AHRQ) recommends that, at a minimum, discharge plans include the following:- Medication reconciliation,: medications cross-checked to ensure no medications were stopped and the safety of new prescriptions- Sick-day management- Proper use and disposal of needles and syringes- Identifying the signs and symptoms of hyper and hypoglycemia- Information on medication changes, pending tests and studies, and follow-up needs must be accurately and promptly communicated to outpatient physicians- Speaking with a nutritionist from the hospital to determine a long-term plan at home- Identification of the health care provider who will provide diabetes care after discharge- Level of understanding related to the diabetes diagnosis, self-monitoring of blood glucose, home blood glucose goals, and when to call the provider- An individualized plan tailored to each specific patient on the tasks to complete
20. Risk factors for readmission
21. References"15. Diabetes Care in the Hospital: Standards of Medical Care in Diabetes—2019" diabetes.org. American Diabetes Association. n.d. Web. (08/31/2020).Triplitt CL, Repas T, Alvarez C. Diabetes Mellitus. In: DiPiro JT, Talbert RL, Yee GC, Matzke GR, Wells BG, Posey L. eds. Pharmacotherapy: A Pathophysiologic Approach, 10e New York, NY: McGraw-Hill; . http://accesspharmacy.mhmedical.com/content.aspx?bookid=1861§ionid=1460658. Accessed August 31, 2020.NICE-SUGAR Study Investigators, Finfer S, Chittock DR, et al. Intensive versus conventional glucose control in critically ill patients. N Engl J Med 2009;360:1283–1297
22. Thank you