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Strategies to Reduce Hypoglycemia

Strategies to Reduce Hypoglycemia. Presented by : Hennie Garza, M.S., R.Ph., C.D.E, Director of Pharmacy Utilization and Outcomes Senior Care Centers http://www.seniorcarecentersltc.com / September 18, 2012. Goals & Objectives. Define Hypoglycemia

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Strategies to Reduce Hypoglycemia

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  1. Strategies to Reduce Hypoglycemia Presented by: Hennie Garza, M.S., R.Ph., C.D.E, Director of Pharmacy Utilization and Outcomes Senior Care Centers http://www.seniorcarecentersltc.com/ September 18, 2012

  2. Goals & Objectives • Define Hypoglycemia • Identify Risk Factors for Hypoglycemia • Identify signs and symptoms of Hypoglycemia • Discuss elements of a hypoglycemia management protocol • Review insulin characteristics and discuss strategies to improve patient safety when administering insulin • Discuss strategies to reduce hypoglycemia

  3. A really good reference: • Journal Clinical Endocrinology & Metabolism • January 2012, 97(1):16-38 • “MANAGEMENT OF HYPERGLYCEMIA IN HOSPITALIZED PATIENTS IN NON-CRITICAL CARE SETTING: AN ENDOCRINE SOCIETY CLINICAL PRACTICE GUIDELINE”

  4. Definition • Hypoglycemia = Plasma glucose less than 70mg/dL • Severe Hypoglycemia = when an individual requires the assistance of another person and cannot be treated with oral carbohydrate due to confusion or unconsciousness. • Cognitive impairment can occur with plasma blood glucoses less than 50mg/dL

  5. Risk factors for hypoglycemia • Older age • Greater illness severity (septic shock, mech. Ventilation, renal failure, malignancy, malnutrition • Diabetes • Use of oral glucose lowering agents & insulin • Cessation of nutrition for procedures • Adjustment in amount of nutritional support • Interruption of the routine for glucose monitoring • Failure to adjust therapy when glucose is trending down

  6. Signs & symptoms • Perspiring or sweating excessively • Weakness, dizziness, faintness • Hunger or excessive eating • Nervousness, irritability, changes in personality • Blurred/impaired vision • Numbness in tongue and lips • Tachycardia or palpitations • Tremors • Headaches • Altered level of consciousness

  7. Does your facility have a protocol?

  8. Nurse Strategies for Treatment

  9. Recommendations

  10. New Beers List 2012

  11. Hypoglycemia Case

  12. Insulin Time-Action Profiles

  13. Human 70/30 mix BID

  14. Analog mix 70/30 or 75/25 BID

  15. Basal-Bolus with Glargine and Rapid-Acting Analog AC

  16. Hypoglycemia Case

  17. Problems with Sliding Scale • COSTLY • Nursing time, Test strips, lancets, Insulin waste • Hypoglycemia risk • We have better options • Reactive instead of proactive • Basal insulin can help reduce reliance on sliding scale and reduce hypoglycemia • Move to “correctional” or “supplemental” dosing if needed

  18. Starting Basal Insulin

  19. Supplemental Insulin

  20. Insulin-common mistakes • New types of insulin and similar drug names make order-entry problematic • Know your different types of insulin • Use “Tall Man” lettering: NovoLOG, NovoLIN • Do not use the abbreviation “u” for units • Spell out numbers i.e. “give two units” • Similar drug packaging contributes to errors (case of missing Novolog but Novolog 70/30) • Methods of storage can impact errors

  21. Insulin – common mistakes cont’d • Communication of Insulin orders problematic • Dangerous Abbreviations will get “U” in trouble • Unclear orders on MAR • Sliding scale insulin orders BIGGEST culprit for errors and bad outcomes—HYPOGLYCEMIA • Multiple sliding scale orders for same resident (morning scale and bedtime scale)

  22. Insulin--hypoglycemia • Insulin has few actual drug interactions, but hypoglycemia is biggest concern • All facilities should have a HYPOGLYCEMIC protocol to follow • A word about Glucagon • Majority of cases of hypoglycemia are result of sliding scale insulin use • Sliding scale is now on the Beers list!

  23. Transitions of care • Care transitions can be challenging • Within the hospital • From acute to post-acute • Medication reconciliation is critical • As patients get better, their insulin needs change • Please work with your post-acute care providers closely

  24. Summary • Strategies to reduce hypoglycemia • Identify patients at risk • Set targets for blood glucose • Move to basal insulin instead of solely using sliding scale insulin • Many elderly patients do well with just 1 or 2 basal injections daily • Bedtime sliding scale most problematic in elderly • Don’t forget to adjust based on patient progress

  25. Questions/Discussion THANK YOU!!! Hennie Garza, M.S., R.Ph., C.D.E Email address: hgarza@seniorcarecentersltc.com

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