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Inpatient Management of Diabetes Mellitus. William Harper, MD, FRCPC Endocrinology & Metabolism Assistant Professor of Medicine, McMaster University. DKA. Monitored setting if Hi-risk elderly & CAD, pH < 7.0, severe K disturbance, decreased LOC IV Fluid Resuscitation (6-8L deficit)
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Inpatient Management of Diabetes Mellitus William Harper, MD, FRCPC Endocrinology & Metabolism Assistant Professor of Medicine, McMaster University
DKA • Monitored setting if Hi-risk • elderly & CAD, pH < 7.0, severe K disturbance, decreased LOC • IV Fluid Resuscitation (6-8L deficit) • Potassium (“no pee no K”) • IV insulin • Identify & Rx underlying cause • Noncompliance, infection, MI, etc.
DKA: IV Fluids • IV NS 1L/h x 2-3h or longer so no more tachycardia, hypotension, orthostatic changes, low JVP. • Then change to 1/2 NS: • 500 cc/h x 1-3h • 250 cc/h x 4-6h • If hypotension recalcitrant to fluids consider AI (Schmidt PGAS II) and send stat cortisol then give solucortef 100 mg IV q8h.
DKA: Mortality • Adults 2-4% • Hypokalemia • MI, CVA, etc. • Kids 0.2-0.4% • Cerebral edema
DKA: Potassium • Need K with initial IV fluid & insulin Rx unless: • Anuric • K > 5.5 mEq/L or hyperkalemic ECG changes > 20 mEq/h: Cardiac monitor > 60 mEq/L: Central line
DKA: IV Insulin • Humulin R or Novolin Toronto • Bolus 0.1-0.2 U/kg IV • Then IV gtt @ 0.1-0.2 U/kg/h (50 U of regular insulin in 500cc D5W; 1U/10cc) • Monitor: CBG q1h • Monitor: Venous BS, electrolytes, creatinine q2h • Aim is to demonstrate correction of Anion Gap (AG) and decrease in BS 4.4 mM/L/h • Monitoring serial serum ketones NOT useful: ßHß (not detected) DKA Rx Acetoacetate (detected)
DKA: IV Insulin • Using insulin to treat 2 different and separate metabolic disturbances in DKA: • Ketoacidosis • Hyperglycemia
DKA: IV Insulin • If AG not correcting and/or BS not decreasing then increase IV gtt rate 1.5-2X • If BS < 13 but AG still not corrected do NOT decrease insulin IV gtt. • Instead start IV glucose gtt: • D5W-D10W @ 100-200 cc/h • Once AG corrected than titrate IV insulin to BS • When BS < 13 and AG normal: reduce IV insulin gtt to 1-2 U/h and add IV glucose if not already done.
DKA: IV Insulin • Can consider switch to SC insulin when: • AG normalized • BS < 15 mM • Insulin IV gtt requirements < 2U/h • Patient able to eat • Overlap insulin IV gtt with 1st SC insulin by 3-4h to avoid recurrent ketosis.
DKA: Other Rx • Bicarbonate • May exacerbate hypokalemia • Only give if pH < 6.9 AND evidence of cardiovascualr instability (arrythmia, CHF, hypotension) • 1-2 amps bicarb in 1L D5W IV over 2h until pH > 7.1 • Phosphate • Routine IV not recommended • Rx symptomatic hypophosphatemia (rhabdo, unexplained CHF or respiratory failure, severe confusion) • 10cc K Phos soln (3.0mEq Pi and 4.4 mEq K/cc) in 1L NS IV over 8-12h
DKA: Other Rx • Cerebral Edema • Usually only kids • Persistent decreased LOC despite standard Rx of DKA • CT scan to confirm diagnosis • Decadron 10 mg IV • Mannitol 25 mg IV
HONC • BS > 55 • Serum OSM > 350 • Coma 25-50% • Mortality rate 25-70%
HONC • Coma Management • ABCs, O2, narcan, D50W, thiamine, etc. • IV Fluid Resusciation (10L free water defecit) • Insulin • IV fluids will decrease BS by 4 mM/L/h by itself • For most patients insulin not absolutely neccesary • Insulin IV bolus 5-10 U, gtt @ 1-2 U/h • Potassium (replace as in DKA) • Identify & Rx underlying precipitant
BS > 11.1 mmol/L Renal threshold for glycosuria (normal GFR) Decreased WBC function Chemotaxsis Phagocytosis Decreased Wound Healing
Goals of Inpatient DM Management • “Avoid hypoglycemia and marked hyperglycemia” • Target BS: 7.0 - 11.0 mM • Avoid Hypoglycemia • Precipitating arrhythmia or other cardiac events • Inducing seizure, focal or cognitive defects periop • Avoid Marked Hyperglycemia (BS > 11.1 mM) • Treat (and avoid) DKA, HONC
DM Inpatient Management • Eating • NPO: temporary (for a test) • NPO: prolonged
DM Inpatient Management • Eating: OHA (T2DM) Insulin (T2DM and T1DM)
BIDS Therapy • T2DM: “Introduction to insulin” • Keep on OHAs • Start NPH 0.2 U/kg SC qhs • Increase by 2-4 U q4d until FBS 4-7 • If dose > 30-40U or if BS high late in day despite OK FBS than split into 2 injections with 2/3 acB and 1/3 acD
Starting Insulin Regimen • TDD = 0.5-0.7 U/kg • “2/3, 1/3” Regimens • 2/3 of TDD acB, 1/3 acD • 2/3 of TDD as Long-acting, 1/3 as short acting • Pre-mix: acB 30/70 acD 30/70 • MDI Regimens • 2/3, 1/3 Regimen: move acD long acting to qhs • i.e. acB N, H acD H qhs N • ac meals H qhs N (bolus 60%, basal 40%) • ac meals H UL q12h (bolus 50%, basal 50%)
Insulin Regimens acB acL acD qhs Bedtime NPH (+/-bids) N NPH bid N N 30/70 bid 30/70 30/70 MDI (3 injections) H + N H N MDI (>4 injections) H (+/-N) H H N MDI (>4 injections) H + UL H H UL CSII (Insulin Pump)
Guideline for Insulin Adjustments • Adjust the insulin that accounts for the high or low reading. • Always compare an abnormal BS reading with the one previous. • If insulin dose is: • Less than 8U, adjust by 1U • 8-20U, adjust by 2U • > 20 U, adjust by 10% (increase), 20% (decrease) • Don’t forget to compensate for a successful adjustment
Surgeon: ? Internal Medicine: ? Endocrinologist: ?
Surgeon: Give 5 U Regular SC now Internist: Increase qhs N to 12 tonight and acB R to 12 tomorrow Endocrine: Increase qhs N to 12 start tonight Decrease acB N15 R7 starting tomorrow AM Check 3AM BS tonight
Guideline for Insulin Adjustments • Adjust the insulin that accounts for the high or low reading. • Always compare an abnormal BS reading with the one previous. • If insulin dose is: • Less than 8U, adjust by 1U • 8-20U, adjust by 2U • > 20 U, adjust by 10% (increase), 20% (decrease) • Don’t forget to compensate for a successful adjustment
DM Inpatient Management • Eating • NPO: temporary (for a test) • NPO: prolonged
NPO for a test: T2DM on Diet Rx • Schedule test for the AM • Hold OHAs on AM of test • CBG @ 7AM: < 3.0 Consider postpone test 3.1-4.0 IV D5W gtt @ 75-100 cc/h 4.1-11.0 Proceed with test, no Rx necessary > 11.1 IV insulin gtt IV D5W gtt @ 75-100 cc/h > 20.0 Check urine ketones, consider postpone test
NPO for a test: T1/T2DM on Insulin • Schedule the test for the AM • Hold AM Insulin on day of test • CBG @ 7AM: < 3.0 Consider postpone test 3.1-11.0 Give ½ of total AM insulin dose as NPH SC IV D5W gtt @ 75-100 cc/h > 11.1 IV insulin gtt IV D5W gtt @ 75-100 cc/h > 20.0 Check urine ketones, consider postpone test
DM Inpatient Management • Eating • NPO: temporary (for a test) • NPO: prolonged • Patient put on D5W if not on feeds or TPN • IV insulin gtt • SC NPH or UL q12h (+/- supplemental scale)
Insulin IV gtt • Add 50 U of Human regular insulin (Humulin R or Novolin Toronto) to 500cc D5W (1U/10cc). • Flush & discard first 50cc. • Infuse insulin solution by IVAC (intravenous infusion pump), piggybacked into D5W running at 100cc/h. • Start insulin @ 0.9 U/h (9cc/h) or start at a rate dependent on patient’s insulin dose: IV insulin gtt rate = ( ½ TDD ) / 24
Insulin IV gtt CPG q1h x 2, then q2h (if BS stable x 2-3 readings consider q4h): Adjust Insulin IV infusion rate as per scale below: <4.0 Call MD 4.1-5.0 0.7 U/h ( 7cc/h) 5.1-6.0 0.9 U/h ( 9cc/h) 6.1-7.0 1.2 U/h (12cc/h) 7.1-9.0 1.5 U/h (15cc/h) 9.1-11.0 2.0 U/h (20cc/h) 11.1-13.0 2.5 U/h (25cc/h) 13.1-15.0 3.0 U/h (30cc/h) 15.1-17.0 3.5 U/h (35cc/h) 17.1-20.0 4.0 U/h (40cc/h) >20.1 Call MD
Evidence to support Inpatient BS control? DIGAMI • AMI, prior dx DM or BS > 11 mM • IV insulin gtt started @ 5 U/h • Titrated to keep BS 7-10.9 mM • Insulin IV > 24h MDI > 3 months • No in-hospital mortality benefit. • Rx Increased hospitalization by 1.8d • 0.5% reduction HbA1c @ 3 months • @ 1 year % on Insulin: 72% Rx Group 49% Cntrl Group • 1 year mort: ARR 7.5% NNT 13 • 3.4 y mort: ARR 11% NNT 9
Evidence to support Inpatient BS control? Leuven, Belgium Study • ICU patients (63% CV Sx) • If BS > 6.1 mM: Rx with IV insulin gtt & TPN +/- tube feeds • Start IV insulin @ 2-4 U/h, titrated to BS 4.4-6.1 mM • Ave insulin dose: Rx group 3.0 U/h Cntrl group 1.4 U/h • Once out of ICU relaxed treatment goal to < 11.1 mM • Mortality in ICU: ARR 3.4% NNT 29 • Mortality in-hospital: ARR 3.7% NNT 27 • Greatest reduction in mortality was sepsis-related. • Insulin Rx reduced: bacteremia, ARF needing HD, need for PRBC, critical illness polyneuropathy, duration of ventilation and length of stay in ICU • To what extent were benefits nutrition related as opposed to insulin related?