EXAM 4 Inpatient Diabetes Management Flores Flashcards
What are the factors or drugs that cause Hyperglycemia regardless of diabetes?
-glucocorticosteroids
-octreotide (treats diarrhea in colon cancer patients)
-parenteral/enteral nutrition
->check their A1c to see if they are diabetic
In an inpatient setting, when do we perform an A1c test?
On patients with diabetes or hyperglycemia (>140 mg/dl) if an A1c was not performed in the prior 3 months
What is the threshold to start antidiabetic therapy?
> 180 mg/dl
->start insulin and/or other meds
What is the goal blood glucose for critical patients (ICU) once they start on diabetic therapy?
140-180 mg/dl
studies have shown that for ICU patients 140-180 is safer to avoid complications of hyperglycemia and hypoglycemia
a goal of 110-140 may be appropriate in patients without significant risk for hypoglycemia
What are the complications of hyperglycemia
delayed wound healing
-CV disease (blood vessels)
-Neuropathy
-Nephropathy (damages the glomeruli)
-Retinopathy (eyes)
When would we allow blood glucose above 180 mg/dl?
-terminal ill patients
-severe comorbidities
-when we want to avoid hypoglycemia
What is the recommended goal range for patients who are non-critical ill in an inpatient setting?
for example patients in a floor bed
100-180 mg/dl
What is the perioperative blood glucose goal and how many hours before the surgery does it refer to?
100-180 mg/dl within 4 hours of surgery
hold oral agents and reduce basal insulin
When should an SGLT2i be held before the surgery?
3 days before surgery
4 days before surgery if it is ertugliflozin
When should Metformin be held before the surgery?
No metformin on the day of surgery
also hold other oral hypoglycemic agents in the morning of the surgery
How should NPH insulin be handled before the surgery?
-give half of the NPH dose
OR
-70-85% of long-acting analog (Lantus, Tresiba) or pump basal insulin
-monitor BG every 2-4h and correct with insulin
When should a patient’s blood glucose be monitored before surgery?
monitor BG every 2-4h and correct with insulin
or pre-meal if they are eating
Why would sometimes a procedure be delayed before their A1c is in control?
To improve wound healing which may be required for a procedure
Can insulin dosing decisions and hypoglycemia assessment be based on the CGM of patients that they use at home?
can still use their CGM they use at home, but needs confirmation from point-of-care measurement, because the CGM may not be as accurate due to the stress on the body in the hospital
same for automated insulin delivery system with CGM -> need to confirm with point-of-care measurement (glucometer)
What is the recommended treatment approach for non-critical-ill patients in the hospital?
poor oral intake:
-Basal insulin or a basal plus bolus correction
adequate nutritional intake
- basal, prandial, and correction components (basal-bolus)
What would not be the best practice in diabetic patients in the hospital?
Sole use of a correction or supplemental insulin (sliding scale) without basal insulin
->so just a sliding scale is not recommended
may still see patients solely on a sliding scale if blood glucose is ok
What is the appropriate way to infuse insulin in critically ill patients?
IV continuous insulin infusion with Self-monitoring blood glucose (SMBG) every 0.5-2 hours
->as the patient gets better switch to injectables
How should insulin doses be adjusted if patients get to the hospital?
reduce by insulin home dose by 20-25% (usually the basal insulin)
How should insulin doses be adjusted if patients get to the hospital, in insulin-naive patients?
if they are eating:
0.5U/kd/d split for basal + bolus
if they are not eating:
0.25U/kg/d for basal
Not going to ask for doses
What is the approach to sending patients home?
start home meds 1-2 days before discharge
-if they were not using insulin before and were controlled, they may stop using the insulin they were started on in the hospital
-if they were on insulin they may need insulin adjustments (especially if their blood glucose is below 70 mg/dl)
How should non-insulin be handled in the hospital?
Metformin: stop on the day of surgery, also may hold before imaging procedures (contrast can impair renal function, metformin-induced risk of lactic acidosis)
-Sulfonylureas: hold due to risk of hypoglycemia (especially if they are not eating in the hospital)
-TZDs: held due to cardiac concerns
-GLP-1 agonist: they are doing studies right now -> stomach upset, pancreatitis risk
-DPP-4i: studies show benefit +/- insulin, hold Saxagliptin and Alogliptin in patients with HF
-SGLTS2i: don’t use if acutely ill - euglycemic DKA risk, might start with patients with HF
Which DPP-4i should be held in patients with HF?
Saxagliptin and Alogliptin
SGLT2i recommendation in the hospital
should be started or continued in patients with HF in the hospital
-if there are no contraindications and after recovery from acute illness
so if they are acutely ill - don’t start???
When are hypoglycemic events likely?
-after giving insulin -> may reduce the dose
-at night -> adjust the dose or drug
-other drugs: if steroids were reduced then reduce insulin, octreotide
-the amount of nutrition
-patients unable to report hypoglycemia symptoms
What are the disease states of a hyperglycemic crisis?
-Diabetic Ketoacidosis (DKA)
-Hyperglycemic Hyperosmolar State (HHS)
to prevent:
-Adherence
-Recognize highs
-Manage highs
-monitor Ketones
-cautious on Sick days
Patients on sick days
-are they eating well
-are they still taking their meds
-they need to check their BG - enough strips
Who is prone to be hyperglycemic with Ketones?
-patients with absolute insulin deficiency -> T1DM
-patients with T2DM that start needing insulin regimen
-patients with hx of DKA with ketones
Difference between DKA and Ketosis
Hyperglycemia + Ketones (in the urine) = Ketosis
->its not a crisis yet
How to treat Ketosis
-Hydration (oral at home), 1L NS in the clinic
-check labs to assess other factors of DKA
-give additional short-acting insulin at home or in the clinic:
mild ketones: Correction dose + 5% of TDD
moderate to severe: Correction dose + 10% of TDD
DKA - HHS spectrum
Which symptoms do both have in common?
-increased Counterregulaotry hormones
-Hyperglycemia
-Dehydration
What are the signs/symptoms of DKA?
usually with Absolute insulin deficiency (T1DM)
-Lipolysis goes up -> inc FFA to liver -> Hyperlipidemia
-Ketogenesis goes up -> Ketoacidioss (metabolic acidosis)
DKA ->
Diabetic: Hyperglycemia
K: Ketones
A: Acidosis (pH < 7.3) with anion gap (>15)
Other specific symptoms of DKA
-Kussmaul respiration
-Fruity acetone breath
-N/V, abdominal pain
-minor mental status change
What are the signs/symptoms of HHS?
Relative insulin deficiency -> since they have some insulin they can deal with HHS longer -> longer hydrated, BG level goes up longer
-Hyperosmolarity (>320 mOsm/kg)
-Hyperglycemia (>600 mg/dl)
-State of mental changes (stupor/coma)
Which labs are different DKA vs HHS
-Arterial / Venous pH is slightly higher in HHS -> in DKA causes the pH to be lower in DKA
-Serum bicarbonate is higher in HHS (less compensation of metabolic acidosis since less ketones in HHS)
-urine and serum ketones are smaller in HHS
-Hyperosmolarity in HHS (> 320 mOsm/kg)
-Anion gap is variable in HHS, in DKA it is >10 or >12
What are the first interventions in a patient having symptoms of hyperglycemia?
-Hydration, fluids (IV if in the clinic)
-give insulin (but not until we know K+ levels - wait until safe (shift of K into cells))
-check labs for ketones and acid-base status
What might contribute to hyperglycemia leading to a hyperglycemic crisis?
-New Diagnosis
-Infection
-Inadequate insulin therapy (adherence, dosing, pump site failure)
-Alcohol use
-CV disease, cerebrovascular event, pulmonary event)
-unknown pregnancy (insulin resistance goes up)
-pancreatitis
Meds that may contribute to hyperglycemic crisis
Corticosteroids
-Thiazide diuretics
-Sympathomimetic agents
-antihypnotics
-SGLT2-inhibitor
What is the interaction between insulin and potassium (K)?
insulin shifts potassium into the cells
->Hypokalemia
so make sure it is safe to give insulin to patients in hyperglycemic crisis -> since their potassium might be low already from dehydration
What should a patient’s K+ levels be to start insulin therapy?
greater than 3.3 mEq/L
What are the doses for fluid therapy?
1 - 1.5 L during the first hour
OR 15-20 ml/kg/h for kids
-> continue until thermodynamically stable
How should fluid therapy be continued after 1 hour?
-continue fluid at 250-500 ml/h (or 4-14 ml/kg/h)
choose NS if the corrected sodium is low
choose 1/2 NS if the corrected sodium is normal or elevated
At what K+ levels should K+ replacement be considered?
< 5.3 mg/dl
often both insulin and potassium are started at the same time in different bags
The patient’s K+ is at 4, what should be done?
the potassium level of 4 is in the range, however since we are giving insulin, the potassium will be shifted into the cell, so it is about to drop
->give K+ supplement: usually 20-30 mEq/L of KCl together with 1/2 NS at 250-500 ml/hr
When would you consider a slower fluid rate?
-CKD (cant handle large fluid volumes, leading to fluid retention and electrolyte imbalances)
-heart failure patients
What happens if fluid is pushed too quickly?
FYI
cerebral edema
What should be added to the fluid as the hyperglycemia resolves?
Dextrose -> so that we can keep giving insulin -> until ketone resolves and the anion gap closes
-give D51/2NS (D5NS or D5W works too)
When does a patient have high osmolality indicating HHS?
REMINDER
> 320 mOsmol/kg
if a patient with ketones, and an anion gap has normal osmolality -> they are on the DKA side of the spectrum
How is Insulin therapy in a patient in the hospital initiated?
there are multiple ways
-start with a bolus: 0.1U/kg IV drip
-followed by continuous infusion: 0.1U/kg/h
-titrate the insulin drip to decrease glucose
by 50-70 mg/dl/h
What should be done as the glucose reaches resolution (< 250 mg/dl)?
decrease insulin rate to 0.05 U/kg/h (or by 50%)
-add dextrose which allows us to keep giving insulin (we need to keep giving insulin otherwise the glucose may start to rise again, need dextrose to prevent hypoglycemia???)
As the glucose resolves to below 250 mg/dl, what is the goal glucose level we want the patient to be?
100-200 mg/dl
->adjust insulin rate to be in the range
What has to be done before the insulin drip is discontinued?
give basal insulin SQ 2-4h before stopping the IV drip
->basal insulin needs time to be absorbed into the bloodstream, without the basal insulin the patient would go back to DKA when the drip is stopped
When should Phosphorus be replaced?
< 1 mg/dl
consider using K-Phos when both Phosphorus and K+ is low
When should Bicarbonate replacement be considered?
Not routinely indicated
-consider if pH is <6.9
-at this point, the patient is very sick (severe acidosis)
-Bicarbonate can cause hypokalemia
How should patients be transitioned to SQ basal insulin after resolving?
use 60-80% of the most recent daily insulin infusion dose as SQ basal insulin
other option:
-0.5-0.8U/kg/day
-start 2-4h before stopping the insulin infusion
What is the discharge plan for patients who have an A1c of >9%?
-Discharge on basal/bolus regimen at same hospital dose OR
-Discharge on oral agents (their home meds) and 80% of hospital basal dose
-for 7-9%:
-restart the outpatient regimen with the addition of basal insulin at 50% of the hospital dose
-follow up: 1-2 weeks or 1 month with PCP
