Inpatient DM Management Flashcards
Premeal blood glucose goal
<140
Random blood glucose goal
<180
When do you modify therapy (what BG level)
<100
Hyperglycemia is defined as…
BG >140
Hypoglycemia is defined as…
BG <70
Severe hypoglycemia is defined as…
BG <40
Factors that can affect hyperglycemia
Prolonged use of correctional insulin as monotherapy
TPN and enteral feeds
Medication use (corticosteroids, thiazides)
Failure to adjust regimen based on BG patterns
Poor coordination between testing and timing of insulin delivery
Patient-specific factors that affect hypoglycemia
Advanced age, decreased PO intake, chronic renal failure, liver disease, history of frequent or severe hypoglycemia
Inpatient factors that affect hypoglycemia
Change in diet
Medication use (beta-blockers, fluoroquinolone ABX, alcohol)
Failure to adjust regimens based on BG patterns
Poor coordination between testing and timing of insulin delivery
3 components of insulin regimen for hyperglycemia
Basal insulin (long-acting)- manages fasting state Nutritional insulin (short or rapid-acting)- prevents rise in glucose, but don't give if patient is NPO or skip a meal Correctional insulin (short or rapid-acting)- extra insulin to correct BG that's still above target, given by a scale
Insulin therapy for T1DM
0.2-0.4 units/kg/day
Give 50-60% as basal insulin and 40-50% as nutritional insulin
Correctional insulin may be given for BG above goal
Adjust dose according to BG values, change in clinical status, or if patient is made NPO
Insulin therapy for T2DM
D/C all PO and non-insulin injectable antidiabetic agents
Insulin naive: 0.3-0.5 units/kg
Outpatient insulin use: decrease outpatient dose by 20-25%
50% of TDD is given as basal insulin, other 50% is split into 3 and given as mealtime insulin
Correctional insulin may be given for BG above goal
First thing to do when a patient is admitted
Assess patient for DM history- are they T1DM or T2DM?
If the patient has no history of DM and their BG is >140, what do you do?
Obtain lab BG testing and monitor based on clinical status
When is it recommended to obtain an A1C?
All patients with DM history or if they have hyperglycemia, if there is no A1C from the last 3 months, no history of diabetes but they are hyperglycemic -> start POC BG for 24-48 hours while checking A1C
What A1C level indicates diabetes?
≥6.5%
In patients with DM history or A1C ≥6.5%, what do you monitor regularly?
Blood glucose
Risks with insulin
Using “U” instead of “units”
Insulin as floor stock
Multiple concentrations of IV compounded insulin infusions/non-standard insulin infusion rates
Testing and reporting errors with BG testing
Risk reduction strategies
Collab with dieticians to adjust parenteral nutrition
BG testing with insulin administration and meal delivery
Good communication during patient transfer
Double check orders for completion and accuracy when prescribing and verifying
Avoid medication errors
Stock only one concentration of insulin infusion bags
Standardize insulin protocols
What can pharmacists do for insulin risk reduction?
Discourage sliding scale insulin Counsel patients before discharge Develop treatment protocols Minimize medication errors Formulary-decision making
What are the most severe metabolic disorders of DM?
DKA and HHS
Precipitating factors of DKA and HHS
Infections, MI, medications, noncompliance, poor sick day management, pancreatitis, drug/alcohol abuse, inadequate dose or D/C of insulin, new onset T1DM
DKA clinical picture (signs and symptoms)
polyuria, polydipsia, weight loss, weakness, mental status change, Kussmaul respirations, N/V, abdominal pain
Glucose level in DKA
> 250
pH in DKA
<7.3
Anion gap in DKA
> 12
Ketones in DKA
positive
Effective serum osmolality in DKA
<320 mOsm/kg
HHS clinical picture (signs and symptoms)
Same as DKA but with seizures and hemiparesis
Glucose level in HHS
> 600
pH in HHS
normal
Anion gap in HHS
variable
Ketones in HHS
negative
Effective serum osmolality in HHS
> 320 mOsm/kg
Initial fluid management
15-20 ml/kg for the first hour
Subsequent management for severe hypovolemia
Use NS
Subsequent management for mild dehydration
Serum sodium normal or high- 1/2 NS
Serum sodium low: NS
Subsequent management for cardiogenic shock
Pressors and monitor hemodynamics
If the BG is 200mg/dl in DKA or BG 300mg/dl in HHS, what fluids do you give the patient?
1/2NS and D5W
Insulin therapy dosing in DKA or HHS
- 1 units/kg as an IV bolus, then 0.1 units/kg/hour continuous infusion
- 14 units/kg/hr as maintenance dose
When do you decrease the insulin infusion rate and what do you decrease it to?
Decrease to 0.02-0.05 U/kg/hr IV when:
DKA: BG 200mg/dl (until resolution, BG 150-200)
HHS: BG 300mg/dl (until patient is mentally alert, BG 200-300)
When to switch from IV insulin to SQ insulin
When there is resolution of crisis and patient is able to eat, initiate SQ insulin and overlap with IV insulin for 1-2 hours
What defines DKA resolution?
BG <200 and TWO of the following:
Venous pH >7.3
Anion gap ≤12 mEq/L
Serum bicarb ≥15 mEq/L
What defines HHS resolution?
Normal osmolality AND normal mental status
Potassium treatment when K+ <3.3 mEq/L
hold insulin and replete at 20-30 mEq/hr until K+ is >3.3 mEq/L
Potassium treatment when K+ 3.3-5.3 mEq/L
20-30 mEq/L K+ should be given with every L of fluid
Potassium treatment when K+ >5.3 mEq/L
don’t give potassium until it falls below the upper limit of normal, monitor q2h
Sodium bicarb treatment
Only use if pH <6.9, 2 ampules of sodium bicarb in 400mL of water and 20mEq of K+ over 2 hours, repeat q2h until the pH >7
Insulin naive dosing when transitioning from IV to SQ insulin
TDD of 0.5-0.8 units/kg with 50% being basal and other 50% divided into 3 for mealtime insulin
