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Inpatient Diabetes Management

Inpatient Diabetes Management. Hospitalization of Patients With Diabetes: Background. Diabetes is associated with: higher rates of hospitalization greater lengths of stay greater cost of hospitalization Diabetes is one of the strongest risk factors for readmission

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Inpatient Diabetes Management

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  1. Inpatient Diabetes Management

  2. Hospitalization of Patients With Diabetes:Background • Diabetes is associated with: • higher rates of hospitalization • greater lengths of stay • greater cost of hospitalization • Diabetes is one of the strongest risk factors for readmission • One in seven readmissions in patients with diabetes is related to substandard diabetes care

  3. U.S. Diabetes Care - 1997 Per Capita Expenditures Diabetes Care 21:296, 1998

  4. InpatientDiabetes Care • Good evidence of association of hyperglycemia and poor outcomes • Growing evidence of the benefit of aggressive treatment of hyperglycemia in the inpatient setting • Few guidelines and very little evidence of the relative value of various approaches to inpatient care of diabetes

  5. Impaired leukocyte function Chemotaxis Adherence Phagocytosis Bactericidal killing Poor wound healing Less fibroblast proliferation Altered immune complement fixation Additional -cell impairment in type 2 Insulin resistance Electrolyte fluxes Volume depletion Gastroparesis A signal to the patient that glucose control is unimportant Potential Consequences of Hyperglycemia in the Hospital

  6. Recent Associations Between Glucose Levels and Inpatient Outcomes • Hyperglycemia a risk factor for: • Complications of strokes • Complications of MI • Complications of vascular and cardiac surgery • Mortality in critically ill • Aggressive insulin treatment improves: • Cardiac surgery outcomes • MI outcomes • Intensive care unit outcomes • Length of hospital stay

  7. Glucose and Stroke • 623 hyperglycemic pts without DM admitted with acute stroke • Mortality and stroke severity increased linearly with increasing admission glucose • Weir et al found glucose >144 predicted double mortality risk • Other studies have shown glucose levels or HBA1c correlate to stroke size, clinical severity, and prognosis in diabetics and non-diabetics >108 >126 >144 >162 <90 >90 Jorgensen, et al . Stroke 25:1977-84, 1994

  8. CABG and Infection • DM increases risk of post-op infection 2-5 fold • Furnary started using insulin infusion during CABG and continued it post-op. Goal was to keep glucose <200 • Deep sternal wound infection rate was 0.8% vs 2.0% without insulin infusion • Mortality was 3.8% vs 19%

  9. Deep Infection Rate Day 1 Blood Glucose Furnary , et al. Ann Thor Surg, 1997;63:356-61

  10. Mortality % Average postoperativeglucose Furnary, J Thor and Cardiovas Surg. May 2003

  11. Glucose Control • Pomposelli studied 97 diabetics undergoing surgery • Postop day 1 glucose >220 increased risk of severe infection 5.9 times • Kortykowski found that the degree of hyperglycemia on admission contributed significantly to length of hospital stay among patients admitted with acute medical problems, including MI and pneumonia

  12. Glucose Level and Treatment In Patients With Diabetes Mellitus and Acute MI • Study of 620 diabetics, admitted with glucose >198 mg/dl • Randomized to IV insulin or conventional therapy at time of MI • Biggest benefit in patients without a history of DM • 58% decrease in mortality • Intensive therapy •  mortality 29% at 1 year •  mortality 28% at 3.4 yrs Malmberg K, et al. Circulation 99:2626, 1999

  13. Effect of Insulin-Glucose Infusion In Diabetic Patients with Acute MI (DIGAMI Study) 11% p =0 .01 p=0.03 Malmberg K, et al. Circulation 99:2626, 1999

  14. Intensive Insulin Therapy in Critically Ill Patients • 1548 patients enrolled in Surgical ICU study • Randomized to IV insulin or control • IV insulin started if blood glucose exceeded 110 mg/dl • Goal of intensive therapy was to keep glucose 80-110 • Control group glucose kept 180-200 • Mean blood glucose was 50 mg/dl lower in IT • Only about 13% had previous diagnosis of diabetes Van den Berghe, G. et al NEJM 345:1359

  15. Intensive Insulin Therapy in Critically Ill Patients • 42% reduction in mortality during ICU stay • Overall in-hospital mortality decreased 34% • Sepsis decreased 46% • Amount of blood transfused decreased 50% • Less need for mechanical ventilation • The primary benefit was in those spending  5 days in the ICU • Greatest benefit was in those with sepsis Van den Berghe, G. et al NEJM 345:1359

  16. Mortality With Intensive Insulin Therapy in the ICU 42% reduction 34% reduction Van den Berghe et al. NEJM 345: 1359, 2001.

  17. MICU Data • 1200 pts admitted to MICU, same protocol • Saw Benefit in pts who required > 3 days in ICU (767 pts) • Decreased mortality: 52% vs 43% • Decreased incidence of AKI • Earlier weaning from ventilator • Earlier discharge from ICU and hospital Van den Berghe, NEJM, 2006 354:449-461

  18. Effect of Intensive Insulin Therapy on Morbidity Van den Berghe G et al. N Engl J Med 2006;354:449-461 Panel A: All pts Panel B: Pts in ICU >3 days

  19. Elevated stress hormones Anorexia, nausea, vomiting A change from usual diet Changes in meal timing Altered injection times Poor coordination of injections and meals Meal interruptions due to procedures Intravenous glucose Medications contributing to hyperglycemia Impaired recognition of hypoglycemia Dyes and procedures increasing medication complications Altered insulin absorption Physician indifference Barriers to Glucose Control In the Hospital

  20. Sliding Scale • Mrs X is a 63 y/o F with Type 2 DM who was admitted with pneumonia • Usual outpatient regimen is: Glyburide, Metformin, and Lantus 20 units qhs • Started on antibiotics, oral agents discontinued, and placed on sliding scale regular insulin: • 70-150: 0 units • 151-200: 2 u • 201-250: 4 u • 251-300: 6 u • >300: 8 u and call MO

  21. Fallacy of the Sliding Scale

  22. Fallacy of the Sliding Scale

  23. Fallacy of the Sliding Scale

  24. Fallacy of the Sliding Scale

  25. Fallacy of the Sliding Scale

  26. Fallacy of the Sliding Scale

  27. Fallacy of the Sliding Scale

  28. Fallacy of the Sliding Scale

  29. Fallacy of the Sliding Scale

  30. Fallacy of the Sliding Scale

  31. Fallacy of the Sliding Scale

  32. Fallacy of the Sliding Scale

  33. Fallacy of the Sliding Scale

  34. Fallacy of the Sliding Scale

  35. Fallacy of the Sliding Scale

  36. Sliding Scale • Often considered standard of care, but no proof they work • Provide no basal insulin • Only give insulin after hyperglycemia occurs prior to a meal • Doesn’t account for carbohydrates eaten during a meal • Leads to roller coaster

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