Management of Hyperglycemia in the Noncritical Care Setting高血糖的非关键保健环境管理(PPT-41)

ManagementofHyperglycemiaintheNoncriticalCareSetting1RECOGNITIONANDDIAGNOSISOFHYPERGLYCEMIAINNONCRITICALLYILLPATIENTS2NumberofUSHospitalDischargesWithDiabetesasAny-ListedDiagnosisCDCP.DiabetesDataandTrends.Availableat:/diabetes/statistics/dmany/fig1.htm.196.4%From1988to2009,thenumberofhospitaldischargeswithdiabetesasany-listeddiagnosisincreasedfrom2.8milliontonearly5.5million.3DistributionofPatient-Day-WeightedMeanPOC-BGValuesforICU~12millionBGreadingsfrom653,359ICUpatients;meanPOC-BG:167mg/dL.SwansonCM,etal.EndocrPract.2011;17:853-861.4RecognitionandDiagnosis

ofHyperglycemiaandDiabetes

intheHospitalSettingAllpatientsAssessforhistoryofdiabetesTestBG(usinglaboratorymethod)onadmissionindependentofpriordiagnosisofdiabetesPatientswithoutahistoryofdiabetesBG>140mg/dL:MonitorwithPOCtestingfor24-48hBG>140mg/dL:OngoingPOCtestingPatientsreceivingtherapiesassociatedwithhyperglycemia(eg,corticosteroids):monitorwithPOCtestingfor24-48hBG>140mg/dL:continuePOCtestingfordurationofhospitalstayPatientswithknowndiabetesorwithhyperglycemiaTestA1CifnoA1Cvalueisavailablefrompast2-3monthsBG,bloodglucose;POC,pointofcare.MoghissiES,etal.EndocrinePract.2009;15:353-369.UmpierrezGE,etal.JClinEndocrinolMetab.2012;97:16-38.5RecognitionandDiagnosis

ofHyperglycemiaandDiabetes

intheHospitalSettingNohistoryofdiabetesBG<140mg/dL(7.8mmol/L)NohistoryofdiabetesBG>140mg/dLStartPOCBGmonitoringx24-48hCheckA1CInitiatePOCBGmonitoringaccordingtoclinicalstatusHistoryofdiabetesBGmonitoringA1C≥6.5%BG,bloodglucose;POC,pointofcare.UmpierrezGE,etal.JClinEndocrinolMetab.2012;97:16-38.UponadmissionAssessallpatientsforahistoryofdiabetesObtainlaboratorybloodglucosetesting6A1CforDiagnosisofDiabetes

intheHospitalImplementationofA1CtestingcanbeusefulAssistwithdifferentiationofnewlydiagnoseddiabetesfromstresshyperglycemiaAssessglycemiccontrolpriortoadmissionFacilitatedesignofanoptimalregimenatthetimeofdischargeA1C>6.5%indicatesdiabetesMoghissiES,etal.EndocrinePract.2009;15:353-369.UmpierrezGE,etal.JClinEndocrinolMetab.2012;97:16-38.7SaudekCD,etal.JAMA.2006;295:1688-1697.ADA.DiabetesCare.2013;36(suppl1):S11-S66.CaveatstoUsingA1CforDiagnosis

ofDiabetesValuesalteredwithseveralconditionsHemoglobinopathies(eg,sicklecelldisease)HighdosesalicylatesHemodialysisTransfusions,irondeficiencyanemiaAnalysisshouldbeperformedusingamethodcertifiedbytheNationalGlycohemoglobinStandardizationprogram8GLYCEMICGOALSFORNONCRITICALLYILLPATIENTS9InpatientGlycemicManagement:DefinitionofTermsHospitalhyperglycemiaAnyBG>140mg/dLStresshyperglycemiaElevationsinbloodglucoselevelsthatoccurinpatientswithnopriorhistoryofdiabetesandA1Clevelsthatarenotsignificantlyelevated(<6.5%)A1Cvalue>6.5%SuggestiveofpriorhistoryofdiabetesHypoglycemiaAnyBG<70mg/dLSeverehypoglycemiaAnyBG<40mg/dL10GlycemicTargetsinNoncriticalCareSettingMaintainfastingandpreprandialBG<140mg/dLModifytherapywhenBG<100mg/dLtoavoidriskofhypoglycemiaMaintainrandomBG<180mg/dLMorestringenttargetsmaybeappropriateinstablepatientswith

previoustightglycemiccontrolLessstringenttargetsmaybeappropriateinterminallyillpatientsorinpatientswithseverecomorbiditiesMoghissiES,etal.EndocrinePract.2009;15:353-369.UmpierrezGE,etal.JClinEndocrinolMetab.2012;97:16-38.11ACHIEVINGGLYCEMICGOALSINTHENONCRITICALLYILLWHILEMINIMIZINGHYPOGLYCEMIARISKGlucoseMonitoring12MonitoringGlycemiaintheNoncriticalCareSettingPOCtestingPreferredmethodforguidingongoingglycemicmanagementofindividualpatientsUseBGmonitoringdeviceswithdemonstratedaccuracyinacutelyillpatientsTimingofglucosemeasuresshouldmatchpatient’snutritionalintakeandmedicationregimenRecommendedschedulesforPOCtestingBeforemealsandatbedtimeinpatientswhoareeatingEvery4-6hinpatientswhoareNPOorreceivingcontinuousenteralfeedingBG,bloodglucose;POC,pointofcare.MoghissiES,etal.EndocrinePract.2009;15:353-369.UmpierrezGE,etal.JClinEndocrinolMetab.2012;97:16-38.13ACHIEVINGGLYCEMICGOALSINTHENONCRITICALLYILLWHILEMINIMIZINGHYPOGLYCEMIARISKHospitalDiet14MedicalNutritionTherapy(MNT)MNTisanessentialcomponentoftheglycemicmanagementprogramforallhospitalizedpatientswithdiabetesandhyperglycemiaProvidingmealswithaconsistentamountofcarbohydratecanbeusefulincoordinatingdosesofrapid-actinginsulintocarbohydrateingestionUmpierrezGE,etal.JClinEndocrinolMetab.2012;97:16-38.15GlycemicMeasuresinPatientsAssignedtoConsistentCarbohydrateor

LiberalDietsintheHospitalCapillarybloodglucose

(mg/dL)P=0.03CBGvalues<70mg/dLwerelessfrequentinpatientsreceivingtheconsistentcarbohydratediet(0.4vs3.2%,P=0.06)CurllM,etal.QualSafetyHealthCare.2010;19:355-359.16ACHIEVINGGLYCEMICGOALSINTHENONCRITICALLYILLWHILEMINIMIZINGHYPOGLYCEMIARISKPharmacologicTherapy17AntihyperglycemicTherapySCInsulinRecommendedformostmedical-surgicalpatientsOADs

NotgenerallyrecommendedContinuousIVInfusion

Selectedmedical-surgicalpatientsPharmacologicalTreatmentofHyperglycemiainNon-ICUSettingMoghissiES,etal.EndocrinePract.2009;15:353-369.UmpierrezGE,etal.JClinEndocrinolMetab.2012;97:16-38.SmileyD,etal.JHospMed.2010;5:212-217.18GlycemicManagementStrategies

inNoncriticallyIllPatientsInsulintherapypreferredregardlessoftypeofdiabetesDiscontinuenoninsulinagentsathospitaladmissionofmostpatientswithtype2diabeteswithacuteillnessUsescheduledSCinsulinwithbasal,nutritional,andcorrection

componentsModifyinsulindoseinpatientstreatedwithinsulinbeforeadmissiontoreduceriskforhypoglycemiaandhyperglycemiaAvoidprolongedtherapywith“slidingscale”insulinaloneUmpierrezGE,etal.JClinEndocrinolMetab.2012;97:16-38.19NoninsulinTherapiesintheHospitalTime-actionprofilesoforalagentscanresultindelayedachievementoftargetglucoserangesinhospitalizedpatientsSulfonylureasareamajorcauseofprolongedhypoglycemiaMetforminiscontraindicatedinpatientswithdecreasedrenalfunction,useofiodinatedcontrastdye,andanystateassociatedwithpoortissueperfusion(CHF,sepsis)ThiazolidinedionesareassociatedwithedemaandCHFα-Glucosidaseinhibitorsareweakglucose-loweringagentsPramlintideandGLP-1receptoragonistscancausenauseaandexertagreatereffectonpostprandialglucoseInsulintherapyisthepreferredapproach20SubcutaneousInsulinOptionsBasalinsulinControlsbloodglucoseinthefastingstateDetemir(Levemir),glargine(Lantus),NPHNutritional(prandial)insulinBluntstheriseinbloodglucosefollowingnutritionalintake(meals,IVdextrose,enteral/parenteralnutrition)Rapid-acting:aspart(NovoLog),glulisine(Apidra),lispro(Humalog)Short-acting:regular(Humulin,Novolin)CorrectioninsulinCorrectshyperglycemiaduetomismatchofnutritionalintakeand/orillness-relatedfactorsandscheduledinsulinadministration21InitiatingInsulinTherapyintheHospitalAdjustaccordingtoresultsofbedsideglucosemonitoringAdjustdoseforNPOstatusorchangesinclinicalstatusObtainpatientweightinkgCalculatetotaldailydose(TDD)

as0.2-0.4unitsperkg/dayChoosethedosingscheduleGive50%-60%ofTDDasbasalinsulinGive40%-50%ofTDDasnutritionalinsulinUsecorrectioninsulinforBGabovegoalrange22InsulinTherapyinPatientsWith

Type2DiabetesDiscontinuenoninsulinagentsonadmissionInsulinnaïve:startingtotaldailydose(TDD):0.3U/kgto0.5U/kgLowerdosesintheelderlyandpatientswithrenalinsufficiencyPreviousinsulintherapy:reduceoutpatientinsulindoseby20%-25%HalfofTDDasbasalinsulingivenatthesametimeofdayandhalfasrapid-actinginsulinin3equallydivideddoses(AC)UmpierrezGE,etal.DiabetesCare.2007;30:2181-2186.23PharmacokineticsofInsulinPreparations24InsulinOnsetPeakDurationNutritionalRapid-actinganalog(aspart,glulisine,lispro)5-15min1-2hours4-6hoursRegular30-60min2-3hours6-10hoursBasalDetemir2hoursRelativelypeakless16-24hoursGlargine2-4hoursRelativelypeakless20-24hoursNPH2-4hours4-10hours12-18hoursHirschI.NEnglJMed.2005;352:174-183.

PorcellatiF,etal.DiabetesCare.2007;30:2447-2552.

Rapid(lispro,aspart,glulisine)HoursLong(glargine)Short(regular)Intermediate(NPH)Long(detemir)InsulinLevel0

24681012141618202224PharmacokineticsofInsulinProducts

AdaptedfromHirschI.NEnglJMed.2005;352:174–183.25Basal-BolusInsulinTherapyinInpatientsWithType2Diabetes(RABBIT2Trial)130nonsurgicalinsulin-naïvepatientsage18-80withknowntype2diabetesadmittedtononcriticalcareunitRandomlyassignedtoslidingscaleinsulin(SSI)orabasal-bolusregimenwithglargineandglulisine0.4unitsperkg/dayforBG140-2000.5unitsperkg/dayforBG>20050%givenasglargineand50%asglulisineOralantidiabeticdrugsdiscontinued2hypoglycemicevents(BG<60mg/dL)ineachgroupUmpierrezGE,etal.DiabetesCare.2007;30:2181-2186.26240–220–200–180–160–140–120–100–Admit12345678910DaysofTherapyBloodGlucose(mg/dL)***††††SSRIBasal-bolusBloodGlucose(BG)ConcentrationOverTimeforBothGroups*P<0.01;†P<0.05.SSRI,slidingscaleregularinsulin.Umpierrez,etal.DiabetesCare.

2007;30:2181-2186.Basal-BolusInsulinTherapyinInpatientsWithType2Diabetes(RABBIT2Trial)27Basal-BolusInsulinTherapyinInpatientsWithType2Diabetes(RABBIT2Trial)AdjustingscheduledinsulinregimenIffastingandpremealBG>140mg/dL,doseofglargineincreasedby20%ForBG<70mg/dL,glarginereducedby20%UmpierrezGE,etal.DiabetesCare.2007;30:2181-2186.28Persistenthyperglycemia(BG>240mg/dL)iscommon(15%)withSSItherapyHypoglycemiaRateDaysofTherapyBG,mg/dL100120140160180200220240Admit1Sliding-scaleBasal-bolus2602803003345672421Rabbit2Trial:SSIResultedinUncontrolledHyperglycemiainSomePatientsBasalBolusGroup:BG<60mg/dL:3%BG<40mg/dL:noneSSRI:BG<60mg/dL:3%BG<40mg/dL:noneUmpierrezGE,etal.DiabetesCare.2007;30:2181-2186.29*Adjustedforage,totaldailyinsulindose(TDD)>0.5U/kg,glomerularfiltrationrate(GFR)<60mL/second,insulinregimen(basal-bolusvsslidingscaleinsulin[SSI]),andpreviousinsulintherapy.FarrokhiF,etal.ADAScientificSessions.2011.Abstr.2060-PO.VariablePvalueUnivariateAnalysisMultivariateAnalysis*Age<0.001<0.001GFR<60mL/s0.0050.11TDD≥0.5U/kg0.0060.31Previousinsulinuse

<0.0010.02Insulinregimen

(basal-bolusvsSSI)<0.0010.001RiskFactorsforHypoglycemia30StrategiesforReducingRisk

forHypoglycemiainNoncriticalCareSettingsAvoidanceofsliding-scaleinsulinaloneUsecautioninprescribingoralantihyperglycemicagentsModifyoutpatientinsulindosesinpatientstreatedwithinsulinpriortoadmissionBraithwaiteSS,etal.EndocrPract.2004;10(suppl2):89-99.31SpecificClinicalSituations:

PatientsWithInsulinPumpsPatientswhouseCSIIpumptherapyintheoutpatientsettingcancontinuetousethesedevicesasinpatientsprovidedthattheyhavethementalandphysicalcapacitytodosoAvailabilityofhospitalpersonnelwithexpertiseinCSIItherapyisrecommendedAformalinpatientinsulinpumpprotocolreducesconfusionandtreatmentvariability32InpatientCSIIProtocolAninsulinpumpshouldNEVERbediscontinuedwithoutinitiationofeithersubcutaneousorintravenousinsulinIfthepumpisdiscontinuedforanyreason,additionalinsulin(eitherIVorsubcutaneous)MUSTbegiven30minutespriortodiscontinuationPatientistoself-manageinsulinpumpandnurseistoverifyanddocumentallbasalratesandbolusdosesadministeredInsulinpumpsmustbediscontinuedforanMRI.Ifthepumpisinterruptedformorethan1hour,anotherinsulinsourceneedstobeorderedNoscheseML,etal.EndocrPract.2009;15:415-424.33InpatientCSIIProtocol34BailonRM,etal.EndocrPract.2009;15:24-29.NoscheseML,etal.EndocrPract.2009;15:415-424.PatientAttestationIconfirmthatIhavebeenfullytrainedontheuseofmyinsulinpumppriortothishospitalization.Iamcapableandwillingtomanagemyinsulinpumpindependentlyduringmyhospitalstay.IfatanytimeIfeelthatIamunabletomanagethepump,Iwillalertmymedicalteam.RequirespatientandwitnesssignatureResultsofanInpatientCSIIProtocol35IDS,inpatientdiabetesservice;IPP,inpatientpumpprotocol.NoscheseML,etal.EndocrPract.2009;15:415-424.IDS+IPPIPPNoIDS/IPPN(%female)34(32)12(50)4(75)Age48±1551±1636±12LOS(days)9.8±15.45.2±6.23±1.5CSIIuse(days)5.4±7.13.2±2.93±1.5MeanCBG(mg/dL)173±43187±62218±46Patientdayswith≥1CBG<70211020AllCBG70-180252424≥1CBG181-300565573≥1CBG>30022760InpatientInsulinTherapyinPatientsTreatedWithInsulinasOutpatientsPatientscompletingquestionnaire(n=17)reportedahighdegreeofsatisfactionwiththeirabilitytocontinueCSIItherapyinthehospitalTherewere2CSIIrelatedadverseevents1infusionsi