SlideShare uma empresa Scribd logo
1 de 32
Baixar para ler offline
Care	
  of	
  Diabe+c	
  Pa+ents	
  	
  
 in	
  the	
  Hospital	
  Se6ng	
  


                   1/11/2011	
  
  Kathia	
  Desronvil,	
  BSN,	
  MSN,	
  FNP-­‐BC	
  	
  
Hospitalist,	
  Internal	
  Medicine	
  Department	
  
             Nash	
  General	
  Hospital	
  
            Rocky	
  Mount,	
  NC	
  27616	
  
   (H)	
  919-­‐890-­‐5561;	
  (C)	
  781-­‐363-­‐6938	
  
             kathia_d@yahoo.com	
  
Na+onal	
  Sta+s+cs	
  
•  Pa$ents	
  with	
  Diabetes	
  are	
  more	
  likely	
  to	
  be	
  hospitalized	
  
   and	
  to	
  have	
  a	
  longer	
  hospital	
  stay	
  
•  About	
  1/4	
  of	
  all	
  US	
  pa$ent	
  admissions	
  account	
  for	
  
   pa$ents	
  with	
  Diabetes	
  	
  
•  Majority	
  of	
  diabe$c	
  pa$ents	
  hospitalized	
  present	
  with	
  
   hyperglycemia	
  
•  Inpa$ent	
  management	
  of	
  the	
  hospitalized	
  diabe$c	
  
   pa$ent	
  must	
  focus	
  on	
  safe	
  glycemic	
  targets	
  to	
  avoid	
  
   adverse	
  outcomes;	
  primarily	
  severe	
  hypoglycemia	
  

  New England Journal of Medicine, 355; 18, November 2, 2006; Diabetes Care, volume 32, number 6, June 2009
Objec+ves	
  
•  Achieve	
  glycemic	
  control	
  to	
  improve	
  clinical	
  outcomes	
  for	
  
   Diabe$c	
  inpa$ents	
  
•  Determine	
  appropriate	
  glycemic	
  targets	
  for	
  different	
  
   diabe$c	
  popula$ons	
  
•  Evaluate	
  treatment	
  op$ons	
  available	
  for	
  achieving	
  op$mal	
  
   glycemic	
  control	
  safely	
  and	
  effec$vely	
  
•  Present	
  op$mal	
  strategies	
  for	
  transi$oning	
  to	
  outpa$ent	
  
   care	
  	
  	
  	
  	
  
•  Discuss	
  approaches	
  to	
  manage	
  the	
  Diabe$c	
  pa$ent	
  
   presen$ng	
  with	
  hyperglycemic	
  or	
  hypoglycemic	
  crises	
  
  New England Journal of Medicine, 355; 18, November 2, 2006; Diabetes Care, volume 32, number 6, June 2009
Diabe+c	
  Pa+ent	
  Popula+ons	
  
•  Known	
  and	
  nondiagnosed	
  diabe$c	
  pa$ent	
  
•  Type	
  2	
  	
  
     – Non-­‐Insulin	
  Dependent	
  Diabetes	
  Mellitus	
  (NIDDM)	
  
     – Insulin-­‐Requiring	
  Diabetes	
  Mellitus	
  
     – Newly-­‐diagnosed	
  diabe$c	
  pa$ent	
  	
  
•  Type	
  1	
  
     – 	
  Insulin-­‐Dependent	
  Diabetes	
  Mellitus	
  (IDDM)	
  	
  
•  Diabe$c	
  pa$ent:	
  
     – ICU	
  vs	
  acute	
  medical/surgical	
  ward	
  	
  
Hyperglycemia	
  in	
  the	
  
  Hospital	
  SeTng	
  
Hyperglycemia	
  Crisis	
  
•  Any	
  BG	
  >	
  140	
  mg/dl	
  
•  Severe	
  hyperglycemia	
  (BG	
  >	
  250	
  mg/dl)	
  	
  
•  DKA	
  (diabe$c	
  ketoacidocis)	
  	
  
     – BG	
  >	
  300	
  mg/dl	
  
     – Primarily	
  Type	
  1,	
  also	
  uncontrolled	
  Type	
  2	
  
•  HHS	
  (hyperosmolar	
  hyperglycemic	
  state)	
  
     – 	
  BG	
  >	
  600	
  mg/dl	
  
     – Type	
  2	
  


  New England Journal of Medicine, 355; 18, November 2, 2006; Diabetes Care, volume 32, number 6, June 2009
Hyperglycemia	
  Crisis	
  
•  Stress	
  hyperglycemia	
  	
  
       – Elevated	
  BG	
  due	
  to	
  stress	
  hormones	
  	
  
       – Nondiagnosed	
  pa$ents	
  with	
  A1c	
  between	
  6.5	
  -­‐	
  7.0%	
  
       – Type	
  2	
  
•  Uncontrolled,	
  hyperglycemia	
  results	
  in	
  increased	
  risk	
  of	
  
   poor	
  outcomes	
  in	
  hospital	
  seTng	
  	
  
•  Hyperglycemia,	
  can	
  have	
  significant	
  damaging	
  implica$ons	
  
   to	
  the	
  vascular,	
  hemodynamic	
  and	
  immune	
  systems	
  


Diabetes Care, volume 32, number 6, June 2009
Hyperglycemia	
  Crisis	
  
•  Triggers	
  are	
  aaributed	
  to:	
  
       – Medical	
  stress	
  (acute	
  illness)	
  
       – Infec$on	
  
       – Medica$ons	
  (i.e.	
  glucocor$coids,	
  lactulose,	
  IVF	
  with	
  
         Dextrose)	
  
       – Supplementa$on	
  (i.e.	
  enteral	
  and	
  parenteral	
  nutri$on)	
  
       – Miscoordina$on	
  of	
  insulin	
  administra$on	
  with	
  meals	
  



Diabetes Care, volume 32, number 6, June 2009
Remote Approach: Glycemic Control
Using Intensive Insulin Therapy
   •  Pros:	
  
          – Targe$ng	
  goals	
  near	
  normalized	
  levels	
  	
  
                  • (BG	
  80-­‐90	
  to	
  100-­‐120	
  mg/dl)	
  
          – Achieved	
  via	
  an	
  insulin	
  infusion	
  pump	
  (Regular)	
  
                  • Allows	
  faster	
  $tra$on	
  and	
  more	
  reliable	
  absorp$on	
  
                    than	
  subcutaneous	
  administra$on	
  
          – Recommended	
  for	
  cri$cally	
  ill	
  pa$ents	
  	
  
                  • ICU,	
  MICU,	
  Postopera$ve,	
  post	
  AMI,	
  etc.	
  
          – Decreased	
  mortality	
  and	
  complica$ons	
  

New England Journal of Medicine, 355; 18, November 2, 2006; Diabetes Care, volume 32, Number6, June 2009.
Remote Approach: Glycemic Control
Using Intensive Insulin Therapy
    •  Cons:	
  
            – Limited	
  randomized	
  trials	
  with	
  inconsistent	
  findings	
  	
  
            – No	
  reduc$on	
  of	
  mortality	
  in	
  cri$cally	
  ill	
  pa$ents	
  	
  
              with	
  $ghter	
  glycemic	
  control	
  
            – Increases	
  risk	
  of	
  adverse	
  outcome	
  of	
  severe	
  
              hypoglycemia	
  (BG	
  <	
  40	
  mg/dl)	
  
            – Reports	
  of	
  increasing	
  mortality	
  resul$ng	
  from	
  
              intensive	
  insulin	
  glycemic	
  control	
  


New England Journal of Medicine, 355; 18, November 2, 2006; Diabetes Care, volume 32, Number6, June 2009.
2011	
  Management	
  Approach	
  	
  
                    for	
  Glycemic	
  Control	
  
•  In	
  the	
  hospital	
  seTng	
  insulin	
  therapy	
  is	
  the	
  preferred	
  
   method	
  for	
  achieving	
  glycemic	
  control.	
  
     – Cri$cally-­‐ill	
  pa$ent	
  (ICU)/severe	
  hyperglycemia	
  crises	
  (DKA/
       HHS)	
  
         •  IV	
  insulin	
  infusion	
  pump	
  with	
  appropriate	
  adjustment	
  
     – Transi$oning	
  to	
  the	
  acute	
  ward,	
  convert	
  to	
  subcutaneous	
  
       insulin	
  	
  
            •  (75-­‐80%	
  of	
  previous	
  total	
  daily	
  dose)	
  




  New England Journal of Medicine, 355; 18, November 2, 2006
2011	
  Management	
  Approach	
  	
  
                   for	
  Glycemic	
  Control	
  
•  Acutely-­‐ill	
  pa$ent(MedSurg	
  ward)	
  
    – Subcutaneous	
  insulin	
  administra$on	
  
       • Components	
  50/50:	
  basal/nutri$onal	
  (prandial),	
  with	
  
         correc$onal	
  dosages	
  as	
  needed	
  (e.g.	
  hyperglycemic	
  
         spikes)	
  
    – General	
  goal	
  of	
  insulin	
  regimen	
  is	
  to	
  mimic	
  the	
  normal	
  
      physiologic	
  process	
  of	
  glucose	
  metaboliza$on	
  in	
  a	
  
      nondiabe$c	
  



 New England Journal of Medicine, 355; 18, November 2, 2006
2011	
  Management	
  Approach	
  	
  
                     for	
  Glycemic	
  Control	
  
•  Insulin	
  dependent	
  diabe$c	
  pa$ent	
  (IDDM)	
  
    – NPO	
  pa$ent:	
  	
  
              •  Basal	
  insulin,	
  with	
  Regular	
  insulin	
  administra$on	
  every	
  6	
  hrs	
  as	
  
                 necessary	
  
                   – Mandatory	
  in	
  Type	
  1	
  	
  
                   – Suggested	
  for	
  type	
  2	
  
              •  Generally	
  pa$ents	
  are	
  placed	
  on	
  a	
  long-­‐ac$ng	
  insulin	
  for	
  basal	
  
                 control	
  with	
  a	
  faster	
  short-­‐ac$ng	
  insulin	
  (e.g.	
  lispro)	
  via	
  sliding	
  
                 scale:	
  reduce	
  risk	
  of	
  overlap	
  and	
  hypoglycemia	
  with	
  Regular	
  
                 insulin	
  
New England Journal of Medicine, 355; 18, November 2, 2006
2011	
  Management	
  Approach	
  	
  
                     for	
  Glycemic	
  Control	
  
       – Pa$ent	
  ea$ng	
  	
  
              •  Con$nue	
  home	
  regimen	
  if	
  previously	
  well-­‐controlled	
  
              •  If	
  BG	
  >	
  200	
  mg/dl	
  on	
  admission;	
  dosage	
  should	
  ojen	
  be	
  
                 increased	
  or	
  change	
  to	
  a	
  basal-­‐prandial	
  regimen	
  
•  Any	
  pa$ent	
  with	
  persistent	
  BG	
  300-­‐	
  400	
  mg/dl	
  w/o	
  DKA	
  or	
  
   HHS	
  not	
  responding	
  to	
  increases	
  in	
  subcutaneous	
  
   administra$on	
  more	
  than	
  24	
  hours	
  should	
  be	
  considered	
  
   for	
  intravenous	
  insulin	
  infusion	
  	
  



New England Journal of Medicine, 355; 18, November 2, 2006
2011	
  Management	
  Approach	
  	
  
                     for	
  Glycemic	
  Control	
  
•  Pa$ents	
  on	
  supplemental	
  nutri$on:	
  Insulin	
  	
  
    – Enteral	
  feeding	
  (i.e.	
  tube	
  feeds,	
  NGT)	
  
              •  Basal	
  insulin,	
  with	
  correc$onal	
  doses	
  of	
  Regular	
  insulin	
  every	
  6	
  
                 hours	
  as	
  needed	
  
       – Parenteral	
  feeding	
  (i.e.	
  peripheral	
  or	
  central	
  IV	
  
         administra$on)	
  
              •  Regular	
  insulin	
  added	
  to	
  feeding	
  solu$on	
  	
  
              •  Titrate	
  insulin	
  in	
  increments	
  5-­‐10	
  units/l	
  to	
  achieve	
  control	
  
       – Generally	
  managed	
  in	
  collabora$on	
  with	
  a	
  Nutri$onist	
  


New England Journal of Medicine, 355; 18, November 2, 2006
2011	
  Management	
  Approach	
  	
  
                     for	
  Glycemic	
  Control	
  
•  NIDDM	
  	
  
       – Oral	
  glycemic	
  agents	
  have	
  limited	
  role	
  	
  
       – Appropriate	
  for	
  the	
  medically	
  stable	
  pa$ent	
  with	
  expected	
  
         consump$on	
  of	
  regular	
  meals	
  	
  
       – Ojen$mes,	
  pa$ents	
  on	
  Mekormin,	
  glyburide	
  are	
  withheld	
  
         secondary	
  to	
  higher	
  risk	
  	
  
              •  Hypoglycemia	
  	
  
              •  Renal	
  insufficiency	
  
              •  Increased	
  acidocis	
  if	
  radiocontrast	
  used	
  for	
  imaging	
  


New England Journal of Medicine, 355; 18, November 2, 2006
Recommended	
  Protocol	
  
•  Upon	
  admission,	
  every	
  pa$ent	
  should	
  be	
  screened	
  for	
  
   Diabetes	
  Mellitus	
  (e.g.	
  basic	
  chemistry	
  panel)	
  
       – Any	
  pa$ent	
  with	
  A1c	
  6.5-­‐7.0%	
  will	
  be	
  monitored	
  
       – Any	
  pa$ent	
  with	
  A1c	
  >	
  7.0%	
  should	
  be	
  evaluated	
  at	
  discharge	
  
         for	
  op$mal	
  dosing	
  on	
  oral	
  glycemics	
  versus	
  insulin	
  ini$a$on	
  
         for	
  beaer	
  control	
  outpa$ent	
  
•  All	
  hospitalized	
  pa$ents	
  with	
  evidence	
  of	
  severe	
  
   hyperglycemia	
  should	
  be	
  managed	
  per	
  an	
  insulin	
  protocol	
  if	
  
   feasible	
  but	
  with	
  precau$on	
  
       – More	
  precise	
  $tra$on,	
  quicker	
  and	
  reliable	
  absorp$on,	
  with	
  
         $ghter	
  glycemic	
  control	
  
New England Journal of Medicine, 355; 18, November 2, 2006
Recommended	
  Protocol	
  
•  Cri$cal	
  Care	
  seTng	
  
     – On	
  infusion	
  pump,	
  monitor	
  BG	
  every	
  1	
  to	
  2	
  hours	
  	
  	
  
•  Pa$ents	
  in	
  the	
  Acute	
  care	
  seTng	
  
     – managed	
  by	
  a	
  basal-­‐prandial	
  regimen,	
  resembling	
  the	
  natural	
  
       physiologic	
  paaerns	
  of	
  glucose	
  metaboliza$on	
  
     – Managed	
  per	
  subcutaneous	
  insulin	
  protocol:	
  monotherapy	
  
       with	
  long-­‐/intermediate	
  ac$ng	
  insulin,	
  combina$on	
  insulin,	
  
       solely	
  on	
  sliding	
  scale	
  (not	
  recommended)	
  
     – BG	
  monitoring	
  with	
  use	
  of	
  point	
  of	
  care	
  (POC)	
  before	
  meals	
  
       and	
  at	
  bed$me	
  (BG	
  every	
  4-­‐6	
  hrs	
  frequency)	
  

  New England Journal of Medicine, 355; 18, November 2, 2006
Recommended	
  Protocol	
  
•  In	
  general,	
  BG	
  target	
  goals:	
  140	
  mg/dl	
  and	
  180	
  mg/dl	
  
     – Avoid	
  target	
  goals	
  <110	
  mg/dl	
  for	
  safety	
  concerns	
  
     – Consider	
  higher	
  target	
  goals	
  for	
  medical	
  ward	
  
•  Insulin	
  therapies	
  available:	
  
     – Basal	
  rate	
  control:	
  
            •  Long-­‐ac$ng:	
  Lantus(Glargine),	
  Levemir(Detemir)	
  
            •  Intermediate	
  ac$ng:	
  NPH	
  
     – Prandial	
  (blunt	
  postprandial	
  spikes	
  at	
  meal$me)	
  
            •  Using	
  sliding	
  scale:	
  premeal	
  vs	
  postmeal	
  coverage	
  
            •  Rapid-­‐ac$ng:	
  Lispro(Humalog),	
  Aspart(Novolog)	
  	
  
            •  Short-­‐ac$ng:Regular	
  (Humulin/Novolin)	
  
  New England Journal of Medicine, 355; 18, November 2, 2006
Recommended	
  Protocol	
  
     – Intermediate	
  and	
  short-­‐ac$ng	
  Combina$on	
  	
  
            •  Humalog	
  75/25	
  or	
  Novolog	
  70/30	
  and	
  50/50	
  NPH/Regular	
  	
  
•  Sliding	
  scale	
  
     –  Usually	
  in	
  combina$on	
  with	
  a	
  basal	
  rate	
  insulin	
  
     –  Some$mes	
  used	
  as	
  monotherapy	
  
     –  Insulin	
  sensi$ve	
  pa$ents	
  (i.e.	
  Type	
  1,	
  lean	
  persons,	
  frail	
  elderly)	
  are	
  
        recommended	
  adjustment	
  via	
  1	
  unit	
  increment	
  scale	
  
     –  Pa$ents	
  with	
  severe	
  insulin	
  resistance	
  (i.e	
  morbidly	
  obese)	
  may	
  
        require	
  2	
  unit	
  increment	
  scale	
  
     –  Adjustments	
  are	
  based	
  on	
  postprandial	
  glycemia	
  	
  

    New England Journal of Medicine, 355; 18, November 2, 2006
Hypoglycemia	
  in	
  the	
  
  Hospital	
  SeTng	
  
Hypoglycemia	
  Crisis	
  
•  Any	
  BG	
  <	
  70	
  mg/dl	
  
•  Severe	
  hypoglycemia:	
  	
  
     – BG	
  <40	
  mg/dl	
  	
  
     – Cogni$ve	
  impairment	
  begins	
  BG	
  <	
  50	
  mg/dl	
  
     – Ojen	
  associated	
  with	
  adrenergic,	
  cholinergic	
  and/or	
  
       neuroglycopenic	
  symptoms	
  (palpita$ons,	
  swea$ng,	
  and/or	
  
       AMS/obtunded/comatose)	
  
           •  Symptoms	
  and	
  physiologic	
  response	
  vary	
  among	
  pa$ents	
  	
  
                     – Higher	
  glycemic	
  thresholds	
  occur	
  in	
  sustained	
  hyperglycemia	
  
                          (poorly	
  controlled	
  Diabe$c)	
  
                     – Lower	
  glycemic	
  thresholds	
  occur	
  in	
  sustained	
  hypoglycemia	
  
                          ($ghtly	
  controlled	
  or	
  insulinoma)	
  
Diabetes Care, volume 32, Number6, June 2009; Lexicomp online, Harrison’s Practice, 2010
Hypoglycemia	
  Crisis	
  
            •  Key	
  danger:	
  “hypoglycemia	
  unawareness”:	
  loss	
  of	
  the	
  warning	
  
               signs/symptoms	
  previously	
  allowed	
  pa$ent	
  to	
  recognize	
  
               impending	
  	
  hypoglycemia	
  crisis	
  	
  
•  Whipple’s	
  triad	
  criteria:	
  
     – Symptoms	
  of	
  hypoglycemia	
  are	
  evident	
  
     – Low	
  plasma	
  concentra$on	
  of	
  glucose	
  via	
  a	
  precise	
  
       measurement	
  method	
  
     – Resolu$on	
  of	
  symptoms	
  with	
  increased	
  glucose	
  level	
  	
  



  Diabetes Care, volume 32, Number6, June 2009; Lexicomp online, Harrison’s Practice, 2010
Hypoglycemia	
  Crisis	
  
•  Triggers	
  are	
  aaributed	
  to:	
  	
  
     – Treatment	
  of	
  Diabetes	
  is	
  the	
  most	
  common	
  cause	
  	
  
     – NPO	
  pa$ent/inadequate	
  nutri$onal	
  intake	
  while	
  on	
  insulin	
  
     – Postprandial	
  (reac$ve)	
  occurs	
  ajer	
  meals	
  	
  
     – Cri$cal	
  illness,	
  infec$on,	
  Sepsis	
  
     – Medica$ons	
  (i.e.	
  oral	
  an$glycemic	
  agents,	
  sulfa-­‐based	
  (ie.	
  
       sulfa,	
  quinine,	
  quinolone	
  an$bio$cs,etc.)	
  	
  
     – Pa$ents	
  with	
  lean	
  body	
  mass	
  (i.e.	
  elderly	
  pa$ents)	
  	
  
     – Old	
  age	
  

  Diabetes Care, volume 32, Number6, June 2009; Lexicomp online, Harrison’s Practice, 2010
Hypoglycemia	
  Crisis	
  
•  Triggers	
  are	
  aaributed	
  to	
  (con$nued):	
  
       – Pa$ents	
  with	
  kidney	
  failure	
  or	
  liver	
  insufficiency	
  
       – Endocrine	
  deficiencies	
  
       – Ethanol	
  binge	
  
       – Insulinoma	
  (tumors)	
  




Diabetes Care, volume 32, Number6, June 2009; Lexicomp online, Harrison’s Practice, 2010
Hypoglycemia	
  Crisis	
  
•  Type	
  1	
  
       – Average	
  2	
  symptoma$c	
  hypoglycemic	
  episodes	
  on	
  a	
  weekly	
  
         basis;	
  especially	
  when	
  $ghtly	
  controlled	
  	
  
       – At	
  least	
  one	
  temporarily,	
  seriously	
  disabling	
  (i.e.	
  
         hospitaliza$on)	
  episode	
  per	
  year	
  
       – BG	
  may	
  decrease	
  to	
  <	
  50	
  mg/dl	
  before	
  symptoma$c	
  
•  Type	
  2	
  
       – Less	
  frequent	
  hypoglycemic	
  episodes	
  
       – Especially	
  aaributed	
  to	
  those	
  treated	
  on	
  insulin	
  and	
  
         sulfonylureas	
  
Diabetes Care, volume 32, Number6, June 2009; Lexicomp online, Harrison’s Practice, 2010
Responding	
  to	
  an	
  acute	
  Hypoglycemic	
  
                     crisis	
  
•  Oral	
  Glucose	
  supplement	
  (if	
  possible)	
  
       – 20	
  gm	
  oral	
  tabs,	
  orange	
  juice	
  (4	
  o.z.),	
  soda	
  (	
  8o.z.);	
  2	
  Tbs	
  
         sugar/water	
  solu$on,	
  hard	
  candy	
  (no	
  chocolate)	
  
       – Parenteral	
  glucose	
  
       – Subcutaneous/intramuscular	
  Glucagon	
  injec$on	
  (especially	
  
         in	
  type	
  1)	
  
       – Intravenous	
  glucose	
  (1	
  ampule	
  D50	
  solu$on)	
  
       – Severe	
  symptoms	
  (obtunded/comatose):	
  Insulin	
  drip	
  	
  (5%	
  or	
  
         10%	
  dextrose)	
  postadministra$on	
  of	
  	
  SC/IM	
  
•  Food	
  consump$on	
  ASAP	
  -­‐	
  replete	
  glycogen	
  stores	
  
Lexicomp online, Harrison’s Practice, 2010
2011	
  Management	
  approach:	
  
                     Hypoglycemia	
  Crisis	
  

•  Test	
  BG	
  at	
  $me	
  of	
  hypoglycemic	
  symptoms	
  
•  Draw	
  blood	
  before	
  administra$on	
  of	
  glucose	
  	
  
•  Determine	
  pa$ent’s	
  diabe$c	
  status	
  (i.e.	
  known,	
  type	
  1	
  
   or	
  2,	
  IDDM	
  vs	
  NIDDM,	
  home	
  regimen)	
  	
  
•  Determine	
  cause	
  of	
  hypoglycemic	
  event	
  (i.e.	
  triggers)	
  
•  Assess	
  regimen	
  for	
  adjustment	
  	
  



Lexicomp online, Harrison’s Practice, 2010
Takeaways	
  
Outpa+ent	
  Transi+on	
  of	
  the	
  
                  Hospitalized	
  Diabe+c	
  Pa+ent	
  
•  Include	
  educa$on	
  and	
  establish	
  a	
  manageable	
  home	
  
   regimen	
  
       – All	
  literate	
  pa$ents	
  should	
  check	
  BG	
  TID/QID	
  and	
  keep	
  diary	
  
         of	
  daily	
  BGs	
  	
  
•  Establish	
  close	
  post	
  admission	
  follow-­‐up	
  for	
  pa$ents	
  if	
  
   treatment	
  was	
  ini$ated,	
  stopped	
  or	
  adjusted	
  	
  
       – 1-­‐2	
  week	
  follow-­‐ups	
  
       – If	
  elevated	
  HgbA1c	
  then	
  1-­‐2	
  months	
  follow-­‐up	
  
•  At	
  discharge,	
  pa$ents	
  on	
  insulin	
  regimen	
  may	
  need	
  to	
  be	
  
   simplified	
  for	
  home	
  management	
  	
  
New England Journal of Medicine, 355; 18, November 2, 2006
Outpa+ent	
  Transi+on	
  of	
  the	
  
                Hospitalized	
  Diabe+c	
  Pa+ent	
  
    – Combina$on	
  therapy,	
  combina$on	
  long-­‐ac$ng	
  with	
  oral	
  
      meds/sliding	
  scale,	
  monotherapy,	
  etc.	
  	
  
•  Many	
  pa$ents	
  are	
  converted	
  to	
  oral	
  an$glycemic	
  agents,	
  
   ajer	
  stabiliza$on	
  with	
  insulin	
  during	
  inpa$ent	
  	
  
•  Ojen$mes	
  recommend	
  discon$nua$on	
  of	
  sulfonylurea	
  
   and	
  other	
  trigger	
  for	
  hypoglycemic	
  	
  
•  Newly-­‐diagnosed	
  pa$ents	
  with	
  modest	
  HgbA1c	
  are	
  ojen	
  
   first	
  recommended	
  lifestyle	
  modifica$on	
  with	
  medical	
  
   nutri$onal	
  therapy	
  MNT	
  with	
  close	
  monitoring	
  every	
  3	
  
   months	
  with	
  Renal,	
  Podiatry,	
  and	
  Opthalmology	
  follow-­‐up	
  
  New England Journal of Medicine, 355; 18, November 2, 2006
Thank	
  You!	
  

Mais conteúdo relacionado

Mais procurados

Lec 2 estimated energy requirement among diabetic patients
Lec 2 estimated energy requirement among diabetic patientsLec 2 estimated energy requirement among diabetic patients
Lec 2 estimated energy requirement among diabetic patientsSiham Gritly
 
Diabetes Patient Presentation Dr Vivek Baliga
Diabetes Patient Presentation Dr Vivek BaligaDiabetes Patient Presentation Dr Vivek Baliga
Diabetes Patient Presentation Dr Vivek BaligaDr Vivek Baliga
 
Recent advances in the treatment of diabetes mellitus
Recent advances in the treatment of diabetes mellitusRecent advances in the treatment of diabetes mellitus
Recent advances in the treatment of diabetes mellituschandiniyrao
 
Diabetes Self Management
Diabetes Self ManagementDiabetes Self Management
Diabetes Self Managementmegbostwick
 
19 Insulin Types
19 Insulin Types19 Insulin Types
19 Insulin Typeskdiwavvou
 
Pharmacotherapy of diabetes mellitus
Pharmacotherapy of diabetes mellitusPharmacotherapy of diabetes mellitus
Pharmacotherapy of diabetes mellitusNaser Tadvi
 
2018 Update in Diabetes Technology: Closed Loop, CGM, and More
2018 Update in Diabetes Technology: Closed Loop, CGM, and More2018 Update in Diabetes Technology: Closed Loop, CGM, and More
2018 Update in Diabetes Technology: Closed Loop, CGM, and MoreAaron Neinstein
 
Diabetes Mellitus(Past,Present and Future)
Diabetes Mellitus(Past,Present and Future)Diabetes Mellitus(Past,Present and Future)
Diabetes Mellitus(Past,Present and Future)Vikas Reddy
 
Management of Diabetes Mellitus
Management of Diabetes MellitusManagement of Diabetes Mellitus
Management of Diabetes MellitusCarmela Domocmat
 
Management of diabetes mellitus.pptx me
Management  of diabetes mellitus.pptx meManagement  of diabetes mellitus.pptx me
Management of diabetes mellitus.pptx meHasan Ibna Kamal MCIPS
 
Diabetes mellitus ppt
Diabetes  mellitus pptDiabetes  mellitus ppt
Diabetes mellitus pptROMAN BAJRANG
 
Counselling diabetic patients
Counselling diabetic patientsCounselling diabetic patients
Counselling diabetic patientsSara Saber
 
Degludec insulin journal review
Degludec insulin journal reviewDegludec insulin journal review
Degludec insulin journal reviewSantosh Narayankar
 
Management of diabetes in elderly
Management of diabetes in elderlyManagement of diabetes in elderly
Management of diabetes in elderlyAditya Sarin
 

Mais procurados (20)

Lec 2 estimated energy requirement among diabetic patients
Lec 2 estimated energy requirement among diabetic patientsLec 2 estimated energy requirement among diabetic patients
Lec 2 estimated energy requirement among diabetic patients
 
Diabetes mellitus
Diabetes mellitusDiabetes mellitus
Diabetes mellitus
 
Diabetes Patient Presentation Dr Vivek Baliga
Diabetes Patient Presentation Dr Vivek BaligaDiabetes Patient Presentation Dr Vivek Baliga
Diabetes Patient Presentation Dr Vivek Baliga
 
Recent advances in the treatment of diabetes mellitus
Recent advances in the treatment of diabetes mellitusRecent advances in the treatment of diabetes mellitus
Recent advances in the treatment of diabetes mellitus
 
Type 2 DM and CKD
Type 2 DM and CKDType 2 DM and CKD
Type 2 DM and CKD
 
Diabetes mellitus
Diabetes  mellitusDiabetes  mellitus
Diabetes mellitus
 
Diabetes Self Management
Diabetes Self ManagementDiabetes Self Management
Diabetes Self Management
 
Type 1 Diabetes
Type 1 Diabetes Type 1 Diabetes
Type 1 Diabetes
 
Insulin therapy for type 2 diabetes patients dr shahjadaselim1
Insulin therapy for type 2 diabetes patients dr shahjadaselim1Insulin therapy for type 2 diabetes patients dr shahjadaselim1
Insulin therapy for type 2 diabetes patients dr shahjadaselim1
 
19 Insulin Types
19 Insulin Types19 Insulin Types
19 Insulin Types
 
Pharmacotherapy of diabetes mellitus
Pharmacotherapy of diabetes mellitusPharmacotherapy of diabetes mellitus
Pharmacotherapy of diabetes mellitus
 
2018 Update in Diabetes Technology: Closed Loop, CGM, and More
2018 Update in Diabetes Technology: Closed Loop, CGM, and More2018 Update in Diabetes Technology: Closed Loop, CGM, and More
2018 Update in Diabetes Technology: Closed Loop, CGM, and More
 
Diabetes Mellitus(Past,Present and Future)
Diabetes Mellitus(Past,Present and Future)Diabetes Mellitus(Past,Present and Future)
Diabetes Mellitus(Past,Present and Future)
 
Management of Diabetes Mellitus
Management of Diabetes MellitusManagement of Diabetes Mellitus
Management of Diabetes Mellitus
 
Clozapine
ClozapineClozapine
Clozapine
 
Management of diabetes mellitus.pptx me
Management  of diabetes mellitus.pptx meManagement  of diabetes mellitus.pptx me
Management of diabetes mellitus.pptx me
 
Diabetes mellitus ppt
Diabetes  mellitus pptDiabetes  mellitus ppt
Diabetes mellitus ppt
 
Counselling diabetic patients
Counselling diabetic patientsCounselling diabetic patients
Counselling diabetic patients
 
Degludec insulin journal review
Degludec insulin journal reviewDegludec insulin journal review
Degludec insulin journal review
 
Management of diabetes in elderly
Management of diabetes in elderlyManagement of diabetes in elderly
Management of diabetes in elderly
 

Destaque

Daily Life (Haiti)
Daily Life (Haiti)Daily Life (Haiti)
Daily Life (Haiti)guimera
 
Care of Diabetic Patients in a Hospital Setting (French)
Care of Diabetic Patients in a Hospital Setting (French)Care of Diabetic Patients in a Hospital Setting (French)
Care of Diabetic Patients in a Hospital Setting (French)The CRUDEM Foundation
 
The Burden of Diabetes in Haiti (French) - The CRUDEM Foundation
The Burden of Diabetes in Haiti (French) - The CRUDEM FoundationThe Burden of Diabetes in Haiti (French) - The CRUDEM Foundation
The Burden of Diabetes in Haiti (French) - The CRUDEM FoundationThe CRUDEM Foundation
 
Malaria in Haiti Symposia - The CRUDEM Foundation
Malaria in Haiti Symposia - The CRUDEM FoundationMalaria in Haiti Symposia - The CRUDEM Foundation
Malaria in Haiti Symposia - The CRUDEM FoundationThe CRUDEM Foundation
 
Tetanus in Haiti Symposia - The CRUDEM Foundation
Tetanus in Haiti Symposia - The CRUDEM FoundationTetanus in Haiti Symposia - The CRUDEM Foundation
Tetanus in Haiti Symposia - The CRUDEM FoundationThe CRUDEM Foundation
 
Basic EKG and Rhythm Interpretation Symposia - The CRUDEM Foundation
Basic EKG and Rhythm Interpretation Symposia - The CRUDEM FoundationBasic EKG and Rhythm Interpretation Symposia - The CRUDEM Foundation
Basic EKG and Rhythm Interpretation Symposia - The CRUDEM FoundationThe CRUDEM Foundation
 
An Introduction to Health Systems; An Overview of the Philippine Health Care ...
An Introduction to Health Systems; An Overview of the Philippine Health Care ...An Introduction to Health Systems; An Overview of the Philippine Health Care ...
An Introduction to Health Systems; An Overview of the Philippine Health Care ...Paolo Victor Medina
 
Basic EKG and Rhythm Interpretation Symposia
Basic EKG and Rhythm Interpretation SymposiaBasic EKG and Rhythm Interpretation Symposia
Basic EKG and Rhythm Interpretation SymposiaThe CRUDEM Foundation
 
Diabetes and the Eye (French) Symposia - The CRUDEM Foundation
Diabetes and the Eye (French) Symposia - The CRUDEM FoundationDiabetes and the Eye (French) Symposia - The CRUDEM Foundation
Diabetes and the Eye (French) Symposia - The CRUDEM FoundationThe CRUDEM Foundation
 

Destaque (9)

Daily Life (Haiti)
Daily Life (Haiti)Daily Life (Haiti)
Daily Life (Haiti)
 
Care of Diabetic Patients in a Hospital Setting (French)
Care of Diabetic Patients in a Hospital Setting (French)Care of Diabetic Patients in a Hospital Setting (French)
Care of Diabetic Patients in a Hospital Setting (French)
 
The Burden of Diabetes in Haiti (French) - The CRUDEM Foundation
The Burden of Diabetes in Haiti (French) - The CRUDEM FoundationThe Burden of Diabetes in Haiti (French) - The CRUDEM Foundation
The Burden of Diabetes in Haiti (French) - The CRUDEM Foundation
 
Malaria in Haiti Symposia - The CRUDEM Foundation
Malaria in Haiti Symposia - The CRUDEM FoundationMalaria in Haiti Symposia - The CRUDEM Foundation
Malaria in Haiti Symposia - The CRUDEM Foundation
 
Tetanus in Haiti Symposia - The CRUDEM Foundation
Tetanus in Haiti Symposia - The CRUDEM FoundationTetanus in Haiti Symposia - The CRUDEM Foundation
Tetanus in Haiti Symposia - The CRUDEM Foundation
 
Basic EKG and Rhythm Interpretation Symposia - The CRUDEM Foundation
Basic EKG and Rhythm Interpretation Symposia - The CRUDEM FoundationBasic EKG and Rhythm Interpretation Symposia - The CRUDEM Foundation
Basic EKG and Rhythm Interpretation Symposia - The CRUDEM Foundation
 
An Introduction to Health Systems; An Overview of the Philippine Health Care ...
An Introduction to Health Systems; An Overview of the Philippine Health Care ...An Introduction to Health Systems; An Overview of the Philippine Health Care ...
An Introduction to Health Systems; An Overview of the Philippine Health Care ...
 
Basic EKG and Rhythm Interpretation Symposia
Basic EKG and Rhythm Interpretation SymposiaBasic EKG and Rhythm Interpretation Symposia
Basic EKG and Rhythm Interpretation Symposia
 
Diabetes and the Eye (French) Symposia - The CRUDEM Foundation
Diabetes and the Eye (French) Symposia - The CRUDEM FoundationDiabetes and the Eye (French) Symposia - The CRUDEM Foundation
Diabetes and the Eye (French) Symposia - The CRUDEM Foundation
 

Semelhante a Care of Diabetic Patients in a Hospital Setting Symposia

Revised Approach to the Inpatient Management of Diabetes 2016 June 14 2016.ppt
Revised Approach to the Inpatient Management of Diabetes 2016 June 14 2016.pptRevised Approach to the Inpatient Management of Diabetes 2016 June 14 2016.ppt
Revised Approach to the Inpatient Management of Diabetes 2016 June 14 2016.ppttuan nguyen
 
glycemic_control_in_the_hospitalized_patient_august_2019.ppt
glycemic_control_in_the_hospitalized_patient_august_2019.pptglycemic_control_in_the_hospitalized_patient_august_2019.ppt
glycemic_control_in_the_hospitalized_patient_august_2019.pptssuser2127042
 
Inpatient hyperglycemia.ver3 (3)
Inpatient hyperglycemia.ver3 (3)Inpatient hyperglycemia.ver3 (3)
Inpatient hyperglycemia.ver3 (3)Mohammad Rehan
 
E4 2013 mk management of hyperglycemia in hospitalized patients an endocrin...
E4  2013 mk management of hyperglycemia in hospitalized patients  an endocrin...E4  2013 mk management of hyperglycemia in hospitalized patients  an endocrin...
E4 2013 mk management of hyperglycemia in hospitalized patients an endocrin...Diabetes for all
 
ueda2013 management of hyperglycaemia-d.mohamed
ueda2013 management of hyperglycaemia-d.mohamedueda2013 management of hyperglycaemia-d.mohamed
ueda2013 management of hyperglycaemia-d.mohamedueda2015
 
Inpatient Diabetes Management - How to Control Hyperglycemia inhsopital
Inpatient Diabetes Management - How to Control Hyperglycemia inhsopitalInpatient Diabetes Management - How to Control Hyperglycemia inhsopital
Inpatient Diabetes Management - How to Control Hyperglycemia inhsopitalUsama Ragab
 
DR. Wedad Bardisi DM Saudi Guideline.pptx
DR. Wedad Bardisi DM Saudi Guideline.pptxDR. Wedad Bardisi DM Saudi Guideline.pptx
DR. Wedad Bardisi DM Saudi Guideline.pptxFayzaRayes
 
DR. Wedad Bardisi DM Saudi Guideline.pptx
DR. Wedad Bardisi DM Saudi Guideline.pptxDR. Wedad Bardisi DM Saudi Guideline.pptx
DR. Wedad Bardisi DM Saudi Guideline.pptxFayzaRayes
 
(마더리스크라운드) 임신과 당뇨병 - 단국대의대 제일병원 김성훈 교수
 (마더리스크라운드) 임신과 당뇨병 - 단국대의대 제일병원 김성훈 교수 (마더리스크라운드) 임신과 당뇨병 - 단국대의대 제일병원 김성훈 교수
(마더리스크라운드) 임신과 당뇨병 - 단국대의대 제일병원 김성훈 교수mothersafe
 
Glucose monitorimg 2.pdf
Glucose monitorimg 2.pdfGlucose monitorimg 2.pdf
Glucose monitorimg 2.pdfIslam Kassem
 
임신과 당뇨병 - 제일병원 김성훈 교수
임신과 당뇨병 - 제일병원 김성훈 교수임신과 당뇨병 - 제일병원 김성훈 교수
임신과 당뇨병 - 제일병원 김성훈 교수mothersafe
 
Diabetes managemen
Diabetes managemenDiabetes managemen
Diabetes managemenmothersafe
 
jhmbf01319-sup-0001.ppt
jhmbf01319-sup-0001.pptjhmbf01319-sup-0001.ppt
jhmbf01319-sup-0001.ppttuan nguyen
 
treatment of diabetes mellitus.pptx
treatment of diabetes mellitus.pptxtreatment of diabetes mellitus.pptx
treatment of diabetes mellitus.pptxRoop
 
Low Carbohydrate Diets
Low Carbohydrate DietsLow Carbohydrate Diets
Low Carbohydrate Dietsfreenetdesign
 
Diabetic ketoacidosis: a case study
Diabetic ketoacidosis: a case studyDiabetic ketoacidosis: a case study
Diabetic ketoacidosis: a case studyLyndon Woytuck
 
Management of neonatal hypoglycemia ppt
Management of neonatal hypoglycemia pptManagement of neonatal hypoglycemia ppt
Management of neonatal hypoglycemia pptNiyati Das
 
ueda2012 -incretin based therapy of type 2 diabetes mellitus_d.adel
ueda2012 -incretin based therapy of type 2 diabetes mellitus_d.adelueda2012 -incretin based therapy of type 2 diabetes mellitus_d.adel
ueda2012 -incretin based therapy of type 2 diabetes mellitus_d.adelueda2015
 

Semelhante a Care of Diabetic Patients in a Hospital Setting Symposia (20)

Revised Approach to the Inpatient Management of Diabetes 2016 June 14 2016.ppt
Revised Approach to the Inpatient Management of Diabetes 2016 June 14 2016.pptRevised Approach to the Inpatient Management of Diabetes 2016 June 14 2016.ppt
Revised Approach to the Inpatient Management of Diabetes 2016 June 14 2016.ppt
 
glycemic_control_in_the_hospitalized_patient_august_2019.ppt
glycemic_control_in_the_hospitalized_patient_august_2019.pptglycemic_control_in_the_hospitalized_patient_august_2019.ppt
glycemic_control_in_the_hospitalized_patient_august_2019.ppt
 
Inpatient hyperglycemia.ver3 (3)
Inpatient hyperglycemia.ver3 (3)Inpatient hyperglycemia.ver3 (3)
Inpatient hyperglycemia.ver3 (3)
 
E4 2013 mk management of hyperglycemia in hospitalized patients an endocrin...
E4  2013 mk management of hyperglycemia in hospitalized patients  an endocrin...E4  2013 mk management of hyperglycemia in hospitalized patients  an endocrin...
E4 2013 mk management of hyperglycemia in hospitalized patients an endocrin...
 
ueda2013 management of hyperglycaemia-d.mohamed
ueda2013 management of hyperglycaemia-d.mohamedueda2013 management of hyperglycaemia-d.mohamed
ueda2013 management of hyperglycaemia-d.mohamed
 
Inpatient Diabetes Management - How to Control Hyperglycemia inhsopital
Inpatient Diabetes Management - How to Control Hyperglycemia inhsopitalInpatient Diabetes Management - How to Control Hyperglycemia inhsopital
Inpatient Diabetes Management - How to Control Hyperglycemia inhsopital
 
DR. Wedad Bardisi DM Saudi Guideline.pptx
DR. Wedad Bardisi DM Saudi Guideline.pptxDR. Wedad Bardisi DM Saudi Guideline.pptx
DR. Wedad Bardisi DM Saudi Guideline.pptx
 
DR. Wedad Bardisi DM Saudi Guideline.pptx
DR. Wedad Bardisi DM Saudi Guideline.pptxDR. Wedad Bardisi DM Saudi Guideline.pptx
DR. Wedad Bardisi DM Saudi Guideline.pptx
 
(마더리스크라운드) 임신과 당뇨병 - 단국대의대 제일병원 김성훈 교수
 (마더리스크라운드) 임신과 당뇨병 - 단국대의대 제일병원 김성훈 교수 (마더리스크라운드) 임신과 당뇨병 - 단국대의대 제일병원 김성훈 교수
(마더리스크라운드) 임신과 당뇨병 - 단국대의대 제일병원 김성훈 교수
 
Glucose monitorimg 2.pdf
Glucose monitorimg 2.pdfGlucose monitorimg 2.pdf
Glucose monitorimg 2.pdf
 
임신과 당뇨병 - 제일병원 김성훈 교수
임신과 당뇨병 - 제일병원 김성훈 교수임신과 당뇨병 - 제일병원 김성훈 교수
임신과 당뇨병 - 제일병원 김성훈 교수
 
Diabetes managemen
Diabetes managemenDiabetes managemen
Diabetes managemen
 
Diabetes mellitus
Diabetes mellitusDiabetes mellitus
Diabetes mellitus
 
Inpatient Diabetes
Inpatient DiabetesInpatient Diabetes
Inpatient Diabetes
 
jhmbf01319-sup-0001.ppt
jhmbf01319-sup-0001.pptjhmbf01319-sup-0001.ppt
jhmbf01319-sup-0001.ppt
 
treatment of diabetes mellitus.pptx
treatment of diabetes mellitus.pptxtreatment of diabetes mellitus.pptx
treatment of diabetes mellitus.pptx
 
Low Carbohydrate Diets
Low Carbohydrate DietsLow Carbohydrate Diets
Low Carbohydrate Diets
 
Diabetic ketoacidosis: a case study
Diabetic ketoacidosis: a case studyDiabetic ketoacidosis: a case study
Diabetic ketoacidosis: a case study
 
Management of neonatal hypoglycemia ppt
Management of neonatal hypoglycemia pptManagement of neonatal hypoglycemia ppt
Management of neonatal hypoglycemia ppt
 
ueda2012 -incretin based therapy of type 2 diabetes mellitus_d.adel
ueda2012 -incretin based therapy of type 2 diabetes mellitus_d.adelueda2012 -incretin based therapy of type 2 diabetes mellitus_d.adel
ueda2012 -incretin based therapy of type 2 diabetes mellitus_d.adel
 

Mais de The CRUDEM Foundation

Care of the Patient with Diabetes in Haiti (French) Symposia
Care of the Patient with Diabetes in Haiti (French) SymposiaCare of the Patient with Diabetes in Haiti (French) Symposia
Care of the Patient with Diabetes in Haiti (French) SymposiaThe CRUDEM Foundation
 
Outpatient Diabetes Education - Haiti Symposia
Outpatient Diabetes Education - Haiti SymposiaOutpatient Diabetes Education - Haiti Symposia
Outpatient Diabetes Education - Haiti SymposiaThe CRUDEM Foundation
 
Outpatient Diabetes Education (French) - Haiti
Outpatient Diabetes Education (French) - HaitiOutpatient Diabetes Education (French) - Haiti
Outpatient Diabetes Education (French) - HaitiThe CRUDEM Foundation
 
Nutrition Presentation - Diabetes Symposium - Haiti
Nutrition Presentation - Diabetes Symposium - Haiti Nutrition Presentation - Diabetes Symposium - Haiti
Nutrition Presentation - Diabetes Symposium - Haiti The CRUDEM Foundation
 
Nutrition Presentation - Diabetes Symposium - Haiti (French)
Nutrition Presentation - Diabetes Symposium - Haiti (French)Nutrition Presentation - Diabetes Symposium - Haiti (French)
Nutrition Presentation - Diabetes Symposium - Haiti (French)The CRUDEM Foundation
 
Neuropathy and Foot Exam - Diabetes Symposia
Neuropathy and Foot Exam - Diabetes SymposiaNeuropathy and Foot Exam - Diabetes Symposia
Neuropathy and Foot Exam - Diabetes SymposiaThe CRUDEM Foundation
 
Neuropathy and Foot Exam - Diabetes Symposia (French)
Neuropathy and Foot Exam - Diabetes Symposia (French)Neuropathy and Foot Exam - Diabetes Symposia (French)
Neuropathy and Foot Exam - Diabetes Symposia (French)The CRUDEM Foundation
 
Care of the Patient with Diabetes in Haiti Symposia - The CRUDEM Foundation
Care of the Patient with Diabetes in Haiti Symposia - The CRUDEM FoundationCare of the Patient with Diabetes in Haiti Symposia - The CRUDEM Foundation
Care of the Patient with Diabetes in Haiti Symposia - The CRUDEM FoundationThe CRUDEM Foundation
 
Diabetes in Pregnancy (French) Symposia - The CRUDEM Foundation
Diabetes in Pregnancy (French) Symposia - The CRUDEM FoundationDiabetes in Pregnancy (French) Symposia - The CRUDEM Foundation
Diabetes in Pregnancy (French) Symposia - The CRUDEM FoundationThe CRUDEM Foundation
 
Heart Failure in Haiti (French) Symposia - The CRUDEM Foundation
Heart Failure in Haiti (French) Symposia - The CRUDEM FoundationHeart Failure in Haiti (French) Symposia - The CRUDEM Foundation
Heart Failure in Haiti (French) Symposia - The CRUDEM FoundationThe CRUDEM Foundation
 
Diabetic Complications in Haiti - The CRUDEM Foundation
Diabetic Complications in Haiti - The CRUDEM FoundationDiabetic Complications in Haiti - The CRUDEM Foundation
Diabetic Complications in Haiti - The CRUDEM FoundationThe CRUDEM Foundation
 
Diabetic Crises in Haiti - The CRUDEM Foundation
Diabetic Crises in Haiti - The CRUDEM FoundationDiabetic Crises in Haiti - The CRUDEM Foundation
Diabetic Crises in Haiti - The CRUDEM FoundationThe CRUDEM Foundation
 
Pediatric Diabetes Symposia - The CRUDEM Foundation
Pediatric Diabetes Symposia - The CRUDEM FoundationPediatric Diabetes Symposia - The CRUDEM Foundation
Pediatric Diabetes Symposia - The CRUDEM FoundationThe CRUDEM Foundation
 
Medications To Treat Tuberculosis Symposia - The CRUDEM Foundation
Medications To Treat Tuberculosis Symposia - The CRUDEM FoundationMedications To Treat Tuberculosis Symposia - The CRUDEM Foundation
Medications To Treat Tuberculosis Symposia - The CRUDEM FoundationThe CRUDEM Foundation
 
Tuberculosis Treatment (French) Symposia - The CRUDEM Foundation
Tuberculosis Treatment (French) Symposia - The CRUDEM FoundationTuberculosis Treatment (French) Symposia - The CRUDEM Foundation
Tuberculosis Treatment (French) Symposia - The CRUDEM FoundationThe CRUDEM Foundation
 
Tuberculosis Treatment Symposia - The CRUDEM Foundation
Tuberculosis Treatment Symposia - The CRUDEM FoundationTuberculosis Treatment Symposia - The CRUDEM Foundation
Tuberculosis Treatment Symposia - The CRUDEM FoundationThe CRUDEM Foundation
 
Les médicaments pour traiter la tuberculose (French) Symposia
Les médicaments pour traiter la tuberculose (French) SymposiaLes médicaments pour traiter la tuberculose (French) Symposia
Les médicaments pour traiter la tuberculose (French) SymposiaThe CRUDEM Foundation
 
Infection Control and Antibiotic Stewardship
Infection Control and Antibiotic StewardshipInfection Control and Antibiotic Stewardship
Infection Control and Antibiotic StewardshipThe CRUDEM Foundation
 
Les Agents Antiretroviraux et Les Toxicites Associes avec Eux (French) Symposia
Les Agents Antiretroviraux et Les Toxicites Associes avec Eux (French) Symposia Les Agents Antiretroviraux et Les Toxicites Associes avec Eux (French) Symposia
Les Agents Antiretroviraux et Les Toxicites Associes avec Eux (French) Symposia The CRUDEM Foundation
 
Hypertension (French) Symposia - The CRUDEM Foundation
Hypertension (French) Symposia - The CRUDEM FoundationHypertension (French) Symposia - The CRUDEM Foundation
Hypertension (French) Symposia - The CRUDEM FoundationThe CRUDEM Foundation
 

Mais de The CRUDEM Foundation (20)

Care of the Patient with Diabetes in Haiti (French) Symposia
Care of the Patient with Diabetes in Haiti (French) SymposiaCare of the Patient with Diabetes in Haiti (French) Symposia
Care of the Patient with Diabetes in Haiti (French) Symposia
 
Outpatient Diabetes Education - Haiti Symposia
Outpatient Diabetes Education - Haiti SymposiaOutpatient Diabetes Education - Haiti Symposia
Outpatient Diabetes Education - Haiti Symposia
 
Outpatient Diabetes Education (French) - Haiti
Outpatient Diabetes Education (French) - HaitiOutpatient Diabetes Education (French) - Haiti
Outpatient Diabetes Education (French) - Haiti
 
Nutrition Presentation - Diabetes Symposium - Haiti
Nutrition Presentation - Diabetes Symposium - Haiti Nutrition Presentation - Diabetes Symposium - Haiti
Nutrition Presentation - Diabetes Symposium - Haiti
 
Nutrition Presentation - Diabetes Symposium - Haiti (French)
Nutrition Presentation - Diabetes Symposium - Haiti (French)Nutrition Presentation - Diabetes Symposium - Haiti (French)
Nutrition Presentation - Diabetes Symposium - Haiti (French)
 
Neuropathy and Foot Exam - Diabetes Symposia
Neuropathy and Foot Exam - Diabetes SymposiaNeuropathy and Foot Exam - Diabetes Symposia
Neuropathy and Foot Exam - Diabetes Symposia
 
Neuropathy and Foot Exam - Diabetes Symposia (French)
Neuropathy and Foot Exam - Diabetes Symposia (French)Neuropathy and Foot Exam - Diabetes Symposia (French)
Neuropathy and Foot Exam - Diabetes Symposia (French)
 
Care of the Patient with Diabetes in Haiti Symposia - The CRUDEM Foundation
Care of the Patient with Diabetes in Haiti Symposia - The CRUDEM FoundationCare of the Patient with Diabetes in Haiti Symposia - The CRUDEM Foundation
Care of the Patient with Diabetes in Haiti Symposia - The CRUDEM Foundation
 
Diabetes in Pregnancy (French) Symposia - The CRUDEM Foundation
Diabetes in Pregnancy (French) Symposia - The CRUDEM FoundationDiabetes in Pregnancy (French) Symposia - The CRUDEM Foundation
Diabetes in Pregnancy (French) Symposia - The CRUDEM Foundation
 
Heart Failure in Haiti (French) Symposia - The CRUDEM Foundation
Heart Failure in Haiti (French) Symposia - The CRUDEM FoundationHeart Failure in Haiti (French) Symposia - The CRUDEM Foundation
Heart Failure in Haiti (French) Symposia - The CRUDEM Foundation
 
Diabetic Complications in Haiti - The CRUDEM Foundation
Diabetic Complications in Haiti - The CRUDEM FoundationDiabetic Complications in Haiti - The CRUDEM Foundation
Diabetic Complications in Haiti - The CRUDEM Foundation
 
Diabetic Crises in Haiti - The CRUDEM Foundation
Diabetic Crises in Haiti - The CRUDEM FoundationDiabetic Crises in Haiti - The CRUDEM Foundation
Diabetic Crises in Haiti - The CRUDEM Foundation
 
Pediatric Diabetes Symposia - The CRUDEM Foundation
Pediatric Diabetes Symposia - The CRUDEM FoundationPediatric Diabetes Symposia - The CRUDEM Foundation
Pediatric Diabetes Symposia - The CRUDEM Foundation
 
Medications To Treat Tuberculosis Symposia - The CRUDEM Foundation
Medications To Treat Tuberculosis Symposia - The CRUDEM FoundationMedications To Treat Tuberculosis Symposia - The CRUDEM Foundation
Medications To Treat Tuberculosis Symposia - The CRUDEM Foundation
 
Tuberculosis Treatment (French) Symposia - The CRUDEM Foundation
Tuberculosis Treatment (French) Symposia - The CRUDEM FoundationTuberculosis Treatment (French) Symposia - The CRUDEM Foundation
Tuberculosis Treatment (French) Symposia - The CRUDEM Foundation
 
Tuberculosis Treatment Symposia - The CRUDEM Foundation
Tuberculosis Treatment Symposia - The CRUDEM FoundationTuberculosis Treatment Symposia - The CRUDEM Foundation
Tuberculosis Treatment Symposia - The CRUDEM Foundation
 
Les médicaments pour traiter la tuberculose (French) Symposia
Les médicaments pour traiter la tuberculose (French) SymposiaLes médicaments pour traiter la tuberculose (French) Symposia
Les médicaments pour traiter la tuberculose (French) Symposia
 
Infection Control and Antibiotic Stewardship
Infection Control and Antibiotic StewardshipInfection Control and Antibiotic Stewardship
Infection Control and Antibiotic Stewardship
 
Les Agents Antiretroviraux et Les Toxicites Associes avec Eux (French) Symposia
Les Agents Antiretroviraux et Les Toxicites Associes avec Eux (French) Symposia Les Agents Antiretroviraux et Les Toxicites Associes avec Eux (French) Symposia
Les Agents Antiretroviraux et Les Toxicites Associes avec Eux (French) Symposia
 
Hypertension (French) Symposia - The CRUDEM Foundation
Hypertension (French) Symposia - The CRUDEM FoundationHypertension (French) Symposia - The CRUDEM Foundation
Hypertension (French) Symposia - The CRUDEM Foundation
 

Último

AUTONOMIC NERVOUS SYSTEM organization and functions
AUTONOMIC NERVOUS SYSTEM organization and functionsAUTONOMIC NERVOUS SYSTEM organization and functions
AUTONOMIC NERVOUS SYSTEM organization and functionsMedicoseAcademics
 
Role of Soap based and synthetic or syndets bar
Role of  Soap based and synthetic or syndets barRole of  Soap based and synthetic or syndets bar
Role of Soap based and synthetic or syndets barmohitRahangdale
 
SGK LEUKEMIA KINH DÒNG BẠCH CÂU HẠT HAY.pdf
SGK LEUKEMIA KINH DÒNG BẠCH CÂU HẠT HAY.pdfSGK LEUKEMIA KINH DÒNG BẠCH CÂU HẠT HAY.pdf
SGK LEUKEMIA KINH DÒNG BẠCH CÂU HẠT HAY.pdfHongBiThi1
 
CPR.nursingoutlook.pdf , Bsc nursing student
CPR.nursingoutlook.pdf , Bsc nursing studentCPR.nursingoutlook.pdf , Bsc nursing student
CPR.nursingoutlook.pdf , Bsc nursing studentsaileshpanda05
 
Different drug regularity bodies in different countries.
Different drug regularity bodies in different countries.Different drug regularity bodies in different countries.
Different drug regularity bodies in different countries.kishan singh tomar
 
Adenomyosis or Fibroid- making right diagnosis
Adenomyosis or Fibroid- making right diagnosisAdenomyosis or Fibroid- making right diagnosis
Adenomyosis or Fibroid- making right diagnosisSujoy Dasgupta
 
BENIGN BREAST DISEASE
BENIGN BREAST DISEASE BENIGN BREAST DISEASE
BENIGN BREAST DISEASE Mamatha Lakka
 
SGK NGẠT NƯỚC ĐHYHN RẤT LÀ HAY NHA .pdf
SGK NGẠT NƯỚC ĐHYHN RẤT LÀ HAY NHA    .pdfSGK NGẠT NƯỚC ĐHYHN RẤT LÀ HAY NHA    .pdf
SGK NGẠT NƯỚC ĐHYHN RẤT LÀ HAY NHA .pdfHongBiThi1
 
pA2 value, Schild plot and pD2 values- applications in pharmacology
pA2 value, Schild plot and pD2 values- applications in pharmacologypA2 value, Schild plot and pD2 values- applications in pharmacology
pA2 value, Schild plot and pD2 values- applications in pharmacologyDeepakDaniel9
 
"Radical excision of DIE in subferile women with deep infiltrating endometrio...
"Radical excision of DIE in subferile women with deep infiltrating endometrio..."Radical excision of DIE in subferile women with deep infiltrating endometrio...
"Radical excision of DIE in subferile women with deep infiltrating endometrio...Sujoy Dasgupta
 
Generative AI in Health Care a scoping review and a persoanl experience.
Generative AI in Health Care a scoping review and a persoanl experience.Generative AI in Health Care a scoping review and a persoanl experience.
Generative AI in Health Care a scoping review and a persoanl experience.Vaikunthan Rajaratnam
 
MedMatch: Your Health, Our Mission. Pitch deck.
MedMatch: Your Health, Our Mission. Pitch deck.MedMatch: Your Health, Our Mission. Pitch deck.
MedMatch: Your Health, Our Mission. Pitch deck.whalesdesign
 
Clinical Research Informatics Year-in-Review 2024
Clinical Research Informatics Year-in-Review 2024Clinical Research Informatics Year-in-Review 2024
Clinical Research Informatics Year-in-Review 2024Peter Embi
 
CONNECTIVE TISSUE (ANATOMY AND PHYSIOLOGY).pdf
CONNECTIVE TISSUE (ANATOMY AND PHYSIOLOGY).pdfCONNECTIVE TISSUE (ANATOMY AND PHYSIOLOGY).pdf
CONNECTIVE TISSUE (ANATOMY AND PHYSIOLOGY).pdfDolisha Warbi
 
Mental health Team. Dr Senthil Thirusangu
Mental health Team. Dr Senthil ThirusanguMental health Team. Dr Senthil Thirusangu
Mental health Team. Dr Senthil Thirusangu Medical University
 

Último (20)

AUTONOMIC NERVOUS SYSTEM organization and functions
AUTONOMIC NERVOUS SYSTEM organization and functionsAUTONOMIC NERVOUS SYSTEM organization and functions
AUTONOMIC NERVOUS SYSTEM organization and functions
 
Role of Soap based and synthetic or syndets bar
Role of  Soap based and synthetic or syndets barRole of  Soap based and synthetic or syndets bar
Role of Soap based and synthetic or syndets bar
 
SGK LEUKEMIA KINH DÒNG BẠCH CÂU HẠT HAY.pdf
SGK LEUKEMIA KINH DÒNG BẠCH CÂU HẠT HAY.pdfSGK LEUKEMIA KINH DÒNG BẠCH CÂU HẠT HAY.pdf
SGK LEUKEMIA KINH DÒNG BẠCH CÂU HẠT HAY.pdf
 
CPR.nursingoutlook.pdf , Bsc nursing student
CPR.nursingoutlook.pdf , Bsc nursing studentCPR.nursingoutlook.pdf , Bsc nursing student
CPR.nursingoutlook.pdf , Bsc nursing student
 
Different drug regularity bodies in different countries.
Different drug regularity bodies in different countries.Different drug regularity bodies in different countries.
Different drug regularity bodies in different countries.
 
American College of physicians ACP high value care recommendations in rheumat...
American College of physicians ACP high value care recommendations in rheumat...American College of physicians ACP high value care recommendations in rheumat...
American College of physicians ACP high value care recommendations in rheumat...
 
Adenomyosis or Fibroid- making right diagnosis
Adenomyosis or Fibroid- making right diagnosisAdenomyosis or Fibroid- making right diagnosis
Adenomyosis or Fibroid- making right diagnosis
 
BENIGN BREAST DISEASE
BENIGN BREAST DISEASE BENIGN BREAST DISEASE
BENIGN BREAST DISEASE
 
SGK NGẠT NƯỚC ĐHYHN RẤT LÀ HAY NHA .pdf
SGK NGẠT NƯỚC ĐHYHN RẤT LÀ HAY NHA    .pdfSGK NGẠT NƯỚC ĐHYHN RẤT LÀ HAY NHA    .pdf
SGK NGẠT NƯỚC ĐHYHN RẤT LÀ HAY NHA .pdf
 
Immune labs basics part 1 acute phase reactants ESR, CRP Ahmed Yehia Ismaeel,...
Immune labs basics part 1 acute phase reactants ESR, CRP Ahmed Yehia Ismaeel,...Immune labs basics part 1 acute phase reactants ESR, CRP Ahmed Yehia Ismaeel,...
Immune labs basics part 1 acute phase reactants ESR, CRP Ahmed Yehia Ismaeel,...
 
How to master Steroid (glucocorticoids) prescription, different scenarios, ca...
How to master Steroid (glucocorticoids) prescription, different scenarios, ca...How to master Steroid (glucocorticoids) prescription, different scenarios, ca...
How to master Steroid (glucocorticoids) prescription, different scenarios, ca...
 
pA2 value, Schild plot and pD2 values- applications in pharmacology
pA2 value, Schild plot and pD2 values- applications in pharmacologypA2 value, Schild plot and pD2 values- applications in pharmacology
pA2 value, Schild plot and pD2 values- applications in pharmacology
 
"Radical excision of DIE in subferile women with deep infiltrating endometrio...
"Radical excision of DIE in subferile women with deep infiltrating endometrio..."Radical excision of DIE in subferile women with deep infiltrating endometrio...
"Radical excision of DIE in subferile women with deep infiltrating endometrio...
 
Generative AI in Health Care a scoping review and a persoanl experience.
Generative AI in Health Care a scoping review and a persoanl experience.Generative AI in Health Care a scoping review and a persoanl experience.
Generative AI in Health Care a scoping review and a persoanl experience.
 
MedMatch: Your Health, Our Mission. Pitch deck.
MedMatch: Your Health, Our Mission. Pitch deck.MedMatch: Your Health, Our Mission. Pitch deck.
MedMatch: Your Health, Our Mission. Pitch deck.
 
Rheumatoid arthritis Part 1, case based approach with application of the late...
Rheumatoid arthritis Part 1, case based approach with application of the late...Rheumatoid arthritis Part 1, case based approach with application of the late...
Rheumatoid arthritis Part 1, case based approach with application of the late...
 
GOUT UPDATE AHMED YEHIA 2024, case based approach with application of the lat...
GOUT UPDATE AHMED YEHIA 2024, case based approach with application of the lat...GOUT UPDATE AHMED YEHIA 2024, case based approach with application of the lat...
GOUT UPDATE AHMED YEHIA 2024, case based approach with application of the lat...
 
Clinical Research Informatics Year-in-Review 2024
Clinical Research Informatics Year-in-Review 2024Clinical Research Informatics Year-in-Review 2024
Clinical Research Informatics Year-in-Review 2024
 
CONNECTIVE TISSUE (ANATOMY AND PHYSIOLOGY).pdf
CONNECTIVE TISSUE (ANATOMY AND PHYSIOLOGY).pdfCONNECTIVE TISSUE (ANATOMY AND PHYSIOLOGY).pdf
CONNECTIVE TISSUE (ANATOMY AND PHYSIOLOGY).pdf
 
Mental health Team. Dr Senthil Thirusangu
Mental health Team. Dr Senthil ThirusanguMental health Team. Dr Senthil Thirusangu
Mental health Team. Dr Senthil Thirusangu
 

Care of Diabetic Patients in a Hospital Setting Symposia

  • 1. Care  of  Diabe+c  Pa+ents     in  the  Hospital  Se6ng   1/11/2011   Kathia  Desronvil,  BSN,  MSN,  FNP-­‐BC     Hospitalist,  Internal  Medicine  Department   Nash  General  Hospital   Rocky  Mount,  NC  27616   (H)  919-­‐890-­‐5561;  (C)  781-­‐363-­‐6938   kathia_d@yahoo.com  
  • 2. Na+onal  Sta+s+cs   •  Pa$ents  with  Diabetes  are  more  likely  to  be  hospitalized   and  to  have  a  longer  hospital  stay   •  About  1/4  of  all  US  pa$ent  admissions  account  for   pa$ents  with  Diabetes     •  Majority  of  diabe$c  pa$ents  hospitalized  present  with   hyperglycemia   •  Inpa$ent  management  of  the  hospitalized  diabe$c   pa$ent  must  focus  on  safe  glycemic  targets  to  avoid   adverse  outcomes;  primarily  severe  hypoglycemia   New England Journal of Medicine, 355; 18, November 2, 2006; Diabetes Care, volume 32, number 6, June 2009
  • 3. Objec+ves   •  Achieve  glycemic  control  to  improve  clinical  outcomes  for   Diabe$c  inpa$ents   •  Determine  appropriate  glycemic  targets  for  different   diabe$c  popula$ons   •  Evaluate  treatment  op$ons  available  for  achieving  op$mal   glycemic  control  safely  and  effec$vely   •  Present  op$mal  strategies  for  transi$oning  to  outpa$ent   care           •  Discuss  approaches  to  manage  the  Diabe$c  pa$ent   presen$ng  with  hyperglycemic  or  hypoglycemic  crises   New England Journal of Medicine, 355; 18, November 2, 2006; Diabetes Care, volume 32, number 6, June 2009
  • 4. Diabe+c  Pa+ent  Popula+ons   •  Known  and  nondiagnosed  diabe$c  pa$ent   •  Type  2     – Non-­‐Insulin  Dependent  Diabetes  Mellitus  (NIDDM)   – Insulin-­‐Requiring  Diabetes  Mellitus   – Newly-­‐diagnosed  diabe$c  pa$ent     •  Type  1   –   Insulin-­‐Dependent  Diabetes  Mellitus  (IDDM)     •  Diabe$c  pa$ent:   – ICU  vs  acute  medical/surgical  ward    
  • 5. Hyperglycemia  in  the   Hospital  SeTng  
  • 6. Hyperglycemia  Crisis   •  Any  BG  >  140  mg/dl   •  Severe  hyperglycemia  (BG  >  250  mg/dl)     •  DKA  (diabe$c  ketoacidocis)     – BG  >  300  mg/dl   – Primarily  Type  1,  also  uncontrolled  Type  2   •  HHS  (hyperosmolar  hyperglycemic  state)   –   BG  >  600  mg/dl   – Type  2   New England Journal of Medicine, 355; 18, November 2, 2006; Diabetes Care, volume 32, number 6, June 2009
  • 7. Hyperglycemia  Crisis   •  Stress  hyperglycemia     – Elevated  BG  due  to  stress  hormones     – Nondiagnosed  pa$ents  with  A1c  between  6.5  -­‐  7.0%   – Type  2   •  Uncontrolled,  hyperglycemia  results  in  increased  risk  of   poor  outcomes  in  hospital  seTng     •  Hyperglycemia,  can  have  significant  damaging  implica$ons   to  the  vascular,  hemodynamic  and  immune  systems   Diabetes Care, volume 32, number 6, June 2009
  • 8. Hyperglycemia  Crisis   •  Triggers  are  aaributed  to:   – Medical  stress  (acute  illness)   – Infec$on   – Medica$ons  (i.e.  glucocor$coids,  lactulose,  IVF  with   Dextrose)   – Supplementa$on  (i.e.  enteral  and  parenteral  nutri$on)   – Miscoordina$on  of  insulin  administra$on  with  meals   Diabetes Care, volume 32, number 6, June 2009
  • 9. Remote Approach: Glycemic Control Using Intensive Insulin Therapy •  Pros:   – Targe$ng  goals  near  normalized  levels     • (BG  80-­‐90  to  100-­‐120  mg/dl)   – Achieved  via  an  insulin  infusion  pump  (Regular)   • Allows  faster  $tra$on  and  more  reliable  absorp$on   than  subcutaneous  administra$on   – Recommended  for  cri$cally  ill  pa$ents     • ICU,  MICU,  Postopera$ve,  post  AMI,  etc.   – Decreased  mortality  and  complica$ons   New England Journal of Medicine, 355; 18, November 2, 2006; Diabetes Care, volume 32, Number6, June 2009.
  • 10. Remote Approach: Glycemic Control Using Intensive Insulin Therapy •  Cons:   – Limited  randomized  trials  with  inconsistent  findings     – No  reduc$on  of  mortality  in  cri$cally  ill  pa$ents     with  $ghter  glycemic  control   – Increases  risk  of  adverse  outcome  of  severe   hypoglycemia  (BG  <  40  mg/dl)   – Reports  of  increasing  mortality  resul$ng  from   intensive  insulin  glycemic  control   New England Journal of Medicine, 355; 18, November 2, 2006; Diabetes Care, volume 32, Number6, June 2009.
  • 11. 2011  Management  Approach     for  Glycemic  Control   •  In  the  hospital  seTng  insulin  therapy  is  the  preferred   method  for  achieving  glycemic  control.   – Cri$cally-­‐ill  pa$ent  (ICU)/severe  hyperglycemia  crises  (DKA/ HHS)   •  IV  insulin  infusion  pump  with  appropriate  adjustment   – Transi$oning  to  the  acute  ward,  convert  to  subcutaneous   insulin     •  (75-­‐80%  of  previous  total  daily  dose)   New England Journal of Medicine, 355; 18, November 2, 2006
  • 12. 2011  Management  Approach     for  Glycemic  Control   •  Acutely-­‐ill  pa$ent(MedSurg  ward)   – Subcutaneous  insulin  administra$on   • Components  50/50:  basal/nutri$onal  (prandial),  with   correc$onal  dosages  as  needed  (e.g.  hyperglycemic   spikes)   – General  goal  of  insulin  regimen  is  to  mimic  the  normal   physiologic  process  of  glucose  metaboliza$on  in  a   nondiabe$c   New England Journal of Medicine, 355; 18, November 2, 2006
  • 13. 2011  Management  Approach     for  Glycemic  Control   •  Insulin  dependent  diabe$c  pa$ent  (IDDM)   – NPO  pa$ent:     •  Basal  insulin,  with  Regular  insulin  administra$on  every  6  hrs  as   necessary   – Mandatory  in  Type  1     – Suggested  for  type  2   •  Generally  pa$ents  are  placed  on  a  long-­‐ac$ng  insulin  for  basal   control  with  a  faster  short-­‐ac$ng  insulin  (e.g.  lispro)  via  sliding   scale:  reduce  risk  of  overlap  and  hypoglycemia  with  Regular   insulin   New England Journal of Medicine, 355; 18, November 2, 2006
  • 14. 2011  Management  Approach     for  Glycemic  Control   – Pa$ent  ea$ng     •  Con$nue  home  regimen  if  previously  well-­‐controlled   •  If  BG  >  200  mg/dl  on  admission;  dosage  should  ojen  be   increased  or  change  to  a  basal-­‐prandial  regimen   •  Any  pa$ent  with  persistent  BG  300-­‐  400  mg/dl  w/o  DKA  or   HHS  not  responding  to  increases  in  subcutaneous   administra$on  more  than  24  hours  should  be  considered   for  intravenous  insulin  infusion     New England Journal of Medicine, 355; 18, November 2, 2006
  • 15. 2011  Management  Approach     for  Glycemic  Control   •  Pa$ents  on  supplemental  nutri$on:  Insulin     – Enteral  feeding  (i.e.  tube  feeds,  NGT)   •  Basal  insulin,  with  correc$onal  doses  of  Regular  insulin  every  6   hours  as  needed   – Parenteral  feeding  (i.e.  peripheral  or  central  IV   administra$on)   •  Regular  insulin  added  to  feeding  solu$on     •  Titrate  insulin  in  increments  5-­‐10  units/l  to  achieve  control   – Generally  managed  in  collabora$on  with  a  Nutri$onist   New England Journal of Medicine, 355; 18, November 2, 2006
  • 16. 2011  Management  Approach     for  Glycemic  Control   •  NIDDM     – Oral  glycemic  agents  have  limited  role     – Appropriate  for  the  medically  stable  pa$ent  with  expected   consump$on  of  regular  meals     – Ojen$mes,  pa$ents  on  Mekormin,  glyburide  are  withheld   secondary  to  higher  risk     •  Hypoglycemia     •  Renal  insufficiency   •  Increased  acidocis  if  radiocontrast  used  for  imaging   New England Journal of Medicine, 355; 18, November 2, 2006
  • 17. Recommended  Protocol   •  Upon  admission,  every  pa$ent  should  be  screened  for   Diabetes  Mellitus  (e.g.  basic  chemistry  panel)   – Any  pa$ent  with  A1c  6.5-­‐7.0%  will  be  monitored   – Any  pa$ent  with  A1c  >  7.0%  should  be  evaluated  at  discharge   for  op$mal  dosing  on  oral  glycemics  versus  insulin  ini$a$on   for  beaer  control  outpa$ent   •  All  hospitalized  pa$ents  with  evidence  of  severe   hyperglycemia  should  be  managed  per  an  insulin  protocol  if   feasible  but  with  precau$on   – More  precise  $tra$on,  quicker  and  reliable  absorp$on,  with   $ghter  glycemic  control   New England Journal of Medicine, 355; 18, November 2, 2006
  • 18. Recommended  Protocol   •  Cri$cal  Care  seTng   – On  infusion  pump,  monitor  BG  every  1  to  2  hours       •  Pa$ents  in  the  Acute  care  seTng   – managed  by  a  basal-­‐prandial  regimen,  resembling  the  natural   physiologic  paaerns  of  glucose  metaboliza$on   – Managed  per  subcutaneous  insulin  protocol:  monotherapy   with  long-­‐/intermediate  ac$ng  insulin,  combina$on  insulin,   solely  on  sliding  scale  (not  recommended)   – BG  monitoring  with  use  of  point  of  care  (POC)  before  meals   and  at  bed$me  (BG  every  4-­‐6  hrs  frequency)   New England Journal of Medicine, 355; 18, November 2, 2006
  • 19. Recommended  Protocol   •  In  general,  BG  target  goals:  140  mg/dl  and  180  mg/dl   – Avoid  target  goals  <110  mg/dl  for  safety  concerns   – Consider  higher  target  goals  for  medical  ward   •  Insulin  therapies  available:   – Basal  rate  control:   •  Long-­‐ac$ng:  Lantus(Glargine),  Levemir(Detemir)   •  Intermediate  ac$ng:  NPH   – Prandial  (blunt  postprandial  spikes  at  meal$me)   •  Using  sliding  scale:  premeal  vs  postmeal  coverage   •  Rapid-­‐ac$ng:  Lispro(Humalog),  Aspart(Novolog)     •  Short-­‐ac$ng:Regular  (Humulin/Novolin)   New England Journal of Medicine, 355; 18, November 2, 2006
  • 20. Recommended  Protocol   – Intermediate  and  short-­‐ac$ng  Combina$on     •  Humalog  75/25  or  Novolog  70/30  and  50/50  NPH/Regular     •  Sliding  scale   –  Usually  in  combina$on  with  a  basal  rate  insulin   –  Some$mes  used  as  monotherapy   –  Insulin  sensi$ve  pa$ents  (i.e.  Type  1,  lean  persons,  frail  elderly)  are   recommended  adjustment  via  1  unit  increment  scale   –  Pa$ents  with  severe  insulin  resistance  (i.e  morbidly  obese)  may   require  2  unit  increment  scale   –  Adjustments  are  based  on  postprandial  glycemia     New England Journal of Medicine, 355; 18, November 2, 2006
  • 21. Hypoglycemia  in  the   Hospital  SeTng  
  • 22. Hypoglycemia  Crisis   •  Any  BG  <  70  mg/dl   •  Severe  hypoglycemia:     – BG  <40  mg/dl     – Cogni$ve  impairment  begins  BG  <  50  mg/dl   – Ojen  associated  with  adrenergic,  cholinergic  and/or   neuroglycopenic  symptoms  (palpita$ons,  swea$ng,  and/or   AMS/obtunded/comatose)   •  Symptoms  and  physiologic  response  vary  among  pa$ents     – Higher  glycemic  thresholds  occur  in  sustained  hyperglycemia   (poorly  controlled  Diabe$c)   – Lower  glycemic  thresholds  occur  in  sustained  hypoglycemia   ($ghtly  controlled  or  insulinoma)   Diabetes Care, volume 32, Number6, June 2009; Lexicomp online, Harrison’s Practice, 2010
  • 23. Hypoglycemia  Crisis   •  Key  danger:  “hypoglycemia  unawareness”:  loss  of  the  warning   signs/symptoms  previously  allowed  pa$ent  to  recognize   impending    hypoglycemia  crisis     •  Whipple’s  triad  criteria:   – Symptoms  of  hypoglycemia  are  evident   – Low  plasma  concentra$on  of  glucose  via  a  precise   measurement  method   – Resolu$on  of  symptoms  with  increased  glucose  level     Diabetes Care, volume 32, Number6, June 2009; Lexicomp online, Harrison’s Practice, 2010
  • 24. Hypoglycemia  Crisis   •  Triggers  are  aaributed  to:     – Treatment  of  Diabetes  is  the  most  common  cause     – NPO  pa$ent/inadequate  nutri$onal  intake  while  on  insulin   – Postprandial  (reac$ve)  occurs  ajer  meals     – Cri$cal  illness,  infec$on,  Sepsis   – Medica$ons  (i.e.  oral  an$glycemic  agents,  sulfa-­‐based  (ie.   sulfa,  quinine,  quinolone  an$bio$cs,etc.)     – Pa$ents  with  lean  body  mass  (i.e.  elderly  pa$ents)     – Old  age   Diabetes Care, volume 32, Number6, June 2009; Lexicomp online, Harrison’s Practice, 2010
  • 25. Hypoglycemia  Crisis   •  Triggers  are  aaributed  to  (con$nued):   – Pa$ents  with  kidney  failure  or  liver  insufficiency   – Endocrine  deficiencies   – Ethanol  binge   – Insulinoma  (tumors)   Diabetes Care, volume 32, Number6, June 2009; Lexicomp online, Harrison’s Practice, 2010
  • 26. Hypoglycemia  Crisis   •  Type  1   – Average  2  symptoma$c  hypoglycemic  episodes  on  a  weekly   basis;  especially  when  $ghtly  controlled     – At  least  one  temporarily,  seriously  disabling  (i.e.   hospitaliza$on)  episode  per  year   – BG  may  decrease  to  <  50  mg/dl  before  symptoma$c   •  Type  2   – Less  frequent  hypoglycemic  episodes   – Especially  aaributed  to  those  treated  on  insulin  and   sulfonylureas   Diabetes Care, volume 32, Number6, June 2009; Lexicomp online, Harrison’s Practice, 2010
  • 27. Responding  to  an  acute  Hypoglycemic   crisis   •  Oral  Glucose  supplement  (if  possible)   – 20  gm  oral  tabs,  orange  juice  (4  o.z.),  soda  (  8o.z.);  2  Tbs   sugar/water  solu$on,  hard  candy  (no  chocolate)   – Parenteral  glucose   – Subcutaneous/intramuscular  Glucagon  injec$on  (especially   in  type  1)   – Intravenous  glucose  (1  ampule  D50  solu$on)   – Severe  symptoms  (obtunded/comatose):  Insulin  drip    (5%  or   10%  dextrose)  postadministra$on  of    SC/IM   •  Food  consump$on  ASAP  -­‐  replete  glycogen  stores   Lexicomp online, Harrison’s Practice, 2010
  • 28. 2011  Management  approach:   Hypoglycemia  Crisis   •  Test  BG  at  $me  of  hypoglycemic  symptoms   •  Draw  blood  before  administra$on  of  glucose     •  Determine  pa$ent’s  diabe$c  status  (i.e.  known,  type  1   or  2,  IDDM  vs  NIDDM,  home  regimen)     •  Determine  cause  of  hypoglycemic  event  (i.e.  triggers)   •  Assess  regimen  for  adjustment     Lexicomp online, Harrison’s Practice, 2010
  • 30. Outpa+ent  Transi+on  of  the   Hospitalized  Diabe+c  Pa+ent   •  Include  educa$on  and  establish  a  manageable  home   regimen   – All  literate  pa$ents  should  check  BG  TID/QID  and  keep  diary   of  daily  BGs     •  Establish  close  post  admission  follow-­‐up  for  pa$ents  if   treatment  was  ini$ated,  stopped  or  adjusted     – 1-­‐2  week  follow-­‐ups   – If  elevated  HgbA1c  then  1-­‐2  months  follow-­‐up   •  At  discharge,  pa$ents  on  insulin  regimen  may  need  to  be   simplified  for  home  management     New England Journal of Medicine, 355; 18, November 2, 2006
  • 31. Outpa+ent  Transi+on  of  the   Hospitalized  Diabe+c  Pa+ent   – Combina$on  therapy,  combina$on  long-­‐ac$ng  with  oral   meds/sliding  scale,  monotherapy,  etc.     •  Many  pa$ents  are  converted  to  oral  an$glycemic  agents,   ajer  stabiliza$on  with  insulin  during  inpa$ent     •  Ojen$mes  recommend  discon$nua$on  of  sulfonylurea   and  other  trigger  for  hypoglycemic     •  Newly-­‐diagnosed  pa$ents  with  modest  HgbA1c  are  ojen   first  recommended  lifestyle  modifica$on  with  medical   nutri$onal  therapy  MNT  with  close  monitoring  every  3   months  with  Renal,  Podiatry,  and  Opthalmology  follow-­‐up   New England Journal of Medicine, 355; 18, November 2, 2006