2. Management of diabetes mellitus in hospitalized patients
دکتر رضوان صالحی دوست
فوق تخصص غدد ومتابولیسم

3. آقای 60 ساله با وزن 70 کیلوگرم تحت درمان با گلیبن کلامید دوعدد و متفورمین سه عدد، به علت تب و تنگی نفس بستری شده است. با تشخیص پنونونی تحت درمان است. به علت احساس تهوع تمایل به غذا خوردن ندارد. HbA1C یک ماه گذشته او %11 است. پیشنهاد شما برای کنترل قند خون بیمار چیست؟

4. Patients who are hyperglycemic have an increased: Mortality rate
Both hyperglycemia and hypoglycemia in the patient with diabetes are associated with adverse outcomes, including death .
Patients who are hyperglycemic have an increased:
Mortality rate
Hospital length of stay
ICU length of stay
Incidence of nosocomial infection
Cardiovascular events
Endocrinol Metab Clin N Am 45 (2016) 875–894, Inpatient diabetes management in the Twenty-First Century

5. The stress of the illness or procedure
Glycemic control is likely to become unstable in patients with type 1 or type 2 diabetes mellitus after admission to a hospital because of:
The stress of the illness or procedure
The changes in dietary intake and physical activity
Management of diabetes mellitus in hospitalized patients. up todate

6. Glucose Target

7. Standard Definition of Glucose Abnormalities
Hyperglycemia in hospitalized patients is defined as blood glucose levels >140 mg/dL. An admission A1C value ≥6.5% suggests that diabetes preceded hospitalization.
Diabetes Care Volume 39, Supplement 1, January 2017

8. Considerations on Admission
In all patients with diabetes, hemoglobin A1c (A1C) should be checked on admission unless patients have a value within the past 3 months.
Diabetes Care Volume 39, Supplement 1, January 2017
Endocrinol Metab Clin N Am 45 (2016) 875–894, Inpatient diabetes management in the Twenty-First Century

9. Glucose target for noncritical ill patients
The ADA suggests a glucose target between 140 and 180 mg/dL for general hospitalized patients .The ADA has not stipulated any differences in target glucose values based on the timing of the measurements, such as preprandial versus postprandial. The Endocrine Society recommends premeal targets <140 mg/dL and "random" glucose levels <180 mg/dL.
Management of diabetes mellitus in hospitalized patients. up todate

10. Blood glucose monitoring
In the patient receiving nutrition, glucose monitoring should be performed before meals to match food ingestion. In the patient not receiving nutrition, glucose monitoring is advised every 4–6 h. for patients receiving intravenous insulin, more frequent blood glucose testing ranging from every 30 min to every 2 h is required.
Diabetes Care Volume 39, Supplement 1, January 2017

11. Insulin delivery
Basal-bolus regimen — insulin may be given subcutaneously with an intermediate-acting insulin, such as NPH, or a long-acting insulin, such as glargine or detemir, combined with premeal rapid or short-acting insulin.
Sliding-scale insulin — We do not endorse the routine use of sliding-scale insulin, particularly when prolonged over the course of a hospitalization.
Correction insulin — Varying doses of short-acting or rapid-acting insulin can be added to usual premeal short- or rapid-acting insulin in patients on basal-bolus regimens to correct premeal glucose excursions.
Insulin infusion
Management of diabetes mellitus in hospitalized patients. up todate

12. Oral Medications and GLP-1 Receptor Agonists
The most recent guidelines from the ADA, AACE, and Endocrine Society recommend against the inpatient use of oral antihyperglycemic medications or glucagonlike peptide-1 receptor agonists (GLP-1 RA) because of the lack of efficacy studies and because of safety issues.
Endocrinol Metab Clin N Am 45 (2016) 875–894, Inpatient diabetes management in the Twenty-First Century

13. Oral Medications and Glucagon Like Peptide-1 Receptor Agonists
Hospitalized patients may continue their oral medications and/or GLP-1 RA only if they meet all the criteria listed in Box 1. All other patients should be treated with insulin.
Endocrinol Metab Clin N Am 45 (2016) 875–894, Inpatient diabetes management in the Twenty-First Century

14. Endocrinol Metab Clin N Am 45 (2016) 875–894, Inpatient diabetes management in the Twenty-First Century

15. Oral Medications and Glucagon Like Peptide-1 Receptor Agonists
In patients:
who are well controlled on their outpatient regimen, and
who are eating, and
in whom no change in their medical condition, and
in whom no change nutritional intake is anticipated, and
new contraindications are neither present nor anticipated during the hospital admission
oral agents may be continued.
Management of diabetes mellitus in hospitalized patients. up todate

16. Insulin
The use of sliding-scale insulin alone without basal and bolus insulin is strongly discouraged (except in select cases).
Endocrinol Metab Clin N Am 45 (2016) 875–894, Inpatient diabetes management in the Twenty-First Century

18. Patients with type 1 diabetes
Basal metabolic needs utilize approximately one-half of an individual's insulin even in the absence of oral intake; thus, patients should continue with some insulin even when not eating.
This is mandatory in type 1 diabetes to prevent ketoacidosis.
Perioperative management of blood glucose in adults with diabetes mellitus.Uptodate

19. Insulin
Patients with established or newly diagnosed diabetes and a good nutrition plan should be started on long-acting basal insulin plus rapid-acting bolus insulin for meals and correction of hyperglycemia while in the hospital. Those who have poor nutritional intake or who are taking nothing by mouth should receive basal insulin along with corrective doses of rapid-acting insulin.
Endocrinol Metab Clin N Am 45 (2016) 875–894, Inpatient diabetes management in the Twenty-First Century

22. Insulin
If the calculated TDD is lower than what they were using at home, they should be started on their outpatient regimen with daily up-titration of their TDD based on BG response in the hospital.
Endocrinol Metab Clin N Am 45 (2016) 875–894, Inpatient diabetes management in the Twenty-First Century

23. Endocrinol Metab Clin N Am 45 (2016) 875–894, Inpatient diabetes management in the Twenty-First Century

24. Endocrinol Metab Clin N Am 45 (2016) 875–894, Inpatient diabetes management in the Twenty-First Century

25. Endocrinol Metab Clin N Am 45 (2016) 875–894, Inpatient diabetes management in the Twenty-First Century

27. Oral Medications and Glucagon Like Peptide-1 Receptor Agonists
It needs to be noted that if oral agents are held, the treating physician should have a plan to resume them 1 to 2 days before discharge to ensure their efficacy and safety.
Endocrinol Metab Clin N Am 45 (2016) 875–894, Inpatient diabetes management in the Twenty-First Century

28. آقای 60 ساله با وزن 70 کیلوگرم تحت درمان با گلیبن کلامید دوعدد و متفورمین سه عدد، به علت تب و تنگی نفس بستری شده است. با تشخیص پنونونی تحت درمان است. به علت احساس تهوع تمایل به غذا خوردن ندارد. HbA1C یک ماه گذشته او %11 است. پیشنهاد شما برای کنترل قند خون بیمار چیست؟

31. Glycemic control in critical ill patients
دکتر رضوان صالحی دوست
فوق تخصص غدد ومتابولیسم

32. Critical Care Setting
Hyperglycemia associated with critical illness (also called stress hyperglycemia or stress diabetes) is a consequence of many factors, including increased cortisol, catecholamines, glucagon, growth hormone, gluconeogenesis, and glycogenolysis. Insulin resistance may also be a contributing factor, since it has been demonstrated in more than 80 percent of critically ill patients. Hyperglycemia is associated with poor clinical outcomes in critically ill children and adults.
Diabetes Care Volume 39, Supplement 1, January 2016

33. Glucose target for critically ill patients
For the majority of critically ill patients, the American Diabetes Association and the American College of Endocrinology recommend a blood glucose target of 140 to 180 mg/dL and initiate insulin therapy for persistent hyperglycemia greater than 180 mg/dL.
Diabetes Care Volume 39, Supplement 1, January 2017

34. Critical Care Setting
In the critical care setting, continuous intravenous insulin infusion has been shown to be the best method for achieving glycemic targets.
Diabetes Care Volume 39, Supplement 1, January 2017

35. critical care setting
There is a lack of consensus on how to best deliver intravenous insulin infusions. Several published insulin infusion protocols appear to be both safe and effective, with low rates of hypoglycemia, although most have been validated only in the ICU setting, where the nurse-to-patient ratio is higher than on the general medical and surgical wards.
Management of diabetes mellitus in hospitalized patients. up todate

36. Insulin Infusion
Manual Calculation of Insulin Infusion Rate Starting rate for units / hour = (Current BG – 60) x 0.02 Example: Current BG is 360 mg/dl ( ) X 0.02 = 6 units/hour (6 ml/hour)
JOSLIN DIABETES CENTER GUIDELINE for INPATIENT MANAGEMENT OF SURGICAL and ICU PATIENTS with DIABETES

37. Insulin Infusion Example: after 1 hour ,
Adjust multiplier to keep in desired glucose target range ( mg/dl)
If BG mg/dl, no change in multiplier: (Current BG – 60) x 0.02
If BG > 180 mg/dl, increase multiplier by 0.01: (Current BG – 60) x 0.03
If BG mg/dl, decrease multiplier by 0.01: (Current BG – 60) x 0.01
If BG <100mg/dl, Stop insulin infusion
Example: after 1 hour ,
Current BG is 330 mg/dl ( ) X 0.03 = units/hour (8 ml/hour)
Current BG is 160 mg/dl ( ) X 0.02 = units/hour (2 ml/hour)
Current BG is 110 mg/dl ( ) X 0.01 = 0.5 units/hour (0.5 ml/hour)
Current BG is 75 mg/dl stop insulin infusion
JOSLIN DIABETES CENTER GUIDELINE for INPATIENT MANAGEMENT OF SURGICAL and ICU PATIENTS with DIABETES

38. Insulin Infusion Algorithm for Critically Ill

39. Intravenous regular insulin infusion
In the course of giving an intravenous regular insulin infusion, we recommend using about half the usual total daily dose of insulin, divided into hourly increments until the trend of blood glucose values is known, and then adjusting the dose accordingly.
Management of diabetes mellitus in hospitalized patients. up todate

41. Aim of the Fluid Infusion
Avoid hypoglycaemia by providing substrate at a steady rate for the insulin infusion
Maintain the fluid balance and electrolytes in the normal range
The use of variable rate intravenous insulin infusion (VRIII) in medical inpatients October 2014 JBDS 09

42. Choice of infusion fluid
The use of variable rate intravenous insulin infusion (VRIII) in medical inpatients October 2014 JBDS 09

43. Choice of infusion fluid
The use of variable rate intravenous insulin infusion (VRIII) in medical inpatients October 2014 JBDS 09

44. Transitioning Intravenous to Subcutaneous Insulin
When the patient receiving intravenous insulin is more stable and the intercurrent event has passed, the subcutaneous insulin regimen can be used.
The use of variable rate intravenous insulin infusion (VRIII) in medical inpatients October 2014 JBDS 09

45. Transitioning Intravenous to Subcutaneous Insulin
Because of the short half-life of intravenous regular insulin, the first dose of subcutaneous insulin must be given before discontinuation of the intravenous insulin infusion. If intermediate or long-acting insulin is used, it should be given two to three hours prior to discontinuation whereas short or rapid-acting insulin should be given one to two hours prior to stopping the infusion.
Management of diabetes mellitus in hospitalized patients. up todate

46. Calculating subcutaneous insulin dose
The options are:
Method A - weight based calculation
Method B - based on insulin requirements during the stable phase of the intravenous insulin infusion
The use of variable rate intravenous insulin infusion (VRIII) in medical inpatients October 2014 JBDS 09

47. Calculating subcutaneous insulin dose
Divide the total dose of insulin administered in last 6 hours of the intravenous insulin infusion by 6 to calculate average hourly dose of insulin. Multiply this by 20 (not 24, to reduce risk of hypoglycaemia) to estimate the patient’s total daily insulin requirement.
The use of variable rate intravenous insulin infusion (VRIII) in medical inpatients October 2014 JBDS 09

49. Glycemic Control in Patients Receiving Total Parenteral Nutrition

50. Total parenteral nutrition
In patients receiving TPN, insulin is typically administered with the nutrition. To determine the correct dose of insulin to add to the TPN fluid, a separate infusion of regular insulin can be used initially. When glucoses have reached goal, the total daily dose of regular insulin provided by the insulin drip is calculated; 80 percent of this amount is added to the TPN fluid as regular insulin. The amount of insulin can be titrated based upon glucose monitoring.
Management of diabetes mellitus in hospitalized patients. up todate

51. If TPN is interrupted  
Because of the potential for inadvertent discontinuation of insulin therapy if TPN is interrupted, many clinicians recommend giving some of the basal insulin as an injection (eg, 50 percent) in patients with type 1 diabetes.
Management of diabetes mellitus in hospitalized patients. up todate

52. Total parenteral nutrition
Endocrinol Metab Clin N Am 45 (2016) 875–894, Inpatient diabetes management in the Twenty-First Century

53. Glycemic control in patients receiving enteral feeds

54. Bolus Enteral Feedings
Diabetes Care Volume 39, Supplement 1, January 2017

55. Enteral Feedings
If the enteral feeds (continuous or bolus) are unexpectedly discontinued, an intravenous 10 percent dextrose solution, providing a similar number of carbohydrate calories as was being administered via the enteral feeds, should be infused in order to prevent hypoglycemia.
Management of diabetes mellitus in hospitalized patients. up todate