1. Management of Hyperglycemia and Diabetes in the Hospital: Case Studies
Bruce W. Bode, MD, FACE
Atlanta Diabetes Associates Atlanta, Georgia

2. Hyperglycemia in Hospitalized Patients
Hyperglycemia occurred in 38% of hospitalized patients
26% had known history of diabetes
12% had no history of diabetes
Newly discovered hyperglycemia was associated with:
Longer hospital stays
Higher admission rates to intensive care units
Less chance to be discharged to home (required more transitional or nursing home care)
Hyperglycemia in Patients With Undiagnosed Diabetes
New hyperglycemia was defined as an admission or in-hospital fasting glucose level of 126 mg/dL (7 mmol/L) or more or a random blood glucose level of 200 mg/dL (11.1 mmol/L) or more on 2 or more determinations. Hyperglycemia was present in 38% of patients admitted to the hospital, of whom 26% had a known history of diabetes, and 12% had no history of diabetes before admission.
Newly discovered hyperglycemia was associated with a higher in-hospital mortality rate (16%) compared with patients with a history of diabetes (3%) and patients with normoglycemia (1.7%; both P < 0.01).
In addition, new hyperglycemic patients had longer hospital stays and a higher admission rate to an intensive care unit, and were less likely to be discharged to home, frequently requiring transfer to a transitional care unit or nursing home facility.
The results indicate that in-hospital hyperglycemia is a common finding and represents an important marker of poor clinical outcome and mortality in patients with and without a history of diabetes. Patients with newly diagnosed hyperglycemia had a significantly higher mortality rate and a lower functional outcome than patients with a known history of diabetes or normoglycemia.
1. Umpierrez GE, Isaacs SD, Bazargan N, et al. Hyperglycemia: an independent marker of in-hospital mortality in patients with undiagnosed diabetes. J Clin Endocrinol Metab. 2002;87:
Umpierrez GE, et al. J Clin Endocrinol Metab. 2002;87:978–982.

3. Hyperglycemia Is an Independent Marker of Inpatient Mortality in Patients With Undiagnosed Diabetes
In-hospital Mortality Rate (%)
Hyperglycemia Is an Independent Marker of Inpatient Mortality in Patients
With Undiagnosed Diabetes
New hyperglycemia was defined as an admission or in-hospital fasting glucose level of 126 mg/dL (7 mmol/L) or more or a random blood glucose level of 200 mg/dL (11.1 mmol/L) or more on 2 or more determinations. Hyperglycemia was present in 38% of patients admitted to the hospital, of whom 26% had a known history of diabetes, and 12% had no history of diabetes before admission.
Newly discovered hyperglycemia was associated with a higher in-hospital mortality rate (16%) compared with patients with a history of diabetes (3%) and patients with normoglycemia (1.7%; both P < 0.01).
In addition, new hyperglycemic patients had longer hospital stays and a higher admission rate to an intensive care unit, and were less likely to be discharged to home, frequently requiring transfer to a transitional care unit or nursing home facility.
The results indicate that in-hospital hyperglycemia is a common finding and represents an important marker of poor clinical outcome and mortality in patients with and without a history of diabetes. Patients with newly diagnosed hyperglycemia had a significantly higher mortality rate and a lower functional outcome than patients with a known history of diabetes or normoglycemia.
1. Umpierrez GE, Isaacs SD, Bazargan N, et al. Hyperglycemia: an independent marker of in-hospital mortality in patients with undiagnosed diabetes. J Clin Endocrinol Metab. 2002;87:978–982.
Patients With Normoglycemia
Patients With History of Diabetes
Newly Discovered Hyperglycemia
Adapted from Umpierrez GE, et al. J Clin Endocrinol Metab. 2002;87:978–982.

4. Prevalence of Hyperglycemia in 181 Cardiac Patients Without Known Diabetes
Percentage of Population (n = 1181)
66% of AMI patients have IGT or previously undiagnosed T2DM on
75 g OGTT
(35% IGT; 31% DM)
Norhammar data demonstrates that 2/3rds of patients admitted to the hospital for an AMI are either hyperglycemic or have undiagnosed DM. Importantly, this does not appear to be stress hyperglycemia in most cases since there is very little change in the pravalence of these disorders when test are repeated 3 months after discharge
Abstract
BACKGROUND: Glycometabolic state at hospital admission is an important risk marker for long-term mortality in patients with acute myocardial infarction, whether or not they have known diabetes mellitus. Our aim was to ascertain the prevalence of impaired glucose metabolism in patients without diagnosed diabetes but with myocardial infarction, and to assess whether such abnormalities can be identified in the early course of a myocardial infarction. METHODS: We did a prospective study, in which we enrolled 181 consecutive patients admitted to the coronary care units of two hospitals in Sweden with acute myocardial infarction, no diagnosis of diabetes, and a blood glucose concentration of less than 11.1 mmol/L. We recorded glucose concentrations during the hospital stay, and did standardised oral glucose tolerance tests with 75 g of glucose at discharge and again 3 months later. FINDINGS: The mean age of our cohort was 63.5 years (SD 9) and the mean blood glucose concentration at admission was 6.5 mmol/L (1.4). The mean 2-h postload blood glucose concentration was 9.2 mmol/L (2.9) at hospital discharge, and 9.0 mmol/L (3.0) 3 months later. 58 of 164 (35%, 95% CI 28-43) and 58 of 144 (40%, 32-48) individuals had impaired glucose tolerance at discharge and after 3 months, respectively, and 51 of 164 (31%, 24-38) and 36 of 144 (25%, 18-32) had previously undiagnosed diabetes mellitus. Independent predictors of abnormal glucose tolerance at 3 months were concentrations of HbA(1c) at admission (p=0.024) and fasting blood glucose concentrations on day 4 (p=0.044). INTERPRETATION: Previously undiagnosed diabetes and impaired glucose tolerance are common in patients with an acute myocardial infarction. These abnormalities can be detected early in the postinfarction period. Our results suggest that fasting and postchallenge hyperglycaemia in the early phase of an acute myocardial infarction could be used as early markers of high-risk individuals.
Norhammar A. Lancet. 2002;359:

5. Hospital Costs Account for Majority of Total Costs of Diabetes
Per Capita Healthcare Expenditures (2002)
Hospital Costs Account for Majority of Total Costs of Diabetes
This chart provides a breakdown of the sources of expenditures related to the care of patients with diabetes. Inpatient days (43.9%), nursing home care (15.1%), and office visits (10.9%) constituted the major expenditure groups by service settings.
Hogan P, Dall T, Nikolov P. Economic costs of diabetes in the US in Diabetes Care ;26:917–932.
Diabetes
Without diabetes
Hogan P, et al. Diabetes Care. 2003;26:917–932.

6. Case 1: Patient With an Acute MI
53-year-old man with DM 2 on SU, metformin, and glitazone presents with an acute MI
BG random is 220 mg/dL
What do you recommend for glucose control?
Sliding-scale rapid analog?
Basal/bolus insulin therapy?
IV insulin drip?

7. Case 1: Patient With an Acute MI
What is your glycemic goal?
80 to 110 mg/dL
80 to 140 mg/dL
80 to 180 mg/dL

8. Glycemic Threshold in Acute MI and Intervention (PTCA)
DIGAMI supports BG <180 mg/dL
Minimal other data:
PTCA reflow better with BG 159 than 209 mg/dL
Malmberg K. BMJ. 1997;314:
Iwakura K, et al. J Am Coll Cardiol. 2003;41:1-7.

9. DIGAMI Study: Diabetes, Insulin Glucose Infusion in Acute Myocardial Infarction (1997)
Acute MI with BG >200 mg/dL
Control vs Intensive Insulin Treatment
Intensive Insulin Treatment
IV insulin for >24 hours followed by
4 insulin injections/day for >3 months
Malmberg K, et al. BMJ. 1997;314:

10. Cardiovascular Risk: Mortality After MI Reduced by Insulin Therapy in the DIGAMI Study
Standard treatment
IV insulin 48 hours, then 4 injections daily
All Subjects
Low-risk and Not Previously on Insulin .7 .7
(N=620)
(N=272) .6 .6
Risk reduction (28%)
Risk reduction (51%) .5
P=0.011 .5
P=0.0004 .4 .4 .3 .3
Slide 6-11
BARRIERS TO INSULIN THERAPY
Cardiovascular Risk
Mortality After MI Reduced by Insulin Therapy in the DIGAMI Study
Patients at high risk of cardiovascular disease are often thought to be inappropriate candidates for treatment with insulin because of the belief that hypoglycemia, hyperinsulinemia, or other metabolic effects of insulin might provoke or worsen the outcome of major cardiovascular events. This figure shows data from the Diabetes Mellitus Insulin-Glucose Infusion in Acute Myocardial Infarction (DIGAMI) trial. This Swedish trial studied the short- term and long-term effects of intensive insulin treatment of patients with diabetes who were enrolled in the trial at the time of a myocardial infarction. The subjects were immediately randomized to continued management according to the judgment of their physicians, or to intravenous infusion of insulin and glucose for 48 hours followed by a four-injection regimen subsequently for as long as 5 years. Other aspects of management of the infarction included treatment with b-blockers, angiotensin-converting enzyme inhibitors, fibrinolytic agents, and aspirin in high proportions of both groups. The rationale underlying the study was the old observation that, in animal experiments and studies of small numbers of humans, infarct size and outcome are improved by insulin- glucose infusion, in part because of suppression of otherwise elevated free fatty acid levels in plasma. The figure shows the cumulative total mortality rates in the whole population of 620 subjects randomized to the two treatments, as well as the rates for a predefined subgroup of subjects who were judged likely to survive the initial hospitalization and were not previously using insulin. The whole population showed an 11% actual and a 28% relative risk reduction with intensive insulin treatment after 5 years, and the subgroup showed a 15% actual and a 51% relative risk reduction. Most of the benefit was apparent in the first month of treatment and presumably was partly due to immediate intravenous infusion of insulin; however, the survival curves tended to separate further over time, suggesting an ongoing benefit from intensive treatment. This study suggests that insulin is an entirely appropriate treatment for patients with type 2 diabetes and high cardiovascular risk, especially at the time of myocardial infarction.
Malmberg K, Rydén L, Hamsten A, Herlitz J, Waldenström, Wedel H, and the DIGAMI study group. Effects of insulin treatment on cause-specific one-year mortality and morbidity in diabetic patients with acute myocardial infarction. Eur Heart J. 1996;17: ; Nattrass M. Managing diabetes after myocardial infarction: time for a more aggressive approach. BMJ. 1997;314:1497; Malmberg K, and the DIGAMI study group. Prospective randomized study of intensive insulin treatment on long term survival after acute myocardial infarction in patients with diabetes mellitus. BMJ ;314: .2 .2 .1 .1 1 2 3 4 5 1 2 3 4 5
Years of Follow-up
Years of Follow-up
Malmberg K, et al. BMJ. 1997;314:

11. Malmberg K et al DIGAMI 2. European Heart J 2005; 26 (650-61)
DIGAMI 2 Study
48 hospitals in 6 countries
3 groups:
Group 1: GIK for 24 hours followed by home insulin Rx (N = 474)
Group 2: GIK infusion followed by standard glucose control (N = 473)
Group 3: Routine metabolic management based on local practice (N = 306)
Patients and Methods
Malmberg K et al DIGAMI 2. European Heart J 2005; 26 (650-61)

12. Conclusion Overall mortality was lower than expected
Overall mortality similar to nondiabetic population
The 3 glucose management strategies did not result in differences of metabolic control
Target glucose levels not achieved in the intensively insulin treatment group
Conclusion

13. Overview of GIK Therapy for Acute MI: A 30­year Perspective
Odds Ratio and Cls
Year
Study
Mortality Rate (%)
GIK Better
Placebo Better
GIK
Control
O-E
Variance
Satler
0.0
1987
Rogers
6.5
12.3
-1.9
2.4
1983
Stanley
7.3
16.4
-2.5
2.8
1978
Heng
8.3
0.0
0.6
0.2
1977
Hjermann
10.6
20.0
-4.8
6.8
P = 0.07
1971
Pentecost
15.0
16.0
-0.5
6.5
1968
MRC
21.4
23.6
-5.1
41.5
1968
Overview of GIK Therapy for Acute MI: A 30-year Perspective
Glucose–insulin–potassium (GIK) therapy has been advocated for the treatment of acute myocardial infarction since the mid 1960s. However, the results from the clinical trials have been inconclusive, largely because of the small number of patients recruited and discrepancies between protocols used in these studies.
A systematic MEDLINE search for all the randomized placebo-controlled studies of GIK therapy in acute myocardial infarction was conducted (1966–1996), and a meta-analysis of the mortality data was performed. Fifteen trials were identified; 5 were excluded because of poor randomization, and one was excluded because recruitment was limited to patients with diabetes. The 9 remaining trials with a total of 1,932 patients were included in the analysis.
Hospital mortality was reduced from 21% (205 of 972 patients) in the placebo group to 16.1% (154 of 956) in the GIK group (P = 0.004; odds ratio, 0.72; 95% confidence interval [CI], 0.57 to 0.90). The proportional mortality reduction was 28% (CI, 10% to 43%). The number of lives saved per 1,000 patients treated was 49 (95% CI, 14 to 83). The findings indicate that GIK therapy may have an important role in reducing the in-hospital mortality after acute myocardial infarction.
1. Fath-Ordoubadi F, Beatt KJ. Glucose-insulin-potassium therapy for treatment of acute myocardial infarction: an overview of randomized placebo-controlled trials. Circulation. 1997;96:1152–1156.
Pilcher
13.9
29.3
-2.6
3.4
1967
Mittra
11.8
28.3
-7.0
6.8
P = 0.007
1965
All Patients
16.1
21.0
-24.0
70.4
P = 0.004 1
GIK = glucose–insulin–potassium; MI = myocardial infarction; CI = confidence interval.
Fath-Ordoubadi F, Beatt KJ. Circulation. 1997;96:1152–1156. Reprinted with permission (

14. CREATE-ECLA
Worldwide study with over 20,000 subjects with ST-elevation MI (STEMI)
GIK infusion vs Control
Outcome: 30 day CV events
Mehta, S et al: JAMA 293: , 2005

15. Baseline Glucose Associated with Mortality
JAMA 293:437, 2005
% mortality
Lowest Middle Highest
Glucose Tertile

16. Case 1: Patient With an Acute MI
For acute MI with elevated glucose, you can either give:
1. IV insulin variable drip or
2. GIK in type 2’s who are easily controlled or
3. ? Intensive SC delivery

17. Case 1: Patient With an Acute MI Now Plans to Go for CABG
What is your glycemic goal?
80 to 110 mg/dL
80 to 140 mg/dL
80 to 180 mg/dL

18. Mortality of DM Patients Undergoing CABG
Furnary AP, et al. J Thorac Cardiovasc Surg. 2003;123:

19. Glycemic Threshold in CABG
Portland data suggest BG:
<150 mg/dL for mortality
<175 mg/dL for infection
<125 mg/dL for atrial fibrillation
Furnary AP, et al. J Thorac Cardiovasc Surg. 2003;123:

20. Costs of Hyperglycemia in the Hospital
For each 50 mg/dL rise in glucose:
Length of Stay increases by 0.76 days
Hospital Charges increase by $2824
Hospital Costs increase by $1769
Furnary et al Am Thorac Surg 2003;75:1392-9

21. Surgical ICU Mortality Effect of Average BG
P=0.0009
BG>150
110<BG<150
P=0.026
BG<110
Van den Berghe G, et al. Crit Care Med. 2003;31:

22. Intensive Insulin Therapy in Critically Ill Patients—Morbidity and Mortality Benefits
Percent Reduction
Mortality
Sepsis
Dialysis
Polyneuropathy
Blood Transfusion
34%
46%
41%
44%
50%
Intensive Insulin Therapy in Critically Ill Patients—Morbidity and Mortality
Benefits
Intensive insulin therapy also reduced overall in-hospital mortality by 34 percent, bloodstream infections by 46 percent, acute renal failure requiring dialysis or hemofiltration by 41 percent, the median number of red-cell transfusions by 50 percent, and critical-illness polyneuropathy by 44 percent, and patients receiving intensive therapy were less likely to require prolonged mechanical ventilation and intensive care.
The benefit of intensive insulin therapy was attributable to its effect on mortality among patients who remained in the intensive care unit for more than five days (20.2 percent with conventional treatment, as compared with 10.6 percent with intensive insulin therapy, P = 0.005).
The greatest reduction in mortality involved deaths due to multiple-organ failure with a proven septic focus
van den Berghe G, Wouters P, Weekers F, et al. Intensive insulin therapy in the critically ill patients. N Engl J Med. 2001;345:1359–1367.
van den Berghe G, et al. N Engl J Med. 2001;345:1359–1367.

23. Target Blood Glucose 80–110 mg/dL ICU patients
80–140 mg/dL in other surgical and medical patients
70–100 mg/dL in pregnancy

24. Threshold Blood Glucose for Starting IV Insulin Infusion
Perioperative care > 140 mg/dL
Surgical ICU care > mg/dL*
Nonsurgical illness > mg/dL†
Pregnancy > 100 mg/dL
*Van den Berghe’s study supports 110 mg/dL; Finney’s study supports 145 mg/dL.
†If drip indication is failure of SQ therapy, use 180 mg/dL; if indication is specific condition (DM 1/ NPO, MI, etc ), use 140 mg/dL.

25. The Ideal IV Insulin Protocol
Easily ordered (signature only)
Effective (gets to goal quickly)
Safe (minimal risk of hypoglycemia)
Easily implemented
Able to be used hospital-wide

26. Essentials of a Good IV Insulin Algorithm
Easily implemented by nursing staff
Dilution of insulin per hospital policy (0.5 or 1U/cc)
Able to seek BG range via:
Hourly BG monitoring
Adjusts to the insulin sensitivity of the patient
Contains transition orders to SC insulin when stable

27. Practical Closed Loop Insulin Delivery
A System for the Maintenance of Overnight Euglycemia and the Calculation of Basal Insulin Requirements in Insulin-Dependent Diabetics
1/slope = Multiplier = 0.02 6 5 4
Insulin Rate (U/hr) 3 2 1
100
200
300
400
Glucose (mg/dL)
White NH, et al. Ann Intern Med. 1982;97:

28. Continuous Variable Rate IV Insulin Drip
Starting rate units/hour = (BG – 60) x 0.02 where BG is current blood glucose and is the multiplier
Check glucose every hour and adjust drip
Adjust multiplier to keep in desired glucose target range (80 to 110 mg/dL or to 140 mg/dL)

29. Continuous Variable Rate IV Insulin Drip
Adjust multiplier (initially 0.02) to obtain glucose in target range 80 to 110 mg/dL
If BG >110 mg/dL and not decreased by 15%, increase by 0.01
If BG <80 mg/dL, decrease by 0.01
If BG 80 to 110 mg/dL, no change in multiplier
If BG is <80 mg/dL, give D50 cc = (100 – BG) x 0.4
Give continuous rate of glucose in IVFs (do not feed meals on drip without bolus SC)
Once eating, continue drip till 2 hours post SQ insulin

30. Average and Standard Deviation of of All Runs
Glucommander
Average and Standard Deviation of of All Runs
1985 to 1998; runs, 120,618 BG’s
Davidson et al, Diabetes Care 28(10): , 2005

31. Typical Glucommander Run
Glucose
Glucose Hi
Low
Multiplier
Multiplier
Insulin
Insulin
Hours
Davidson et al, Diabetes Care 28(10): , 2005

32. Case 1: Patient With an Acute MI Now Post-CABG and Ready to Eat
Currently on IV insulin at ~2 units IV/hr
What do you now do?
Sliding scale rapid acting insulin only?
Basal/bolus insulin therapy?
Premixed insulin therapy?
Basal insulin?

33. Physiologic Serum Insulin Secretion Profile75
Breakfast
Lunch
Dinner 50
Plasma insulin (μU/mL) 25
4:00
8:00
12:00
16:00
20:00
24:00
4:00
8:00
Time

34. Plasma insulin (μU/mL)
Basal/Bolus Treatment Program With Rapid-acting and Long-acting Analogs 75
Breakfast
Lunch
Dinner
Aspart,
Lispro or
Glulisine
Aspart,
Lispro, or
Glulisine
Aspart,
Lispro, Or
Glulisine 50
Plasma insulin (μU/mL)
Glargine or
Detemir 25
4:00
8:00
12:00
16:00
20:00
24:00
4:00
8:00
Time

35. Converting to SC Insulin
If >0.5 U/hr IV insulin required with normal BG, start long-acting insulin (glargine)
Must start SC insulin at least 2 hours before stopping IV insulin
Some centers start long-acting insulin on initiation of IV insulin or the night before stopping the drip

36. Total Intravenous vs Subcutaneous 24-Hour Insulin Requirements (units)
IV Insulin Infusion Under Basal Conditions Correlates Well With Subsequent SC Insulin Requirement
Total Intravenous vs Subcutaneous 24-Hour Insulin Requirements (units)
Subcutaneous (units)
Intravenous
Units IV
Hawkins JB Jr, et al. Endocr Pract. 1995;1:

38. Converting to SC Insulin
Establish 24-hour insulin requirement
Extrapolate from average over last 4-8 hours, if stable
Give half the amount as basal
Give PC boluses based on CHO intake
Start at CHO/ins 1 CHO = 1.5 units rapid-acting insulin
Monitor AC TID, HS, and 3 AM
Correction bolus for all BG >140 mg/dL
(Bg-100)/(1700/daily insulin requirement)

39. Case 2: A Person on steroids with new hyperglycemia (BG ~225 mg/dl)
What is the best insulin treatment for this patient on steroids? (BG 150 to 300 mg/dL)
Sliding scale only with rapid-acting insulin?
IV insulin variable rate infusion?
NPH or 70/30 twice a day?
Basal Insulin once a day?
Bolus insulin premeal?
Basal Bolus insulin therapy?

40. Plasma insulin (μU/mL)
Basal/Bolus Treatment Program With Rapid-acting and Long-acting Analogs 75
Breakfast
Lunch
Dinner
Aspart,
Lispro or
Glulisine
Aspart,
Lispro, or
Glulisine
Aspart,
Lispro, Or
Glulisine 50
Plasma insulin (μU/mL)
Glargine or
Detemir 25
4:00
8:00
12:00
16:00
20:00
24:00
4:00
8:00
Time

41. How to Initiate MDI Starting dose = 0.5 x wt in kg
Basal dose (glargine) = 40% to 50% of starting dose given at bedtime or anytime
Bolus dose (aspart/lispro) = 15% to 20% of starting dose at each meal
Correction bolus = (BG - 100)/correction factor, where CF=1700/total daily dose

42. How to Initiate MDI Starting dose = 0.5 x wt in kg
Weight is 100 kg; 0.5 x 100 = 50 units
Basal dose (glargine) = 50% of starting dose at HS; 0.5 x 50 = 25 units at HS
Total bolus dose (aspart / lispro) = % of starting dose ÷ 3; x 50 = 25 ÷ 3 = 8 units AC (TID)
Correction bolus = (BG - 100)/ CF, where CF=1700/total daily dose; CF=30

43. Correction Bolus Formula
Current BG - Ideal BG
Glucose correction factor
Example:
Current BG: 250 mg/dL
Ideal BG: 100 mg/dL
Glucose correction factor: 30 mg/dL
250 –
= 5.0 units

45. Case 3: A Person With Diabetes on Tube Feedings
What is the best insulin treatment for a DM patient on tube feedings? (BG 150 to 300 mg/dL)
Sliding scale only with rapid-acting insulin?
IV insulin variable rate infusion?
NPH or 70/30 every 8 hours?
Glargine every 12 hours?
Regular insulin every 6 hours?

46. Case 3: A Person With Diabetes on Tube Feedings (cont’d)
What is the best insulin treatment for a DM patient on tube feedings? (BG 150 to 300 mg/dL)
If unstable, first give IV insulin and determine the requirement over 24 hours and then change to SC basal (glargine q12h) with supplemental rapid-acting every 4 to 6 hours
Can also use NPH q8h or regular q6h as the basal dose

47. Case 4: A Person With Diabetes on TPN
What is the best insulin treatment for a DM patient on TPN? (BG 150 to 300 mg/dL)
If unstable, first give IV insulin variable drip and determine the requirement over 24 hours and then add all the insulin to the TPN bag
Continue to supplement every 4 to 6 hours with SC rapid-acting insulin using BG – 100 / CF where CF is equal to 3000 divided by weight in kg. On average, CF = 30 to 40

48. Case 5: DM 1 Patient Going for Outpatient Surgery
What do you tell the patient to do?
Hold insulin
Take half their dose
Take their basal only with supplement if needed (>140 mg/dL)
Hold insulin and will start IV insulin

49. Case 6: DM 1 Patient in DKA (ph 7.0; BG 400 mg/dL: weight 80 kg)
What amount of fluids do you give immediately?
1 liter saline
2 liters saline
1 liter 0.45% saline
2 liters 0.45% saline

50. Case 6: DM 1 Patient in DKA (ph 7.0; BG 400 mg/dL: weight 80 kg)
Do you give NaCO3?
When do you start potassium and how much?
When do you start dextrose and how much?
My preference is 2 liters saline followed by D50.45 saline with 40 meq KCL/liter at mL/hr. Monitor electrolytes q4-8h

52. Case 7: Hypoglycemia
What is the preferred in hospital treatment of hypoglycemia?
Juice with sugar added
50% IV dextrose (1 amp or 50cc)
50% IV dextrose (1/2 amp or 25cc)
50% IV dextrose (based on glucose level)

53. Protocol for Insulin in Hospitalized Patient
Treatment of hypoglycemia
Any BG <80 mg/dL: D50 IV = (100 - BG) x 0.4
If eating, may use 15 gm of rapid CHO (prefer glucose tablets)
Do not hold insulin when BG normal

54. Hospital Diabetes Plan
What can we do for patients admitted to the hospital?
Protocols for all diabetes/hyperglycemic patients
Finger stick BG AC QID on all admissions
Check all steroid-treated patients
Diagnose diabetes
FBG >126 mg/dL
Any BG >200 mg/dL

55. Hospital Diabetes Plan (cont’d)
What can we do for patients admitted to the hospital?
Document diagnosis in chart
Hyperglycemia is diabetes until proven
Bring to all physicians’ attention
Note on problem list and face sheet
Check hemoglobin A1C
Hold metformin; Hold TZD with CHF, liver dysfunction
Start insulin in all hospitalized patients with BG >140 mg/dL

57. Hospital Diabetes Plan (cont’d)
Protocol for insulin in hospitalized patient
Treat any patient with BG >140 mg/dL with insulin
Treat any BG >140 mg/dL with rapid-acting insulin (BG-100) / (3000 / wt [kg]) or 1700 / total daily insulin
Treat any recurrent BG >180 mg/dL with IV insulin if failing SC therapy or >140 mg/dL if NPO, acute MI, perioperative, ICU, or >100 mg/dL if pregnant
If >0.5 U/h IV insulin required, start long-acting insulin

58. Hospital Diabetes Plan (cont’d)
Protocol for insulin in hospitalized patient
Daily total: Pre-admission or weight (kg) x 0.5 U
50% as glargine (basal)
50% as total rapid-acting insulin (bolus)
Give in proportion to meal’s CHO eaten
BG >140 mg/dL: (BG-100) / CF
CF = 1700 / total daily insulin or 3000 / wt (kg)
Do not use sliding scale as only diabetes management

59. Hospital Diabetes Plan (cont’d)
What can we do for patients admitted to the hospital?
Get diabetes education consult
Instruct patient in monitoring and recording
See that patient has meter on discharge
Decide on case-specific program for discharge
Arrange early follow-up with PCP

60. Questions
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