1. Hypoglycemia & Hyperglycemia Dave Joffe, BSPharm, CDE, FACA Part 4

2. May be associated with specific conditions in hospitalized patient populations: Renal failure Heart failure Infection Sepsis Decrease in glucocorticoid use Decreased oral intake or alteration in enteral or parenteral nutrition Hypoglycemia- in the hospital Clement S, Braithwaite SS, Magee MF, et al. Management of diabetes and hyperglycemia in hospitals. Diabetes Care. 2004;27:553-591. Campbell KB, Braithwaite SS. Hospital Management of Hyperglycemia. Clinical Diabetes. 2004;22:81-88.

3. Frequent blood glucose monitoring Glucose levels should be monitored hourly until levels are stable After stabilization of glucose levels, monitoring may be performed every 2-4 hours Adjustment of prandial insulin doses to account for alterations in oral intake Adjustment of basal and prandial insulin TDD during high dose glucocorticoid administration: 30% basal insulin and 70% prandial insulin Hypoglycemia Prevention Clement S, Braithwaite SS, Magee MF, et al. Management of diabetes and hyperglycemia in hospitals. Diabetes Care. 2004;27:553-591 Campbell KB, Braithwaite SS. Hospital Management of Hyperglycemia. Clinical Diabetes. 2004;22:81-88

4.  Patients Responsive: Administer oral carbohydrate. Recheck blood glucose in 15 minutes and if blood glucose > 70 administer meal 30 minutes after.  Patient NPO Responsive: Either establish IV access and administer 10-20g of 50% Dextrose OR administer 1g Glucagon IM. Recheck blood glucose every 15 minutes and administer carbohydrate again (PO or IV)if blood glucose is not greater then 70mg/dL.  Patient Nonresponsive: Establish IV access and administer 25g of 50% Dextrose OR administer 1g Glucagon IM. Check glucose in 15 minutes and if not > 70mg/dL then follow physicians orders. Hypoglycemia

5. Patient initiated on feeding tube at noon and her blood glucose was 418 Normal dose of insulin and at 2 pm her blood glucose was 453 Physician ordered 10 units of regular insulin to be given IV The nurse gave the 10 mL quantity of insulin to the patient, therefore giving 1,000 units of insulin at 3 pm Insulin Disaster

6. By 5:55 pm, the patients blood sugar was 102 and oxygen + tube feeding continued At 8:55 pm, blood glucose 78 and at 9:25 pm blood glucose 87 By 9:30 pm, the patient did not have an audible heart rate and was not breathing The patient died at 9:45 pm despite CPR Insulin Disaster

7. Develop a facility plan on how to treat hypoglycemia and insulin overdose based on amount of insulin given Education of staff on proper administration and potency of insulin Recognize different measurements and create standardization of ordering by using only one measurement, i.e. “units” Prevention of Error

8. Hyperglycemia: Pathophysiology Abnormal utilization of glucose in the body Resistance in tissues Not enough insulin present to get glucose into the cell Continuously high levels of glucose in the body lead to macrovascular & microvascular complications Excess glucose begins to spill over into urine When the brain is not able to utilize the glucose it begins converting fats into an energy source it can use Produces ketones Ketoacidosis is the buildup of ketones in the blood which can cause shortness of breath, nausea, vomiting, and very dry mouth.

9. Hyperglycemia: The Values Consistent levels >126 mg/dl indicate chronic hyperglycemia Patients educated to seek medical attention if glucose values are persistently above 240 mg/dl

10. Hyperglycemia: The Causes Diabetes Mellitus (most common cause) Critical illness Physical trauma, surgery, MI, stroke, ect. Physiological Stress Presence of infection or inflammation Via endogenous catecholamines