BLOOD GLUCOSE CONTROL A learning module for Staff How to Use this Module • Use this module to educate staff on glucose control. • Sample slides have been prepared on identifying and managing patients with hyperglycemia. • You may copy and paste your facility order sets and add your own key points to match your policy and protocols. Blood Glucose Control Objectives 1. The importance of blood glucose control in surgical patients. 2. Understand the pathophysiology related to hyperglycemia and safety. 3. Educate staff to the policies, procedures, and protocols. Why is Blood Glucose Control so Important in the Perioperative Setting? Hyperglycemia vs No Hyperglycemia All Patients 16 14 12 10 8 6 4 2 0 30% of all hyperglycemic patients were not diabetic! All p<0.01 Normal Gluc>180 All Pts Bariatric Colectomy SCOAP data courtesy of Sung (Steve) Kwon Pathophysiology of Hyperglycemia RECEPTOR DEFECT GLUCOSE INCREASED GLUCOSE PRODUCTION INSULIN RESISTANCE DECREASED INSULIN PRODUCTION ‘Stress’ Hyperglycemia-What Happens? • Cytokines/inflammatory mediators contribute to: • Inability of immunoglobulin to bind with surface of invading bacteria so decreased bacteriocidal capacity. • Impaired platelet function 54% increased blood stream infections 59% increase acute renal failure requiring dialysis and 50% increase in blood transfusions. • Relative hypoinsulinemia contributes to: • • • • • Decreased insulin sensitivity. Unrestrained free fatty acids and hepatic fatty acids. Increased ketone bodies and metabolic acidosis. Impaired myocardial contractility and larger infarct sizes. Glycosuria induced osmotic diuresis and extracellular K+ shift. Berghe, 2001; Goldberg & Inzucchi, 2005 Adapted from Whitman, 2012 WSHA Webcast Resulting Complications of Hyperglycemia and Stress Hyperglycemia Decreased tissue perfusion Impaired metabolism Impaired cardiac function Pro-thrombotic state Pro-inflammatory state Decreased wound healing Braitwaithe, et al. 2008; Adapted from Inzucchi, Magee, & O’Malley, 2010 Image retrieved from: http://pennstatehershey.adam.com/content.aspx?productId=42&pid=42&gid=000254 Adapted from Whitman, 2012 WSHA Webcast Insulin (µU/mL) Physiologic Insulin Secretion: Basal/Bolus Concept 50 Nutritional Insulin 25 0 Basal Insulin Glucose (mg/dL) Breakfast Lunch 150 100 50 0 Suppresses Glucose Production Between Meals & Overnight Dinner Nutritional Glucose The 50/50 Rule Basal Glucose 7 8 9 10 11 12 1 2 3 4 5 6 7 8 9 A.M. P.M. Time of Day Adapted from Maynard & Wesorick, Society of Hospital Medicine, 2008 J. Whitman, Perioperative Glucose Control, Webcast 2012 Current Best Practices • Insulin infusion: • If NPO and unstable. • Basal insulin: • Covers the baseline insulin needs. • Essential for all type 1 diabetics to prevent ketosis. • In most cases should be given even if patient is NPO. • Nutritional insulin: • Covers increases in serum glucose after caloric intake. • Correctional insulin: • Additional to scheduled nutritional dose. Wisse, 2012 Adapted from Whitman, 2012 WSHA Webcast Oral Hypoglycemic Agents STOP BG (mg/dL) Why Not Sliding Scale? Insulin Insulin Insulin Target range Insulin Theoretical glucose levels with SSI Adapted from Whitman, 2012 WSHA Webcast Perioperative Blood Glucose Control Protocols and Standing Orders Perioperative Blood Glucose Control Protocol Insulin Pump Standing Orders SQ Insulin Standing Orders Pre-Operative Period • ALL patients with a blood glucose of 180mg/dl and greater. • Regardless of diabetes diagnosis or not. • NOT to be used on OB patients, 23 hour admits or those admitted with DKA or HHS (hyperglycemic crises) Review the protocol Intra-operative Glucose Control Period • Measure BG at induction and 1h into case. • Anesthesia associated with hyperglycemia even in non-diabetic subjects. • Measure BG every 1h in Type 1 DM patients. • Method of glycemic control intra-operatively. • IV insulin (DM1, critically ill, neurosurgery, TBI). • Basal insulin with bolus correction doses. • Some hospitals have placed glucometers on every anesthesia cart. Wisse, 2012 Post-Operative Period • Initiate for BG >140 mg/dL x2 or >180 mg/dL range • Goal range 110-180 mg/dL • Standard infusions are regular insulin 100ml/100 units on a dedicated line Post-Operative Period (cont) • Check BG every hour until at goal • Then decrease BG checks to every 2 hours • Hourly checks should always be resumed if patient falls outside of goal range Key Steps in Transitioning Off the Insulin Pump Suggested Criteria •BG range 90-140 mg/dL . •Stable insulin infusion rate. • Do know criteria for transitioning off insulin •Nutrition intake is current or anticipated. pump •Need last four hours of insulin drip data. • DO overlap SC and IV Insulin. Minimize hyperglycemia because of short ½ life of IV insulin. • DO use rapid analogs (Apidra) after meal if uncertain patient will eat. • DO expect basal and nutritional insulin if patient is eating. • DO ensure adequate food intake when switching patients with ketotic diabetes to SC insulin • DO arrange for follow-up post hospitalization even if insulin is temporary. Carlson, et al., 2006 Adapted from Whitman 2012 WSHA Webcast Transition Algorithm SKAGIT REGIONAL HEALTH SKAGIT VALLEY HOSPITAL SKAGIT REGIONAL CLINICS Attention Physician: All must be checked to initiate order Blood Glucose (BG) Goals: Pre-meal Goal - 90-150mg/dL or Goal Postprandial BG: HS Goal 90-180mg/dL or Blood Glucose (BG) Monitoring Frequency: Before meals & at bed time HgA1C Goal for BG @ 3 am 2 hours after meals or every 6 hours if NPO 2-3AM • If transitioning from IV insulin see Transition Protocols Basal Insulin: Give units of Glargine (Lantus) Post-Breakfast Nutritional Insulin Give units of Glulisine (Apidra) Post-Lunch Give units of Glulisine (Apidra) Post-Dinner Give units of Glulisine (Apidra) Bedtime Give units of Glulisine (Apidra) Correction Algorithm for Hyperglycemia: To be administered IN ADDITION TO the scheduled insulin dose to correct pre-meal BG. • Administer correctional insulin immediately post meal Low Medium High Individualized Algorithm • Give full dose if 50-100% of meal eaten • Give half dose if less than 50% of meal eaten • If BG check is every 6 hours for NPO patient, use the pre-meal Algorithm Insulin doses • Correction insulin type will be the same type as nutritional insulin MANDATORY BG CHECK AT 3AM IF BEDTIME CORRECTIONAL INSULIN GIVEN. IF 3AM BG > 150mg/d USE BEDTIME BG DOSING LOW DOSE ALGORITHM (For patients requiring less than 40 units insulin/day) Premeal BG Additional Insulin 150-199 1 unit 200-249 2 units 250-299 3 units 300-349 4 units greater than 349 5 units Additional Insulin Bedtime / 3am BG 150-199 None 200-249 1 units 2 units 250-299 3 units 300-349 4 units greater than 349 MEDIUM DOSE ALGORITHM (For patients requiring 40 to 80 units insulin/day) Premeal BG Additional Insulin 1 unit 150-199 200-249 3 units 250-299 5 units 300-349 7 units greater than 349 8 units Bedtime / 3am BG Additional Insulin 150-199 None 2 units 200-249 250-299 3 units 300-349 5 units greater than 349 7 units HIGH DOSE ALGORITHM (For patients requiring more than 80 units insulin/day) Premeal BG Additional Insulin 150-199 2 units 200-249 4 units 250-299 7 units 300-349 10 units greater than 350 12 units Bedtime / 3am BG Additional Insulin 150-199 None 200-249 2 units 250-299 5 units 300-349 7 units greater than 349 10 units INDIVIDUALIZED ALGORITHM (For patients requiring an individualized protocol) Premeal BG Additional Insulin 150-199 200-249 250-299 300-349 greater than 350 Bedtime / 3am BG Additional Insulin 150-199 200-249 250-299 300-349 greater than 349 Hypoglycemia Protocol for blood glucose less than 70mg/dL A. If pt can take PO, give 15 grams of fast-acting carbohydrate (120mL apple/orange juice, 240mL nonfat milk) B. If patient cannot take PO, give 25mL of D50 as IV push C. Check finger-stick glucose every 15-20 minutes until BG above 100mg/dL Date: Time: Provider Signature: ULIN SUBCUTANEOUS PROTOCOL • Transition any time of day. • Give basal insulin 2hrs prior to stopping IV insulin. • TDD of SC basal insulin = IV units insulin used last 4 hrs x 5. • Also give nutritional insulin if timing with a meal. INSULIN SUBCUTANEOUS PROTOCOL Signs and Symptoms of Hypoglycemia • Sweating • Anxiety • Confusion • Hunger • Dizziness • Tachycardia • Irritability • Shakiness • Trembling • Pallor • Headache • Weakness Hypoglycemia can occur without symptoms, so it is important to check blood glucose levels regularly. Adapted from Whitman, 2012 WSHA Webcast Treating Hypoglycemia: 3 Steps Give 15g of glucose or another fast-acting carbohydrate • • • • 4oz (1/2 cup) fruit juice 8 oz (1 cup) milk 1 Tbsp honey IV Dextrose Wait 15 mins Recheck BG – give another 15g if necessary * Assess for cause Goal to restore BG above 100 Avoid overtreatment (excessive amount of glucose), which may result in significant hyperglycemia over next 4-6 hrs. Adapted from Whitman, 2012 WSHA Webcast PATIENT CARE FLOW SHEET: Blood Glucose Section The section of this documentation form is appropriate for all nurses to review whether they are on Med/Surg, Telemetry, or Critical Care units. Documentation of blood glucose control issues include documenting the hyperglycemia and hypoglycemia as well as the treatment. Look closely at this section: Smooth Transition: Inpatient to Outpatient • If discharging patient new to insulin: • Make the decision as early as possible. • Teach, teach, teach. • Early follow-up a must. • Pens vs. vial/syringe. • If changing outpatient regimen significantly: • Communicate with PCP. • Document rationale. • Educate patient. Wisse, 2012, Adapted from Whitman 2012 WSHA webcast THE FINISH LINE!!! CONGRATULATIONS! You have finished the Surgical Glucose Control: Policies, Procedures, and Protocols Learning Module If you have any questions, please contact your Clinical Educator, your unit’s Diabetes Champion, or one of the Diabetes Educators.