Hyperglycemia in Hospitalized Patients

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Robert J. Rushakoff, MD Professor of Medicine University of California, San Francisco robert.rushakoff@ucsf.edu Hyperglycemia in Hospitalized Patients Strategies For Implementing Change Nuts and electrical discharges

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Strategies For Implementing Inpatient Glycemic Control www.rushakoff.com www.endotext.com ucsfinpatientdiabetes. pbworks.com

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Diabetes as a Secondary Diagnosis What is inpatient diabetes mind?

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Inpatient Diabetes Goals Appropriate Glucose Control Based on physiology and result thinks about Inpatient Diabetes Goals Normal glucoses for everybody A high glucose implies disappointment Sliding Scales are banned Some hypoglycemia is satisfactory Inpatient Diabetes Goals Who Cares Just get tolerant home Sliding Scales are fine Avoid that alarming hypoglycemia

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Goals for Inpatient administration Evidence, assuming any, for expressed objectives Methods to Achieve Glucose Goals Insulin arrange shapes NPO Patients eating TPN and hyperalimentation Special Situations Glucocorticoids Implementation Cases Care of the Hospitalized Diabetic Patient

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Target Glucose Levels Alive

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Target Glucose Levels No DKA or Hyperosmolar Coma

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Quantifying the Impact of a Short-Interval Interruption of Insulin-Pump Infusion Sets on Glycemic Excursions Diabetes Care 31:238–239, 2008

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Target Glucose Levels Occasional hypo-and hyperglycemia

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Target Glucose Levels No hypo-or hyperglycemia Prevent liquid and electrolyte variations from the norm optional to osmotic diuresis Improve WBC work Improve gastric exhausting Decrease surgical difficulties Earlier clinic dischange Decreased post-MI mortality Decreased post-CABG bleakness and mortality

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Target Glucose Levels Normal Glucoses Decreased Morbidity and Mortality

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Problems With High Glucoses

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Increased Infections Early postoperative glucose control predicts nosocomial contaminations rate in diabetic patients Pomposelli et al: J Parenteral Ent Nut. 1998; 22:77-81 Relative hazard for "genuine" postop diseases expanded to 5.7 when glucose >220 mg/dl

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Increased Infections Relative Odds of Wound Infections 121-206 - 207-229 1.17 230-252 1.86 253-353 1.78 (p<0.05 for upward pattern) Perioperative Glycemic Control and the Risk of Infectious Complications in a Cohort of Adults with Diabetes Golden et al: Diabetes Care, 22:1408, 1999 411 diabetics who experienced CABG Leg and mid-section wounds, pneumonia and UTI

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Glucose and post-CABG dismalness and mortality Diabetes and Coronary Artery Bypass Surgery. An examination of perioperative glycemic control and results Diabetes Care 2003; 26:1518-1524 Retrospective Review of 291 patients surviving 24 h post operation 40% with retinopathy, nephropathy or neuropathy Inpatient Complications For every 1 mmol/l (18 mg/dl) increment in postop day 1 more than 6.1 mmol/l (110 mg/dl), a 17% expansion danger of entanglements

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HIGH BLOOD GLUCOSE LEVELS ASSOCIATED WITH INCREASED MORTALITY IN ICU Retrospective Review of 216,000 basically sick patients directed by the Veterans Affairs Inpatient Evaluation Center situated in Cincinnati Hyperglycemia was a free indicator of mortality beginning at 111 mg/dl. Impact was most prominent with intense myocardial dead tissue, precarious angina, and stroke heart assault - 1.6-5 time a stroke it raised hazard from 3.4 to 15.1 times temperamental angina it raised hazard from 1.7 to 6.2 times Falciglia et al: ADA Scientific Meetings, 2006, late breaking abstracts

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HIGH BLOOD GLUCOSE LEVELS ASSOCIATED WITH INCREASED MORTALITY IN ICU Retrospective Review of 216,000 fundamentally sick patients directed by the Veterans Affairs Inpatient Evaluation Center situated in Cincinnati A critical however weaker impact was found in patients with sepsis, pneumonia, and aspiratory embolism. Hyperglycemia was not observed to be connected with mortality in ailments, for example, COPD and hepatic disappointment . In diabetes patients, the expansion in mortality hazard was not seen until mean glucose was >146 mg/dl Falciglia et al: ADA Scientific Meetings, 2006, late breaking abstracts

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Hyperglycemia: an autonomous marker of in-healing facility mortality in patients with undiscovered diabetes Retrospective Review Hyperglycemia in 38% 26% known diabetes 12% no known diabetes Mortality New hyperglycemia 16% Known Diabetes 3% Nondiabetics 1.7% J. Clin Endocrinol. 2002;87:978-982.

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TPN: Adverse Outcomes Hyperglycemia Is Associated With Adverse Outcomes in Patients Receiving Total Parenteral Nutrition Cheung et al: Diabetes Care, 28:2367-2371, 2005 Risk of confusions in connection to mean every day blood glucose level

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Risk of Complications by glucose level quartile in the wake of changing for age, sex and nearness of previous diabetes Cheung et al: Diabetes Care, 28:2367-2371, 2005

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Intervention Studies

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Decreased post-CABG grimness and mortality Intensive Intervention by a Diabetes Team Diminishes Excess Hospital Mortality in Patients with diabetes who experience CABG Kalin et al. Diabetes Suppl. 47:A87 1998 Diabetes group took after patient Perioperative IV insulin mixture Algorithm based SQ premeal insulin Mortality amid CABG 1993-96 Relative hazard National 1.46 Beth Israel 1.02

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Decreased post-MI mortality Effects of insulin treatment on cause-particular one year mortality and grimness in diabetic patients with intense myocardial dead tissue. DIGAMI Study Group. Malmberg et al. Eur Heart J 1996 PeriMI IV insulin imbuement Algorithm based SQ premeal insulin for 1 year Mortality (%) 1 year 3.4 years Control 26 44 Insulin 19 33

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DIGAMI Design 620 patients MI inside 24 hours Previous known DM with glucose > 11 mmol/l (198 mg/dl) or glucose > 11 mmol/l without known DM Exclusion: (half of 1240 were rejected) To wiped out for agree Unable to oversee multidose insulin Usual intense CCU MI mind Treatment amass Infusion for >24 hours (until stable) , then 3 months numerous shots insulin J Am Coll Cardiol 1995;26:57-65

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DIGAMI2 (European Heart J. Prepublication Feb 2005) Group 1 – IV insulin then long haul SQ insulin Group 2 – IV insulin then standard treatment Group 3 – Standard treatment Mortality

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Decreased Infections Insulin imbuement enhances neutrophil work in diabetic heart surgery patients. Rassias AJ, Marrin CA, Arruda J, Whalen PK, Beach M, Yeager MP. Anesth Analg 1999; 88:1011-6. Perioperative IV insulin mixture Neutrophil phagocytic movement % benchmark Control 47 Insulin 75

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Decreased Infections Glucose control brings down the danger of twisted disease in diabetics after open heart operations Zerr et al: Ann Thoracic Surgery, 1997, 63:356-61 Furnary et al . Archives of Thoracic Surgery 1999, 67:352-60 Furnary et al . J Thoracic Cardiovascular Surgery 2003, 125: 1007-1021 Perioperative IV insulin implantation Protocol to keep up glucoses <200 Incidence of Deep Wound Infections (%) 1997 1999 Routine Control 2.4 2.0 "Tight" Control 1.5 0.8

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Decreased Infections Glucose control diminishes mortality in diabetics after open heart operations Furnary et al . J Thoracic Cardiovascular Surgery 2003, 125: 1007-1021 14.5 % 6.0 % 4.1 % 2.3 % 1.3 % 0.9 %

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Decreased Morbidity and Mortality Intensive Insulin Therapy in Critically Ill Patients. Van sanctum Berghe G, Wouters P, Weekers F, et al. N Engl J Med 2001; 345:1359-1367. Patients (all) on mechanical Ventilation in ICU Randomly alloted to IV insulin keeping up glucoses between 80-110 mg/dl or ordinary treatment (iv insulin if glucose >215 mg/dl then keep up glucose between 180-200.) % given Insulin 24 hour dosage AM glucose Intensive 99 71U 103 Conventional 39 33U 153

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Decreased Morbidity and Mortality 12 month mortality Intensive 4.6% Conventional 8.6% Main impact on patients in ICU >5 days Intensive Insulin Therapy in Critically Ill Patients. Van nook Berghe G, Wouters P, Weekers F, et al. N Engl J Med 2001; 345:1359-1367. Patients (all) on mechanical Ventilation in ICU Randomly appointed to IV insulin keeping up glucoses between 80-110 mg/dl or customary treatment (iv insulin if glucose >215 mg/dl then keep up glucose between 180-200.)

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Decreased Morbidity and Mortality Intensive Insulin Therapy in Critically Ill Patients. Van lair Berghe G, Wouters P, Weekers F, et al. N Engl J Med 2001; 345:1359-1367. Patients (all) on mechanical Ventilation in ICU Randomly doled out to IV insulin keeping up glucoses between 80-110 mg/dl or customary treatment (iv insulin if glucose >215 mg/dl then keep up glucose between 180-200.) Intensive Treatment lessened: In healing facility mortality 34% Sepsis 46% Need for dialysis 41% Number of transfusions 44%

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Decreased Morbidity and Mortality Post-operation got high dosage glucose - 200-300 g in 24 hours All grown-ups getting mechanical ventilation who were admitted to emergency unit had heart surgery 59 percent had experienced coronary sidestep surgery, 27 percent valve substitution, and 14 percent a joined system Randomly appointed to IV insulin keeping up glucoses between 80-110 mg/dl or ordinary treatment (iv insulin if glucose >215 mg/dl then keep up glucose between 180-200.) Whole glucose, so Plasma range would be: 90-123 mg/dl

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Intensive Intraoperative Insulin Therapy versus Conventional Glucose Management amid Cardiac Surgery Patients: Adults with and without diabetes who were experiencing on-pump cardiovascular surgery. Essential result : composite of death, sternal contaminations, delayed ventilation, heart arrhythmias, stroke, and renal disappointment inside 30 days after surgery. Optional result measures were length of remain in the emergency unit healing center. Interven

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