Diabetes affects 25.

8 million people of all ages

•8.3% of the U.S. population
–Diagnosed: 18.8 million
–Undiagnosed: 7.0 million
•Leading cause of kidney failure, nontraumatic lower-limb amputation, new cases of blindness among
adults
•Major cause of heart disease and stroke
•Seventh leading cause of death
56 y/o male PMH HTN, HL, DM2 (A1c 9%) presenting for CABG
Home Meds: Metformin 1000mg BID, Glipizide XL 10 mg daily, Atorvastatin 20mg daily, Lisinopril 40mg
daily
What would you do for glycemic control in the perioperative period?

Furnary AP et al. (Ann Thorac Surg 1999;67:352-62 & J Thorac Cardiovasc Surg 2003;125:1007-21):
Portland Diabetic Project

3554 diabetics undergoing coronary artery bypass grafting, were treated with either subcutaneous
insulin (SI) or continuous insulin infusion (CII) in the perioperative period
BG goal was 100-150 mg/dL
BG control was significantly better with insulin infusion (average of 177 mg/dL vs 213 mg/dL with SI)
Better BG control was significantly associated with a decrease in the proportion of patients with deep
wound infections
Mortality was significantly lower in the CII group, and was lowest in patients with average postoperative
BG < 150 mg/dL

After starting the insulin gtt, what is your target BG range for this patient?
NICE SUGAR
NEJM 2009;360-1283-1297
•6104 patients (medical and surgical) assigned to intensive therapy (BG 81-108) or conventional therapy
(BG less than 180)
•Average BG 115 vs 144
•At 90 days, higher mortality in intensive therapy group
•No difference between surgical or medical patients
•Severe hypoglycemia: 6.8% vs 0.5%
Goals of Glycemic Control in the Inpatient Setting: ADA/AACE CONSENSUS
Avoidance of a certain level of hyperglycemia (BG above 180) above which IV insulin should be started
•Goal is BG of 140-180
•Avoidance of BGs less than 110 as target
•Avoidance of hypoglycemia (< 70), especially severe hypoglycemia (< 54)
65 y/o (or 16 y/o) male with no known PMH presenting with CAP/ or s/p trauma and newly diagnosed
hyperglycemia with BS in the 300s on presentation (no DKA/HHNK). Insulin gtt was initiated and 36
hours later, BS are <200 and you would like to stop the insulin gtt. He is currently requiring >2 units/hr.
A1c was ordered at admission (correctly so, given no prior A1c in the last 2-3 months) and is 12.3.
For his diabetes care, you…
A. Stop his insulin gtt and order moderate-dose SSI
B. Calculate his drip requirements over the last 6-8 hours with stable BS and give 80% of that total
daily dose divided in half basal/half mealtime doses with overlap with gtt
C. Start metformin 1000mg BID and SSI
 D. Call an endocrine consult
Transitioning from Insulin Gtt
Should occur when patient is stable, able to eat and preferably in the morning
An overlap between infusion and SQ insulin MUST be done is T1DM and is preferred in T2DM, duration
of the overlap depends on the onset of action of the SQ insulin
When converting, 24-hr requirements are based on insulin infusion- avg rate over last 6-8 hours if stable
range and take 80% of the total 24-hr requirement
If premixed, 2/3 in the AM, 1/3 in PM
If basal/mealtime insulin, basal 50%, mealtime 50% split over three meals
If insulin infusion is less than 2U/hr in DM2, previously well-controlled on oral agents, okay to switch
back to oral agents pending their other clinical issues plus SSI
Rabbit 2 Trial

16 y/o male with Type 1DM on insulin pump therapy presents with acute appendicitis going to the OR
Or
28 y/o female with Type 1 DM on insulin pump therapy G1P0 presenting to L&D at 37 weeks in
spontaneous labor
With regards to diabetes care, you should…
A. Continue the insulin pump on presentation
B. Stop the insulin pump and initiate an insulin gtt
C. Stop the insulin pump and initiate SSI
D. Wait, what is an insulin pump?
Typically, most guidelines recommend insulin gtt perioperatively with suspension of the insulin pump
•If the patient has mental and physical capacity to use pump, okay to continue, otherwise, initiate
insulin gtt
•Note- not all bariatric surgery patients have T2DM- if T1DM; will require insulin gtt
•Most hospitals consult endocrine for insulin pump patients
•Most patients should be transitioned back to pump, unless clinical status at discharge inhibits them
from being able to work their pump
57 y/o male with HTN, HL, DM2 presenting with severe flank pain with radiation to the groin currently
on Metformin 1000mg BID at home with current BS of 156
Or
61 y/o female with HTN, HL, DM2 presenting with acute onset SOB and cough on Glipizide XL 2.5mg
daily at home with current BS of 156
What would you like to continue for treatment of diabetes?
Continue all home antihyperglycemic medications
Continue all home antihyperglycemic medications and start SSI
Hold all home antihyperglycemic medications and start SSI
Initiate insulin gtt
•Typically inappropriate; preferred either SQ insulin or insulin gtt (critically ill)
•Oral agents; however, can be continued in stable patients with normal nutritional intake, normal blood
glucose levels, and stable renal and cardiac function (inpatient psych would be a good example)
•Disadvantages of oral agents:
• MFM: lactic acidosis can occur in setting of renal dysfunction, circulatory compromise, CHF
exacerbation, IV contrast. Also, GI intolerance- nausea/diarrhea.
• Insulin secretagogues (SUs/ repaglinide): hypoglycemia with reduced caloric intake
• TZDs: can worsen fluid retention/ increase risk of CHF
• GLP-1 agonists: can potential exacerbate any experienced GI sxs during hospitalization
◦ *If patient requires insulin inpatient- 0.3 U/kg/d in elderly/renal failure, 0.4 U/ kg/d with BS 140-
200, 0.5 U/kg/d with BS 201-400
54 y/o female with HTN, HL, DM2 (A1c 6.8%- MFM 500mg BID) presenting with chest pain scheduled for
cardiac catheterization the following day currently ordered for SSI (lispro AC)
or
54 y/o female with HTN, HL, DM2 (A1c 6.8%- MFM 500mg BID) scheduled for TAH the following day, but
being admitted the night before
What are you ordering for her diabetes care?
A. Continue metformin and SSI as ordered
B. Continue metformin and at MN when pt NPO, SSI change to q6hr regular
C. Hold metformin and continue SSI as ordered
D. Hold metformin and at MN when pt NPO, change SSI to q6hr (regular insulin)
What if this patient is on 20 units of lantus nightly and metformin 1000mg BID?
The night before surgery, the diabetes regimen should be adjusted as follows:

A. Hold the metformin and continue the lantus 20 units at night and start SSI q6hr
B. Hold the lantus and continue the metformin and start SSI q6hr
C. Decrease the lantus by 50% at night, hold the metformin and start SSI q6hr
D. No changes in current regimen
64 y/o female PMH sig for HTN, HL, ESRD s/p renal transplant POD0 starting on high dose steroids
without history of hyperglycemia
or
42 y/o male with severe IBD being initiated on TPN without history of hyperglycemia
What should you consider ordering at this time?
A. Low-dose SSI
B. POC accuchecks for 24-48 hrs post- initiation steroids/TPN
C. Insulin gtt
Metformin 500mg BID
Management of Hyperglycemia in Hospitalized Patients in Non-Critical Care Setting:
Non-DM patient being started on hyperglycemia-inducing therapies (steroids, octreotide, TPN), POC
accuchecks 24-48 hrs post-initiation; if BS >140, cont POC testing
•If pt hyperglycemic on glucocorticoid therapy, initiate insulin therapy
Pager goes off overnight. Nurse calling regarding your alert, able to eat/drink diabetic patient- most
recent accucheck 55.
How do you treat the low BS?
A. Give 1amp of D50
B. Give 1mg IM glucagon
C. Go back to sleep
Give 15g of rapid-acting CHO
• Most hospitals have protocols, but not all.
 • Per Endo Society guidelines, Nurse-initiated strategies:
• BS <70 in pt who is alert, able to eat/drink- give 15g of rapid-acting CHO: 1 (15-30g) tube
glucose gel, 4 (4g) glucose tabs, 4 oz juice, 6 oz regular soda
• BS <70 alert/awake pt, NPO or unable to swallow: 1mg glucagon SQ/IM or 1/2Amp D50
(12.5 g)
• BS<70 w/ altered consciousness, 1/2amp D50
• Altered consciousness with no IV access, glucagon 1mg IM
• **in all above, check BS q15 min until BS >80 or >100 on insulin gtt
• NOTE: glucagon may cause nausea/vomiting. Turn pt on side following administration.
*TF patients on standing insulin- hold TFs, need dextrose in IVF to prevent lows.
Can apply to all- newly requiring insulin patient being sent home, never used insulin prior and had no
meter. SW provided meter on this admission.
Besides prescribing insulin, what else do you need to prescribe for this patient?