Insulin Titration for Hyperglycemia
Oleh:
dr. Bowo Pramono, SpPD-KEMD
Curriculum Vitae
Lahir • TEGAL 27-jan 1959
Istri: • dr. Astuti, SpS (K), 2 putri
Dokter Umum: • FK UGM 17-01-1985
SpPD : • FK UGM 24-11-1997
K-EMD : • 14-05-2008
• 1987-2002 PKM Kedung Waringin Bekasi
Pekerjaan: • 1999-2004 RSU Selong Lombok Timur
• 2004-2019 RS DR Sardjito/FK UGM
BUKU PANDUAN PEMBERIAN
INSULIN
Page 19 – 23 Page 59 – 66 Page 60 – 74
2007 2007 2005
2018
Hyperglycemia & Mortality
Hyperglycemia
Frequently in
crittically ill
patients (DM/non
DM): Stroke, AMI,
Cardiac surgery, Cause of
Marker of severity Increased hospital
Trauma, General increased
of illness mortality
Surgical, After mortality
Organ
Transplantation,
DKA/HHS, Septic
Shock etc.
Hospital Mortality Rate &
Mean Glucose Value
Mean (mg/dL) Mortality Rate (%) No of Patients
80 - 99 9,6 264
100 - 119 12,2 491
120 - 139 15,1 338
140 - 159 18,8 202
160 - 179 28,4 141
180 - 199 29,4 102
200 - 249 37,5 144
250 - 299 32,9 70
>300 42,5 40
1826 ICU patients in The Stamford Hospital from Oct 1st,1999 to
April 4th, 2002 (Krinsley, J.S., Mayo Clin Proc. 2003, 76:1471-78)
Stress & Insulin Resistance
Immune Phagocyte, neutrophil & monocyte
function dysfunction
Cardiovascular ↑infarct size, ↑ischemia
Thrombosis ↓fibrinolytic activation, ↑ PAI-1
↑brain ischemia neuronal
The Brain damageacidosis &lactate↑
Hyperglycemia & SystemInflammation IL-6, IL-18,TNF-↑
Endothelial ↓relaxant,antithrombotic,antioxidant
Induced ROS Stree oksidatif
generation
Intravenous insulin infusion VS S.C
DKA & HHS
Pre, intra & postoperative major surgery
Postoperative cardiac surgery
Organ transplantation
Indication for IMA or cardiogenic shock
i.v. insulin Stroke
therapy Corticosteroid therapy
Prolonged fasting (>12 hours) in type 2 DM
Total parenteral nutrition
Labor & delivery
Other illness requiring prompt glucose control
Edema anasarca
Stategy for known s.c. insulin doses in type 1&2 DM
Should be easy to order
Effective (achive goal glucose quickly)
Safe (to hypoglycemia & kalemia evaluated every 1 or 2 hour)
Intravenous Easy to follow
Insulin Protocol
Include to changes doses i.v.insulin & dextrose therapy to hypoglycemia
Easy to get or to used
Reached from price
Suggested Glucose Target Range
for I.V. Insulin infusion Therapy
PATIENT POPULATION GLUCOSE (mg/dL)
Critical ill Surgical Patient 80-110
Other surgical and non-surgical 90-140
patients
Women during labor and delivery 70-100
Bode et al., 2004
Goal BG: mg/dL (Usually 80-180, ICU patients 80-110)
Standard drip 100 units in 100 ml NaCl 0,9% via infus device or Syringe pump
Surgical patients who have OAD within 24 hr, should start when BG>120mg/dL,
Guideline for I.V. Other pts can start when BG>70mg/dL
Insulin Infusion Insulin infusion should be discontinued when patients is eating and has received 1 st
dose of subcutaneous insulin
I.v. fluids: Patients need 5-10 GM/hour
(D5%=100-200ml/hours)
• Start here for most pts
Algorithm 1
• For not controlled with Algr 1,
• If CABG, if organ transplant, islet cell transplant,
Initiating the Algorithm 2 Glucocorticoid Tx, or DM pts with >80 units/day
insulin
Infusion
• For not controlled with Algr 2,
Algorithm 3 • No pats start here without an authorization from the
endocrine service
• For not controlled with Algr 3
Algorithm 4 • No pats start here. Patients not controlled with the
above algorithm need an endocrine consult
Algorithm I.v. Insulin Infusion Therapy
Moving
Moving up: Moving down:
Algorithm to • An algorithm failure is defined • BG<70mg/dL x 2
Algorithm as BG outside the goal range
and the BG does not change
by at least 60mg/dL within 1
hour
Patients Monitoring
Check capillary BG every hour until is
within goal range for 4 hours
• Decrease to every 2- 4hours
• Stable may decreased to every 4 hours
Hourly monitoring
• For critically ill patiens if they have
stable BG
Treatment of Hypoglycemia (<60mg/dL)
Discontinued insulin drip AND
Give D40% i.v.: -pts awake 25ml -pts not awake 50ml
Recheck BG every 20 minutes and repeat 25 ml D40% i.v. if <60mg/dL
Restart drip if BG >70mg/dL x2 checks
Restart drip with lower algorithm (moving down)
Notify the Physician
For any BG change >100mg/dL 1hour
For BG >360mg/dL
For hypoglycemia wich has not resolved within 20
minutes of administering 50ml D40% i.v. and
discontinuing the insulin drip
Conversion i.v. s.c. insulin Tx
Volume resuscitation or pressor support can be discontinued & ready to
resume eating
S.C. insulin should be initiated at least 2 hour before discontinued i.v.
S.C. insulin: basal+nutritional insulin requirement include correction doses for
hyperglycemia
Insulin basal in the form long acting peakless analogue (ex:glargine)
Example i.v. s.c.
Patient has received average of 2U/hr during previous 6 hour
SC TDD= 80% of 24hr insulin
80% (2U/hr x 24)=38U
Basal dose= 50% TDD SC
50% x 38U= 19U
Bolus total dose of SCTDD= 50%(38U)
19U19U/3dd=6 U each meal (RI)
Premeal Correction Dose for Hyperglycemia
Conclusion
Hypoglycemia is emergencies and caracterized by Whipple Triad
Recovery of hypoglycemia by insulin contraregulator or glucose or dextrose
Degree of hyperglycemia was associated with hospital mortality
Acute hyperglycemia stress is an out- comes indicator of hospitalized patients
Increasing BG decreased immediately by insulin iv or sc
I.V. insulin drip is better than s.c. dose is easier to be controlled, hypoglycemia &
hypokalemia is milder than s.c. tightly monitored BG/1 hour
I.V. insulin infusion follow some algorithm to achieve BG target
DM tipe 1
1980
1980 2011
