Management of Hyperglycemia in the Noncritical Care Setting[高血糖的非关键保健环境管理](PPT-41)课件.ppt

1、12CDCP. Diabetes Data and Trends. Available at: http:/www.cdc.gov/diabetes/statistics/dmany/fig1.htm.196.4% From 1988 to 2009, the number of hospital discharges with diabetes as any-listed diagnosis increased from 2.8 million to nearly 5.5 million. 312 million BG readings from 653,359 ICU patients;

2、mean POC-BG: 167 mg/dL.Swanson CM, et al. Endocr Pract. 2011;17:853-861.4BG, blood glucose; POC, point of care.Moghissi ES, et al. Endocrine Pract. 2009;15:353-369.Umpierrez GE, et al. J Clin Endocrinol Metab. 2012;97:16-38.5No history of diabetesBG 140 mg/dLStart POCBG monitoring x 24-48 hCheck A1C

3、Initiate POC BG monitoring according to clinical statusHistory of diabetes BG monitoring A1C 6.5% BG, blood glucose; POC, point of care.Umpierrez GE, et al. J Clin Endocrinol Metab. 2012;97:16-38.Upon admissionAssess all patients for a history of diabetes Obtain laboratory blood glucose testing6Mogh

4、issi ES, et al. Endocrine Pract. 2009;15:353-369.Umpierrez GE, et al. J Clin Endocrinol Metab. 2012;97:16-38.7Saudek CD, et al. JAMA. 2006;295:1688-1697.ADA. Diabetes Care. 2013;36(suppl 1):S11-S66.89Hospital hyperglycemiaAny BG 140 mg/dLStress hyperglycemiaElevations in blood glucose levels that oc

5、cur in patients with no prior history of diabetes and A1C levels that are not significantly elevated (6.5%Suggestive of prior history of diabetesHypoglycemiaAny BG 70 mg/dLSevere hypoglycemiaAny BG 40 mg/dL10Moghissi ES, et al. Endocrine Pract. 2009;15:353-369.Umpierrez GE, et al. J Clin Endocrinol

6、Metab. 2012;97:16-38.1112BG, blood glucose; POC, point of care.Moghissi ES, et al. Endocrine Pract. 2009;15:353-369.Umpierrez GE, et al. J Clin Endocrinol Metab. 2012;97:16-38.1314Umpierrez GE, et al. J Clin Endocrinol Metab. 2012;97:16-38.15Capillary blood glucose(mg/dL)P=0.03CBG values 70 mg/dL we

7、re less frequent in patients receiving the consistent carbohydrate diet (0.4 vs 3.2%, P=0.06)Curll M, et al. Qual Safety Health Care. 2010;19:355-359.1617Antihyperglycemic TherapySC InsulinRecommended for most medical-surgical patientsOADs Not generally recommendedContinuous IV Infusion Selected med

8、ical-surgical patientsMoghissi ES, et al. Endocrine Pract. 2009;15:353-369.Umpierrez GE, et al. J Clin Endocrinol Metab. 2012;97:16-38.Smiley D, et al. J Hosp Med. 2010;5:212-217.18Umpierrez GE, et al. J Clin Endocrinol Metab. 2012;97:16-38.19Insulin therapy is the preferred approach20Basal insulinC

9、ontrols blood glucose in the fasting stateDetemir (Levemir), glargine (Lantus), NPHNutritional (prandial) insulinBlunts the rise in blood glucose following nutritional intake (meals, IV dextrose, enteral/parenteral nutrition)Rapid-acting: aspart (NovoLog), glulisine (Apidra), lispro (Humalog)Short-a

10、cting: regular (Humulin, Novolin)Correction insulinCorrects hyperglycemia due to mismatch of nutritional intake and/or illness-related factors and scheduled insulin administration21Obtain patient weight in kgCalculate total daily dose (TDD)as 0.2-0.4 units per kg/dayChoose the dosing scheduleGive 50

11、%-60% of TDD as basal insulinGive 40%-50% of TDD as nutritional insulinUse correction insulin for BG above goal range22Umpierrez GE, et al. Diabetes Care. 2007;30:2181-2186.2324InsulinOnsetPeakDurationNutritionalRapid-acting analog(aspart, glulisine, lispro)5-15 min1-2 hours4-6 hoursRegular30-60 min

12、2-3 hours6-10 hoursBasalDetemir2 hoursRelatively peakless16-24 hoursGlargine2-4 hoursRelatively peakless20-24 hoursNPH2-4 hours4-10 hours12-18 hoursHirsch I. N Engl J Med. 2005;352:174-183.Porcellati F, et al. Diabetes Care. 2007;30:2447-2552.Rapid (lispro, aspart, glulisine)HoursLong (glargine)Shor

13、t (regular)Intermediate (NPH)Long (detemir)InsulinLevel0 2 4 6 8 10 12 14 16 18 20 22 24Adapted from Hirsch I. N Engl J Med. 2005;352:174183. 25Umpierrez GE, et al. Diabetes Care. 2007;30:2181-2186.26240 220 200 180 160 140 120 100 Admit 1 2 3 4 5 6 7 8 9 10Days of TherapyBlood Glucose (mg/dL)*SSRIB

14、asal-bolusBlood Glucose (BG) Concentration Over Time for Both Groups* P0.01; P0.05.SSRI, sliding scale regular insulin.Umpierrez, et al. Diabetes Care. 2007;30:2181-2186.27Umpierrez GE, et al. Diabetes Care. 2007;30:2181-2186.28Days of TherapyBG, mg/dL100120140160180200220240Admit 1Sliding-scaleBasa

15、l-bolus2602803003345672421Rabbit 2 Trial: SSI Resulted in Uncontrolled Hyperglycemia in Some Patients Basal Bolus Group:BG 60 mg/dL: 3%BG 40 mg/dL: noneSSRI:BG 60 mg/dL: 3%BG 0.5 U/kg, glomerular filtration rate (GFR) 60 mL/second, insulin regimen (basal-bolus vs sliding scale insulin SSI), and prev

16、ious insulin therapy.Farrokhi F, et al. ADA Scientific Sessions. 2011. Abstr. 2060-PO.VariableP valueUnivariate AnalysisMultivariate Analysis*Age0.0010.001GFR 60 mL/s0.0050.11TDD 0.5 U/kg0.0060.31Previous insulin use 0.0010.02Insulin regimen(basal-bolus vs SSI)0.0010.00130Braithwaite SS, et al. Endo

17、cr Pract. 2004;10(suppl 2):89-99.31A formal inpatient insulin pump protocol reduces confusion and treatment variability32Noschese ML, et al. Endocr Pract. 2009;15:415-424.3334Bailon RM, et al. Endocr Pract. 2009;15:24-29.Noschese ML, et al. Endocr Pract. 2009;15:415-424.Patient AttestationI confirm

18、that I have been fully trained on the use of my insulin pump prior to this hospitalization.I am capable and willing to manage my insulin pump independently during my hospital stay.If at any time I feel that I am unable to manage the pump, I will alert my medical team.Requires patient and witness sig

19、nature35IDS, inpatient diabetes service; IPP, inpatient pump protocol.Noschese ML, et al. Endocr Pract. 2009;15:415-424.IDS + IPPIPPNo IDS/IPPN (% female)34 (32)12 (50)4 (75)Age481551163612LOS (days)9.815.45.26.231.5CSII use (days)5.47.13.22.931.5Mean CBG (mg/dL)173431876221846Patient days with1 CBG

20、 30022760Noschese ML, et al. Endocr Pract. 2009;15:415-424.36Prevalence of hyperglycemia and hypoglycemia ininpatients who continued (pump on) or discontinued(pump off) CSII during their hospital stay Bailon RM, et al. Endocr Pract. 2009;15:24-29.37Blood glucose (mg/dL)Pump On Pump Off Values per personBailon RM, et al. Endocr Pract. 2009;15:24-29.38Blood glucose (mg/dL)Pump On Pump Off Bailon RM, et al. Endocr Pract. 2009;15:24-29.394041