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Tight Glycemic Control Avoiding Alpine Sugars

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					Tight Glycemic Control:
   How Sweet It Is!
   Virginia Point of Care
       Coordinators
       April 22, 2005
             Disclosures

• State faculty for the Surgical Infection
  Prevention Initiative
• No financial or other conflicts of
  interest
  – Claudette Dalton, M.D.
         ―What, me worry?‖
• Surgical Infection Prevention Initiative
  (SIP) /Surgical Care Improvement Project
  (SCIP)
• Literature
• JCAHO/ CMS/ ACS/ ASA/ ICU/ POC/
  NQF/ IOM/ QI/ PI/ VHQC
• ICU standard of care
• ? General standard of care
    Core Knowledge Needed
• Impact on outcomes
• Target BGs/Protocols
• Difference between insulins and how they
  are given
• How/when to test consistently
• Treatment and prevention of hypoglycemia
• Documentation pathways
• Terms and definitions
                   Definitions
• Hyperglycemia is a blood sugar over 110 in a
  fasting patient and over 125 in a patient who has
  eaten.
• Hypoglycemia—40-70 mg/Dl
• Point of care testing
  – Immediate results that alter management
• Diabetes mellitus
  – Types I and II, gestational
• Hyperglycemia
  – Steroids
  – Stress
  – Other meds
     Conditions that Predispose to
             Hypoglycemia
• Advanced age              • Lack of coordination with
• Decreased oral intake       transportation and floor
• Chronic renal failure     • Knowledge deficits by
                              providers
• Liver disease
                            • Unreadable, unusual or
• Use of Beta blockers        convoluted orders
• Mistiming of meals in     • Difficult to follow
  relationship to insulin     protocols
  dosing
                            • Physician insisting on
• Infrequent or missed        different protocol
  monitoring
         What is the evidence?
• Risk of microvascular complications
    – Renal and retinal disease
    – Diabetes Control and Complications Trial
• Risk of macrovascular complications
    – CAD and stroke
    – Capes SE. Stroke 2001; 32:2427
    – DIGAMI and Malmberg K. Circulation. 1999. 99:2626-
      2632
•   Risk of mortality
•   Risk of infections
•   Cost of care
•   ACE and AACE recommendations
      Unanswered Questions
• What is ―optimal control‖?
• How long does the patient need to be in
  good control?
• Can we take ―tight control‖ too far?
• What is the role of lipids in glucose
  control?
• Do we need to aggressively treat other
  medical conditions at the same time?
      The Role of Blood Sugar in
              Infections
• Poor wound healing in general/many already
  colonized
• Deoxyglucose inhibits glycolytic metabolism which
  generates energy for superoxide production
• No absolute Km identified but glucose level
  proportional to neutrophil activity
• Granulocyte functions—improve when glucose
  control is good—i.e. <200mg/dL
  –   Adherence
  –   Delays chemotaxis
  –   Impairs phagocytosis
  –   Decreased bacteriocidal activity
Other DM Complications in Surgery
• Cellular immunity
  – Decreased complement fixation
• Collagen—increased collagenase activity
• Role of microvascular damage
• 34% of insulin dependent diabetics are
  colonized with s. aureus
• Cardiac cellular function
            Vanderbilt Study
 Latham R. et.al. Infact Control Hosp Epidemiol.
               2001; 22:607-612

• Prospective, 1044 CABG and valve ops
• 6% had undiagnosed diabetes
• SSI pts.—62% of known diabetics had
  hyperglycemia/37% of non-DM patients
• Dx of DM associated with 2.7X risk for SSI
• Rate of SSIs correlated with degree of
  hyperglycemia
• Hyperglycemia during periop is independent risk
  factor
           Vanderbilt, con’t
• Similar to other studies, 6% were
  undiagnosed diabetics
• 19% in this study had abnormal HgbA1c
  and another 11% had glucose >200
• But Hgb A1c did not correlate with SSIs
• Still, suggest that screening with HgbA1c
  for diagnosis of DM is cost effective if
  therapy is initiated
 Perioperative Glucose Control
• 1,000 cardiothoracic surgery patients
• Diabetics and non-diabetics with hyperglycemia




 Patients with a blood sugar > 300 mg/dL during or within 48 hours of surgery
 had more than 3X the likelihood of a wound infection!
 Latham R, et al. Infect Control Hosp Epidemiol. 2001.
        What factor makes the
             difference?
• Patients may be undiagnosed (4.2%--or higher!)
• Most infections when glucose level is >200 mg/dL
• Risk same if glucose high anytime in first 48
  hours
• Hyperglycemia doubles risk—2—2.7X
   – 20mg/Dl increase = 30% increase risk of death
• May directly affect cardiac cellular function
• Can be stress or medication induced
   – Capes SE. Lancet. 2000. 773-778 and Clement S.
     Diabetes Care. 2004. 27:553-591
 Ain’t No Mountain High Enough…
• Enormous percentage of our patients are
  diabetic
• Another percentage are undiagnosed or
  hyperglycemic from other causes
• Adding nutrition and crisis management
• Source of blood
• Timing of testing
• Tests used
    Ain’t no Valley Low Enough…
• Hypoglycemia is a blood glucose of 40-70
• Institution dependent
• Cause seizures, brain death if too low
• Anesthesia and sedation block usual
  symptoms
• Blood source
• Timing of testing
• Tests used
Is There a River Wide Enough?
• Who is the crew and who is the coxswain?
• Untraditional looking crew
    – Nutritionist, Pharmacist, QI/PI, managers
    – Lab, nurses, doctors, educators
• Constant educational needs
• Policies
• Which protocol?
• Point of care testing and decision making
• Patients go through multiple units while in the
  hospital—transitions are trouble points
• Costs/equipment
          Protocol, protocol, who has a
                    protocol?
• Portland, van den Berghe, Yale, home-grown?
• Elements to look for
    –   While NPO, when feeding, when crisis
    –   Timing of doses/testing
    –   Subcu vs IV—continuous (CII) vs. bolus
    –   Different protocol for night shift, for sicker patients, for iconoclastic
        docs?
•   Start higher to avoid going lower—how low is too low?
•   How many get hypoglycemic on each protocol?
•   KISS –or not?
•   Education, re-education and more education
•   Requires an IV for most of the protocols
              UVA Protocol
• ICU generated
• 95 is ICU target, <175 is SIP target, 125-175 is
  general floor target
• No subcu
• Tests q 1h till stable X 2, then q 2h
• Hypoglycemia at 80 mg/Dl--!!! This is very
  unusual
• Capillary unless needs checking, then venous—
  not sure why we do not use arterial in ICU
 UVA SIP Glucose Compliance
70

60

50

40
                                                 % BG < 200
30

20

10

0
     June   Sept   Oct   Nov   Dec   Jan   Feb
                       Portland
    Furnary. J Thorac CardiovascSurg, 2003; 125: 1007-21

• http://www.starwood.com
• Endocr Pract 2004; 10: 21-33
• Tests q .5-2 hrs
• Continuous IV only
• Avg. 3 day Blood glucose
• 13,649 patients since 1987—prospective
  interventional
• 1.5% hypoglycemia rate (60 mg/Dl)
           van den Berghe
           NEJM 2001. 345:1359-1367

• 1548 SICU patients. Randomized,
  prospective, controlled.
• IV insulin to maintain between 80 and 110
  mg/Dl
• Relatively short
• Measures q 2h until goal, then q 4h
• Hypoglycemia at 60
• No additional protocols for adding
  nutrition, crises, weaning
                       Yale
• Goldberg PA, et al. Diabetes Care. 2004;
  27:461-467
• Current BG leads you to table. Hourly rate of
  change is guide. Nomogram. Complicated.
• Target is 100-139 mg/Dl. Very little
  hypoglycemia
• Mean time to target is 4.6 hrs. Median is 9 hrs.
• Protocol rated ―easy‖, no additions for nutrition,
  weaning, crises.
             Other protocols
• Markovitz—Endocr Pract. 2002; 8:10-16
  – Has default algorithm
  – Testing frequency lowers as stabilizes
  – Hourly rate=hourly maintenance rate +(blood glucose-
    150)/ISF
  – Cut off is 100
• UNC—not published yet
  – Target of 80-110. Has no hypoglycemia cut-off.
• Florida Hospital—not published, looks like blend
  of Markovitz format and Portland amounts
• Glucommander
      Free Form Protocols-Basic
              Concepts
• Usual start dose is 0.15 u/kg
• Continuous IV weaned to bolus weaned to usual
• Think Basal/Nutritional/Correction (Crisis) as
  three distinct levels with different needs
• Basal needs long acting agent like glargine
• Nutritional needs medium acting at 1 unit/10
  gms of CHO
• Crisis/correctional needs short acting like Lispro
  or Aspartine
    More Basics to Keep in Mind
•   Use regular insulin or NPH in drips
•   Regular insulin at doses of 0.5-1 unit/ml
•   Infuse at 0.1 unit dose increments
•   Use IV fluids with glucose—usually D5
•   Monitor potassium
•   Have D50 available and oral CHO also.
   But is CII cheaper than SQ?
• Direct and indirect costs for 3 days of q 4h
  SQ=$32/pt
• Costs of 3 days of Cont IV infusion with q
  1-2 h test =$170/pt ($138 difference)
• Cost of DSWI =$2613/pt + $2081 for 1.8
  additional days
• $4694-138 =$4556/pt or $4,556,000 per
  1000 CABGs
• US Hospital savings = 103K CABGs =$469
  million/yr
        Point of Care Testing
• Essential
• Timing is crucial
• Which blood source? Urine? Same over time?
• Sensitivity vs. specificity
• What interferes with the test you use?
• No way to get trends at this time
• What would you want in a testor that you do not
  have now…?
• Who needs to be involved? What skills do they
  need or bring to share?
      More on POC Testing
• Bedside monitoring vs. central lab
• Does the person doing the test matter?
• Self-monitoring?
• Cost, accuracy, accountability
• Will we live long enough to see a non-
  invasive bedside monitor? Wireless?
• Ketones, albumin, HbA1c, glycated serum
  proteins-better than blood glucose?
         The Pieces You Need
•   Know the literature and other rationales
•   Have a credible champion
•   The right protocol
•   Forms, policies and order sets
•   The right team
•   Enough equipment
•   Strong Quality Improvement department
     What to Do with the Pieces
•   Start with one unit
•   Keep all data in one place
•   Solid communication system
•   Accurate test administered by trained
    professionals
•   Timely changes in treatment
•   Start high, move lower
•   Never stop educating
•   Have a safety plan
•   Consider special circumstances
     Data that may help you…
• Knowing what percentage of patients are
  diabetic—and guesstimating percent of
  unrecognized hyperglycemic patients
• Literature
• Knowing what surgical infection rate is
• Estimating cost to your institution in terms
  of:
  – Mortality
  – LOS
  – Financial Costs
              Thanks…
• Questions, comments,
  suggestions?
• ced2t@virginia.edu

				
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