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 damageacidosis &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)

19U19U/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