TRANSCRIPT:
[00:00:00] Betsy Kubacka: Thank you for joining me for this presentation, titles: A Spotlight on Perioperative Glycemic Management. My name is Betsy Kubacka. I am a nurse practitioner, registered dietician, and a diabetes educator. I serve as Glytec’s Vice President of Clinical Partner Solutions, as well as practice as an endocrinology nurse practitioner at Harford Healthcare in Connecticut.
[00:00:31] Betsy Kubacka: Today we're going to be talking about perioperative glycemic management. This will include the challenges of perioperative glycemic management, as well as the goals for perioperative glycemic management, we will also be discussing medication management plans. For example, when is glycemic management best served using IV insulin? When is it best served using subcutaneous injections? Recognizing those patient populations that are at higher risk for hypoglycemia.
[00:00:51] Betsy Kubacka: Care challenges: Inpatient glycemic care brings many challenges. Hyperglycemia is common, and we see it in more than 30% of our hospitalized patients and up to 40% in surgical patients.
[00:01:17] Betsy Kubacka: Severe illness and surgical stress predisposes patients to insulin resistance, thus leading to hyperglycemia, and we know the effects of hyperglycemia are immune dysfunction, impaired wound healing, oxidative stress, all those things that we don't want happening for our patients who are trying to recover.
[00:01:37] Betsy Kubacka: We also have limited support structures within our hospital systems. Often, we lack endocrine support that includes diabetes educators as well as physicians. And our inpatient prescribers often share that they have varied knowledge and comfort in prescribing insulin. Insulin is a high alert, high risk medication, thus making it more stressful to make sure that we get it right and avoid those hypoglycemic events.
[00:02:07] Betsy Kubacka: Challenges beyond this are glycemic control is often a focus of the critical care areas with less focus in those general medical surgical units. Our staff fears hypoglycemia, so they want to often withhold insulin due to fear. How often have we heard “Let's keep 'em sweet rather than making them go low”?
[00:02:29] Betsy Kubacka: Patients fear insulin. I've often had patients tell me that they don't want insulin. They've been told that once they receive insulin, they'll always be on insulin. So often we have to convince our patients that insulin is the best therapy for them in the hospital. Additionally, we have dosing in care challenges. Coordination of glucose testing, meal delivery, and insulin administration is very challenging.
[00:02:53] Betsy Kubacka: Oftentimes, we have things like meal on demand. We have food being brought in from home, and we have patients with variable appetites and meal intakes, making it even more challenging to be able to dose that insulin correctly and keep our patients in our prescribed target range dose.
[00:03:15] Betsy Kubacka: So perioperative hyperglycemia has adverse outcomes. We know that in the body glucose control is finally regulated. It is a balance between the liver and the pancreas, making sure that we're utilizing glucose appropriately and keeping our target ranges. Surgery and anesthesia alter this balance. Studies have shown that correction of hyperglycemia decreases mortality and reduces those risks.
[00:03:42] Betsy Kubacka: Tight control can lead to hypoglycemia and an increased risk for mortality. And we'll talk a little bit more about that later in the presentation. So when we have our patients who are going to be having surgery, we really need to screen for diabetes. Looking at that A1C, oftentimes we find that patients don't know they have diabetes, and so when we screen, we're able to then get them under better control before surgery.
[00:04:09] Betsy Kubacka: Look at that A1C for those that have known diabetes, is there control? What does that long term glycemic control look like? What is the severity of hyperglycemia on admission? We don't want our patients coming into the hospital with blood glucose of 300 and then being brought to the surgery.
[00:04:31] Betsy Kubacka: So checking that blood glucose and then monitoring postoperatively for hyperglycemia is very important. We know that perioperative hyperglycemia is very common in general surgery 20 to 40%,in cardiac surgery up to 80%, and 12 to 30% of that hyperglycemia is not related to a history of diabetes, rather it is stress hyperglycemia.
[00:04:55] Betsy Kubacka: So we know the magnitude of stress hyperglycemia, and this is related to the severity of the surgery and the type of anesthesia. So surgical stress increases our hormonal counter regulatory response. Thus, it is affecting the way our body is processing our glucose and insulin.
[00:05:21] Betsy Kubacka: We have reduced insulin production and we have increased glucose release leading to hyperglycemia. Surgeries that require general anesthesia include the thorax and the abdomen, have a higher risk for stress hyperglycemia, where laparoscopic surgery has a lower risk for stress hyperglycemic.
[00:05:50] Betsy Kubacka: So there's been a lot of buzz around ERAS enhanced recovery after surgery. This is a consumption of carbohydrate rich beverages, and usually it's right before surgery and that preoperative car bloating is designed to counteract the state of insulin resistance due to that stress and starvation response, creating that increased glucose release. Avoiding that catabolic state is associated, we wanna avoid that catabolic state really.
[00:06:16] Betsy Kubacka: So we wanna increase insulin sensitivity and decrease that risk for hyperglycemia. So ultimately this is associated with reduced length of stay and our patients get better faster when we use ERAs. However, providing these preoperative carbohydrate containing beverages for patients with diabetes is not recommended.
[00:06:38] Betsy Kubacka: You're not going to get that desired effect of decreasing that insulin resist sensitivity. So what we would like you to do is you can give fluids, however, omit the extra carbohydrates prior to the surgery.
[00:07:02] Betsy Kubacka: So let's discuss a little bit about our clinical studies and what they tell us about perioperative care. In the preoperative period, an increased glucose is linked to a higher mortality risk. So we wanna make sure that our patients have a glucose within target ranges before surgery. Greater than 216 has been shown to increase mortality from 3% to 5% to 12% in one year.
[00:07:29] Betsy Kubacka: Preoperative A1C are also important to look at. Those A1C values will give us insight as to how that patient will recover from surgery with relation to wound complications and other infectious complications. Intraoperative glycemic control mostly has been studied in cardiac surgery, but it's very interesting because for every 20 milligrams per deciliter, above 100 milligrams per deciliter, there was a 30% increase in adverse outcomes, and ultimately a blood glucose less than 200 had 13% risk for adverse outcomes, where a blood glucose greater than 250 had a 63% adverse outcome.
[00:08:07] Betsy Kubacka: So again, it's very important to keep our patients in good control. So postoperative glycemic management, we wanna keep those blood sugars less than 180 to decrease the surgical site infections and make sure the wound healing occurs for our patients. Stress hyperglycemia in patients without a history of diabetes has been shown over and over to have worse outcomes with elevated blood glucose than those with a history of diabetes.
[00:08:40] Betsy Kubacka: And we know tighter control may be desired for some surgical patients, those postop CV patients, we often wanna see tighter control. Tighter control brings higher risk for hypoglycemia and increased risk for mortality with that hypoglycemia. However, we wanna use products like IV Glucommander, which brings a very low risk of hypoglycemia.
[00:09:02] Betsy Kubacka: It's been shown to have a large reduction 62.6% in one study of preventable hypoglycemic adverse drug events. So what are the recommendations? When we have a patient come in for surgery, or we're scheduling our patient for surgery, we wanna make sure that we check the A1C and preoperative blood glucose.
[00:09:27] Betsy Kubacka: It is recommended that that preoperative A1C be less than or equal to 8%, and that the blood glucose before surgery is less than 180. We have several organizations that support this. They also recommend overall blood glucose to be managed to be less than 180. We see that the Critical Care Society recommends maintaining blood glucose less than one 50, a little tighter than the others, and usually for those patients who are in the non ICUs, we're looking at a blood glucose less than 140 as a pre-prandial blood glucose, and then overall, less than 180.
[00:10:10] Betsy Kubacka: So when we look at our, our different types of diabetes, we know type one is an insulin deficiency. We know that those patients will be treated with insulin, both preoperatively, intraoperatively, and postoperatively. With type two, it's a little more complicated. Some may be on insulin prior to surgery. But most are on many different combinations of oral medications to manage their diabetes.
[00:10:36] Betsy Kubacka: So when they come into the hospital, we need to convert these patients from these oral medications to insulin. So when we're looking at pre-op glycemic management, we are taking into consideration the type of diabetes, the nature and extent of the surgical procedure, the length of the pre-op and post-op fasting stay, the state of control before that surgery, the A1C, and so in type two, We're going to be modifying those oral medications before surgery.
[00:11:08] Betsy Kubacka: For most, they can take the oral medications right up to the day before surgery. The caveat is the SGLT-2, we wanna actually hold those three days prior to surgery. And we also wanna reduce some of that basal insulin if they are on insulin.
[00:11:28] Betsy Kubacka: Oftentimes our patients would type two are over basalized. So we wanna take that into consideration whether we want to make a slight reduction in that pre surgical day basal insulin dose. Type one diabetes we do not wanna hold that basal insulin. We may wanna reduce that dose lightly, especially for those who are going to be NPO for a longer period of time. But we wanna make sure our patients have insulin on board and prevent DKA because we know that the stress of surgery can cause severe hyperglycemia in ketoacidosis.
[00:11:47] Betsy Kubacka: So this is just a chart showing and there's many charts out there available for review in literature. So this is just really reviewing what we would recommend to our patients prior to surgery when on oral medication.
[00:12:14] Betsy Kubacka: And as I stated earlier, the SGLT-2 are the ones that we would hold for a longer period of time before surgery, and that's really to reduce the risk for euglycemic DKA. Many of you might have seen that with our patients who are on SGLT-2 inhibitors, and especially because, you know, they have a higher risk for dehydration during the surgery and postoperatively with those decreased oral intakes.
[00:12:39] Betsy Kubacka: So we wanna make sure that we're being very attentive to that medication. Otherwise, most medications can be, can be continued till the night before day of surgery. When it comes to insulin, for the most part 20% reduction in prior insulin doses, like PM doses is recommended for our patients who are taking insulin.
[00:13:07] Betsy Kubacka: We still wanna continue to give them insulin, but a slight reduction. So the day of surgery, if their insulin regimen is in the morning, then again we would reduce our long acting insulins by 80%. Any NPH or combo insulin, we would reduce by 50% in that morning. So best practice is to check blood glucose before surgery.
[00:13:33] Betsy Kubacka: In that pre-op period, you may wanna use subcutaneous insulin or IV insulin. So those are your two choices. If your patient is going to be undergoing ambulatory surgery, a surgery of short duration, less than four hours, minimally invasive, the patient's going to be hemodynamically stable, then you can consider using subcutaneous insulin for those procedures.
[00:13:58] Betsy Kubacka: In patients who are going to have long surgeries with anticipated hemodynamic changes, significant fluid shifts, temperature changes, use of tropes, those are the patients you may wanna consider IV insulin for both pre-op, intra-op and post-op. Some pearls to keep in mind is rapid acting insulin should not be given more frequently than every two hours to, uh, minimize that risk of insulin stacking.
[00:14:27] Betsy Kubacka: You also may consider not giving more than two doses if you're doing every two hours and watch for that effect, ensuring that the patient will not experience hypoglycemia. IV insulin is more responsive, and it is recommended for those patients who are going to have longer surgeries and those surgeries that put the patient at higher risk.
[00:14:49] Betsy Kubacka: The variables that alter subcutaneous insulin absorption and uh, distribution also need to be considered. So we wanna make sure that we are prescribing the correct type of insulin for our patients after surgery. Many patients can resume their regimen when they go home. We're seeing more and more insulin pumps, and so if a patient is going to be coming in for surgery and we want to continue that insulin pump, we're going to need some preoperative planning.
[00:15:22] Betsy Kubacka: We have to consider where that pump insertion site is and where that surgical field will be, so we need to make sure that the patient has the correct placement. We also have to consider does the patient have a closed loop system? In that case, they'll also be wearing a continuous glucose monitor. So again, understanding that we need to stay away from those surgical fields in the placement of that equipment.
[00:15:47] Betsy Kubacka: During the surgery, primarily our patients will be running their basal rates through the insulin pump, and it's recommended that frequent monitoring of blood glucose occurs. Um, as we know, hypoglycemia may go unrecognized as the patient is under anesthesia and we are not able to see those signs and symptoms.
[00:16:06] Betsy Kubacka: For those patients who are on insulin pumps that we want to, take them off of the pump during the surgery, we can consider insulin infusions, but making sure that we have a bridging process, restarting that insulin pump at least one hour before stopping that insulin infusion is recommended. and just, you know, understanding that insulin pumps are primarily utilized in patients with type one, so we wanna make sure they always have insulin on board to prevent DKA.
[00:16:34] Betsy Kubacka: However, there are, there is a growing number of patients with type two diabetes who are also utilizing insulin pumps. So IV insulin, in order to use it appropriately, we need to use protocols that are validated. So they offer us guidance on how to titrate that insulin and when the blood glucose should be checked.
[00:17:00] Betsy Kubacka: We wanna make sure that we have a target glucose in mind and that we minimize or avoid any hypoglycemia. We know nursing primarily plays a critical role in IV insulin administration in the ICU settings in the OR, it's often managed by the anesthesiologist or nurse anesthetist. Initiating Glucommander for those of you who are using Glucommander, you are aware of this, we need two factors in order to manage a patient on IV insulin using Glucommander.
[00:17:32] Betsy Kubacka: One is the multiplier. The multiplier is a sensitivity factor, and it will set that initial insulin infusion rate, so the choices are usually anywhere from 0.01 to 0.05, 0.01 being a very sensitive patient that would be a patient that has type one diabetes and we wanna start them maybe more moderately or lower on that insulin infusion where 0.05 is more appropriate for an insulin resistant.
[00:18:03] Betsy Kubacka: Patient often, this is the multiplier that we initiate for those post-op CV patients to get them into target quickly. Our targets may vary for the patient population we are treating. We often use the 120 to 160. However, as we saw based on recommendations for multiple organizations, the target of 140 to 180 is also very appropriate for patients and does carry that lower risk for hypoglycemia.
[00:18:33] Betsy Kubacka: I often see CV surgery wants tighter control studies have shown better outcomes with tighter control. And again, with Glucommander you can have peace of mind that hypoglycemia risk is very low, and so 100 to 140 may be a target chosen for those postop CV patients. And the chart below just kind of shows you based on the blood glucose, what the initial multiplier, you know, chosen will result insulin infusion rate and there's a difference based on that multiplier.
[00:19:02] Betsy Kubacka:. Patients that are on IV Glucommander, we are able to get the patient's glucose into target and maintain that glucose within target throughout the procedure. So really the key takeaway is IV insulin is very responsive and it can achieve and maintain glucose throughout that target range during the procedure and if the patient will be transitioned to the ICU, then we can continue that. Is IV insulin there as well.
[00:19:34] Betsy Kubacka: Technology- driven insulin management: There's many benefits to eGMS. It is a quicker but very controlled time to target range. Maintenance of glucose in those tighter target ranges is safe with lower variability and lower risk for hypoglycemia.
[00:19:57] Betsy Kubacka: There are fewer calculation errors for those of you who have used those paper protocols. I know we have a presentation on that. You know, they're complicated and they can lead to errors. We have built in alerts within Glucommander, and we also know that it is FDA cleared because it is well studied and, and has many studies to validate its ethicacy.
[00:20:23] Betsy Kubacka: When transitioning from IV to subcutaneous insulin, we wanna ensure that the patient has insulin on board. We know that IV insulin has a very short half-life. When we shut that IV insulin off, the patient essentially is going to metabolize and be without insulin within 15 minutes or so, half-life of about seven minutes.
[00:20:45] Betsy Kubacka: So that first subcutaneous injection should be given before that insulin infusion is stopped to allow adequate time for that SubQ insulin to begin working. We know rapid acting insulin starts working in about 15 minutes, where that long-acting insulin, if you're using glargine, that can take two to four hours to really start taking effect.
[00:21:05] Betsy Kubacka: So it's imperative that our patients receive that basal insulin if they have type one. And for others, we wanna prevent a rebound hyperglycemia occurrence. So we wanna make sure they have insulin on board. When using Glucommander, the transition process is seamless because we do have a total daily dose recommendation from the program.
[00:21:27] Betsy Kubacka: And if you have SubQ Glucommander, it will transition the patient directly from IV to subcutaneous insulin. When ordering subcutaneous insulin, sliding scale is very much discouraged. It is a reactive approach. It is never preventing that hyperglycemic event. Instead, we're always chasing that hyperglycemia, so we put our patients on a rollercoaster ride going up and down with the insulin delivery.
[00:21:55] Betsy Kubacka: The recommended is the proactive approach of giving basal prandial or meal coverage. We all, you know, prandial is meal coverage as well as correctional insulin. So for those who are eating, we give them basal insulin and that that's to cover the fasting state. The overnight glucose is a good indicator if our basal insulin is at the appropriate dose. For meals, we wanna give them rapid acting insulin, and we wanna bring that blood sugar down related to the carbohydrate intake. And then if the blood sugar is above target before the patient even begins to eat, they require a little correctional insulin to bring that blood glucose down different than the way sliding scale is used.
[00:22:40] Betsy Kubacka: So for patients who are on insulin prior to presentation for surgery, you wanna make sure that we reduce the home dose By 20 to 25%, sometimes even more, especially for those on U500, I've often had to reduce those doses by 50%. Patients, the diet's gonna be controlled in the hospital. They're gonna have variable meal intakes.
[00:23:05] Betsy Kubacka: So again, we wanna make sure that we account for those things when we're, we're looking at our insulin dosing. We wanna look at those A1C values when we start as well, because a high A1C is a poor indicator of either poor compliance or an insulin regimen that is not appropriate for your patients.
[00:23:24] Betsy Kubacka: So really evaluating the patient's home regimen to what we think that we need to start our patients. Most of the time it will be a reduction. If the patient is on a high basal dose with little to no prandial dosing or a high basal dose and maybe an oral med like metformin, you wanna really take that insulin dose and redistribute it between basal and meal bolus.
[00:23:49] Betsy Kubacka: Again, what I would do is reduce it by 20 to 25% and then split it in half, give half of that dose as basal. And then the other as prandial insulin and really watch and monitor for the effects. And you could always go up the next day.
[00:24:18] Betsy Kubacka: So how do we determine the dose for subcutaneous insulin dosing? We're going to use our home insulin doses as we discussed earlier, for those who are on insulin prior to admission. But for those patients who are not on insulin, and oftentimes we have patients on multiple oral medications or non-insulin injectables, and we need to convert them to insulin when they come to the hospital. We do that by using a weight-based multiplier, which is exactly like it sounds. You take the multiplier, multiply it by the patient's weight in kilograms to come up with how much the patient needs as a total insulin dose for that day.
[00:24:47] Betsy Kubacka: So for instance, a patient requires .3 multiplier, this would be an insulin naive patient, older, frail, renal insufficiency, those patients at higher risk for hypoglycemia, we would use a 0.3 multiplier, multiply it by the weight. To come up with a dose 50 times 0.3. If the patient weighs 50 kilograms, would give us our total daily dose.
[00:25:14] Betsy Kubacka: Most of our type two patients, we would use a multiplier of 0.5. For those who are very insulin resistant, maybe they came in with a very high A1C steroids, we may choose a higher multiplier of 0.7. Again, these are usually our patients who are not taking insulin at home and we don't, We wanna start them fresh.
[00:25:36] Betsy Kubacka: We then take that total insulin dose and we split it between basal and nutritional insulin. The basal can be given once or twice daily. The meal bolus would be given, with every meal throughout the day, so usually three times a day. Now, for those patients who are receiving a continuous tube feeding, we wanna also cover those carbohydrates so we can give those patients basal insulin plus scheduled nutritional boluses either every four or six hours, and then we give correctional insulin on top of those meal boluses if the glucose is elevated
[00:26:02] Betsy Kubacka: You're gonna wanna adjust those doses on a daily basis based on the response. If you're using a lot of correctional insulin throughout the day, add it to your scheduled insulin, and that way you can get your patient into control quicker.
[00:26:27] Betsy Kubacka: So when prescribing insulin order sets will help drive the prescribing practice. So organizations usually have insulin order sets, which will drive our providers to order basal meal bolus and correctional insulin. And they usually include hypoglycemia protocol as they should, as well as when nurses should notify providers and how frequent those blood glucose checks should be.
[00:26:56] Betsy Kubacka: Now in initiating Glucommander, we also can be started as a weight-based multiplier. As we discussed earlier. Here we see an example of a patient who weighs 56.7 kilograms, started on a 0.5 multiplier, and Glucommander has simply taken the weight, multiplied it by the multiplier to come up with 28 units as the total daily dose, the distribution will be 50 per 50, 50% basal, 50% meal bolus.
[00:27:27] Betsy Kubacka: So I can expect that this patient will receive 14 units of basal and the other 14 units will be distributed evenly across breakfast, lunch, and dinner. Also for those patients who are already on insulin and we don't wanna use a weight-based multiplier, we wanna actually set a dose. We see on the right how you would prescribe using custom dosing.
[00:27:48] Betsy Kubacka: So in custom dosing, I'm ordering the total basal dose. I'm ordering the breakfast, lunch, and dinner doses to initiate Glucommander. The first 24 hours on Glucommander will be based on the prescriber's. The following day, Glucommander starts making adjustments based on the glycemic response of the patient to the insulin given.
[00:28:15] Betsy Kubacka: So we also have some special considerations. Our populations don't always fit into those buckets and categories, and it's not always so easy. For steroids, patients are often receiving dexamethasone now intraoperatively. It's to decrease the risk of postoperative nausea, vomiting, inflammation, and also post-operative pain.
[00:28:36] Betsy Kubacka: So our anesthesiologists are really liking dexamethasone. On the diabetes side and the hyperglycemia prevention side, we know that steroids are counter regulatory hormones. They impair that insulin action, decrease increased resistance and, and decrease secretion of insulin. So many of our patients will experience hyperglycemia postoperatively when given steroids, even if they don't have diabetes.
[00:28:56] Betsy Kubacka: So we do have some guidelines with regard to how we would dose insulin understanding that, that as the steroids are tapered, we also need to decrease that dose of insulin. So, you know, if it is prednisone, that that actually peaks throughout the day.
[00:29:21] Betsy Kubacka: So we usually increase the meal insulin at lunch and dinner time because it really has a shorter acting effect. And if they're only getting once a day overnight, they're going to come down those blood sugars. So the basal insulin doesn't require an increase, It's just those meal bolus.
[00:29:43] Betsy Kubacka: Versus a long-acting dexamethasone. In that case, you're gonna see the effect throughout the day and night. And, and so we will need an increase in both basal and meal boluses. And again, just really being cognizant that when steroids are tapered or when they're stopped, we need to decrease those insulin doses in anticipation of less need.
[00:30:03] Betsy Kubacka: Insulin insufficiency is another area that we always have to we have to watch them more closely. Loss of renal clearance of insulin occurs in renal insufficiency, so that insulin is hanging around longer. It's not being metabolized as quickly. So we do have a higher risk for hypoglycemia.
[00:30:25] Betsy Kubacka: Endogenous insulin is primarily metabolized by the kidney. So again, understanding that that's gonna be a problem. A1Cs may be falsely low in our patients with renal disease, so sometimes we can't use those as a gauge for prior glucose control. The recommendation is to be as conservative as possible for those patients with renal insufficiency.
[00:30:53] Betsy Kubacka: Starting with a 0.3 multiplier and that higher target range, 140 to 180 is what we recommend for our patients with renal insufficiency. In those days that the patient is on dialysis, we tend to see more hypoglycemia. So again, having, you know, possibly making some adjustments. For those dialysis days and, and the greatest risk for hypoglycemia is overnight.
[00:31:19] Betsy Kubacka: Often our patients with, with long term renal insufficiency are hypoglycemic unaware, so it is important that we actually check the blood sugar not rely on the patient reporting hypoglycemic signs and symptoms. When it comes to artificial nutrition, we know that we also have challenges in managing glucose, so definitely work with the inpatient dieticians because we wanna provide formulas that are lower in carbohydrates when possible.
[00:31:48] Betsy Kubacka: I know we wanna meet all the nutritional needs. I'm also a registered dietician. We wanna meet the needs of the patient, but we do have to look at all the formulas available to be able to give our patients the best nutrition and and the lowest carbohydrate.
[00:32:08] Betsy Kubacka: Sometimes if it's a continuous tube feeding, you may wanna start with an insulin drip to determine those daily insulin needs. If you run the drip concurrently with the tube feeding, you'll be able to see how much insulin that patient needs throughout the day. You can use the last four to six hours of drip rates to calculate the daily needs but being sure that those drip rates have been relatively stable. Still use the full 24 hours as that resistance can change over the day, and you might overestimate the amount of insulin the patient needs.
[00:32:33] Betsy Kubacka: So really looking at where's my stable insulin drip rate, and then calculating the total daily dose based on those drip rates.
[00:33:02] Betsy Kubacka: In summary, hyperglycemia is associated with adverse clinical outcomes in surgical patients. We wanna make sure that we screen our patients for diabetes and we wanna make sure that we look at those pre and post surgical glucose levels.We wanna treat hyperglycemia when presented. Insulin is preferred for the management of hyperglycemia. And remember, IV insulin is very responsive, easily titratable to meet the needs of the patient, keeping that patient in target range. And then when we transition from IV to subcutaneous insulin, we have to make sure that our patients are medically stable.
[00:33:24] Betsy Kubacka: We wanna prevent rebound hyperglycemia. And we wanna prevent hypoglycemia for those patients that we have on subcutaneous insulin. Assess those glucose responses. If a patient experiences a blood glucose less than a hundred, modify the treatment plan and look at when did that glucose occur if it occurred overnight or early morning, and it was a fasting state, you wanna adjust the basal insulin if it occurred after breakfast, then you wanna adjust the breakfast dose if it occurred after lunch, you wanna adjust the lunch dose if it occurred after dinner, you wanna occur adjust that dinner dose.
[00:33:57] Betsy Kubacka: So again, looking at that glycemic response and then addressing the appropriate insulin dose to that. Always keep in mind those special consideration populations we talked about, the steroid population, the renal insufficiency, those on artificial nutrition as well as those insulin pump patients, and really remembering that glycemic targets need to be modified according to our goals and the clinical status of our patients.
[00:34:33] Betsy Kubacka: With that, I thank you so much for your attention to this presentation and welcome any feedback you may. Thank you.
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