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Npo Diabetic Patient

Management Of Hospitalized Patients With Type 2 Diabetes Mellitus

Management Of Hospitalized Patients With Type 2 Diabetes Mellitus

Suboptimal glycemic control in hospitalized patients with type 2 (non–insulin-dependent) diabetes mellitus can have adverse consequences, including increased neurologic ischemia, delayed wound healing and an increased infection rate. Poor glycemic control can also affect the outcome of the primary illness. If possible, hospitalized diabetic patients should continue their previous antihyperglycemic treatment regimen. Decreased physical activity and the stress of illness often lead to hyperglycemia in hospitalized patients with type 2 diabetes. When indicated, insulin is given either as a supplement to usual therapy or as a temporary substitute. The overall benefit of the traditional sliding-scale insulin regimen has been questioned. Insulin supplementation given according to an algorithm may be a logical alternative. Any antihyperglycemic regimen should be administered and monitored in a manner coincident with the intake of food or other sources of calories. Factors that can alter glycemic control acutely, including specific medical conditions and medications, should be identified and anticipated. Diabetes mellitus is a common secondary diagnosis in hospitalized patients. In 1988, diabetes was one of the diagnoses recorded for 2.8 million patients discharged from hospitals in the United States. Altogether, these patients spent 24.5 million days in hospitals. Diabetes was the secondary diagnosis in more than 80 percent of these patients, with the most frequently listed primary diagnoses being circulatory and cardiovascular diseases.1 Patients with diabetes are hospitalized twice as often as those who do not have this disease, and they are likely to stay in the hospital 30 percent longer.2 Furthermore, annual insurance claims for inpatient care are four times higher amon Continue reading >>

Peri-operative Glycemic Control

Peri-operative Glycemic Control

The challenge of peri-operative glycemic control Surgery and general anesthesia frequently lead to imbalances in glucose control, both intra-operatively and in the peri-operative period. These imbalances can occur in diabetic and non-diabetic patients and involve a complex relationship between patient factors such as baseline glucose control and underlying comorbidities and surgical/operative factors such as procedure complexity and type of anesthesia. The post-operative period brings additional challenges such as unpredictability in nutritional intake, hyperalimentation, and later, post-surgical complications such as sepsis. Peri-operative hyperglycemia has been identified as a risk factor for morbidity and mortality. Intensive insulin therapy (IIT) has been shown to decrease post-operative infection rates and improve mortality in cardiac surgery patients. However, IIT has also been linked to increased incidence of severe hypoglycemia and related adverse events. Furthermore, the generalizability of specific blood glucose targets over a wide patient population is unclear; initial research showing improved outcomes with IIT in cardiac surgery patients has not played out in other patient groups. The Hospitalist physician deals with peri-operative glycemic management in several settings. In the pre-operative clinic the Hospitalist must assess the surgical suitability of patients with disorders of glucose control. Patients with baseline diabetes have increased incidence of post-operative morbidity and mortality largely due to increased cardiovascular complications and poor wound healing. Also in the pre-operative setting, the Hospitalist is expected to formulate a plan for management of glucose control in the days leading up to surgery. In the inpatient peri-operative sett Continue reading >>

To Hold Or Not To Hold: Understanding Insulin

To Hold Or Not To Hold: Understanding Insulin

You’re about to walk into your patient’s room with a syringe full of insulin. The unit secretary shouts, “Hey. The physician just made your patient NPO.” Ugh...now what? Do you give the insulin? Do you hold it? Are you confident that you would know what to do every time? If you don’t, you’re not alone. However, by understanding the different CATEGORIES of insulin, I guarantee you will! There are 3 categories of insulin: Basal, Prandial (bolus), and Correction (sliding scale). Basal (Lantus, NPH, Levemir) This is the insulin your body needs just to meet its basal metabolic functions. Let’s say you decide not to eat for a day. If you’re NOT a diabetic, your cells still need glucose for energy, so your liver continuously kicks out a small amount of glucose (gluconeogenesis) – prompting your pancreas to secrete a small amount of insulin – to feed your body’s cells (energy). Remember? Insulin acts as the key to unlock the door of the cell to let the glucose in. If you ARE a diabetic and decide not to eat, your liver will still kick out glucose but since your pancreas doesn’t secrete insulin (Type I), all of your insulin needs, need to come exogenously (shot) – we need to give you a shot of basal insulin…even when you’re not eating – remember, the liver will still kick out glucose! 24 hours a day – 365 days a year – you have glucose in your bloodstream whether you’re eating it or your liver is kicking it out! Therefore, basal insulin should NEVER be held. Patients with Type I diabetes need basal insulin 24 hours a day. If they are NPO, the general rule of thumb is that they need ½ of their usual dose. For example, if they are on 50 units of Lantus a day, when they are NPO, they need approximately 25 units. Prandial (Novolog, Humalog) Its Continue reading >>

Nothing By Mouth - Wikipedia

Nothing By Mouth - Wikipedia

This article needs additional citations for verification . Please help improve this article by adding citations to reliable sources . Unsourced material may be challenged and removed. Nothing by mouth is a medical instruction meaning to withhold food and fluids. It is also known as nil per os (npo or NPO), a Latin phrase whose English translation is most literally, "nothing through the mouth". Variants include nil by mouth (NBM), nihil/non/nulla per os, or complete bowel rest. [1] A liquid-only diet may also be referred to as bowel rest. [2] NPO is one of the abbreviations that is not used in AMA style ; "nothing by mouth" is spelled out instead. The typical reason for NPO instructions is the prevention of aspiration pneumonia , e.g. in those who will undergo general anesthesia , or those with weak swallowing musculature, or in case of gastrointestinal bleeding , gastrointestinal blockage , or acute pancreatitis . Alcohol overdoses that result in vomiting or severe external bleeding also warrant NPO instructions for a period. Pre-surgery NPO orders are typically between 6 and 12 hours prior to surgery, through recovery suite discharge, but may be longer if long acting medications or oral post-meds were administered. It is not uncommon for the food NPO period to be longer than that for liquid, as the American Board of Anesthesiology advises against liquid NPO periods greater than eight hours.[ citation needed ] The NPO periods for illness tend to be much longer, although exceptions are made for small scheduled amounts of water consumption if an IV drip is not in use. With sufficient IV fluids, NPO periods of several days have been utilized successfully in non-diabetic patients (although short NPO periods in diabetics are possible with IV fluids, insulin, and dextrose.[ Continue reading >>

Fasting For Surgery: What If I Have A Low?

Fasting For Surgery: What If I Have A Low?

I have diabetes and will be getting an operation. I am not supposed to eat or drink after midnight, but after four hours, my blood glucose drops. What can I take to bring it up? Continue reading >>

13. Diabetes Care In The Hospital

13. Diabetes Care In The Hospital

Consider performing an A1C on all patients with diabetes or hyperglycemia admitted to the hospital if not performed in the prior 3 months. C Insulin therapy should be initiated for treatment of persistent hyperglycemia starting at a threshold ≥180 mg/dL (10.0 mmol/L). Once insulin therapy is started, a target glucose range of 140–180 mg/dL (7.8–10.0 mmol/L) is recommended for the majority of critically ill patients A and noncritically ill patients. C More stringent goals, such as 110–140 mg/dL (6.1–7.8 mmol/L) may be appropriate for selected critically ill patients, as long as this can be achieved without significant hypoglycemia. C Intravenous insulin infusions should be administered using validated written or computerized protocols that allow for predefined adjustments in the insulin infusion rate based on glycemic fluctuations and insulin dose. E A basal plus bolus correction insulin regimen is the preferred treatment for noncritically ill patients with poor oral intake or those who are taking nothing by mouth. An insulin regimen with basal, nutritional, and correction components is the preferred treatment for patients with good nutritional intake. A The sole use of sliding scale insulin in the inpatient hospital setting is strongly discouraged. A A hypoglycemia management protocol should be adopted and implemented by each hospital or hospital system. A plan for preventing and treating hypoglycemia should be established for each patient. Episodes of hypoglycemia in the hospital should be documented in the medical record and tracked. E The treatment regimen should be reviewed and changed if necessary to prevent further hypoglycemia when a blood glucose value is <70 mg/dL (3.9 mmol/L). C There should be a structured discharge plan tailored to the individual p Continue reading >>

Preoperative Glycemic Control For Adult Patients With Diabetes Undergoing Elective Surgery

Preoperative Glycemic Control For Adult Patients With Diabetes Undergoing Elective Surgery

Tristan B. Weir, BS, Florida State University College of Medicine, Larry C. Deeb, MD, Florida State University College of Medicine As the prevalence of diabetes continues to increase in the United States, a higher proportion of elective surgical candidates will require specific preoperative education and guidelines to maximize patient outcomes and reduce the costs of care. The purpose of this article is to review the current literature to determine how preoperative glycemic control affects the lengths of hospital stays, postoperative complications, and mortality in people living with type 1 and 2 diabetes. Additional recommendations are provided for preoperative hypo- and hyperglycemia, the use of insulin pumps or continuous glucose monitors, and day-of-surgery management of insulin and oral hypoglycemic agents. Gaps in medical evidence are acknowledged and future directions in research are proposed to provide high-quality guidelines for the preoperative care of adult patients with diabetes. Introduction As the prevalence of diabetes increases in the United States, practicing physicians must be able to educate and manage these patients in the preoperative setting. With 29.1 million (9.3% of the U.S. population) Americans living with diabetes today, nearly 1 in 10 surgical candidates may have diabetes and require special recommendations before surgery [1]. While the 2011 Joint British Diabetes Societies Inpatient Care Group (JBDS) created guidelines for the preoperative management of patients with diabetes undergoing elective surgery, many physicians in the U.S. may not know these guidelines exist [2]. In a 2014 study on preoperative hemoglobin A1C (A1C) and its effect on clinical outcomes for patients undergoing surgery, the authors say “there are no standards of care Continue reading >>

Hyperglycemia In The Hospital

Hyperglycemia In The Hospital

Hyperglycemia is the medical term for blood glucose (sugar) that is too high. High blood glucose (HBG) is a common problem for people with diabetes. Blood glucose can also rise too high for patients in the hospital, even if they do not have diabetes. This patient guide explains why some patients develop HBG when they are hospitalized and how their HBG is treated. Until about 10 years ago, doctors thought that HBG in hospital patients was not harmful as long as their blood sugar stayed at or below 200 milligrams per deciliter (mg/dL). Recent research studies show that HBG above 180 increases the risk of complications in hospital patients. Keeping blood sugar below this level with insulin treatment lowers the risk for these problems. Most doctors agree that controlling blood sugar so it stays below 180 mg/dl is best for very ill patients in intensive care units ( ICU). Less clear is what the best target blood sugar should be for inpatients who are admitted for general surgery or non-critical medical conditions. In some patients, insulin treatment can cause low blood sugar, called hypoglycemia. Just like blood sugar levels that are too high, blood sugars that are too low are not safe and should be avoided. This patient guide for glucose control in the hospital is based on The Endocrine Society’s practice guideline for health care providers on preventing and treating HBG. This guide applies just to patients on a regular hospital floor, not those who are in an ICU. What causes HBG in the hospital? Many conditions can cause or worsen HBG in hospital patients. These include: Physical stress of illness, trauma, or surgery Inability to move around Steroids like prednisone and some other medicines Skipping diabetes medicines Liquid food given through a feeding tube or nutrition Continue reading >>

Management Of Diabetes Mellitus In Hospitalized Patients

Management Of Diabetes Mellitus In Hospitalized Patients

INTRODUCTION Patients with type 1 or type 2 diabetes mellitus are frequently admitted to a hospital, usually for treatment of conditions other than the diabetes [1,2]. In one study, 25 percent of patients with type 1 diabetes and 30 percent with type 2 diabetes had a hospital admission during one year; patients with higher values for glycated hemoglobin (A1C) were at highest risk for admission [2]. The prevalence of diabetes rises with increasing age, as does the prevalence of other diseases; both factors increase the likelihood that an older person admitted to a hospital will have diabetes. The treatment of patients with diabetes who are admitted to the general medical wards of the hospital for a procedure or intercurrent illness is reviewed here. The treatment of hyperglycemia in critically ill patients, the perioperative management of diabetes, and the treatment of complications of the diabetes itself, such as diabetic ketoacidosis, are discussed separately. (See "Glycemic control and intensive insulin therapy in critical illness" and "Perioperative management of blood glucose in adults with diabetes mellitus" and "Diabetic ketoacidosis and hyperosmolar hyperglycemic state in adults: Treatment" and "Management of hypoglycemia during treatment of diabetes mellitus".) GOALS IN THE HOSPITAL SETTING The main goals in patients with diabetes needing hospitalization are to minimize disruption of the metabolic state, prevent adverse glycemic events (especially hypoglycemia), return the patient to a stable glycemic balance as quickly as possible, and ensure a smooth transition to outpatient care. These goals are not always easy to achieve. On the one hand, the stress of the acute illness tends to raise blood glucose concentrations. On the other hand, the anorexia that often a Continue reading >>

Managing Glucose Levels In Hospital Patients

Managing Glucose Levels In Hospital Patients

Managing glucose levels in hospital patients Author: Stacey A. Seggelke, MS, RN, ACNS-BC, BC-ADM, CDE, Over the last 25 years, more than twice as many patients have been discharged from U.S. hospitals with a diagnosis of diabetes mellitus (DM). In 2006, the number reached an estimated 5.2 million. The increase stems from many factors, including the overall rise in obesity, which parallels the increase in type 2 diabetes. Typically, about 25% of hospital patients have a diagnosis of DM or hyperglycemia during their hospital stay. Historically, managing hyperglycemia in the hospital has been seen as secondary to managing the admitting diagnosis. But a growing body of literature supports targeted glucose control, because hyperglycemia in hospital patients can prolong lengths of stay, increase the infection risk, and raise mortality. This article, which addresses glucose management in hospital patients who arent critically ill, is based largely on guidelines from the American Diabetes Association (ADA) and the American Association of Clinical Endocrinologists (AACE). Generally, hyperglycemia in hospital patients is classified as known DM, newly diagnosed DM, or stress hyperglycemia. Known DM applies to patients with preexisting type 1, type 2, or gestational diabetes. Newly diagnosed DM refers to patients newly diagnosed during their hospital stay who meet ADA diagnostic criteria. A hemoglobin A1c (HbA1c) level of 6.5% or higher indicates DM and reflects an average blood glucose (BG) level of 140 mg/dL. The HbA1c test indicates the average BG level over the preceding 2 to 3 months; an elevated HbA1c level indicates the patients BG level was high before admission. Hospital patients with HbA1c levels of 6.5% or higher usually are classified as newly diagnosed, even though th Continue reading >>

Perioperative Management Of The Diabetic Patient

Perioperative Management Of The Diabetic Patient

Perioperative Management of the Diabetic Patient Author: Mira Loh-Trivedi, PharmD; Chief Editor: William A Schwer, MD more... Diabetes mellitus (DM) is an increasingly common medical condition affecting approximately 8% of the population of the United States. Of these 25 million people, it is estimated that nearly 7 million are unaware that they have the disease until faced with associated complications. [ 1 , 2 ] The prevalence of DM is even greater in hospitalized patients. The American Diabetes Association conservatively estimates that 12-25% of hospitalized adult patients have diabetes mellitus (DM). With the increasing prevalence of diabetic patients undergoing surgery, and the increased risk of complications associated with diabetes mellitus, appropriate perioperative assessment and management are imperative. An estimated 25% of diabetic patients will require surgery. Mortality rates in diabetic patients have been estimated to be up to 5 times greater than in nondiabetic patients, often related to the end-organ damage caused by the disease. Chronic complications resulting in microangiopathy (retinopathy, nephropathy, and neuropathy) and macroangiopathy (atherosclerosis) directly increase the need for surgical intervention and the occurrence of surgical complications due to infections and vasculopathies. [ 3 , 4 , 5 , 6 ] Infections account for 66% of postoperative complications and nearly one quarter of perioperative deaths in patients with DM. Data suggest impaired leukocyte function, including altered chemotaxis and phagocytic activity. Tight control of serum glucose is important to minimize infection. In addition to postoperative infectious complications, postoperative myocardial ischemia is increased among patients with DM undergoing cardiac and noncardiac su Continue reading >>

Patient Instructions

Patient Instructions

Instructions for patients undergoing local anesthesia, nitrous oxide (laughing gas) sedation, oral (children and adult) anesthesia: You may have a light meal (oatmeal, cereal, toast with a small glass of juice) 2-4 hours before your scheduled appointment. For patients undergoing oral sedation, a friend or family member should accompany the patient to their appointment, stay in the doctors office during the procedure, escort the patient home and observe the patient for 24 hours. Instructions for intravenous (IV) sedation: Patients undergoing Intravenous (IV) Sedation should have nothing to eat or drink for 6-8 hours prior to their appointment. If your appointment is in the morning, please refrain from all meals and beverages after midnight. If your appointment is in the afternoon, please eat a light breakfast (cereal, oatmeal, toast with a glass of juice/coffee) 6 hours prior to your scheduled appointment. Patients should wear loose, comfortable clothing (workout pants/sweats pants/shorts, a short sleeved t-shirt and shoes without a heel) to your appointment and should get plenty of sleep the night before. Minors should always have a parent or legal guardian accompany them to their appointment. A friend or family member should accompany the patient to their appointment, stay in the doctors office during the procedure, escort the patient home and observe the patient for 24 hours. Daily/Routine Medications: Patients taking daily medications may take their medications at their normal times with a few small sips of water. Diabetic Patients undergoing Intravenous (IV) Sedation: Patients with Diabetes should attempt to schedule their appointments in the morning when possible. For Non-Insulin Dependent Diabetics undergoing Sedation: All oral agents (Metformin, Glipizide, Glybu Continue reading >>

Diabetic Npo Patient

Diabetic Npo Patient

#1 1 OK... one thing is inadequate fluids can lead to hemoconcentration....sort of like if you don't put enough water in the Koolaid- it's too sweet. The underlying problem leading to NPO could be an issue that elevates blood sugar d/t hormones released during stress responses; illness is a stressor that triggers stress hormones- it's a protective mechanism, but in diabetics, their hormones are already messed up, so added stress just makes the "normal" diabetic problems worse. Longterm insulin is the "base" that non-diabetics have normally with a healthy pancreas (blood sugar fluctuates all the time in everyone). The sliding scale is for the accuchek results and/or meals. You don't want to eliminate the base (or the blood sugar will rise more)- but some will decrease the dose, depending on what all is going on. Longterm insulin CAN cause hypoglycemia- but it's not common. I've been on Lantus for over 3 years- and never had a problem with the Lantus causing lows. The fast acting stuff is more likely to cause lows- but NPO will decrease that risk....but it's still there. If someone becomes too dehydrated, and doesn't have enough carbs, their muscle breaks down fat into ketones, which can be lethal (type I are more prone to this, but type II CAN develop ketoacidosis, rarely... typeII can develop HHNK- hyperglycemic hyper osmotic non-ketotic syndrome.... the ketones DON'T build up, but the symptoms are similar to DKA (that should all be in the chapter on diabetes). This is the same principal as the high-protein low-carb diets that go too far; ketones are toxins- and not meant to be the primary fuel of the brain. The brain ONLY uses glucose for energy- so sometimes the "normal" blood sugars are increased during illness to prevent the brain from being starved of fuel. Protein Continue reading >>

An 18-year-old Patient With Type 1 Diabetes Undergoing Surgery

An 18-year-old Patient With Type 1 Diabetes Undergoing Surgery

Description of Case An 18-year-old Caucasian male with type 1 diabetes presented to the emergency department complaining of severe left knee pain and swelling after sustaining a knee injury that occurred during a high school football match. Joint effusions were visible and palpable above the left knee, and there was significant loss of smooth motion of the knee, passively performed. Plain X rays showed no signs of fractures. The patient had had type 1 diabetes for six years, and his insulin regimen consisted of insulin glargine, 35 units at 8:00 p.m., and insulin lispro, 23 units at 8:00 a.m. and 16 units at 8:00 p.m. The patient had no apparent complications related to type 1 diabetes. On examination he was alert, his pulse was 76 bpm regular, and his blood pressure was 118/66 mm Hg. Recently, the patient had had frequent episodes of both hyperglycemia and hypoglycemia. However, he had never developed diabetic ketoacidosis (DKA). His recent HbA1c was 9.5%, demonstrating inadequate glycemic control. The patient was referred to an orthopedic surgeon, and arthroscopy was scheduled a few days later. A complex tear of the medial meniscus extending to the articular surfaces was diagnosed. Partial meniscectomy was recommended. (This procedure usually takes about one hour—nonetheless, the preoperative preparation for general anesthesia and the postoperative recovery may add several hours to this time.) When Would You Have This Patient Report to the Hospital? The Day before Surgery or the Morning of Surgery? This patient should be hospitalized no later than the evening before surgery, given his history of frequent episodes of hypo- and hyperglycemia and his poor glycemic control. This should allow for final optimization of glucose control before surgery. Ideally, frequent con Continue reading >>

Guidelines For Perioperative Management Of The Diabetic Patient

Guidelines For Perioperative Management Of The Diabetic Patient

Surgery Research and Practice Volume 2015 (2015), Article ID 284063, 8 pages 1Texas A&M Health Science Center, 8447 State Highway 47, Bryan, TX 77807, USA 2Division of Pulmonary, Critical Care & Sleep Medicine, Texas A&M Health Science Center, Corpus Christi, 1177 West Wheeler Avenue, Suite 1, Aransas Pass, TX 78336, USA Academic Editor: Roland S. Croner Copyright © 2015 Sivakumar Sudhakaran and Salim R. Surani. This is an open access article distributed under the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. Abstract Management of glycemic levels in the perioperative setting is critical, especially in diabetic patients. The effects of surgical stress and anesthesia have unique effects on blood glucose levels, which should be taken into consideration to maintain optimum glycemic control. Each stage of surgery presents unique challenges in keeping glucose levels within target range. Additionally, there are special operative conditions that require distinctive glucose management protocols. Interestingly, the literature still does not report a consensus perioperative glucose management strategy for diabetic patients. We hope to outline the most important factors required in formulating a perioperative diabetic regimen, while still allowing for specific adjustments using prudent clinical judgment. Overall, through careful glycemic management in perioperative patients, we may reduce morbidity and mortality and improve surgical outcomes. 1. Introduction Diabetes has classically been defined as a group of metabolic diseases characterized by hyperglycemia due to defects in insulin secretion, insulin action, or a combination of both [1]. The vast majority of di Continue reading >>

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