Society of Hospital Medicine (SHM): Hospital Medicine 2011 (SHM Annual Meeting)

GRAPEVINE, TEX. – Hospitalists don’t need to go out and do a lot of extra work to complete the Performance Practice Assessment portion of their maintenance of certification requirements.

Dr. Kelly J. Caverzagie, a hospitalist at Henry Ford Hospital who consults with the American Board of Internal Medicine on maintenance of certification (MOC) issues, said hospitalists can generally use work they are already doing to complete the Performance Practice Assessment, or Part 4, of the MOC process. Part 4 requires physicians to earn 20 points by completing either a Practice Improvement Module (PIM) or an Approved Quality Improvement (AQI) Pathway.

For hospitalists who are involved in a large-scale quality improvement project like the Society of Hospital Medicine’s Project BOOST (Better Outcomes for Older Adults Through Safe Transitions), they only need to complete the AQI project report, provide a description of the project, and report on their experience and the project’s impact. Physicians must have participated in the activity within the past 24 months and the sponsoring organization must verify their participation.

"The goal is to reduce the redundancy," Dr. Caverzagie said at the annual meeting of the Society of Hospital Medicine.

So far, the ABIM has preapproved Project BOOST, as well as the SHM’s VTE Prevention Collaborative and Glycemic Control Initiative project for the AQI Pathway. ABIM has approved a number of other quality improvement projects in other specialty areas.

Hospitalists also can receive MOC credit for quality improvement activities that are specific to their hospitals. For example, physicians who have access to aggregate quality data and are getting ready to begin a quality improvement project in their hospital can use the ABIM’s Self-Directed PIM. Those physicians who have completed their project within the past 24 months can use the Completed Project PIM.

With both of these PIMs, physicians have the chance to choose their own measures, as long as they have been approved or endorsed by a national organization like the National Quality Forum, are drawn from evidence-based guidelines, or are locally developed resource-use or process-efficiency measures. In addition to the hospital’s own data, physicians who are completing either the Self-Director or Completed-Project PIMs also can use data from health plans, medical societies, national or regional registries, and physician recognition programs, Dr. Caverzagie said.

Hospitalists also can use the hospital-based PIM, but that is being phased out and will eventually be rolled into the Self-Directed and Completed Project PIMs, Dr. Caverzagie advised.

Other PIMs that could be useful for hospitalists include the Clinical Supervision PIM for physicians who supervise trainees; the Communication With Referring Physicians PIM, which is helpful for hospitalists who work in a comanagement service or a preoperative clinic; and the Essentials of Quality Improvement PIM, which allows physicians with purely research or administrative roles to fulfill Part 4 requirements.

Dr. Caverzagie said that he had no conflicts to disclose.

GRAPEVINE, TEX. – Hospitalists don’t need to go out and do a lot of extra work to complete the Performance Practice Assessment portion of their maintenance of certification requirements.

Dr. Kelly J. Caverzagie, a hospitalist at Henry Ford Hospital who consults with the American Board of Internal Medicine on maintenance of certification (MOC) issues, said hospitalists can generally use work they are already doing to complete the Performance Practice Assessment, or Part 4, of the MOC process. Part 4 requires physicians to earn 20 points by completing either a Practice Improvement Module (PIM) or an Approved Quality Improvement (AQI) Pathway.

For hospitalists who are involved in a large-scale quality improvement project like the Society of Hospital Medicine’s Project BOOST (Better Outcomes for Older Adults Through Safe Transitions), they only need to complete the AQI project report, provide a description of the project, and report on their experience and the project’s impact. Physicians must have participated in the activity within the past 24 months and the sponsoring organization must verify their participation.

"The goal is to reduce the redundancy," Dr. Caverzagie said at the annual meeting of the Society of Hospital Medicine.

So far, the ABIM has preapproved Project BOOST, as well as the SHM’s VTE Prevention Collaborative and Glycemic Control Initiative project for the AQI Pathway. ABIM has approved a number of other quality improvement projects in other specialty areas.

Hospitalists also can receive MOC credit for quality improvement activities that are specific to their hospitals. For example, physicians who have access to aggregate quality data and are getting ready to begin a quality improvement project in their hospital can use the ABIM’s Self-Directed PIM. Those physicians who have completed their project within the past 24 months can use the Completed Project PIM.

With both of these PIMs, physicians have the chance to choose their own measures, as long as they have been approved or endorsed by a national organization like the National Quality Forum, are drawn from evidence-based guidelines, or are locally developed resource-use or process-efficiency measures. In addition to the hospital’s own data, physicians who are completing either the Self-Director or Completed-Project PIMs also can use data from health plans, medical societies, national or regional registries, and physician recognition programs, Dr. Caverzagie said.

Hospitalists also can use the hospital-based PIM, but that is being phased out and will eventually be rolled into the Self-Directed and Completed Project PIMs, Dr. Caverzagie advised.

Other PIMs that could be useful for hospitalists include the Clinical Supervision PIM for physicians who supervise trainees; the Communication With Referring Physicians PIM, which is helpful for hospitalists who work in a comanagement service or a preoperative clinic; and the Essentials of Quality Improvement PIM, which allows physicians with purely research or administrative roles to fulfill Part 4 requirements.

Dr. Caverzagie said that he had no conflicts to disclose.

GRAPEVINE, TEX. – Hospitalists don’t need to go out and do a lot of extra work to complete the Performance Practice Assessment portion of their maintenance of certification requirements.

Dr. Kelly J. Caverzagie, a hospitalist at Henry Ford Hospital who consults with the American Board of Internal Medicine on maintenance of certification (MOC) issues, said hospitalists can generally use work they are already doing to complete the Performance Practice Assessment, or Part 4, of the MOC process. Part 4 requires physicians to earn 20 points by completing either a Practice Improvement Module (PIM) or an Approved Quality Improvement (AQI) Pathway.

For hospitalists who are involved in a large-scale quality improvement project like the Society of Hospital Medicine’s Project BOOST (Better Outcomes for Older Adults Through Safe Transitions), they only need to complete the AQI project report, provide a description of the project, and report on their experience and the project’s impact. Physicians must have participated in the activity within the past 24 months and the sponsoring organization must verify their participation.

"The goal is to reduce the redundancy," Dr. Caverzagie said at the annual meeting of the Society of Hospital Medicine.

So far, the ABIM has preapproved Project BOOST, as well as the SHM’s VTE Prevention Collaborative and Glycemic Control Initiative project for the AQI Pathway. ABIM has approved a number of other quality improvement projects in other specialty areas.

Hospitalists also can receive MOC credit for quality improvement activities that are specific to their hospitals. For example, physicians who have access to aggregate quality data and are getting ready to begin a quality improvement project in their hospital can use the ABIM’s Self-Directed PIM. Those physicians who have completed their project within the past 24 months can use the Completed Project PIM.

With both of these PIMs, physicians have the chance to choose their own measures, as long as they have been approved or endorsed by a national organization like the National Quality Forum, are drawn from evidence-based guidelines, or are locally developed resource-use or process-efficiency measures. In addition to the hospital’s own data, physicians who are completing either the Self-Director or Completed-Project PIMs also can use data from health plans, medical societies, national or regional registries, and physician recognition programs, Dr. Caverzagie said.

Hospitalists also can use the hospital-based PIM, but that is being phased out and will eventually be rolled into the Self-Directed and Completed Project PIMs, Dr. Caverzagie advised.

Other PIMs that could be useful for hospitalists include the Clinical Supervision PIM for physicians who supervise trainees; the Communication With Referring Physicians PIM, which is helpful for hospitalists who work in a comanagement service or a preoperative clinic; and the Essentials of Quality Improvement PIM, which allows physicians with purely research or administrative roles to fulfill Part 4 requirements.

Dr. Caverzagie said that he had no conflicts to disclose.

GRAPEVINE, TEX. – Hospitalists will have new opportunities to show just how indispensable they are as the provisions of the Affordable Care Act go into effect, according to Dr. Robert Kocher, who helped formulate the health reform law that was enacted last year.

Dr. Kocher, an internist who previously served as a member of President Obama’s National Economic Council, said that hospital administrators will probably be looking to hospitalists to help them cope with elements of the health reform law, such as requirements to reduce readmissions and possible participation in accountable care organizations.

The Affordable Care Act also makes "productivity adjustments" that cut Medicare payments to hospitals, he said. As a result, hospitals will be under pressure to be as efficient as possible and hospitalists will be in a position to help cut costs in a number of ways, from reducing redundancies on care teams to improving hand offs, said Dr. Kocher, a principal at the Center for U.S. Health System Reform at McKinsey & Company.

Hospitalists also have an opportunity to show their worth as hospitals try to better use technology to drive down costs. "Technology lowers prices in every other part of the economy, but it doesn’t in health care," Dr. Kocher said. "There’s no reason why that shouldn’t be possible in health care."

And physicians shouldn’t drag their feet when it comes to preparing for the implementation of the Affordable Care Act, because, despite efforts to repeal the law, Dr. Kocher predicted that it is here to stay. "I doubt this Congress is going to meaningfully change the law," he said.

The one place where the law could be threatened right now is in the courts, he said. There are several challenges to the law winding their way through the federal court system, and legal experts expect that the issue of the law’s constitutionality will end up before the Supreme Court at some point.

A ruling from the high court is likely to be very close, but it’s unclear what direction it will go in, Dr. Kocher said. But even if the court were to strike down the law’s mandate that individuals purchase health insurance, there are other ways, short of a mandate, that the government could use to incentivize people to buy coverage, he added.

GRAPEVINE, TEX. – Hospitalists will have new opportunities to show just how indispensable they are as the provisions of the Affordable Care Act go into effect, according to Dr. Robert Kocher, who helped formulate the health reform law that was enacted last year.

Dr. Kocher, an internist who previously served as a member of President Obama’s National Economic Council, said that hospital administrators will probably be looking to hospitalists to help them cope with elements of the health reform law, such as requirements to reduce readmissions and possible participation in accountable care organizations.

The Affordable Care Act also makes "productivity adjustments" that cut Medicare payments to hospitals, he said. As a result, hospitals will be under pressure to be as efficient as possible and hospitalists will be in a position to help cut costs in a number of ways, from reducing redundancies on care teams to improving hand offs, said Dr. Kocher, a principal at the Center for U.S. Health System Reform at McKinsey & Company.

Hospitalists also have an opportunity to show their worth as hospitals try to better use technology to drive down costs. "Technology lowers prices in every other part of the economy, but it doesn’t in health care," Dr. Kocher said. "There’s no reason why that shouldn’t be possible in health care."

And physicians shouldn’t drag their feet when it comes to preparing for the implementation of the Affordable Care Act, because, despite efforts to repeal the law, Dr. Kocher predicted that it is here to stay. "I doubt this Congress is going to meaningfully change the law," he said.

The one place where the law could be threatened right now is in the courts, he said. There are several challenges to the law winding their way through the federal court system, and legal experts expect that the issue of the law’s constitutionality will end up before the Supreme Court at some point.

A ruling from the high court is likely to be very close, but it’s unclear what direction it will go in, Dr. Kocher said. But even if the court were to strike down the law’s mandate that individuals purchase health insurance, there are other ways, short of a mandate, that the government could use to incentivize people to buy coverage, he added.

GRAPEVINE, TEX. – Hospitalists will have new opportunities to show just how indispensable they are as the provisions of the Affordable Care Act go into effect, according to Dr. Robert Kocher, who helped formulate the health reform law that was enacted last year.

Dr. Kocher, an internist who previously served as a member of President Obama’s National Economic Council, said that hospital administrators will probably be looking to hospitalists to help them cope with elements of the health reform law, such as requirements to reduce readmissions and possible participation in accountable care organizations.

The Affordable Care Act also makes "productivity adjustments" that cut Medicare payments to hospitals, he said. As a result, hospitals will be under pressure to be as efficient as possible and hospitalists will be in a position to help cut costs in a number of ways, from reducing redundancies on care teams to improving hand offs, said Dr. Kocher, a principal at the Center for U.S. Health System Reform at McKinsey & Company.

Hospitalists also have an opportunity to show their worth as hospitals try to better use technology to drive down costs. "Technology lowers prices in every other part of the economy, but it doesn’t in health care," Dr. Kocher said. "There’s no reason why that shouldn’t be possible in health care."

And physicians shouldn’t drag their feet when it comes to preparing for the implementation of the Affordable Care Act, because, despite efforts to repeal the law, Dr. Kocher predicted that it is here to stay. "I doubt this Congress is going to meaningfully change the law," he said.

The one place where the law could be threatened right now is in the courts, he said. There are several challenges to the law winding their way through the federal court system, and legal experts expect that the issue of the law’s constitutionality will end up before the Supreme Court at some point.

A ruling from the high court is likely to be very close, but it’s unclear what direction it will go in, Dr. Kocher said. But even if the court were to strike down the law’s mandate that individuals purchase health insurance, there are other ways, short of a mandate, that the government could use to incentivize people to buy coverage, he added.

GRAPEVINE, TEX. – Convulsive status epilepticus is a medical emergency that requires quick thinking and quick action to protect the patient from both acute and long-term damage.

Convulsive seizures can be strong enough to break bones, Dr. David Likosky said at the annual meeting of the Society of Hospital Medicine. They can acutely endanger the patient and, if not controlled, pave the way for more frequent episodes.

Experts now recognize that repeated seizures can cause brain injury that increases the risk of more seizures, "kindling is the idea that the more seizures you have, the more likely you are to have them," said Dr. Likosky, a neurohospitalist and director of the stroke program at Evergreen Medical Center in Kirkland, Wash. "There is even some evidence that patients who have repeated convulsive status can develop areas of gliosis over time."

The definition of status epilepticus has changed somewhat recently, he said. "It used to be a seizure lasting more than 20-30 minutes or frequent seizures without a return to a normal level of consciousness in between. Now most neurologists will call any seizure that lasts more than 5 minutes status and treat [as if it is] status," according to Dr. Likosky, who has developed an algorhithm for treating convulsive status epilepticus in the emergency department.

These events are not rare, with more than 152,000 cases presenting each year, resulting in about 42,000 deaths. "The odds are that you are going to see one of these at some time, and you need to be able to treat it."

Status doesn’t occur only in patients with a known epilepsy diagnosis. Infections, tumors, brain abscess, traumatic brain injury, metabolic derangement, and drug overdose can all precipitate an event. For patients with an epilepsy diagnosis, a frequent cause is medication noncompliance.

"Convulsive status is a medical emergency," Dr. Likosky said. "The repeated seizures cause a huge amount of metabolic stress, which can even lead to a mycoardial infarction."

The rapid cycling between convulsive and nonconvulsive states can cause hypotension. Strong muscle contractions can result in hypoxia and metabolic acidosis and actually put enough torque on the bones to crack them. Patients can go into shock, and all of these things complicate an already-dire situation.

Dr. Likosky’s treatment algorithm is similar to one published this year in the journal Neurohospitalist. Dr. Edward Manno, a neurointensivist at the Cerebrovascular Center in Cleveland, created a decision tree outlining the treatment process step by step (Neurohospitalist 2011;1:23-31).

As in most emergency situations, the first step is to maintain an open airway, using pulse oximetry and cardiac monitoring to measure vitals. A quick glucose test is necessary because hypoglycemia can be at the root of a seizure storm.

Intravenous benzodiazepines are the first level of treatment. Lorazepam, diazepam, and midazolam are frequently employed. Although all are effective, a 2001 study found that lorazepam was more effective than diazepam in treating status epilepticus (N. Engl. J. Med. 2001;345:631-7).

"A new study is looking at the effectiveness of intramuscular midazolam that can be given by medics, or even at home," Dr. Likosky said. The results should be available later this year.

Sometimes patients in status require a fairly large drug dose to stop the seizures. "Since the underlying point is to treat aggressively and quickly, underdosing really hurts these patients. People vary, for example, in how much lorazepam to give. Some give 2 mg and some give 4 mg, but don’t be shy about increasing it to 6 or even 8, Dr. Likosky said."

If the patient doesn’t respond to initial benzodiazepine treatment, the next step is to administer fosphenytoin intravenously. "The key here is that one size does not fit all. You can’t just give 1 g. What you want is 18-20 mg/kg. The most important thing is to get [the patient] to a good level, and you may even give an additional dose on top of that," increasing to 30 mg/kg if necessary.

If this doesn’t arrest the seizure, phenobarbital or pentobarbital are in order. "Keep in mind that they cause respiratory suppression, especially when given in high doses to someone who has already had a benzodiazepine. If you haven’t intubated the patient before this, you have to do it now, prophylactically, in case breathing stops."

Other antiepileptic medications should be tried next. An intravenous loading dose of valproic acid (20-25 mg/kg) or levetiracetam (500-1,000 mg) are two possible choices.

Refractory status occurs when a patient fails benzodiazepine, phenytoin, and antiseizure medications. "This is when you start thinking about anesthetics. You need to titrate these according to the EEG." Propofol, midazolam infusion, pentobarbital, or ketamine are possibilities here.

"Keep in mind you do not want a neuromuscular blockade," Dr. Likosky said. "It’s easy to stop convulsions [via paralysis] but it doesn’t really do what you want," which is normalizing the EEG.

The goal for the EEG changes is a transformation of the spike/wave epileptiform pattern to burst suppression – a pattern of flatter lines interrupted by bursts of electrical discharge. Motor symptoms are not a reliable indicator of ongoing seizure activity.

Several studies have shown that EEG status can persist after motor symptoms resolve, Dr. Likosky said. A 1996 study highlights this phenomenon. Of 164 patients treated for convulsive status epilepticus, 48% still showed persistent electrographic seizure activity after their motor seizures ceased (Epilepsia 1998;39:833-40).

These patients must be treated aggressively with regular lightening of sedating medications, accompanied by an assessment of their clinical picture and EEG findings.

Dr. Likosky reported having no financial disclosures relevant to his lecture.

GRAPEVINE, TEX. – Convulsive status epilepticus is a medical emergency that requires quick thinking and quick action to protect the patient from both acute and long-term damage.

Convulsive seizures can be strong enough to break bones, Dr. David Likosky said at the annual meeting of the Society of Hospital Medicine. They can acutely endanger the patient and, if not controlled, pave the way for more frequent episodes.

Experts now recognize that repeated seizures can cause brain injury that increases the risk of more seizures, "kindling is the idea that the more seizures you have, the more likely you are to have them," said Dr. Likosky, a neurohospitalist and director of the stroke program at Evergreen Medical Center in Kirkland, Wash. "There is even some evidence that patients who have repeated convulsive status can develop areas of gliosis over time."

The definition of status epilepticus has changed somewhat recently, he said. "It used to be a seizure lasting more than 20-30 minutes or frequent seizures without a return to a normal level of consciousness in between. Now most neurologists will call any seizure that lasts more than 5 minutes status and treat [as if it is] status," according to Dr. Likosky, who has developed an algorhithm for treating convulsive status epilepticus in the emergency department.

These events are not rare, with more than 152,000 cases presenting each year, resulting in about 42,000 deaths. "The odds are that you are going to see one of these at some time, and you need to be able to treat it."

Status doesn’t occur only in patients with a known epilepsy diagnosis. Infections, tumors, brain abscess, traumatic brain injury, metabolic derangement, and drug overdose can all precipitate an event. For patients with an epilepsy diagnosis, a frequent cause is medication noncompliance.

"Convulsive status is a medical emergency," Dr. Likosky said. "The repeated seizures cause a huge amount of metabolic stress, which can even lead to a mycoardial infarction."

The rapid cycling between convulsive and nonconvulsive states can cause hypotension. Strong muscle contractions can result in hypoxia and metabolic acidosis and actually put enough torque on the bones to crack them. Patients can go into shock, and all of these things complicate an already-dire situation.

Dr. Likosky’s treatment algorithm is similar to one published this year in the journal Neurohospitalist. Dr. Edward Manno, a neurointensivist at the Cerebrovascular Center in Cleveland, created a decision tree outlining the treatment process step by step (Neurohospitalist 2011;1:23-31).

As in most emergency situations, the first step is to maintain an open airway, using pulse oximetry and cardiac monitoring to measure vitals. A quick glucose test is necessary because hypoglycemia can be at the root of a seizure storm.

Intravenous benzodiazepines are the first level of treatment. Lorazepam, diazepam, and midazolam are frequently employed. Although all are effective, a 2001 study found that lorazepam was more effective than diazepam in treating status epilepticus (N. Engl. J. Med. 2001;345:631-7).

"A new study is looking at the effectiveness of intramuscular midazolam that can be given by medics, or even at home," Dr. Likosky said. The results should be available later this year.

Sometimes patients in status require a fairly large drug dose to stop the seizures. "Since the underlying point is to treat aggressively and quickly, underdosing really hurts these patients. People vary, for example, in how much lorazepam to give. Some give 2 mg and some give 4 mg, but don’t be shy about increasing it to 6 or even 8, Dr. Likosky said."

If the patient doesn’t respond to initial benzodiazepine treatment, the next step is to administer fosphenytoin intravenously. "The key here is that one size does not fit all. You can’t just give 1 g. What you want is 18-20 mg/kg. The most important thing is to get [the patient] to a good level, and you may even give an additional dose on top of that," increasing to 30 mg/kg if necessary.

If this doesn’t arrest the seizure, phenobarbital or pentobarbital are in order. "Keep in mind that they cause respiratory suppression, especially when given in high doses to someone who has already had a benzodiazepine. If you haven’t intubated the patient before this, you have to do it now, prophylactically, in case breathing stops."

Other antiepileptic medications should be tried next. An intravenous loading dose of valproic acid (20-25 mg/kg) or levetiracetam (500-1,000 mg) are two possible choices.

Refractory status occurs when a patient fails benzodiazepine, phenytoin, and antiseizure medications. "This is when you start thinking about anesthetics. You need to titrate these according to the EEG." Propofol, midazolam infusion, pentobarbital, or ketamine are possibilities here.

"Keep in mind you do not want a neuromuscular blockade," Dr. Likosky said. "It’s easy to stop convulsions [via paralysis] but it doesn’t really do what you want," which is normalizing the EEG.

The goal for the EEG changes is a transformation of the spike/wave epileptiform pattern to burst suppression – a pattern of flatter lines interrupted by bursts of electrical discharge. Motor symptoms are not a reliable indicator of ongoing seizure activity.

Several studies have shown that EEG status can persist after motor symptoms resolve, Dr. Likosky said. A 1996 study highlights this phenomenon. Of 164 patients treated for convulsive status epilepticus, 48% still showed persistent electrographic seizure activity after their motor seizures ceased (Epilepsia 1998;39:833-40).

These patients must be treated aggressively with regular lightening of sedating medications, accompanied by an assessment of their clinical picture and EEG findings.

Dr. Likosky reported having no financial disclosures relevant to his lecture.

GRAPEVINE, TEX. – Convulsive status epilepticus is a medical emergency that requires quick thinking and quick action to protect the patient from both acute and long-term damage.

Convulsive seizures can be strong enough to break bones, Dr. David Likosky said at the annual meeting of the Society of Hospital Medicine. They can acutely endanger the patient and, if not controlled, pave the way for more frequent episodes.

Experts now recognize that repeated seizures can cause brain injury that increases the risk of more seizures, "kindling is the idea that the more seizures you have, the more likely you are to have them," said Dr. Likosky, a neurohospitalist and director of the stroke program at Evergreen Medical Center in Kirkland, Wash. "There is even some evidence that patients who have repeated convulsive status can develop areas of gliosis over time."

The definition of status epilepticus has changed somewhat recently, he said. "It used to be a seizure lasting more than 20-30 minutes or frequent seizures without a return to a normal level of consciousness in between. Now most neurologists will call any seizure that lasts more than 5 minutes status and treat [as if it is] status," according to Dr. Likosky, who has developed an algorhithm for treating convulsive status epilepticus in the emergency department.

These events are not rare, with more than 152,000 cases presenting each year, resulting in about 42,000 deaths. "The odds are that you are going to see one of these at some time, and you need to be able to treat it."

Status doesn’t occur only in patients with a known epilepsy diagnosis. Infections, tumors, brain abscess, traumatic brain injury, metabolic derangement, and drug overdose can all precipitate an event. For patients with an epilepsy diagnosis, a frequent cause is medication noncompliance.

"Convulsive status is a medical emergency," Dr. Likosky said. "The repeated seizures cause a huge amount of metabolic stress, which can even lead to a mycoardial infarction."

The rapid cycling between convulsive and nonconvulsive states can cause hypotension. Strong muscle contractions can result in hypoxia and metabolic acidosis and actually put enough torque on the bones to crack them. Patients can go into shock, and all of these things complicate an already-dire situation.

Dr. Likosky’s treatment algorithm is similar to one published this year in the journal Neurohospitalist. Dr. Edward Manno, a neurointensivist at the Cerebrovascular Center in Cleveland, created a decision tree outlining the treatment process step by step (Neurohospitalist 2011;1:23-31).

As in most emergency situations, the first step is to maintain an open airway, using pulse oximetry and cardiac monitoring to measure vitals. A quick glucose test is necessary because hypoglycemia can be at the root of a seizure storm.

Intravenous benzodiazepines are the first level of treatment. Lorazepam, diazepam, and midazolam are frequently employed. Although all are effective, a 2001 study found that lorazepam was more effective than diazepam in treating status epilepticus (N. Engl. J. Med. 2001;345:631-7).

"A new study is looking at the effectiveness of intramuscular midazolam that can be given by medics, or even at home," Dr. Likosky said. The results should be available later this year.

Sometimes patients in status require a fairly large drug dose to stop the seizures. "Since the underlying point is to treat aggressively and quickly, underdosing really hurts these patients. People vary, for example, in how much lorazepam to give. Some give 2 mg and some give 4 mg, but don’t be shy about increasing it to 6 or even 8, Dr. Likosky said."

If the patient doesn’t respond to initial benzodiazepine treatment, the next step is to administer fosphenytoin intravenously. "The key here is that one size does not fit all. You can’t just give 1 g. What you want is 18-20 mg/kg. The most important thing is to get [the patient] to a good level, and you may even give an additional dose on top of that," increasing to 30 mg/kg if necessary.

If this doesn’t arrest the seizure, phenobarbital or pentobarbital are in order. "Keep in mind that they cause respiratory suppression, especially when given in high doses to someone who has already had a benzodiazepine. If you haven’t intubated the patient before this, you have to do it now, prophylactically, in case breathing stops."

Other antiepileptic medications should be tried next. An intravenous loading dose of valproic acid (20-25 mg/kg) or levetiracetam (500-1,000 mg) are two possible choices.

Refractory status occurs when a patient fails benzodiazepine, phenytoin, and antiseizure medications. "This is when you start thinking about anesthetics. You need to titrate these according to the EEG." Propofol, midazolam infusion, pentobarbital, or ketamine are possibilities here.

"Keep in mind you do not want a neuromuscular blockade," Dr. Likosky said. "It’s easy to stop convulsions [via paralysis] but it doesn’t really do what you want," which is normalizing the EEG.

The goal for the EEG changes is a transformation of the spike/wave epileptiform pattern to burst suppression – a pattern of flatter lines interrupted by bursts of electrical discharge. Motor symptoms are not a reliable indicator of ongoing seizure activity.

Several studies have shown that EEG status can persist after motor symptoms resolve, Dr. Likosky said. A 1996 study highlights this phenomenon. Of 164 patients treated for convulsive status epilepticus, 48% still showed persistent electrographic seizure activity after their motor seizures ceased (Epilepsia 1998;39:833-40).

These patients must be treated aggressively with regular lightening of sedating medications, accompanied by an assessment of their clinical picture and EEG findings.

Dr. Likosky reported having no financial disclosures relevant to his lecture.

GRAPEVINE, TEX. – Convulsive status epilepticus is a medical emergency that requires quick thinking and quick action to protect the patient from both acute and long-term damage.

Convulsive seizures can be strong enough to break bones, Dr. David Likosky said at the annual meeting of the Society of Hospital Medicine. They can acutely endanger the patient and, if not controlled, pave the way for more frequent episodes.

Experts now recognize that repeated seizures can cause brain injury that increases the risk of more seizures, "kindling is the idea that the more seizures you have, the more likely you are to have them," said Dr. Likosky, a neurohospitalist and director of the stroke program at Evergreen Medical Center in Kirkland, Wash. "There is even some evidence that patients who have repeated convulsive status can develop areas of gliosis over time."

The definition of status epilepticus has changed somewhat recently, he said. "It used to be a seizure lasting more than 20-30 minutes or frequent seizures without a return to a normal level of consciousness in between. Now most neurologists will call any seizure that lasts more than 5 minutes status and treat [as if it is] status," according to Dr. Likosky, who has developed an algorhithm for treating convulsive status epilepticus in the emergency department.

These events are not rare, with more than 152,000 cases presenting each year, resulting in about 42,000 deaths. "The odds are that you are going to see one of these at some time, and you need to be able to treat it."

Status doesn’t occur only in patients with a known epilepsy diagnosis. Infections, tumors, brain abscess, traumatic brain injury, metabolic derangement, and drug overdose can all precipitate an event. For patients with an epilepsy diagnosis, a frequent cause is medication noncompliance.

"Convulsive status is a medical emergency," Dr. Likosky said. "The repeated seizures cause a huge amount of metabolic stress, which can even lead to a mycoardial infarction."

The rapid cycling between convulsive and nonconvulsive states can cause hypotension. Strong muscle contractions can result in hypoxia and metabolic acidosis and actually put enough torque on the bones to crack them. Patients can go into shock, and all of these things complicate an already-dire situation.

Dr. Likosky’s treatment algorithm is similar to one published this year in the journal Neurohospitalist. Dr. Edward Manno, a neurointensivist at the Cerebrovascular Center in Cleveland, created a decision tree outlining the treatment process step by step (Neurohospitalist 2011;1:23-31).

As in most emergency situations, the first step is to maintain an open airway, using pulse oximetry and cardiac monitoring to measure vitals. A quick glucose test is necessary because hypoglycemia can be at the root of a seizure storm.

Intravenous benzodiazepines are the first level of treatment. Lorazepam, diazepam, and midazolam are frequently employed. Although all are effective, a 2001 study found that lorazepam was more effective than diazepam in treating status epilepticus (N. Engl. J. Med. 2001;345:631-7).

"A new study is looking at the effectiveness of intramuscular midazolam that can be given by medics, or even at home," Dr. Likosky said. The results should be available later this year.

Sometimes patients in status require a fairly large drug dose to stop the seizures. "Since the underlying point is to treat aggressively and quickly, underdosing really hurts these patients. People vary, for example, in how much lorazepam to give. Some give 2 mg and some give 4 mg, but don’t be shy about increasing it to 6 or even 8, Dr. Likosky said."

If the patient doesn’t respond to initial benzodiazepine treatment, the next step is to administer fosphenytoin intravenously. "The key here is that one size does not fit all. You can’t just give 1 g. What you want is 18-20 mg/kg. The most important thing is to get [the patient] to a good level, and you may even give an additional dose on top of that," increasing to 30 mg/kg if necessary.

If this doesn’t arrest the seizure, phenobarbital or pentobarbital are in order. "Keep in mind that they cause respiratory suppression, especially when given in high doses to someone who has already had a benzodiazepine. If you haven’t intubated the patient before this, you have to do it now, prophylactically, in case breathing stops."

Other antiepileptic medications should be tried next. An intravenous loading dose of valproic acid (20-25 mg/kg) or levetiracetam (500-1,000 mg) are two possible choices.

Refractory status occurs when a patient fails benzodiazepine, phenytoin, and antiseizure medications. "This is when you start thinking about anesthetics. You need to titrate these according to the EEG." Propofol, midazolam infusion, pentobarbital, or ketamine are possibilities here.

"Keep in mind you do not want a neuromuscular blockade," Dr. Likosky said. "It’s easy to stop convulsions [via paralysis] but it doesn’t really do what you want," which is normalizing the EEG.

The goal for the EEG changes is a transformation of the spike/wave epileptiform pattern to burst suppression – a pattern of flatter lines interrupted by bursts of electrical discharge. Motor symptoms are not a reliable indicator of ongoing seizure activity.

Several studies have shown that EEG status can persist after motor symptoms resolve, Dr. Likosky said. A 1996 study highlights this phenomenon. Of 164 patients treated for convulsive status epilepticus, 48% still showed persistent electrographic seizure activity after their motor seizures ceased (Epilepsia 1998;39:833-40).

These patients must be treated aggressively with regular lightening of sedating medications, accompanied by an assessment of their clinical picture and EEG findings.

Dr. Likosky reported having no financial disclosures relevant to his lecture.

GRAPEVINE, TEX. – Convulsive status epilepticus is a medical emergency that requires quick thinking and quick action to protect the patient from both acute and long-term damage.

Convulsive seizures can be strong enough to break bones, Dr. David Likosky said at the annual meeting of the Society of Hospital Medicine. They can acutely endanger the patient and, if not controlled, pave the way for more frequent episodes.

Experts now recognize that repeated seizures can cause brain injury that increases the risk of more seizures, "kindling is the idea that the more seizures you have, the more likely you are to have them," said Dr. Likosky, a neurohospitalist and director of the stroke program at Evergreen Medical Center in Kirkland, Wash. "There is even some evidence that patients who have repeated convulsive status can develop areas of gliosis over time."

The definition of status epilepticus has changed somewhat recently, he said. "It used to be a seizure lasting more than 20-30 minutes or frequent seizures without a return to a normal level of consciousness in between. Now most neurologists will call any seizure that lasts more than 5 minutes status and treat [as if it is] status," according to Dr. Likosky, who has developed an algorhithm for treating convulsive status epilepticus in the emergency department.

These events are not rare, with more than 152,000 cases presenting each year, resulting in about 42,000 deaths. "The odds are that you are going to see one of these at some time, and you need to be able to treat it."

Status doesn’t occur only in patients with a known epilepsy diagnosis. Infections, tumors, brain abscess, traumatic brain injury, metabolic derangement, and drug overdose can all precipitate an event. For patients with an epilepsy diagnosis, a frequent cause is medication noncompliance.

"Convulsive status is a medical emergency," Dr. Likosky said. "The repeated seizures cause a huge amount of metabolic stress, which can even lead to a mycoardial infarction."

The rapid cycling between convulsive and nonconvulsive states can cause hypotension. Strong muscle contractions can result in hypoxia and metabolic acidosis and actually put enough torque on the bones to crack them. Patients can go into shock, and all of these things complicate an already-dire situation.

Dr. Likosky’s treatment algorithm is similar to one published this year in the journal Neurohospitalist. Dr. Edward Manno, a neurointensivist at the Cerebrovascular Center in Cleveland, created a decision tree outlining the treatment process step by step (Neurohospitalist 2011;1:23-31).

As in most emergency situations, the first step is to maintain an open airway, using pulse oximetry and cardiac monitoring to measure vitals. A quick glucose test is necessary because hypoglycemia can be at the root of a seizure storm.

Intravenous benzodiazepines are the first level of treatment. Lorazepam, diazepam, and midazolam are frequently employed. Although all are effective, a 2001 study found that lorazepam was more effective than diazepam in treating status epilepticus (N. Engl. J. Med. 2001;345:631-7).

"A new study is looking at the effectiveness of intramuscular midazolam that can be given by medics, or even at home," Dr. Likosky said. The results should be available later this year.

Sometimes patients in status require a fairly large drug dose to stop the seizures. "Since the underlying point is to treat aggressively and quickly, underdosing really hurts these patients. People vary, for example, in how much lorazepam to give. Some give 2 mg and some give 4 mg, but don’t be shy about increasing it to 6 or even 8, Dr. Likosky said."

If the patient doesn’t respond to initial benzodiazepine treatment, the next step is to administer fosphenytoin intravenously. "The key here is that one size does not fit all. You can’t just give 1 g. What you want is 18-20 mg/kg. The most important thing is to get [the patient] to a good level, and you may even give an additional dose on top of that," increasing to 30 mg/kg if necessary.

If this doesn’t arrest the seizure, phenobarbital or pentobarbital are in order. "Keep in mind that they cause respiratory suppression, especially when given in high doses to someone who has already had a benzodiazepine. If you haven’t intubated the patient before this, you have to do it now, prophylactically, in case breathing stops."

Other antiepileptic medications should be tried next. An intravenous loading dose of valproic acid (20-25 mg/kg) or levetiracetam (500-1,000 mg) are two possible choices.

Refractory status occurs when a patient fails benzodiazepine, phenytoin, and antiseizure medications. "This is when you start thinking about anesthetics. You need to titrate these according to the EEG." Propofol, midazolam infusion, pentobarbital, or ketamine are possibilities here.

"Keep in mind you do not want a neuromuscular blockade," Dr. Likosky said. "It’s easy to stop convulsions [via paralysis] but it doesn’t really do what you want," which is normalizing the EEG.

The goal for the EEG changes is a transformation of the spike/wave epileptiform pattern to burst suppression – a pattern of flatter lines interrupted by bursts of electrical discharge. Motor symptoms are not a reliable indicator of ongoing seizure activity.

Several studies have shown that EEG status can persist after motor symptoms resolve, Dr. Likosky said. A 1996 study highlights this phenomenon. Of 164 patients treated for convulsive status epilepticus, 48% still showed persistent electrographic seizure activity after their motor seizures ceased (Epilepsia 1998;39:833-40).

These patients must be treated aggressively with regular lightening of sedating medications, accompanied by an assessment of their clinical picture and EEG findings.

Dr. Likosky reported having no financial disclosures relevant to his lecture.

GRAPEVINE, TEX. – Convulsive status epilepticus is a medical emergency that requires quick thinking and quick action to protect the patient from both acute and long-term damage.

Convulsive seizures can be strong enough to break bones, Dr. David Likosky said at the annual meeting of the Society of Hospital Medicine. They can acutely endanger the patient and, if not controlled, pave the way for more frequent episodes.

Experts now recognize that repeated seizures can cause brain injury that increases the risk of more seizures, "kindling is the idea that the more seizures you have, the more likely you are to have them," said Dr. Likosky, a neurohospitalist and director of the stroke program at Evergreen Medical Center in Kirkland, Wash. "There is even some evidence that patients who have repeated convulsive status can develop areas of gliosis over time."

The definition of status epilepticus has changed somewhat recently, he said. "It used to be a seizure lasting more than 20-30 minutes or frequent seizures without a return to a normal level of consciousness in between. Now most neurologists will call any seizure that lasts more than 5 minutes status and treat [as if it is] status," according to Dr. Likosky, who has developed an algorhithm for treating convulsive status epilepticus in the emergency department.

These events are not rare, with more than 152,000 cases presenting each year, resulting in about 42,000 deaths. "The odds are that you are going to see one of these at some time, and you need to be able to treat it."

Status doesn’t occur only in patients with a known epilepsy diagnosis. Infections, tumors, brain abscess, traumatic brain injury, metabolic derangement, and drug overdose can all precipitate an event. For patients with an epilepsy diagnosis, a frequent cause is medication noncompliance.

"Convulsive status is a medical emergency," Dr. Likosky said. "The repeated seizures cause a huge amount of metabolic stress, which can even lead to a mycoardial infarction."

The rapid cycling between convulsive and nonconvulsive states can cause hypotension. Strong muscle contractions can result in hypoxia and metabolic acidosis and actually put enough torque on the bones to crack them. Patients can go into shock, and all of these things complicate an already-dire situation.

Dr. Likosky’s treatment algorithm is similar to one published this year in the journal Neurohospitalist. Dr. Edward Manno, a neurointensivist at the Cerebrovascular Center in Cleveland, created a decision tree outlining the treatment process step by step (Neurohospitalist 2011;1:23-31).

As in most emergency situations, the first step is to maintain an open airway, using pulse oximetry and cardiac monitoring to measure vitals. A quick glucose test is necessary because hypoglycemia can be at the root of a seizure storm.

Intravenous benzodiazepines are the first level of treatment. Lorazepam, diazepam, and midazolam are frequently employed. Although all are effective, a 2001 study found that lorazepam was more effective than diazepam in treating status epilepticus (N. Engl. J. Med. 2001;345:631-7).

"A new study is looking at the effectiveness of intramuscular midazolam that can be given by medics, or even at home," Dr. Likosky said. The results should be available later this year.

Sometimes patients in status require a fairly large drug dose to stop the seizures. "Since the underlying point is to treat aggressively and quickly, underdosing really hurts these patients. People vary, for example, in how much lorazepam to give. Some give 2 mg and some give 4 mg, but don’t be shy about increasing it to 6 or even 8, Dr. Likosky said."

If the patient doesn’t respond to initial benzodiazepine treatment, the next step is to administer fosphenytoin intravenously. "The key here is that one size does not fit all. You can’t just give 1 g. What you want is 18-20 mg/kg. The most important thing is to get [the patient] to a good level, and you may even give an additional dose on top of that," increasing to 30 mg/kg if necessary.

If this doesn’t arrest the seizure, phenobarbital or pentobarbital are in order. "Keep in mind that they cause respiratory suppression, especially when given in high doses to someone who has already had a benzodiazepine. If you haven’t intubated the patient before this, you have to do it now, prophylactically, in case breathing stops."

Other antiepileptic medications should be tried next. An intravenous loading dose of valproic acid (20-25 mg/kg) or levetiracetam (500-1,000 mg) are two possible choices.

Refractory status occurs when a patient fails benzodiazepine, phenytoin, and antiseizure medications. "This is when you start thinking about anesthetics. You need to titrate these according to the EEG." Propofol, midazolam infusion, pentobarbital, or ketamine are possibilities here.

"Keep in mind you do not want a neuromuscular blockade," Dr. Likosky said. "It’s easy to stop convulsions [via paralysis] but it doesn’t really do what you want," which is normalizing the EEG.

The goal for the EEG changes is a transformation of the spike/wave epileptiform pattern to burst suppression – a pattern of flatter lines interrupted by bursts of electrical discharge. Motor symptoms are not a reliable indicator of ongoing seizure activity.

Several studies have shown that EEG status can persist after motor symptoms resolve, Dr. Likosky said. A 1996 study highlights this phenomenon. Of 164 patients treated for convulsive status epilepticus, 48% still showed persistent electrographic seizure activity after their motor seizures ceased (Epilepsia 1998;39:833-40).

These patients must be treated aggressively with regular lightening of sedating medications, accompanied by an assessment of their clinical picture and EEG findings.

Dr. Likosky reported having no financial disclosures relevant to his lecture.

GRAPEVINE, TEX. – Convulsive status epilepticus is a medical emergency that requires quick thinking and quick action to protect the patient from both acute and long-term damage.

Convulsive seizures can be strong enough to break bones, Dr. David Likosky said at the annual meeting of the Society of Hospital Medicine. They can acutely endanger the patient and, if not controlled, pave the way for more frequent episodes.

Experts now recognize that repeated seizures can cause brain injury that increases the risk of more seizures, "kindling is the idea that the more seizures you have, the more likely you are to have them," said Dr. Likosky, a neurohospitalist and director of the stroke program at Evergreen Medical Center in Kirkland, Wash. "There is even some evidence that patients who have repeated convulsive status can develop areas of gliosis over time."

The definition of status epilepticus has changed somewhat recently, he said. "It used to be a seizure lasting more than 20-30 minutes or frequent seizures without a return to a normal level of consciousness in between. Now most neurologists will call any seizure that lasts more than 5 minutes status and treat [as if it is] status," according to Dr. Likosky, who has developed an algorhithm for treating convulsive status epilepticus in the emergency department.

These events are not rare, with more than 152,000 cases presenting each year, resulting in about 42,000 deaths. "The odds are that you are going to see one of these at some time, and you need to be able to treat it."

Status doesn’t occur only in patients with a known epilepsy diagnosis. Infections, tumors, brain abscess, traumatic brain injury, metabolic derangement, and drug overdose can all precipitate an event. For patients with an epilepsy diagnosis, a frequent cause is medication noncompliance.

"Convulsive status is a medical emergency," Dr. Likosky said. "The repeated seizures cause a huge amount of metabolic stress, which can even lead to a mycoardial infarction."

The rapid cycling between convulsive and nonconvulsive states can cause hypotension. Strong muscle contractions can result in hypoxia and metabolic acidosis and actually put enough torque on the bones to crack them. Patients can go into shock, and all of these things complicate an already-dire situation.

Dr. Likosky’s treatment algorithm is similar to one published this year in the journal Neurohospitalist. Dr. Edward Manno, a neurointensivist at the Cerebrovascular Center in Cleveland, created a decision tree outlining the treatment process step by step (Neurohospitalist 2011;1:23-31).

As in most emergency situations, the first step is to maintain an open airway, using pulse oximetry and cardiac monitoring to measure vitals. A quick glucose test is necessary because hypoglycemia can be at the root of a seizure storm.

Intravenous benzodiazepines are the first level of treatment. Lorazepam, diazepam, and midazolam are frequently employed. Although all are effective, a 2001 study found that lorazepam was more effective than diazepam in treating status epilepticus (N. Engl. J. Med. 2001;345:631-7).

"A new study is looking at the effectiveness of intramuscular midazolam that can be given by medics, or even at home," Dr. Likosky said. The results should be available later this year.

Sometimes patients in status require a fairly large drug dose to stop the seizures. "Since the underlying point is to treat aggressively and quickly, underdosing really hurts these patients. People vary, for example, in how much lorazepam to give. Some give 2 mg and some give 4 mg, but don’t be shy about increasing it to 6 or even 8, Dr. Likosky said."

If the patient doesn’t respond to initial benzodiazepine treatment, the next step is to administer fosphenytoin intravenously. "The key here is that one size does not fit all. You can’t just give 1 g. What you want is 18-20 mg/kg. The most important thing is to get [the patient] to a good level, and you may even give an additional dose on top of that," increasing to 30 mg/kg if necessary.

If this doesn’t arrest the seizure, phenobarbital or pentobarbital are in order. "Keep in mind that they cause respiratory suppression, especially when given in high doses to someone who has already had a benzodiazepine. If you haven’t intubated the patient before this, you have to do it now, prophylactically, in case breathing stops."

Other antiepileptic medications should be tried next. An intravenous loading dose of valproic acid (20-25 mg/kg) or levetiracetam (500-1,000 mg) are two possible choices.

Refractory status occurs when a patient fails benzodiazepine, phenytoin, and antiseizure medications. "This is when you start thinking about anesthetics. You need to titrate these according to the EEG." Propofol, midazolam infusion, pentobarbital, or ketamine are possibilities here.

"Keep in mind you do not want a neuromuscular blockade," Dr. Likosky said. "It’s easy to stop convulsions [via paralysis] but it doesn’t really do what you want," which is normalizing the EEG.

The goal for the EEG changes is a transformation of the spike/wave epileptiform pattern to burst suppression – a pattern of flatter lines interrupted by bursts of electrical discharge. Motor symptoms are not a reliable indicator of ongoing seizure activity.

Several studies have shown that EEG status can persist after motor symptoms resolve, Dr. Likosky said. A 1996 study highlights this phenomenon. Of 164 patients treated for convulsive status epilepticus, 48% still showed persistent electrographic seizure activity after their motor seizures ceased (Epilepsia 1998;39:833-40).

These patients must be treated aggressively with regular lightening of sedating medications, accompanied by an assessment of their clinical picture and EEG findings.

Dr. Likosky reported having no financial disclosures relevant to his lecture.

GRAPEVINE, TEX. – Convulsive status epilepticus is a medical emergency that requires quick thinking and quick action to protect the patient from both acute and long-term damage.

Convulsive seizures can be strong enough to break bones, Dr. David Likosky said at the annual meeting of the Society of Hospital Medicine. They can acutely endanger the patient and, if not controlled, pave the way for more frequent episodes.

Experts now recognize that repeated seizures can cause brain injury that increases the risk of more seizures, "kindling is the idea that the more seizures you have, the more likely you are to have them," said Dr. Likosky, a neurohospitalist and director of the stroke program at Evergreen Medical Center in Kirkland, Wash. "There is even some evidence that patients who have repeated convulsive status can develop areas of gliosis over time."

The definition of status epilepticus has changed somewhat recently, he said. "It used to be a seizure lasting more than 20-30 minutes or frequent seizures without a return to a normal level of consciousness in between. Now most neurologists will call any seizure that lasts more than 5 minutes status and treat [as if it is] status," according to Dr. Likosky, who has developed an algorhithm for treating convulsive status epilepticus in the emergency department.

These events are not rare, with more than 152,000 cases presenting each year, resulting in about 42,000 deaths. "The odds are that you are going to see one of these at some time, and you need to be able to treat it."

Status doesn’t occur only in patients with a known epilepsy diagnosis. Infections, tumors, brain abscess, traumatic brain injury, metabolic derangement, and drug overdose can all precipitate an event. For patients with an epilepsy diagnosis, a frequent cause is medication noncompliance.

"Convulsive status is a medical emergency," Dr. Likosky said. "The repeated seizures cause a huge amount of metabolic stress, which can even lead to a mycoardial infarction."

The rapid cycling between convulsive and nonconvulsive states can cause hypotension. Strong muscle contractions can result in hypoxia and metabolic acidosis and actually put enough torque on the bones to crack them. Patients can go into shock, and all of these things complicate an already-dire situation.

Dr. Likosky’s treatment algorithm is similar to one published this year in the journal Neurohospitalist. Dr. Edward Manno, a neurointensivist at the Cerebrovascular Center in Cleveland, created a decision tree outlining the treatment process step by step (Neurohospitalist 2011;1:23-31).

As in most emergency situations, the first step is to maintain an open airway, using pulse oximetry and cardiac monitoring to measure vitals. A quick glucose test is necessary because hypoglycemia can be at the root of a seizure storm.

Intravenous benzodiazepines are the first level of treatment. Lorazepam, diazepam, and midazolam are frequently employed. Although all are effective, a 2001 study found that lorazepam was more effective than diazepam in treating status epilepticus (N. Engl. J. Med. 2001;345:631-7).

"A new study is looking at the effectiveness of intramuscular midazolam that can be given by medics, or even at home," Dr. Likosky said. The results should be available later this year.

Sometimes patients in status require a fairly large drug dose to stop the seizures. "Since the underlying point is to treat aggressively and quickly, underdosing really hurts these patients. People vary, for example, in how much lorazepam to give. Some give 2 mg and some give 4 mg, but don’t be shy about increasing it to 6 or even 8, Dr. Likosky said."

If the patient doesn’t respond to initial benzodiazepine treatment, the next step is to administer fosphenytoin intravenously. "The key here is that one size does not fit all. You can’t just give 1 g. What you want is 18-20 mg/kg. The most important thing is to get [the patient] to a good level, and you may even give an additional dose on top of that," increasing to 30 mg/kg if necessary.

If this doesn’t arrest the seizure, phenobarbital or pentobarbital are in order. "Keep in mind that they cause respiratory suppression, especially when given in high doses to someone who has already had a benzodiazepine. If you haven’t intubated the patient before this, you have to do it now, prophylactically, in case breathing stops."

Other antiepileptic medications should be tried next. An intravenous loading dose of valproic acid (20-25 mg/kg) or levetiracetam (500-1,000 mg) are two possible choices.

Refractory status occurs when a patient fails benzodiazepine, phenytoin, and antiseizure medications. "This is when you start thinking about anesthetics. You need to titrate these according to the EEG." Propofol, midazolam infusion, pentobarbital, or ketamine are possibilities here.

"Keep in mind you do not want a neuromuscular blockade," Dr. Likosky said. "It’s easy to stop convulsions [via paralysis] but it doesn’t really do what you want," which is normalizing the EEG.

The goal for the EEG changes is a transformation of the spike/wave epileptiform pattern to burst suppression – a pattern of flatter lines interrupted by bursts of electrical discharge. Motor symptoms are not a reliable indicator of ongoing seizure activity.

Several studies have shown that EEG status can persist after motor symptoms resolve, Dr. Likosky said. A 1996 study highlights this phenomenon. Of 164 patients treated for convulsive status epilepticus, 48% still showed persistent electrographic seizure activity after their motor seizures ceased (Epilepsia 1998;39:833-40).

These patients must be treated aggressively with regular lightening of sedating medications, accompanied by an assessment of their clinical picture and EEG findings.

Dr. Likosky reported having no financial disclosures relevant to his lecture.

GRAPEVINE, TEX. – Convulsive status epilepticus is a medical emergency that requires quick thinking and quick action to protect the patient from both acute and long-term damage.

Convulsive seizures can be strong enough to break bones, Dr. David Likosky said at the annual meeting of the Society of Hospital Medicine. They can acutely endanger the patient and, if not controlled, pave the way for more frequent episodes.

Experts now recognize that repeated seizures can cause brain injury that increases the risk of more seizures, "kindling is the idea that the more seizures you have, the more likely you are to have them," said Dr. Likosky, a neurohospitalist and director of the stroke program at Evergreen Medical Center in Kirkland, Wash. "There is even some evidence that patients who have repeated convulsive status can develop areas of gliosis over time."

The definition of status epilepticus has changed somewhat recently, he said. "It used to be a seizure lasting more than 20-30 minutes or frequent seizures without a return to a normal level of consciousness in between. Now most neurologists will call any seizure that lasts more than 5 minutes status and treat [as if it is] status," according to Dr. Likosky, who has developed an algorhithm for treating convulsive status epilepticus in the emergency department.

These events are not rare, with more than 152,000 cases presenting each year, resulting in about 42,000 deaths. "The odds are that you are going to see one of these at some time, and you need to be able to treat it."

Status doesn’t occur only in patients with a known epilepsy diagnosis. Infections, tumors, brain abscess, traumatic brain injury, metabolic derangement, and drug overdose can all precipitate an event. For patients with an epilepsy diagnosis, a frequent cause is medication noncompliance.

"Convulsive status is a medical emergency," Dr. Likosky said. "The repeated seizures cause a huge amount of metabolic stress, which can even lead to a mycoardial infarction."

The rapid cycling between convulsive and nonconvulsive states can cause hypotension. Strong muscle contractions can result in hypoxia and metabolic acidosis and actually put enough torque on the bones to crack them. Patients can go into shock, and all of these things complicate an already-dire situation.

Dr. Likosky’s treatment algorithm is similar to one published this year in the journal Neurohospitalist. Dr. Edward Manno, a neurointensivist at the Cerebrovascular Center in Cleveland, created a decision tree outlining the treatment process step by step (Neurohospitalist 2011;1:23-31).

As in most emergency situations, the first step is to maintain an open airway, using pulse oximetry and cardiac monitoring to measure vitals. A quick glucose test is necessary because hypoglycemia can be at the root of a seizure storm.

Intravenous benzodiazepines are the first level of treatment. Lorazepam, diazepam, and midazolam are frequently employed. Although all are effective, a 2001 study found that lorazepam was more effective than diazepam in treating status epilepticus (N. Engl. J. Med. 2001;345:631-7).

"A new study is looking at the effectiveness of intramuscular midazolam that can be given by medics, or even at home," Dr. Likosky said. The results should be available later this year.

Sometimes patients in status require a fairly large drug dose to stop the seizures. "Since the underlying point is to treat aggressively and quickly, underdosing really hurts these patients. People vary, for example, in how much lorazepam to give. Some give 2 mg and some give 4 mg, but don’t be shy about increasing it to 6 or even 8, Dr. Likosky said."

If the patient doesn’t respond to initial benzodiazepine treatment, the next step is to administer fosphenytoin intravenously. "The key here is that one size does not fit all. You can’t just give 1 g. What you want is 18-20 mg/kg. The most important thing is to get [the patient] to a good level, and you may even give an additional dose on top of that," increasing to 30 mg/kg if necessary.

If this doesn’t arrest the seizure, phenobarbital or pentobarbital are in order. "Keep in mind that they cause respiratory suppression, especially when given in high doses to someone who has already had a benzodiazepine. If you haven’t intubated the patient before this, you have to do it now, prophylactically, in case breathing stops."

Other antiepileptic medications should be tried next. An intravenous loading dose of valproic acid (20-25 mg/kg) or levetiracetam (500-1,000 mg) are two possible choices.

Refractory status occurs when a patient fails benzodiazepine, phenytoin, and antiseizure medications. "This is when you start thinking about anesthetics. You need to titrate these according to the EEG." Propofol, midazolam infusion, pentobarbital, or ketamine are possibilities here.

"Keep in mind you do not want a neuromuscular blockade," Dr. Likosky said. "It’s easy to stop convulsions [via paralysis] but it doesn’t really do what you want," which is normalizing the EEG.

The goal for the EEG changes is a transformation of the spike/wave epileptiform pattern to burst suppression – a pattern of flatter lines interrupted by bursts of electrical discharge. Motor symptoms are not a reliable indicator of ongoing seizure activity.

Several studies have shown that EEG status can persist after motor symptoms resolve, Dr. Likosky said. A 1996 study highlights this phenomenon. Of 164 patients treated for convulsive status epilepticus, 48% still showed persistent electrographic seizure activity after their motor seizures ceased (Epilepsia 1998;39:833-40).

These patients must be treated aggressively with regular lightening of sedating medications, accompanied by an assessment of their clinical picture and EEG findings.

Dr. Likosky reported having no financial disclosures relevant to his lecture.

GRAPEVINE, TEX.  – The time to start an effective diabetes discharge plan is the moment the hyperglycemic patient is admitted to the hospital.

"I’m making a plea for the idea that a successful transition from the hospital to home begins with patient admission," Dr. John MacIndoe said at the annual meeting of the Society of Hospital Medicine.

Getting a hemoglobin A_1C on every hyperglycemic patient is a critical part of the plan. "With this information, we have a crystal ball in our hands. Almost all of the decisions we need to make about glycemic control are based on that very important thing we should do on admission: Get the HbA_1c. That is a window into the 3 months prior to admission, telling you what the baseline glucose was before the patient became ill."

But even with the best clinical information, there’s no point in designing a diabetes discharge plan to which the patient can’t adhere because of financial or social barriers. "Identify patients with issues that will complicate their outpatient diabetes management, because what you send them home on has to work well for them."

Financial barriers (lack of health insurance or very high insurance deductibles) have become ever more common over the past few years, said Dr. MacIndoe of the HealthPartners Medical Group and Clinics in Minneapolis. Social barriers might include poor home support, difficulty with getting to the pharmacy or doctor’s office, and substance abuse problems that interfere with any kind of self-care.

"When you see these, it’s critical to get diabetes educators and social services involved [to] try to overcome those problems. Get the issues out on the table early and you have a much better shot at identifying the solution."

The baseline HbA_1c is a key piece of information in determining a patient’s diabetes status during the hospitalization. "This allows you to identify the patient with a history of diabetes, the patient who has prediabetes or undiagnosed diabetes, and the one who develops temporary hyperglycemia simply from stress related to their illness, either before or during hospitalization. Regardless of the etiology, they all need to be treated aggressively to get the blood sugar in that target range."

But as the acute illness subsides, so may the need for insulin. "During recovery, patients almost always need less, and sometimes they need none at all. Use that admission HbA_1c to predict predischarge and outpatient needs."

Dr. MacIndoe offered the following scenarios based on the admission HbA_1c:

• Below 5.7%. These patients "don’t have diabetes and don’t need insulin. So take them off any insulin and monitor for 24 hours, and send them home with nothing to worry about."

• 5.8%-6.5%. "This person has a high risk for diabetes, but should be able to get off insulin entirely. You should recommend lifestyle changes [such as exercising and losing weight], because the data suggest that over time these patients are likely to develop diabetes, and lifestyle changes can prevent or postpone that." The American Diabetes Association now recommends adding metformin to the regimen of a prediabetic patient if the patient is younger than 60 years and overweight, he said.

• 6.6%-6.9%. "This is a person with well-controlled diabetes. If newly diagnosed, this patient needs to learn how to improve his lifestyle to maintain this control. And obviously, if it is a patient with established diabetes, you should send them home on whatever regimen they came in on, because it’s working."

• 7%-10%. "A level like this at admission means that diabetes is not well-controlled. If this is a new diagnosis, I usually send the patient home on an oral agent that won’t cause hypoglycemia. If it’s a known diabetic patient, you have an opportunely to make a difference here by increasing their regimen, either with orals or with insulin."

• 10% or higher. "This is urgently uncontrolled diabetes. Even though we’re loathe to start insulin on an inpatient before discharge, this is one time we would." This situation often requires repeat conversations and connection with diabetes educators, Dr. MacIndoe added. "People are not really in the frame of mind to comprehend what this all means," when they’re admitted. "Get them to see the educator as soon as they can understand what’s going on."

But even the best discharge plan won’t help if the patient doesn’t follow though because of financial or social issues. "Don’t forget, they have to be able to afford it. If they can’t, they are not likely to tell you so. They just won’t get it filled and will probably find themselves back" in the emergency department.

"Most of us really don’t have a clue about the real costs of medications, supplies, strips, lancets, lab tests, and medical office copays," he continued. "The average price of a blood glucose strip is $1.25. If you’re telling them to test four times a day, that’s $140 a month and almost $1,700 a year, if they test the way they should."

Going generic with medications can help patients save money and boost the chance of successful management. "This [name brand] stuff is not cheap. Patients can get a month of generic metformin and sulfonylurea options at a discount pharmacy for $4, or 3 months for $10."

Analog insulins are considerably more expensive than "good old NPH [isophane insulin] and regular insulin," Dr. MacIndoe said. "Given that fact, I would strongly suggest that you consider sending the patient with financial barriers home on NPH and regular because of its affordability. This combination will work if the patient remembers to eat regularly, particularly at lunch and snack time."

Finally, he said, get these patients back for a follow-up within 2 weeks of discharge. "It’s critical that they be seen 7-14 days afterward, particularly if they’re on a new regimen. It’s usually easier to get them to the diabetes educator, since most physicians are too busy, or too focused on the main reason they were in the hospital rather than [on] their diabetes."

Dr. MacIndoe disclosed that he is on the speakers bureau of Sanofi-Aventis.

GRAPEVINE, TEX.  – The time to start an effective diabetes discharge plan is the moment the hyperglycemic patient is admitted to the hospital.

"I’m making a plea for the idea that a successful transition from the hospital to home begins with patient admission," Dr. John MacIndoe said at the annual meeting of the Society of Hospital Medicine.

Getting a hemoglobin A_1C on every hyperglycemic patient is a critical part of the plan. "With this information, we have a crystal ball in our hands. Almost all of the decisions we need to make about glycemic control are based on that very important thing we should do on admission: Get the HbA_1c. That is a window into the 3 months prior to admission, telling you what the baseline glucose was before the patient became ill."

But even with the best clinical information, there’s no point in designing a diabetes discharge plan to which the patient can’t adhere because of financial or social barriers. "Identify patients with issues that will complicate their outpatient diabetes management, because what you send them home on has to work well for them."

Financial barriers (lack of health insurance or very high insurance deductibles) have become ever more common over the past few years, said Dr. MacIndoe of the HealthPartners Medical Group and Clinics in Minneapolis. Social barriers might include poor home support, difficulty with getting to the pharmacy or doctor’s office, and substance abuse problems that interfere with any kind of self-care.

"When you see these, it’s critical to get diabetes educators and social services involved [to] try to overcome those problems. Get the issues out on the table early and you have a much better shot at identifying the solution."

The baseline HbA_1c is a key piece of information in determining a patient’s diabetes status during the hospitalization. "This allows you to identify the patient with a history of diabetes, the patient who has prediabetes or undiagnosed diabetes, and the one who develops temporary hyperglycemia simply from stress related to their illness, either before or during hospitalization. Regardless of the etiology, they all need to be treated aggressively to get the blood sugar in that target range."

But as the acute illness subsides, so may the need for insulin. "During recovery, patients almost always need less, and sometimes they need none at all. Use that admission HbA_1c to predict predischarge and outpatient needs."

Dr. MacIndoe offered the following scenarios based on the admission HbA_1c:

• Below 5.7%. These patients "don’t have diabetes and don’t need insulin. So take them off any insulin and monitor for 24 hours, and send them home with nothing to worry about."

• 5.8%-6.5%. "This person has a high risk for diabetes, but should be able to get off insulin entirely. You should recommend lifestyle changes [such as exercising and losing weight], because the data suggest that over time these patients are likely to develop diabetes, and lifestyle changes can prevent or postpone that." The American Diabetes Association now recommends adding metformin to the regimen of a prediabetic patient if the patient is younger than 60 years and overweight, he said.

• 6.6%-6.9%. "This is a person with well-controlled diabetes. If newly diagnosed, this patient needs to learn how to improve his lifestyle to maintain this control. And obviously, if it is a patient with established diabetes, you should send them home on whatever regimen they came in on, because it’s working."

• 7%-10%. "A level like this at admission means that diabetes is not well-controlled. If this is a new diagnosis, I usually send the patient home on an oral agent that won’t cause hypoglycemia. If it’s a known diabetic patient, you have an opportunely to make a difference here by increasing their regimen, either with orals or with insulin."

• 10% or higher. "This is urgently uncontrolled diabetes. Even though we’re loathe to start insulin on an inpatient before discharge, this is one time we would." This situation often requires repeat conversations and connection with diabetes educators, Dr. MacIndoe added. "People are not really in the frame of mind to comprehend what this all means," when they’re admitted. "Get them to see the educator as soon as they can understand what’s going on."

But even the best discharge plan won’t help if the patient doesn’t follow though because of financial or social issues. "Don’t forget, they have to be able to afford it. If they can’t, they are not likely to tell you so. They just won’t get it filled and will probably find themselves back" in the emergency department.

"Most of us really don’t have a clue about the real costs of medications, supplies, strips, lancets, lab tests, and medical office copays," he continued. "The average price of a blood glucose strip is $1.25. If you’re telling them to test four times a day, that’s $140 a month and almost $1,700 a year, if they test the way they should."

Going generic with medications can help patients save money and boost the chance of successful management. "This [name brand] stuff is not cheap. Patients can get a month of generic metformin and sulfonylurea options at a discount pharmacy for $4, or 3 months for $10."

Analog insulins are considerably more expensive than "good old NPH [isophane insulin] and regular insulin," Dr. MacIndoe said. "Given that fact, I would strongly suggest that you consider sending the patient with financial barriers home on NPH and regular because of its affordability. This combination will work if the patient remembers to eat regularly, particularly at lunch and snack time."

Finally, he said, get these patients back for a follow-up within 2 weeks of discharge. "It’s critical that they be seen 7-14 days afterward, particularly if they’re on a new regimen. It’s usually easier to get them to the diabetes educator, since most physicians are too busy, or too focused on the main reason they were in the hospital rather than [on] their diabetes."

Dr. MacIndoe disclosed that he is on the speakers bureau of Sanofi-Aventis.

GRAPEVINE, TEX.  – The time to start an effective diabetes discharge plan is the moment the hyperglycemic patient is admitted to the hospital.

"I’m making a plea for the idea that a successful transition from the hospital to home begins with patient admission," Dr. John MacIndoe said at the annual meeting of the Society of Hospital Medicine.

Getting a hemoglobin A_1C on every hyperglycemic patient is a critical part of the plan. "With this information, we have a crystal ball in our hands. Almost all of the decisions we need to make about glycemic control are based on that very important thing we should do on admission: Get the HbA_1c. That is a window into the 3 months prior to admission, telling you what the baseline glucose was before the patient became ill."

But even with the best clinical information, there’s no point in designing a diabetes discharge plan to which the patient can’t adhere because of financial or social barriers. "Identify patients with issues that will complicate their outpatient diabetes management, because what you send them home on has to work well for them."

Financial barriers (lack of health insurance or very high insurance deductibles) have become ever more common over the past few years, said Dr. MacIndoe of the HealthPartners Medical Group and Clinics in Minneapolis. Social barriers might include poor home support, difficulty with getting to the pharmacy or doctor’s office, and substance abuse problems that interfere with any kind of self-care.

"When you see these, it’s critical to get diabetes educators and social services involved [to] try to overcome those problems. Get the issues out on the table early and you have a much better shot at identifying the solution."

The baseline HbA_1c is a key piece of information in determining a patient’s diabetes status during the hospitalization. "This allows you to identify the patient with a history of diabetes, the patient who has prediabetes or undiagnosed diabetes, and the one who develops temporary hyperglycemia simply from stress related to their illness, either before or during hospitalization. Regardless of the etiology, they all need to be treated aggressively to get the blood sugar in that target range."

But as the acute illness subsides, so may the need for insulin. "During recovery, patients almost always need less, and sometimes they need none at all. Use that admission HbA_1c to predict predischarge and outpatient needs."

Dr. MacIndoe offered the following scenarios based on the admission HbA_1c:

• Below 5.7%. These patients "don’t have diabetes and don’t need insulin. So take them off any insulin and monitor for 24 hours, and send them home with nothing to worry about."

• 5.8%-6.5%. "This person has a high risk for diabetes, but should be able to get off insulin entirely. You should recommend lifestyle changes [such as exercising and losing weight], because the data suggest that over time these patients are likely to develop diabetes, and lifestyle changes can prevent or postpone that." The American Diabetes Association now recommends adding metformin to the regimen of a prediabetic patient if the patient is younger than 60 years and overweight, he said.

• 6.6%-6.9%. "This is a person with well-controlled diabetes. If newly diagnosed, this patient needs to learn how to improve his lifestyle to maintain this control. And obviously, if it is a patient with established diabetes, you should send them home on whatever regimen they came in on, because it’s working."

• 7%-10%. "A level like this at admission means that diabetes is not well-controlled. If this is a new diagnosis, I usually send the patient home on an oral agent that won’t cause hypoglycemia. If it’s a known diabetic patient, you have an opportunely to make a difference here by increasing their regimen, either with orals or with insulin."

• 10% or higher. "This is urgently uncontrolled diabetes. Even though we’re loathe to start insulin on an inpatient before discharge, this is one time we would." This situation often requires repeat conversations and connection with diabetes educators, Dr. MacIndoe added. "People are not really in the frame of mind to comprehend what this all means," when they’re admitted. "Get them to see the educator as soon as they can understand what’s going on."

But even the best discharge plan won’t help if the patient doesn’t follow though because of financial or social issues. "Don’t forget, they have to be able to afford it. If they can’t, they are not likely to tell you so. They just won’t get it filled and will probably find themselves back" in the emergency department.

"Most of us really don’t have a clue about the real costs of medications, supplies, strips, lancets, lab tests, and medical office copays," he continued. "The average price of a blood glucose strip is $1.25. If you’re telling them to test four times a day, that’s $140 a month and almost $1,700 a year, if they test the way they should."

Going generic with medications can help patients save money and boost the chance of successful management. "This [name brand] stuff is not cheap. Patients can get a month of generic metformin and sulfonylurea options at a discount pharmacy for $4, or 3 months for $10."

Analog insulins are considerably more expensive than "good old NPH [isophane insulin] and regular insulin," Dr. MacIndoe said. "Given that fact, I would strongly suggest that you consider sending the patient with financial barriers home on NPH and regular because of its affordability. This combination will work if the patient remembers to eat regularly, particularly at lunch and snack time."

Finally, he said, get these patients back for a follow-up within 2 weeks of discharge. "It’s critical that they be seen 7-14 days afterward, particularly if they’re on a new regimen. It’s usually easier to get them to the diabetes educator, since most physicians are too busy, or too focused on the main reason they were in the hospital rather than [on] their diabetes."

Dr. MacIndoe disclosed that he is on the speakers bureau of Sanofi-Aventis.

GRAPEVINE, TEX.  – The time to start an effective diabetes discharge plan is the moment the hyperglycemic patient is admitted to the hospital.

"I’m making a plea for the idea that a successful transition from the hospital to home begins with patient admission," Dr. John MacIndoe said at the annual meeting of the Society of Hospital Medicine.

Getting a hemoglobin A_1C on every hyperglycemic patient is a critical part of the plan. "With this information, we have a crystal ball in our hands. Almost all of the decisions we need to make about glycemic control are based on that very important thing we should do on admission: Get the HbA_1c. That is a window into the 3 months prior to admission, telling you what the baseline glucose was before the patient became ill."

But even with the best clinical information, there’s no point in designing a diabetes discharge plan to which the patient can’t adhere because of financial or social barriers. "Identify patients with issues that will complicate their outpatient diabetes management, because what you send them home on has to work well for them."

Financial barriers (lack of health insurance or very high insurance deductibles) have become ever more common over the past few years, said Dr. MacIndoe of the HealthPartners Medical Group and Clinics in Minneapolis. Social barriers might include poor home support, difficulty with getting to the pharmacy or doctor’s office, and substance abuse problems that interfere with any kind of self-care.

"When you see these, it’s critical to get diabetes educators and social services involved [to] try to overcome those problems. Get the issues out on the table early and you have a much better shot at identifying the solution."

The baseline HbA_1c is a key piece of information in determining a patient’s diabetes status during the hospitalization. "This allows you to identify the patient with a history of diabetes, the patient who has prediabetes or undiagnosed diabetes, and the one who develops temporary hyperglycemia simply from stress related to their illness, either before or during hospitalization. Regardless of the etiology, they all need to be treated aggressively to get the blood sugar in that target range."

But as the acute illness subsides, so may the need for insulin. "During recovery, patients almost always need less, and sometimes they need none at all. Use that admission HbA_1c to predict predischarge and outpatient needs."

Dr. MacIndoe offered the following scenarios based on the admission HbA_1c:

• Below 5.7%. These patients "don’t have diabetes and don’t need insulin. So take them off any insulin and monitor for 24 hours, and send them home with nothing to worry about."

• 5.8%-6.5%. "This person has a high risk for diabetes, but should be able to get off insulin entirely. You should recommend lifestyle changes [such as exercising and losing weight], because the data suggest that over time these patients are likely to develop diabetes, and lifestyle changes can prevent or postpone that." The American Diabetes Association now recommends adding metformin to the regimen of a prediabetic patient if the patient is younger than 60 years and overweight, he said.

• 6.6%-6.9%. "This is a person with well-controlled diabetes. If newly diagnosed, this patient needs to learn how to improve his lifestyle to maintain this control. And obviously, if it is a patient with established diabetes, you should send them home on whatever regimen they came in on, because it’s working."

• 7%-10%. "A level like this at admission means that diabetes is not well-controlled. If this is a new diagnosis, I usually send the patient home on an oral agent that won’t cause hypoglycemia. If it’s a known diabetic patient, you have an opportunely to make a difference here by increasing their regimen, either with orals or with insulin."

• 10% or higher. "This is urgently uncontrolled diabetes. Even though we’re loathe to start insulin on an inpatient before discharge, this is one time we would." This situation often requires repeat conversations and connection with diabetes educators, Dr. MacIndoe added. "People are not really in the frame of mind to comprehend what this all means," when they’re admitted. "Get them to see the educator as soon as they can understand what’s going on."

But even the best discharge plan won’t help if the patient doesn’t follow though because of financial or social issues. "Don’t forget, they have to be able to afford it. If they can’t, they are not likely to tell you so. They just won’t get it filled and will probably find themselves back" in the emergency department.

"Most of us really don’t have a clue about the real costs of medications, supplies, strips, lancets, lab tests, and medical office copays," he continued. "The average price of a blood glucose strip is $1.25. If you’re telling them to test four times a day, that’s $140 a month and almost $1,700 a year, if they test the way they should."

Going generic with medications can help patients save money and boost the chance of successful management. "This [name brand] stuff is not cheap. Patients can get a month of generic metformin and sulfonylurea options at a discount pharmacy for $4, or 3 months for $10."

Analog insulins are considerably more expensive than "good old NPH [isophane insulin] and regular insulin," Dr. MacIndoe said. "Given that fact, I would strongly suggest that you consider sending the patient with financial barriers home on NPH and regular because of its affordability. This combination will work if the patient remembers to eat regularly, particularly at lunch and snack time."

Finally, he said, get these patients back for a follow-up within 2 weeks of discharge. "It’s critical that they be seen 7-14 days afterward, particularly if they’re on a new regimen. It’s usually easier to get them to the diabetes educator, since most physicians are too busy, or too focused on the main reason they were in the hospital rather than [on] their diabetes."

Dr. MacIndoe disclosed that he is on the speakers bureau of Sanofi-Aventis.

GRAPEVINE, TEX.  – The time to start an effective diabetes discharge plan is the moment the hyperglycemic patient is admitted to the hospital.

"I’m making a plea for the idea that a successful transition from the hospital to home begins with patient admission," Dr. John MacIndoe said at the annual meeting of the Society of Hospital Medicine.

Getting a hemoglobin A_1C on every hyperglycemic patient is a critical part of the plan. "With this information, we have a crystal ball in our hands. Almost all of the decisions we need to make about glycemic control are based on that very important thing we should do on admission: Get the HbA_1c. That is a window into the 3 months prior to admission, telling you what the baseline glucose was before the patient became ill."

But even with the best clinical information, there’s no point in designing a diabetes discharge plan to which the patient can’t adhere because of financial or social barriers. "Identify patients with issues that will complicate their outpatient diabetes management, because what you send them home on has to work well for them."

Financial barriers (lack of health insurance or very high insurance deductibles) have become ever more common over the past few years, said Dr. MacIndoe of the HealthPartners Medical Group and Clinics in Minneapolis. Social barriers might include poor home support, difficulty with getting to the pharmacy or doctor’s office, and substance abuse problems that interfere with any kind of self-care.

"When you see these, it’s critical to get diabetes educators and social services involved [to] try to overcome those problems. Get the issues out on the table early and you have a much better shot at identifying the solution."

The baseline HbA_1c is a key piece of information in determining a patient’s diabetes status during the hospitalization. "This allows you to identify the patient with a history of diabetes, the patient who has prediabetes or undiagnosed diabetes, and the one who develops temporary hyperglycemia simply from stress related to their illness, either before or during hospitalization. Regardless of the etiology, they all need to be treated aggressively to get the blood sugar in that target range."

But as the acute illness subsides, so may the need for insulin. "During recovery, patients almost always need less, and sometimes they need none at all. Use that admission HbA_1c to predict predischarge and outpatient needs."

Dr. MacIndoe offered the following scenarios based on the admission HbA_1c:

• Below 5.7%. These patients "don’t have diabetes and don’t need insulin. So take them off any insulin and monitor for 24 hours, and send them home with nothing to worry about."

• 5.8%-6.5%. "This person has a high risk for diabetes, but should be able to get off insulin entirely. You should recommend lifestyle changes [such as exercising and losing weight], because the data suggest that over time these patients are likely to develop diabetes, and lifestyle changes can prevent or postpone that." The American Diabetes Association now recommends adding metformin to the regimen of a prediabetic patient if the patient is younger than 60 years and overweight, he said.

• 6.6%-6.9%. "This is a person with well-controlled diabetes. If newly diagnosed, this patient needs to learn how to improve his lifestyle to maintain this control. And obviously, if it is a patient with established diabetes, you should send them home on whatever regimen they came in on, because it’s working."

• 7%-10%. "A level like this at admission means that diabetes is not well-controlled. If this is a new diagnosis, I usually send the patient home on an oral agent that won’t cause hypoglycemia. If it’s a known diabetic patient, you have an opportunely to make a difference here by increasing their regimen, either with orals or with insulin."

• 10% or higher. "This is urgently uncontrolled diabetes. Even though we’re loathe to start insulin on an inpatient before discharge, this is one time we would." This situation often requires repeat conversations and connection with diabetes educators, Dr. MacIndoe added. "People are not really in the frame of mind to comprehend what this all means," when they’re admitted. "Get them to see the educator as soon as they can understand what’s going on."

But even the best discharge plan won’t help if the patient doesn’t follow though because of financial or social issues. "Don’t forget, they have to be able to afford it. If they can’t, they are not likely to tell you so. They just won’t get it filled and will probably find themselves back" in the emergency department.

"Most of us really don’t have a clue about the real costs of medications, supplies, strips, lancets, lab tests, and medical office copays," he continued. "The average price of a blood glucose strip is $1.25. If you’re telling them to test four times a day, that’s $140 a month and almost $1,700 a year, if they test the way they should."

Going generic with medications can help patients save money and boost the chance of successful management. "This [name brand] stuff is not cheap. Patients can get a month of generic metformin and sulfonylurea options at a discount pharmacy for $4, or 3 months for $10."

Analog insulins are considerably more expensive than "good old NPH [isophane insulin] and regular insulin," Dr. MacIndoe said. "Given that fact, I would strongly suggest that you consider sending the patient with financial barriers home on NPH and regular because of its affordability. This combination will work if the patient remembers to eat regularly, particularly at lunch and snack time."

Finally, he said, get these patients back for a follow-up within 2 weeks of discharge. "It’s critical that they be seen 7-14 days afterward, particularly if they’re on a new regimen. It’s usually easier to get them to the diabetes educator, since most physicians are too busy, or too focused on the main reason they were in the hospital rather than [on] their diabetes."

Dr. MacIndoe disclosed that he is on the speakers bureau of Sanofi-Aventis.

GRAPEVINE, TEX.  – The time to start an effective diabetes discharge plan is the moment the hyperglycemic patient is admitted to the hospital.

"I’m making a plea for the idea that a successful transition from the hospital to home begins with patient admission," Dr. John MacIndoe said at the annual meeting of the Society of Hospital Medicine.

Getting a hemoglobin A_1C on every hyperglycemic patient is a critical part of the plan. "With this information, we have a crystal ball in our hands. Almost all of the decisions we need to make about glycemic control are based on that very important thing we should do on admission: Get the HbA_1c. That is a window into the 3 months prior to admission, telling you what the baseline glucose was before the patient became ill."

But even with the best clinical information, there’s no point in designing a diabetes discharge plan to which the patient can’t adhere because of financial or social barriers. "Identify patients with issues that will complicate their outpatient diabetes management, because what you send them home on has to work well for them."

Financial barriers (lack of health insurance or very high insurance deductibles) have become ever more common over the past few years, said Dr. MacIndoe of the HealthPartners Medical Group and Clinics in Minneapolis. Social barriers might include poor home support, difficulty with getting to the pharmacy or doctor’s office, and substance abuse problems that interfere with any kind of self-care.

"When you see these, it’s critical to get diabetes educators and social services involved [to] try to overcome those problems. Get the issues out on the table early and you have a much better shot at identifying the solution."

The baseline HbA_1c is a key piece of information in determining a patient’s diabetes status during the hospitalization. "This allows you to identify the patient with a history of diabetes, the patient who has prediabetes or undiagnosed diabetes, and the one who develops temporary hyperglycemia simply from stress related to their illness, either before or during hospitalization. Regardless of the etiology, they all need to be treated aggressively to get the blood sugar in that target range."

But as the acute illness subsides, so may the need for insulin. "During recovery, patients almost always need less, and sometimes they need none at all. Use that admission HbA_1c to predict predischarge and outpatient needs."

Dr. MacIndoe offered the following scenarios based on the admission HbA_1c:

• Below 5.7%. These patients "don’t have diabetes and don’t need insulin. So take them off any insulin and monitor for 24 hours, and send them home with nothing to worry about."

• 5.8%-6.5%. "This person has a high risk for diabetes, but should be able to get off insulin entirely. You should recommend lifestyle changes [such as exercising and losing weight], because the data suggest that over time these patients are likely to develop diabetes, and lifestyle changes can prevent or postpone that." The American Diabetes Association now recommends adding metformin to the regimen of a prediabetic patient if the patient is younger than 60 years and overweight, he said.

• 6.6%-6.9%. "This is a person with well-controlled diabetes. If newly diagnosed, this patient needs to learn how to improve his lifestyle to maintain this control. And obviously, if it is a patient with established diabetes, you should send them home on whatever regimen they came in on, because it’s working."

• 7%-10%. "A level like this at admission means that diabetes is not well-controlled. If this is a new diagnosis, I usually send the patient home on an oral agent that won’t cause hypoglycemia. If it’s a known diabetic patient, you have an opportunely to make a difference here by increasing their regimen, either with orals or with insulin."

• 10% or higher. "This is urgently uncontrolled diabetes. Even though we’re loathe to start insulin on an inpatient before discharge, this is one time we would." This situation often requires repeat conversations and connection with diabetes educators, Dr. MacIndoe added. "People are not really in the frame of mind to comprehend what this all means," when they’re admitted. "Get them to see the educator as soon as they can understand what’s going on."

But even the best discharge plan won’t help if the patient doesn’t follow though because of financial or social issues. "Don’t forget, they have to be able to afford it. If they can’t, they are not likely to tell you so. They just won’t get it filled and will probably find themselves back" in the emergency department.

"Most of us really don’t have a clue about the real costs of medications, supplies, strips, lancets, lab tests, and medical office copays," he continued. "The average price of a blood glucose strip is $1.25. If you’re telling them to test four times a day, that’s $140 a month and almost $1,700 a year, if they test the way they should."

Going generic with medications can help patients save money and boost the chance of successful management. "This [name brand] stuff is not cheap. Patients can get a month of generic metformin and sulfonylurea options at a discount pharmacy for $4, or 3 months for $10."

Analog insulins are considerably more expensive than "good old NPH [isophane insulin] and regular insulin," Dr. MacIndoe said. "Given that fact, I would strongly suggest that you consider sending the patient with financial barriers home on NPH and regular because of its affordability. This combination will work if the patient remembers to eat regularly, particularly at lunch and snack time."

Finally, he said, get these patients back for a follow-up within 2 weeks of discharge. "It’s critical that they be seen 7-14 days afterward, particularly if they’re on a new regimen. It’s usually easier to get them to the diabetes educator, since most physicians are too busy, or too focused on the main reason they were in the hospital rather than [on] their diabetes."

Dr. MacIndoe disclosed that he is on the speakers bureau of Sanofi-Aventis.

GRAPEVINE, TEX. – There is no one-size-fits-all method of transitioning hospitalized diabetic patients off intravenous insulin to subcutaneous insulin.

A combination of a basal bolus of insulin, plus a sliding scale dictated by the patient’s blood sugar, is usually the way to go, although the process varies slightly depending on the before- and after-nutritional mode, Dr. John MacIndoe said at the annual meeting of the Society of Hospital Medicine.

"An important point to remember is that using sliding-scale insulin as a sole strategy for glucose control in someone who needs insulin every day is not a good idea," said Dr. MacIndoe of HealthPartners Medical Group and Clinics, Minneapolis.

There are no evidence-based guidelines to provide a framework for the process, he said. "There are several protocols with supportive data, but no head-to-head trials comparing one to the other. This is a fairly young area with much less evidence than we would really like."

The initial changeover is managed by a basal bolus insulin protocol. This consists of a single dose of basal insulin (usually glargine) given once per day, along with scheduled insulin according to meal pattern, and sliding-scale insulin given throughout the day as indicated by blood glucose.

"Generally speaking, half of the insulin one requires over 24 hours (half of the total daily dose) is a long-acting preparation which covers the continuous amount of glucose put out by the liver," Dr. MacIndoe said. "This is referred to as basal insulin. The other half is that which is needed to cover the carbohydrate ingested with meals. This is usually given in thirds, with each meal, as a rapid-acting insulin."

The subcutaneous insulin for the first 24 hours after transition is considered to be 80% of the total daily dose required on intravenous insulin, Dr. MacIndoe said. "The subcutaneous total daily dose (TDD) is also dependent on what kind of nutrition the patient was given during the time on IV insulin, and the [newly implemented] type of nutrition," he said. "We see three common patterns here: NPO to NPO; NPO to meals; and enteral to meals."

For the NPO patient who will remain NPO, "things are pretty straightforward. You give a dose of basal glargine that’s equal to the TDD calculated for the subcutaneous transition."

Because the patient isn’t eating, there’s no need for additional scheduled nutritional insulin. However, sliding-scale insulin will be given as needed every 4-6 hours, depending on whether the insulin is a rapid-acting analog or regular insulin.

For patients switching from NPO to meals, the basal insulin will also be equal to the dose-calculated TDD for subcutaneous transition. At mealtime, patients get additional rapid-acting insulin at a dose equal in amount to one-third of the basal insulin dose; thus, by the end of the day, 50% of all the insulin given will be the single dose of glargine and 50% will be a rapid-acting analog, divided into three doses.

These patients need a constant carbohydrate diet, "which is essential because we can then predict the amount of insulin they will need with every meal," Dr. MacIndoe said. "You’ll have a finger stick ordered at each meal and bedtime, and, until they’re stable, a 2-hour postprandial check and maybe even a 3 a.m. value if they receive bedtime sliding-scale [insulin]." The most commonly used scales call for insulin to be given if the blood sugar exceeds 150 mg/dL.

Patients switching from enteral to meals "are a little trickier," he said. "It is important to remember that half of the IV insulin was covering nutrition and half covering their true basal needs. So as you transfer to meals, the basal dose of glargine will be equal to half of the calculated TDD of subcutaneus insulin, and at each meal the patient receives rapid-acting insulin equivalent to one-third of the basal dose."

"One of the toughest things to gauge in a patient after transition is whether and how quickly they will begin to eat. The key point is that the patient should be getting blood sugar measurements at mealtime; if it’s above target, they should receive whatever sliding-scale dose is called for with the meal, even if they might not be hungry."

Hold the nutritional dose until after the patient has finished eating, Dr. MacIndoe said. "If they complete their full meal or at least 50%, they can get the full dose of insulin. But if they eat less than 50%, they should only get half of the nutritional dose. The assessment and the insulin dosing should occur within 15 minutes of the meal, if possible."

Dr. MacIndoe disclosed that he is on the speakers bureau of Sanofi-Aventis.

GRAPEVINE, TEX. – There is no one-size-fits-all method of transitioning hospitalized diabetic patients off intravenous insulin to subcutaneous insulin.

A combination of a basal bolus of insulin, plus a sliding scale dictated by the patient’s blood sugar, is usually the way to go, although the process varies slightly depending on the before- and after-nutritional mode, Dr. John MacIndoe said at the annual meeting of the Society of Hospital Medicine.

"An important point to remember is that using sliding-scale insulin as a sole strategy for glucose control in someone who needs insulin every day is not a good idea," said Dr. MacIndoe of HealthPartners Medical Group and Clinics, Minneapolis.

There are no evidence-based guidelines to provide a framework for the process, he said. "There are several protocols with supportive data, but no head-to-head trials comparing one to the other. This is a fairly young area with much less evidence than we would really like."

The initial changeover is managed by a basal bolus insulin protocol. This consists of a single dose of basal insulin (usually glargine) given once per day, along with scheduled insulin according to meal pattern, and sliding-scale insulin given throughout the day as indicated by blood glucose.

"Generally speaking, half of the insulin one requires over 24 hours (half of the total daily dose) is a long-acting preparation which covers the continuous amount of glucose put out by the liver," Dr. MacIndoe said. "This is referred to as basal insulin. The other half is that which is needed to cover the carbohydrate ingested with meals. This is usually given in thirds, with each meal, as a rapid-acting insulin."

The subcutaneous insulin for the first 24 hours after transition is considered to be 80% of the total daily dose required on intravenous insulin, Dr. MacIndoe said. "The subcutaneous total daily dose (TDD) is also dependent on what kind of nutrition the patient was given during the time on IV insulin, and the [newly implemented] type of nutrition," he said. "We see three common patterns here: NPO to NPO; NPO to meals; and enteral to meals."

For the NPO patient who will remain NPO, "things are pretty straightforward. You give a dose of basal glargine that’s equal to the TDD calculated for the subcutaneous transition."

Because the patient isn’t eating, there’s no need for additional scheduled nutritional insulin. However, sliding-scale insulin will be given as needed every 4-6 hours, depending on whether the insulin is a rapid-acting analog or regular insulin.

For patients switching from NPO to meals, the basal insulin will also be equal to the dose-calculated TDD for subcutaneous transition. At mealtime, patients get additional rapid-acting insulin at a dose equal in amount to one-third of the basal insulin dose; thus, by the end of the day, 50% of all the insulin given will be the single dose of glargine and 50% will be a rapid-acting analog, divided into three doses.

These patients need a constant carbohydrate diet, "which is essential because we can then predict the amount of insulin they will need with every meal," Dr. MacIndoe said. "You’ll have a finger stick ordered at each meal and bedtime, and, until they’re stable, a 2-hour postprandial check and maybe even a 3 a.m. value if they receive bedtime sliding-scale [insulin]." The most commonly used scales call for insulin to be given if the blood sugar exceeds 150 mg/dL.

Patients switching from enteral to meals "are a little trickier," he said. "It is important to remember that half of the IV insulin was covering nutrition and half covering their true basal needs. So as you transfer to meals, the basal dose of glargine will be equal to half of the calculated TDD of subcutaneus insulin, and at each meal the patient receives rapid-acting insulin equivalent to one-third of the basal dose."

"One of the toughest things to gauge in a patient after transition is whether and how quickly they will begin to eat. The key point is that the patient should be getting blood sugar measurements at mealtime; if it’s above target, they should receive whatever sliding-scale dose is called for with the meal, even if they might not be hungry."

Hold the nutritional dose until after the patient has finished eating, Dr. MacIndoe said. "If they complete their full meal or at least 50%, they can get the full dose of insulin. But if they eat less than 50%, they should only get half of the nutritional dose. The assessment and the insulin dosing should occur within 15 minutes of the meal, if possible."

Dr. MacIndoe disclosed that he is on the speakers bureau of Sanofi-Aventis.

GRAPEVINE, TEX. – There is no one-size-fits-all method of transitioning hospitalized diabetic patients off intravenous insulin to subcutaneous insulin.

A combination of a basal bolus of insulin, plus a sliding scale dictated by the patient’s blood sugar, is usually the way to go, although the process varies slightly depending on the before- and after-nutritional mode, Dr. John MacIndoe said at the annual meeting of the Society of Hospital Medicine.

"An important point to remember is that using sliding-scale insulin as a sole strategy for glucose control in someone who needs insulin every day is not a good idea," said Dr. MacIndoe of HealthPartners Medical Group and Clinics, Minneapolis.

There are no evidence-based guidelines to provide a framework for the process, he said. "There are several protocols with supportive data, but no head-to-head trials comparing one to the other. This is a fairly young area with much less evidence than we would really like."

The initial changeover is managed by a basal bolus insulin protocol. This consists of a single dose of basal insulin (usually glargine) given once per day, along with scheduled insulin according to meal pattern, and sliding-scale insulin given throughout the day as indicated by blood glucose.

"Generally speaking, half of the insulin one requires over 24 hours (half of the total daily dose) is a long-acting preparation which covers the continuous amount of glucose put out by the liver," Dr. MacIndoe said. "This is referred to as basal insulin. The other half is that which is needed to cover the carbohydrate ingested with meals. This is usually given in thirds, with each meal, as a rapid-acting insulin."

The subcutaneous insulin for the first 24 hours after transition is considered to be 80% of the total daily dose required on intravenous insulin, Dr. MacIndoe said. "The subcutaneous total daily dose (TDD) is also dependent on what kind of nutrition the patient was given during the time on IV insulin, and the [newly implemented] type of nutrition," he said. "We see three common patterns here: NPO to NPO; NPO to meals; and enteral to meals."

For the NPO patient who will remain NPO, "things are pretty straightforward. You give a dose of basal glargine that’s equal to the TDD calculated for the subcutaneous transition."

Because the patient isn’t eating, there’s no need for additional scheduled nutritional insulin. However, sliding-scale insulin will be given as needed every 4-6 hours, depending on whether the insulin is a rapid-acting analog or regular insulin.

For patients switching from NPO to meals, the basal insulin will also be equal to the dose-calculated TDD for subcutaneous transition. At mealtime, patients get additional rapid-acting insulin at a dose equal in amount to one-third of the basal insulin dose; thus, by the end of the day, 50% of all the insulin given will be the single dose of glargine and 50% will be a rapid-acting analog, divided into three doses.

These patients need a constant carbohydrate diet, "which is essential because we can then predict the amount of insulin they will need with every meal," Dr. MacIndoe said. "You’ll have a finger stick ordered at each meal and bedtime, and, until they’re stable, a 2-hour postprandial check and maybe even a 3 a.m. value if they receive bedtime sliding-scale [insulin]." The most commonly used scales call for insulin to be given if the blood sugar exceeds 150 mg/dL.

Patients switching from enteral to meals "are a little trickier," he said. "It is important to remember that half of the IV insulin was covering nutrition and half covering their true basal needs. So as you transfer to meals, the basal dose of glargine will be equal to half of the calculated TDD of subcutaneus insulin, and at each meal the patient receives rapid-acting insulin equivalent to one-third of the basal dose."

"One of the toughest things to gauge in a patient after transition is whether and how quickly they will begin to eat. The key point is that the patient should be getting blood sugar measurements at mealtime; if it’s above target, they should receive whatever sliding-scale dose is called for with the meal, even if they might not be hungry."

Hold the nutritional dose until after the patient has finished eating, Dr. MacIndoe said. "If they complete their full meal or at least 50%, they can get the full dose of insulin. But if they eat less than 50%, they should only get half of the nutritional dose. The assessment and the insulin dosing should occur within 15 minutes of the meal, if possible."

Dr. MacIndoe disclosed that he is on the speakers bureau of Sanofi-Aventis.

GRAPEVINE, TEX. – There is no one-size-fits-all method of transitioning hospitalized diabetic patients off intravenous insulin to subcutaneous insulin.

A combination of a basal bolus of insulin, plus a sliding scale dictated by the patient’s blood sugar, is usually the way to go, although the process varies slightly depending on the before- and after-nutritional mode, Dr. John MacIndoe said at the annual meeting of the Society of Hospital Medicine.

"An important point to remember is that using sliding-scale insulin as a sole strategy for glucose control in someone who needs insulin every day is not a good idea," said Dr. MacIndoe of HealthPartners Medical Group and Clinics, Minneapolis.

There are no evidence-based guidelines to provide a framework for the process, he said. "There are several protocols with supportive data, but no head-to-head trials comparing one to the other. This is a fairly young area with much less evidence than we would really like."

The initial changeover is managed by a basal bolus insulin protocol. This consists of a single dose of basal insulin (usually glargine) given once per day, along with scheduled insulin according to meal pattern, and sliding-scale insulin given throughout the day as indicated by blood glucose.

"Generally speaking, half of the insulin one requires over 24 hours (half of the total daily dose) is a long-acting preparation which covers the continuous amount of glucose put out by the liver," Dr. MacIndoe said. "This is referred to as basal insulin. The other half is that which is needed to cover the carbohydrate ingested with meals. This is usually given in thirds, with each meal, as a rapid-acting insulin."

The subcutaneous insulin for the first 24 hours after transition is considered to be 80% of the total daily dose required on intravenous insulin, Dr. MacIndoe said. "The subcutaneous total daily dose (TDD) is also dependent on what kind of nutrition the patient was given during the time on IV insulin, and the [newly implemented] type of nutrition," he said. "We see three common patterns here: NPO to NPO; NPO to meals; and enteral to meals."

For the NPO patient who will remain NPO, "things are pretty straightforward. You give a dose of basal glargine that’s equal to the TDD calculated for the subcutaneous transition."

Because the patient isn’t eating, there’s no need for additional scheduled nutritional insulin. However, sliding-scale insulin will be given as needed every 4-6 hours, depending on whether the insulin is a rapid-acting analog or regular insulin.

For patients switching from NPO to meals, the basal insulin will also be equal to the dose-calculated TDD for subcutaneous transition. At mealtime, patients get additional rapid-acting insulin at a dose equal in amount to one-third of the basal insulin dose; thus, by the end of the day, 50% of all the insulin given will be the single dose of glargine and 50% will be a rapid-acting analog, divided into three doses.

These patients need a constant carbohydrate diet, "which is essential because we can then predict the amount of insulin they will need with every meal," Dr. MacIndoe said. "You’ll have a finger stick ordered at each meal and bedtime, and, until they’re stable, a 2-hour postprandial check and maybe even a 3 a.m. value if they receive bedtime sliding-scale [insulin]." The most commonly used scales call for insulin to be given if the blood sugar exceeds 150 mg/dL.

Patients switching from enteral to meals "are a little trickier," he said. "It is important to remember that half of the IV insulin was covering nutrition and half covering their true basal needs. So as you transfer to meals, the basal dose of glargine will be equal to half of the calculated TDD of subcutaneus insulin, and at each meal the patient receives rapid-acting insulin equivalent to one-third of the basal dose."

"One of the toughest things to gauge in a patient after transition is whether and how quickly they will begin to eat. The key point is that the patient should be getting blood sugar measurements at mealtime; if it’s above target, they should receive whatever sliding-scale dose is called for with the meal, even if they might not be hungry."

Hold the nutritional dose until after the patient has finished eating, Dr. MacIndoe said. "If they complete their full meal or at least 50%, they can get the full dose of insulin. But if they eat less than 50%, they should only get half of the nutritional dose. The assessment and the insulin dosing should occur within 15 minutes of the meal, if possible."

Dr. MacIndoe disclosed that he is on the speakers bureau of Sanofi-Aventis.

GRAPEVINE, TEX. – There is no one-size-fits-all method of transitioning hospitalized diabetic patients off intravenous insulin to subcutaneous insulin.

A combination of a basal bolus of insulin, plus a sliding scale dictated by the patient’s blood sugar, is usually the way to go, although the process varies slightly depending on the before- and after-nutritional mode, Dr. John MacIndoe said at the annual meeting of the Society of Hospital Medicine.

"An important point to remember is that using sliding-scale insulin as a sole strategy for glucose control in someone who needs insulin every day is not a good idea," said Dr. MacIndoe of HealthPartners Medical Group and Clinics, Minneapolis.

There are no evidence-based guidelines to provide a framework for the process, he said. "There are several protocols with supportive data, but no head-to-head trials comparing one to the other. This is a fairly young area with much less evidence than we would really like."

The initial changeover is managed by a basal bolus insulin protocol. This consists of a single dose of basal insulin (usually glargine) given once per day, along with scheduled insulin according to meal pattern, and sliding-scale insulin given throughout the day as indicated by blood glucose.

"Generally speaking, half of the insulin one requires over 24 hours (half of the total daily dose) is a long-acting preparation which covers the continuous amount of glucose put out by the liver," Dr. MacIndoe said. "This is referred to as basal insulin. The other half is that which is needed to cover the carbohydrate ingested with meals. This is usually given in thirds, with each meal, as a rapid-acting insulin."

The subcutaneous insulin for the first 24 hours after transition is considered to be 80% of the total daily dose required on intravenous insulin, Dr. MacIndoe said. "The subcutaneous total daily dose (TDD) is also dependent on what kind of nutrition the patient was given during the time on IV insulin, and the [newly implemented] type of nutrition," he said. "We see three common patterns here: NPO to NPO; NPO to meals; and enteral to meals."

For the NPO patient who will remain NPO, "things are pretty straightforward. You give a dose of basal glargine that’s equal to the TDD calculated for the subcutaneous transition."

Because the patient isn’t eating, there’s no need for additional scheduled nutritional insulin. However, sliding-scale insulin will be given as needed every 4-6 hours, depending on whether the insulin is a rapid-acting analog or regular insulin.

For patients switching from NPO to meals, the basal insulin will also be equal to the dose-calculated TDD for subcutaneous transition. At mealtime, patients get additional rapid-acting insulin at a dose equal in amount to one-third of the basal insulin dose; thus, by the end of the day, 50% of all the insulin given will be the single dose of glargine and 50% will be a rapid-acting analog, divided into three doses.

These patients need a constant carbohydrate diet, "which is essential because we can then predict the amount of insulin they will need with every meal," Dr. MacIndoe said. "You’ll have a finger stick ordered at each meal and bedtime, and, until they’re stable, a 2-hour postprandial check and maybe even a 3 a.m. value if they receive bedtime sliding-scale [insulin]." The most commonly used scales call for insulin to be given if the blood sugar exceeds 150 mg/dL.

Patients switching from enteral to meals "are a little trickier," he said. "It is important to remember that half of the IV insulin was covering nutrition and half covering their true basal needs. So as you transfer to meals, the basal dose of glargine will be equal to half of the calculated TDD of subcutaneus insulin, and at each meal the patient receives rapid-acting insulin equivalent to one-third of the basal dose."

"One of the toughest things to gauge in a patient after transition is whether and how quickly they will begin to eat. The key point is that the patient should be getting blood sugar measurements at mealtime; if it’s above target, they should receive whatever sliding-scale dose is called for with the meal, even if they might not be hungry."

Hold the nutritional dose until after the patient has finished eating, Dr. MacIndoe said. "If they complete their full meal or at least 50%, they can get the full dose of insulin. But if they eat less than 50%, they should only get half of the nutritional dose. The assessment and the insulin dosing should occur within 15 minutes of the meal, if possible."

Dr. MacIndoe disclosed that he is on the speakers bureau of Sanofi-Aventis.

GRAPEVINE, TEX. – There is no one-size-fits-all method of transitioning hospitalized diabetic patients off intravenous insulin to subcutaneous insulin.

A combination of a basal bolus of insulin, plus a sliding scale dictated by the patient’s blood sugar, is usually the way to go, although the process varies slightly depending on the before- and after-nutritional mode, Dr. John MacIndoe said at the annual meeting of the Society of Hospital Medicine.

"An important point to remember is that using sliding-scale insulin as a sole strategy for glucose control in someone who needs insulin every day is not a good idea," said Dr. MacIndoe of HealthPartners Medical Group and Clinics, Minneapolis.

There are no evidence-based guidelines to provide a framework for the process, he said. "There are several protocols with supportive data, but no head-to-head trials comparing one to the other. This is a fairly young area with much less evidence than we would really like."

The initial changeover is managed by a basal bolus insulin protocol. This consists of a single dose of basal insulin (usually glargine) given once per day, along with scheduled insulin according to meal pattern, and sliding-scale insulin given throughout the day as indicated by blood glucose.

"Generally speaking, half of the insulin one requires over 24 hours (half of the total daily dose) is a long-acting preparation which covers the continuous amount of glucose put out by the liver," Dr. MacIndoe said. "This is referred to as basal insulin. The other half is that which is needed to cover the carbohydrate ingested with meals. This is usually given in thirds, with each meal, as a rapid-acting insulin."

The subcutaneous insulin for the first 24 hours after transition is considered to be 80% of the total daily dose required on intravenous insulin, Dr. MacIndoe said. "The subcutaneous total daily dose (TDD) is also dependent on what kind of nutrition the patient was given during the time on IV insulin, and the [newly implemented] type of nutrition," he said. "We see three common patterns here: NPO to NPO; NPO to meals; and enteral to meals."

For the NPO patient who will remain NPO, "things are pretty straightforward. You give a dose of basal glargine that’s equal to the TDD calculated for the subcutaneous transition."

Because the patient isn’t eating, there’s no need for additional scheduled nutritional insulin. However, sliding-scale insulin will be given as needed every 4-6 hours, depending on whether the insulin is a rapid-acting analog or regular insulin.

For patients switching from NPO to meals, the basal insulin will also be equal to the dose-calculated TDD for subcutaneous transition. At mealtime, patients get additional rapid-acting insulin at a dose equal in amount to one-third of the basal insulin dose; thus, by the end of the day, 50% of all the insulin given will be the single dose of glargine and 50% will be a rapid-acting analog, divided into three doses.

These patients need a constant carbohydrate diet, "which is essential because we can then predict the amount of insulin they will need with every meal," Dr. MacIndoe said. "You’ll have a finger stick ordered at each meal and bedtime, and, until they’re stable, a 2-hour postprandial check and maybe even a 3 a.m. value if they receive bedtime sliding-scale [insulin]." The most commonly used scales call for insulin to be given if the blood sugar exceeds 150 mg/dL.

Patients switching from enteral to meals "are a little trickier," he said. "It is important to remember that half of the IV insulin was covering nutrition and half covering their true basal needs. So as you transfer to meals, the basal dose of glargine will be equal to half of the calculated TDD of subcutaneus insulin, and at each meal the patient receives rapid-acting insulin equivalent to one-third of the basal dose."

"One of the toughest things to gauge in a patient after transition is whether and how quickly they will begin to eat. The key point is that the patient should be getting blood sugar measurements at mealtime; if it’s above target, they should receive whatever sliding-scale dose is called for with the meal, even if they might not be hungry."

Hold the nutritional dose until after the patient has finished eating, Dr. MacIndoe said. "If they complete their full meal or at least 50%, they can get the full dose of insulin. But if they eat less than 50%, they should only get half of the nutritional dose. The assessment and the insulin dosing should occur within 15 minutes of the meal, if possible."

Dr. MacIndoe disclosed that he is on the speakers bureau of Sanofi-Aventis.

GRAPEVINE, TEX. – There is no one-size-fits-all method of transitioning hospitalized diabetic patients off intravenous insulin to subcutaneous insulin.

A combination of a basal bolus of insulin, plus a sliding scale dictated by the patient’s blood sugar, is usually the way to go, although the process varies slightly depending on the before- and after-nutritional mode, Dr. John MacIndoe said at the annual meeting of the Society of Hospital Medicine.

"An important point to remember is that using sliding-scale insulin as a sole strategy for glucose control in someone who needs insulin every day is not a good idea," said Dr. MacIndoe of HealthPartners Medical Group and Clinics, Minneapolis.

There are no evidence-based guidelines to provide a framework for the process, he said. "There are several protocols with supportive data, but no head-to-head trials comparing one to the other. This is a fairly young area with much less evidence than we would really like."

The initial changeover is managed by a basal bolus insulin protocol. This consists of a single dose of basal insulin (usually glargine) given once per day, along with scheduled insulin according to meal pattern, and sliding-scale insulin given throughout the day as indicated by blood glucose.

"Generally speaking, half of the insulin one requires over 24 hours (half of the total daily dose) is a long-acting preparation which covers the continuous amount of glucose put out by the liver," Dr. MacIndoe said. "This is referred to as basal insulin. The other half is that which is needed to cover the carbohydrate ingested with meals. This is usually given in thirds, with each meal, as a rapid-acting insulin."

The subcutaneous insulin for the first 24 hours after transition is considered to be 80% of the total daily dose required on intravenous insulin, Dr. MacIndoe said. "The subcutaneous total daily dose (TDD) is also dependent on what kind of nutrition the patient was given during the time on IV insulin, and the [newly implemented] type of nutrition," he said. "We see three common patterns here: NPO to NPO; NPO to meals; and enteral to meals."

For the NPO patient who will remain NPO, "things are pretty straightforward. You give a dose of basal glargine that’s equal to the TDD calculated for the subcutaneous transition."

Because the patient isn’t eating, there’s no need for additional scheduled nutritional insulin. However, sliding-scale insulin will be given as needed every 4-6 hours, depending on whether the insulin is a rapid-acting analog or regular insulin.

For patients switching from NPO to meals, the basal insulin will also be equal to the dose-calculated TDD for subcutaneous transition. At mealtime, patients get additional rapid-acting insulin at a dose equal in amount to one-third of the basal insulin dose; thus, by the end of the day, 50% of all the insulin given will be the single dose of glargine and 50% will be a rapid-acting analog, divided into three doses.

These patients need a constant carbohydrate diet, "which is essential because we can then predict the amount of insulin they will need with every meal," Dr. MacIndoe said. "You’ll have a finger stick ordered at each meal and bedtime, and, until they’re stable, a 2-hour postprandial check and maybe even a 3 a.m. value if they receive bedtime sliding-scale [insulin]." The most commonly used scales call for insulin to be given if the blood sugar exceeds 150 mg/dL.

Patients switching from enteral to meals "are a little trickier," he said. "It is important to remember that half of the IV insulin was covering nutrition and half covering their true basal needs. So as you transfer to meals, the basal dose of glargine will be equal to half of the calculated TDD of subcutaneus insulin, and at each meal the patient receives rapid-acting insulin equivalent to one-third of the basal dose."

"One of the toughest things to gauge in a patient after transition is whether and how quickly they will begin to eat. The key point is that the patient should be getting blood sugar measurements at mealtime; if it’s above target, they should receive whatever sliding-scale dose is called for with the meal, even if they might not be hungry."

Hold the nutritional dose until after the patient has finished eating, Dr. MacIndoe said. "If they complete their full meal or at least 50%, they can get the full dose of insulin. But if they eat less than 50%, they should only get half of the nutritional dose. The assessment and the insulin dosing should occur within 15 minutes of the meal, if possible."

Dr. MacIndoe disclosed that he is on the speakers bureau of Sanofi-Aventis.

GRAPEVINE, TEX. – There is no one-size-fits-all method of transitioning hospitalized diabetic patients off intravenous insulin to subcutaneous insulin.

A combination of a basal bolus of insulin, plus a sliding scale dictated by the patient’s blood sugar, is usually the way to go, although the process varies slightly depending on the before- and after-nutritional mode, Dr. John MacIndoe said at the annual meeting of the Society of Hospital Medicine.

"An important point to remember is that using sliding-scale insulin as a sole strategy for glucose control in someone who needs insulin every day is not a good idea," said Dr. MacIndoe of HealthPartners Medical Group and Clinics, Minneapolis.

There are no evidence-based guidelines to provide a framework for the process, he said. "There are several protocols with supportive data, but no head-to-head trials comparing one to the other. This is a fairly young area with much less evidence than we would really like."

The initial changeover is managed by a basal bolus insulin protocol. This consists of a single dose of basal insulin (usually glargine) given once per day, along with scheduled insulin according to meal pattern, and sliding-scale insulin given throughout the day as indicated by blood glucose.

"Generally speaking, half of the insulin one requires over 24 hours (half of the total daily dose) is a long-acting preparation which covers the continuous amount of glucose put out by the liver," Dr. MacIndoe said. "This is referred to as basal insulin. The other half is that which is needed to cover the carbohydrate ingested with meals. This is usually given in thirds, with each meal, as a rapid-acting insulin."

The subcutaneous insulin for the first 24 hours after transition is considered to be 80% of the total daily dose required on intravenous insulin, Dr. MacIndoe said. "The subcutaneous total daily dose (TDD) is also dependent on what kind of nutrition the patient was given during the time on IV insulin, and the [newly implemented] type of nutrition," he said. "We see three common patterns here: NPO to NPO; NPO to meals; and enteral to meals."

For the NPO patient who will remain NPO, "things are pretty straightforward. You give a dose of basal glargine that’s equal to the TDD calculated for the subcutaneous transition."

Because the patient isn’t eating, there’s no need for additional scheduled nutritional insulin. However, sliding-scale insulin will be given as needed every 4-6 hours, depending on whether the insulin is a rapid-acting analog or regular insulin.

For patients switching from NPO to meals, the basal insulin will also be equal to the dose-calculated TDD for subcutaneous transition. At mealtime, patients get additional rapid-acting insulin at a dose equal in amount to one-third of the basal insulin dose; thus, by the end of the day, 50% of all the insulin given will be the single dose of glargine and 50% will be a rapid-acting analog, divided into three doses.

These patients need a constant carbohydrate diet, "which is essential because we can then predict the amount of insulin they will need with every meal," Dr. MacIndoe said. "You’ll have a finger stick ordered at each meal and bedtime, and, until they’re stable, a 2-hour postprandial check and maybe even a 3 a.m. value if they receive bedtime sliding-scale [insulin]." The most commonly used scales call for insulin to be given if the blood sugar exceeds 150 mg/dL.

Patients switching from enteral to meals "are a little trickier," he said. "It is important to remember that half of the IV insulin was covering nutrition and half covering their true basal needs. So as you transfer to meals, the basal dose of glargine will be equal to half of the calculated TDD of subcutaneus insulin, and at each meal the patient receives rapid-acting insulin equivalent to one-third of the basal dose."

"One of the toughest things to gauge in a patient after transition is whether and how quickly they will begin to eat. The key point is that the patient should be getting blood sugar measurements at mealtime; if it’s above target, they should receive whatever sliding-scale dose is called for with the meal, even if they might not be hungry."

Hold the nutritional dose until after the patient has finished eating, Dr. MacIndoe said. "If they complete their full meal or at least 50%, they can get the full dose of insulin. But if they eat less than 50%, they should only get half of the nutritional dose. The assessment and the insulin dosing should occur within 15 minutes of the meal, if possible."

Dr. MacIndoe disclosed that he is on the speakers bureau of Sanofi-Aventis.

GRAPEVINE, TEX. – There is no one-size-fits-all method of transitioning hospitalized diabetic patients off intravenous insulin to subcutaneous insulin.

A combination of a basal bolus of insulin, plus a sliding scale dictated by the patient’s blood sugar, is usually the way to go, although the process varies slightly depending on the before- and after-nutritional mode, Dr. John MacIndoe said at the annual meeting of the Society of Hospital Medicine.

"An important point to remember is that using sliding-scale insulin as a sole strategy for glucose control in someone who needs insulin every day is not a good idea," said Dr. MacIndoe of HealthPartners Medical Group and Clinics, Minneapolis.

There are no evidence-based guidelines to provide a framework for the process, he said. "There are several protocols with supportive data, but no head-to-head trials comparing one to the other. This is a fairly young area with much less evidence than we would really like."

The initial changeover is managed by a basal bolus insulin protocol. This consists of a single dose of basal insulin (usually glargine) given once per day, along with scheduled insulin according to meal pattern, and sliding-scale insulin given throughout the day as indicated by blood glucose.

"Generally speaking, half of the insulin one requires over 24 hours (half of the total daily dose) is a long-acting preparation which covers the continuous amount of glucose put out by the liver," Dr. MacIndoe said. "This is referred to as basal insulin. The other half is that which is needed to cover the carbohydrate ingested with meals. This is usually given in thirds, with each meal, as a rapid-acting insulin."

The subcutaneous insulin for the first 24 hours after transition is considered to be 80% of the total daily dose required on intravenous insulin, Dr. MacIndoe said. "The subcutaneous total daily dose (TDD) is also dependent on what kind of nutrition the patient was given during the time on IV insulin, and the [newly implemented] type of nutrition," he said. "We see three common patterns here: NPO to NPO; NPO to meals; and enteral to meals."

For the NPO patient who will remain NPO, "things are pretty straightforward. You give a dose of basal glargine that’s equal to the TDD calculated for the subcutaneous transition."

Because the patient isn’t eating, there’s no need for additional scheduled nutritional insulin. However, sliding-scale insulin will be given as needed every 4-6 hours, depending on whether the insulin is a rapid-acting analog or regular insulin.

For patients switching from NPO to meals, the basal insulin will also be equal to the dose-calculated TDD for subcutaneous transition. At mealtime, patients get additional rapid-acting insulin at a dose equal in amount to one-third of the basal insulin dose; thus, by the end of the day, 50% of all the insulin given will be the single dose of glargine and 50% will be a rapid-acting analog, divided into three doses.

These patients need a constant carbohydrate diet, "which is essential because we can then predict the amount of insulin they will need with every meal," Dr. MacIndoe said. "You’ll have a finger stick ordered at each meal and bedtime, and, until they’re stable, a 2-hour postprandial check and maybe even a 3 a.m. value if they receive bedtime sliding-scale [insulin]." The most commonly used scales call for insulin to be given if the blood sugar exceeds 150 mg/dL.

Patients switching from enteral to meals "are a little trickier," he said. "It is important to remember that half of the IV insulin was covering nutrition and half covering their true basal needs. So as you transfer to meals, the basal dose of glargine will be equal to half of the calculated TDD of subcutaneus insulin, and at each meal the patient receives rapid-acting insulin equivalent to one-third of the basal dose."

"One of the toughest things to gauge in a patient after transition is whether and how quickly they will begin to eat. The key point is that the patient should be getting blood sugar measurements at mealtime; if it’s above target, they should receive whatever sliding-scale dose is called for with the meal, even if they might not be hungry."

Hold the nutritional dose until after the patient has finished eating, Dr. MacIndoe said. "If they complete their full meal or at least 50%, they can get the full dose of insulin. But if they eat less than 50%, they should only get half of the nutritional dose. The assessment and the insulin dosing should occur within 15 minutes of the meal, if possible."

Dr. MacIndoe disclosed that he is on the speakers bureau of Sanofi-Aventis.