CGM in the Hospital
Dee Sawyer, MS, APRN, MLDE, AGCNS-BC, BC-ADM, CDE
Diabetes Clinical Nurse Specialist
Objective
• Upon completion of this activity, participants will be able identify the emerging roles of continuous glucose monitoring in hospitalized diabetes patients.
• Conflict of interest: Stock shareholder - Dexcom
Diabetes and Hospitalizations
• Threefold greater chance for hospitalization• 40.3 million hospital inpatient days• $237 billion direct medical care cost• $4966 annual per capita health care
expenditure for inpatient
1. CDC, National Diabetes Statistics Report, 2017 2. ADA, Economic Costs of Diabetes in the US in 2017. Diab Care. 2018 Mar: 14: 917- 928.
Hospital Glycemic Control
Control Hyperglycemia
Minimize hypoglycemia
Both independent risks factors for poor clinical outcome and increased mortality.
Hospital Goals for Glycemic Control
Target BG 140-180 mg/dL
ICU
IV Insulin
Non ICU
Sub Q Basal, bolus,
correction
Glycemic Challenges During Hospitalization
• Patients with pre-existing diabetes
• Patients without diabetes
• Stress hyperglycemia• Systemic
glucocorticoids• Infections• Poor PO nutrition intake• PN and EN nutrition• Acute/chronic kidney
injury
Monitoring BG in the Hospital• Point of Care glucose testing
– Measure blood glucose one point in time– Accuracy FDA standards: +/- 15% Bg < 75 mg/dL; +/- 20% > 75
mg/dL
• Nova StatStrip hospital meter- approved for arterial, venous, capillary, neonatal blood glucose testing– Only system approved for use in critically ill patients– Corrects for interferences- Hematocrit, Ascorbic Acid, Uric Acid,
Acetaminophen (Paracetamol), Bilirubin, Maltose, Galactose, Oxygen
Early Model
• Used for research and glucose clamp studies
• Came on market 1984• Early continuous
glucose monitoring + insulin/dextrose to regulate blood glucose
CGM in the Hospital
• NOT approved for hospital use by FDA• Must use continue to use glucose monitoring • Policy to address use and limits in hospital
setting.
1 Gomez and Umpierrez, Continuous Glucose
CGM Use in Hospitalized PatientsBenefits• Allows for frequent measurement of interstitial
glucose every 5-15 minutes • Trends glucose direction and magnitude Limitations• Warm up period• Interference from diagnostic testing• Patient’s alertness to self manage• Maintaining staff competency
Personal CGM Devices
• Dexcom® G6• Medtronic™ Guardian• Abbott FreeStyle Libre• Senseonics Eversense CGM system
Dexcom G6
From User GuideAcetaminophen > 1g every 6 hrs may affect sensor
readings“Because we haven’t tested every x-ray and scanner, we don’t know if they damage the G6.”
Medtronic GUARDIAN™ CONNECT SMART CGM
Do not expose your sensor or transmitter to MRIequipment, diathermy devices, or other devices (for example, x-ray, CT scan, or other types of radiation) that generate strong magnetic fields
Always remove your sensor and transmitter before entering a room that has x-ray, MRI, diathermy, or CT scan equipment.
FreeStyle Libre Flash Glucose Monitoring System
Warning: Remove the sensor before MRI, CT scan, X-ray, or diathermy treatment
Limitation: The built-in blood glucose meter is not for use on dehydrated, hypotensive, in shock, hyperglycemic-hyperosmolar state, with or without ketosis, neonates, critically-ill patients, pregnant women, persons on dialysis or for diagnosis or screening of diabetes.
Eversense CGM SystemImplanted Sensor
Warning:MRI: The Smart Transmitter MUST BE REMOVED before
undergoing an MRI procedure.Lithotripsy: Lithotripsy to break up masses like kidney
stones or gallstones is not recommended. Diathermy: Energy from diathermy therapy can transfer
through the sensor and cause tissue damage in the insertion area.
Electrocautery: Electrocautery near an inserted sensor may damage the device.
Research Findings forInpatient CGM Use
• General wards– Comparison of CGM vs POC testing – Results found CGM detected more hypoglycemia and hyperglycemia
events.
• ICU– 88 critically ill patients, 929 paired sample OptiScanner® central
venous catheter was adequate for ICU patients but still recommended another method of glucose monitoring be used.
– Computerized simulation demonstrated increased frequency of BG monitoring reduced occurrence of hypo-, hyper-glycemia and glucose variability.
1. Gomez and Umpierrez, Continuous Glucose Monitoring in Insulin Treated Patients in Non-ICU Settings, J Diab Sci n Technol, 2014, vol 8, pp 930-036. 2. Shinotsuka et al., Manual vs Automated monitoring Accuracy of GlucosE II (MANAGE II), Critical Care . 2016. 20:380. 3. Krinsley et al., The impact of measurement frequency on the domains of glycemic control in critically ill- a Monte Carlo simulation. J Diab Sci Technol. 2915L 9: 237-45. 4. Umpierrez & Klonoff, Diab TechologyUpdate: Use of Insulin Pumps and Continuous Glucose Monitoring in Hospital. Diab Care 2018. 41:1579-1589.
Beside Continuous Monitoring for Critical Care
• OptiScanner® 5000– Approved by FDA– Trends plasma glucose every
15 minutes– No calibration– 0.15 mL per draw
• In Europe, approved for IV monitoring– GlucoClear – Edwards Life
Science– Glysure System – Glysure– Eirus by Maquet Getinge
Group
Bedside Monitoring for Critical CareMicroEye®/ContinuMon®• Available in Europe only• Easy-to-use device inserted using
common peripheral venous catheters.
• Delivers dialysate to an external sensor system.
• Provides real-time data to standalone monitors or hospital information systems.
• Use with ContinuMon® for accurate monitoring of glucose.
• Concurrent collection of samples for offline analysis.
CGM Inpatient Studies Needed
Wallia et al. Consensus Statement on Inpatient Use of Continuous Glucose Monitoring. J of Diab Sci Technol. 2017, Vol 1: 1036-1044.