Atlanta Diabetes Associates
Atlanta, Georgia

• Hyperglycemia occurred in 38% of hospitalized patients
—
26% had known history of diabetes
— 12% had no history of diabetes
• Newly discovered hyperglycemia was associated with:
— Longer hospital stays
—
Higher admission rates to intensive care units
— Less chance to be discharged to home (required more transitional or nursing home care)
Umpierrez GE, et al. J Clin Endocrinol Metab . 2002;87:978 –982
.

Hyperglycemia Is an Independent Marker of
Inpatient Mortality in Patients With Undiagnosed
Diabetes
P < 0.01
P < 0.01
In-hospital
Mortality
Rate (%)
10
8
6
4
2
0
18
16
14
12
1.7
3
16
Patients
With
Normoglycemia
Patients
With History of Diabetes
Newly
Discovered
Hyperglycemia
Adapted from Umpierrez GE, et al. J Clin Endocrinol Metab . 2002;87:978 –982
.

100%
75%
50%
25%
0%
At Discharge
Norhammar A. Lancet. 2002;359:2140-2144
.
66% of AMI patients have IGT or previously undiagnosed T2DM on
75 g OGTT
(35% IGT; 31% DM)

Per Capita Healthcare Expenditures (2002)
7,000
6,000
5,000
Dollars
4,000
3,000
2,000
1,000
0
Inpatient Nursing Home Physician's
Office
Diabetes Without diabetes
Outpatient
Prescription
Insulin and
Supplies
Hogan P, et al. Diabetes Care . 2003;26:917 – 932 .

• 53-year-old man with DM 2 on SU, metformin, and glitazone presents with an acute MI
• BG random is 220 mg/dL
• What do you recommend for glucose control?
1.
Sliding-scale rapid analog?
2.
Basal/bolus insulin therapy?
3.
IV insulin drip?

• What is your glycemic goal?
1.
80 to 110 mg/dL
2.
80 to 140 mg/dL
3.
80 to 180 mg/dL

• DIGAMI supports BG <180 mg/dL
• Minimal other data:
— PTCA reflow better with BG 159 than
209 mg/dL
Malmberg K. BMJ. 1997;314:1512-1515.
Iwakura K, et al. J Am Coll Cardiol. 2003;41:1-7 .

Diabetes, Insulin Glucose Infusion in Acute Myocardial
Infarction (1997)
• Acute MI with BG >200 mg/dL
• Control vs Intensive Insulin Treatment
• Intensive Insulin Treatment
IV insulin for >24 hours followed by
4 insulin injections/day for >3 months
Malmberg K, et al. BMJ. 1997;314:1512-1515 .

Mortality After MI Reduced by Insulin Therapy in the DIGAMI
Study
All Subjects
.7
.6
.5
.4
.3
.2
.1
0
0
(N=620)
Risk reduction (28%)
P=0.011
1 2 3
Years of Follow-up
4
Standard treatment
IV insulin 48 hours, then 4 injections daily
5
.3
.2
.1
0
0
.7
Low-risk and Not Previously on Insulin
.6
.5
(N=272)
Risk reduction (51%)
P=0.0004
.4
1 2 3
Years of Follow-up
4 5
Malmberg K, et al. BMJ. 1997;314:1512-1515 .

 48 hospitals in 6 countries
 3 groups:
– Group 1: GIK for 24 hours followed by home insulin Rx (N = 474)
– Group 2: GIK infusion followed by standard glucose control (N = 473)
– Group 3: Routine metabolic management based on local practice (N = 306)
Malmberg K et al DIGAMI 2. European Heart J 2005; 26 (650-61)

 Overall mortality was lower than expected
 Overall mortality similar to nondiabetic population
 The 3 glucose management strategies did not result in differences of metabolic control
 Target glucose levels not achieved in the intensively insulin treatment group

Year
Study Mortality Rate (%)
GIK Control O-E Variance
Odds Ratio and Cls
GIK Better Placebo Better
1987 Satler 0.0
0.0
0.0
0.0
1983
1978
Rogers
Stanley
6.5
12.3
-1.9
7.3
16.4
-2.5
2.4
2.8
1977 Heng 8.3
0.0
0.6
0.2
P = 0.07
1971
1968
1968
Hjermann 10.6
20.0
-4.8
Pentecost 15.0
16.0
-0.5
MRC 21.4
23.6
-5.1
6.8
6.5
41.5
1967
1965
Pilcher 13.9
29.3
-2.6
Mittra 11.8
28.3
-7.0
All Patients 16.1
21.0
-24.0
3.4
6.8
70.4
GIK = glucose
–insulin–potassium; MI = myocardial infarction; CI = confidence interval.
1
Fath-Ordoubadi F, Beatt KJ.
Circulation. 1997;96:1152 –1156. Reprinted with permission
(http://lww.com)
P = 0.007
P = 0.004

 Worldwide study with over 20,000 subjects with ST-elevation MI (STEMI)
 GIK infusion vs Control
 Outcome: 30 day CV events
Mehta, S et al: JAMA 293: 437- 446, 2005

% mortality
10
8
6
4
16
14
12
2
0
JAMA 293:437, 2005
Lowest Middle Highest
Glucose Tertile

• For acute MI with elevated glucose, you can either give:
1. IV insulin variable drip or
2. GIK in type 2’s who are easily controlled or
3. ? Intensive SC delivery

• What is your glycemic goal?
1.
80 to 110 mg/dL
2.
80 to 140 mg/dL
3.
80 to 180 mg/dL

16
14
12
10
8
6
4
2
0
Cardiac-related mortality
Noncardiac-related mortality
<150 150-175 175-200 200-225 225-50
Average postoperative glucose (mg/dL)
Furnary AP, et al. J Thorac Cardiovasc Surg. 2003;123:1007-1021.
>250

• Portland data suggest BG:
— <150 mg/dL for mortality
— <175 mg/dL for infection
— <125 mg/dL for atrial fibrillation
Furnary AP, et al. J Thorac Cardiovasc Surg. 2003;123:1007-1021.

For each 50 mg/dL rise in glucose:
Length of Stay increases by 0.76 days
Hospital Charges increase by $2824
Hospital Costs increase by $1769
Furnary et al Am Thorac Surg 2003;75:1392-9

Effect of Average BG
P=0.000
9
45
40
35
30
25
20
15
10
5
0
0 50
P=0.026
BG>150
110<BG<150
BG<110
100 150
Days after inclusion
200
Van den Berghe G, et al. Crit Care Med. 2003;31:359-366.
250

0
-10
Percent
Reduction
-20
-30
-40
-50
-60
Mortality
34%
Sepsis
46%
Dialysis
Blood
Transfusion Polyneuropathy
41%
50%
44% van den Berghe G, et al. N Engl J Med. 2001;345:1359 –1367
.

• 80 –110 mg/dL ICU patients
• 80 –140 mg/dL in other surgical and medical patients
• 70 –100 mg/dL in pregnancy

• Perioperative care
• Surgical ICU care
• Nonsurgical illness
• Pregnancy
> 140 mg/dL
> 110-140 mg/dL*
> 140-180 mg/dL
†
> 100 mg/dL
*Van den Berghe’s study supports 110 mg/dL; Finney’s study supports 145 mg/dL.
†
If drip indication is failure of SQ therapy, use 180 mg/dL; if indication is specific condition
(DM 1/ NPO, MI, etc ), use 140 mg/dL.

• Easily ordered (signature only)
• Effective (gets to goal quickly)
• Safe (minimal risk of hypoglycemia)
• Easily implemented
• Able to be used hospital-wide

• Easily implemented by nursing staff
• Dilution of insulin per hospital policy (0.5 or
1U/cc)
• Able to seek BG range via:
— Hourly BG monitoring
— Adjusts to the insulin sensitivity of the patient
• Contains transition orders to SC insulin when stable

A System for the Maintenance of Overnight Euglycemia and the Calculation of Basal Insulin Requirements in
Insulin-Dependent Diabetics
1/slope = Multiplier = 0.02
6
5
4
3
2
1
0
0 100 200
Glucose (mg/dL)
300 400
White NH, et al. Ann Intern Med. 1982;97:210-214.

• Starting rate units/hour = (BG – 60) x 0.02
where BG is current blood glucose and 0.02 is the multiplier
• Check glucose every hour and adjust drip
• Adjust multiplier to keep in desired glucose target range (80 to 110 mg/dL or
100 to 140 mg/dL)

• Adjust multiplier (initially 0.02) to obtain glucose in target range 80 to 110 mg/dL
— If BG >110 mg/dL and not decreased by 15%, increase by 0.01
— If BG <80 mg/dL, decrease by 0.01
— If BG 80 to 110 mg/dL, no change in multiplier
• If BG is <80 mg/dL, give D50 cc = (100 – BG) x 0.4
• Give continuous rate of glucose in IVFs
(do not feed meals on drip without bolus SC)
• Once eating, continue drip till 2 hours post SQ insulin

Glucommander
Average and Standard Deviation of of All Runs
1985 to 1998; 5808 runs, 120,618 BG’s
400
350
300
250
200
150
100
50
0
0 2 4 6 8
10 12 14 16 18 20 22 24
Hours
Davidson et al, Diabetes Care 28(10): 2418-2423, 2005

Typical Glucommander Run
400
350
300
Glucose
250
200
150
100
50
Glucose
Insulin
5
4
7
6
1
0
3
2
0
Insulin
Multiplier
10 20 30
Hours
40
Davidson et al, Diabetes Care 28(10): 2418-2423, 2005
Hi
Low
50
0.06
0.05
0.04
Multiplier
0.03
0.02
0.01
60
0

• Currently on IV insulin at ~2 units IV/hr
• What do you now do?
1.
Sliding scale rapid acting insulin only?
2.
Basal/bolus insulin therapy?
3.
Premixed insulin therapy?
4.
Basal insulin?

75
Breakfast Lunch Dinner
50
25
4:00 8:00 12:00 16:00
Time
20:00 24:00 4:00 8:00

75
50
Breakfast Lunch
Aspart,
Lispro or
Glulisine
Aspart,
Lispro, or
Glulisine
Dinner
Aspart,
Lispro,
Or
Glulisine
25
Glargine or
Detemir
4:00 8:00 12:00 16:00
Time
20:00 24:00 4:00 8:00

• If >0.5 U/hr IV insulin required with normal
BG, start long-acting insulin (glargine)
• Must start SC insulin at least 2 hours before stopping IV insulin
• Some centers start long-acting insulin on initiation of IV insulin or the night before stopping the drip

IV Insulin Infusion Under Basal Conditions
Correlates Well With Subsequent SC Insulin
Requirement
Total Intravenous vs Subcutaneous 24-Hour
Insulin Requirements (units)
Intravenous
Units IV
Hawkins JB Jr, et al. Endocr Pract. 1995;1:385-389.

(Column Calculated)
INSULIN IV INFUSION STANDING ORDERS FOR TARGET BG
80-110mg/dl
1) Starting Orders a) Discontinue all previous diabetes medication orders.
b) Obtain Basic Metabolic profile now, in 6 hours, then daily.
c) IV fluid: ( )Normal Saline ( )D5/½ Normal Saline ( )D5/½ Normal Saline/20meq K+
( )Other______________________________________________________________
If patient is “NPO” and not receiving TPN or continuous enteral feedings and BG is less than 250, then
the IV fluid selected and the rate of infusion should reflect a glucose source of not less than 5gm per hour.
d) Rate of fluid infusion __________ml/hr (KVO rate at a minimum)
e) ________meq KCl (If K+ level is less than 4, order the above listed IV fluid with 20meq K+)
f) Diet: ( )NPO ( )Continuous enteral feeding ( )TPN mixed without insulin
( )Other__________________________________________________________________
(Do not feed calorie-containing foods unless additional mealtime insulin is ordered).
2) IV Insulin Administration
a) Mix 250 units of Human R insulin in 250ml Normal Saline (1 unit/ml)
b) Flush approximately 30ml through line prior to administration
c) Do not use filter or filtered set with insulin
d) Piggyback insulin drip into IV fluid using an IV infusion pump with capability of 0.1ml/hr
3) Initiate IV insulin flow sheet
4) Blood glucose testing
a) Check BG now and every hour by finger stick using hospital certified BG meter
b) Do not alternate sites without physician approval
c) After hourly BGs remain in the desired range for 4 consecutive hours, may begin BG testing every 2 hours.
d) Have laboratory verify “stat” all BGs less than 40 or greater than 500
5) Determination of IV insulin infusion rate (units of insulin/hour) = (BG-60) x (Multiplier)
a) Initiate infusion using the drip rate (ml/hr) shown in column 2 for the current BG Tier (see Figure 1)
b) To determine the new drip rate for each hourly BG measurement, compare the current BG Tier with
the previous BG Tier.
1.
If the current BG Tier has dropped, stay in the same column to determine the new drip rate (ml/hr).
2.
If the current BG Tier has not changed or is higher, move 1 column to the right to determine the new drip rate (ml/hr).
c) When hourly BG is 80-110, remain in the current column and adjust the rate according.
d) When hourly BG is less than 80, move 1 column to the left to calculate new drip rate and refer to Figure 2.
6) Treatment for hypoglycemia (BG less than 80)
a) Move 1 column to the left and give D50 by IV push using dosing chart provided (see Figure No. 2) b) Recheck BG in 15 minutes (repeat 6a above if BG is still less than 80)
c) Resume hourly BG monitoring and insulin drip adjustments
7) Notify physician If: a) BG is less than 60 for 2 consecutive BG measurements. b) BG reverts back to levels greater than 200 for 2 consecutive BG measurements.
c) Insulin requirement exceeding 24 units per hour does not result in a lower BG level.
d) Patient’s K+ level drops to less than 4.
e) Continuous enteral feedings, TPN, or IV insulin infusion is stopped or interrupted.
8) Transition to subcutaneous insulin
a) BGs should be within target range for at least 4 hours before IV insulin is discontinued
b) Calculate total daily insulin (TDI) = (units of insulin for the last 4 hours of IV drip) x (6) for patients on D5W
c) Begin glargine = 50% TDI (for pregnant patients use NPH twice daily)
d) Begin fast acting analog = 50% TDI divided by 3 (give 3 times a day immediately before meals).
e) Continue IV insulin infusion for 2 hours after initiation of subcutaneous therapy.
f) Refer to Subcutaneous Insulin Standing Orders for administration times and dosage adjustments.
g) Refer patient for diabetes education, nutritional services, and discharge planning (to ensure the patient can afford medications/supplies and has follow-up disease state management after discharge).
The Column Chart & Sample Clinical Guidelines are the property of the Georgia
Hospital Association’s Diabetes SIG: All Rights Reserved; Copyright Pending.

• Establish 24-hour insulin requirement
— Extrapolate from average over last 4-8 hours, if stable
• Give half the amount as basal
• Give PC boluses based on CHO intake
— Start at CHO/ins 1 CHO = 1.5 units rapid-acting insulin
• Monitor AC TID, HS, and 3
AM
• Correction bolus for all BG >140 mg/dL
— (Bg-100)/(1700/daily insulin requirement)

• What is the best insulin treatment for this patient on steroids? (BG 150 to 300 mg/dL)
1.
Sliding scale only with rapid-acting insulin?
2.
IV insulin variable rate infusion?
3.
NPH or 70/30 twice a day?
4.
Basal Insulin once a day?
5.
Bolus insulin premeal?
6.
Basal Bolus insulin therapy?

75
50
Breakfast Lunch
Aspart,
Lispro or
Glulisine
Aspart,
Lispro, or
Glulisine
Dinner
Aspart,
Lispro,
Or
Glulisine
25
Glargine or
Detemir
4:00 8:00 12:00 16:00
Time
20:00 24:00 4:00 8:00

• Starting dose = 0.5 x wt in kg
• Basal dose (glargine) = 40% to 50% of starting dose given at bedtime or anytime
• Bolus dose (aspart/lispro) = 15% to 20% of starting dose at each meal
• Correction bolus = (BG - 100)/correction factor, where CF=1700/total daily dose

• Starting dose = 0.5 x wt in kg
• Weight is 100 kg; 0.5 x 100 = 50 units
• Basal dose (glargine) = 50% of starting dose at HS; 0.5 x 50 = 25 units at HS
• Total bolus dose (aspart / lispro) =
50% of starting dose ÷ 3;
0.5 x 50 = 25 ÷ 3 = 8 units AC (TID)
• Correction bolus = (BG - 100)/ CF, where
CF=1700/total daily dose; CF=

30

• Example:
— Current BG: 250 mg/dL
— Ideal BG: 100 mg/dL
— Glucose correction factor: 30 mg/dL
250 – 100
30
= 5.0 units

4. CORRECTION DOSE INSULIN TYPE :

Rapid Acting Analog

Regular Insulin
[ ] Low Dose Algorithm (for thin, elderly, or renal patients) [Blood Glucose (BG) – 100 / 50]
BG ac, hs, 0300h Additional Insulin
141-175
176-225
226-275
276-325
1 unit
2 units
3 units
4 units
326-375
If greater than 375
5 units
Contact M.D.
[ ] Moderate Dose Algorithm (for average size adult) [BG – 100/ 40]
BG ac, hs, 0300h
141-160
161-200
201-240
241-280
281-320
If great than 320
Additional Insulin
1 unit
2 units
3 units
4 units
5 units
Contact M.D.
[ ] Moderate High Dose Algorithm (for obese or infected patients or those on steroids) [BG-100/30]
BG ac, hs, 0300h
141-145
146-175
Additional Insulin
1 unit
2 units
176-205
206-235
236-265
296-325
3 units
4 units
5 units
7 units
If greater than 326 Contact M.D.
[ ] High Dose Algorithm (for very insulin resistant patients or septic patients) [BG-100/20]
BG ac, hs, 0300h
141- 150
151-170
171-190
191-210
Additional Insulin
2 units
3 units
4 units
5 units
211-230
231-250
251-270
6 units
7 units
8 units
271-290
If greater than 291
9 units
Contact M.D.
*If above correction is not working and BG is persistently >140 mg/dl, consider using an individualized correction dose algorithm with calculations.
[ ] Calculate the Individualized Correction Dose for BG > 140 mg/dl, using the formula:

• What is the best insulin treatment for a DM patient on tube feedings? (BG 150 to 300 mg/dL)
1.
Sliding scale only with rapid-acting insulin?
2.
IV insulin variable rate infusion?
3.
NPH or 70/30 every 8 hours?
4.
Glargine every 12 hours?
5.
Regular insulin every 6 hours?

• What is the best insulin treatment for a DM patient on tube feedings? (BG 150 to 300 mg/dL)
If unstable, first give IV insulin and determine the requirement over 24 hours and then change to SC basal (glargine q12h) with supplemental rapidacting every 4 to 6 hours
Can also use NPH q8h or regular q6h as the basal dose

• What is the best insulin treatment for a DM patient on TPN? (BG 150 to 300 mg/dL)
If unstable, first give IV insulin variable drip and determine the requirement over 24 hours and then add all the insulin to the TPN bag
Continue to supplement every 4 to 6 hours with SC rapid-acting insulin using BG – 100 /
CF where CF is equal to 3000 divided by weight in kg. On average, CF =

30 to 40

• What do you tell the patient to do?
1.
Hold insulin
2.
Take half their dose
3.
Take their basal only with supplement if needed (>140 mg/dL)
4.
Hold insulin and will start IV insulin

• What amount of fluids do you give immediately?
1.
1 liter saline
2.
2 liters saline
3.
1 liter 0.45% saline
4.
2 liters 0.45% saline

• Do you give NaCO
3
?
• When do you start potassium and how much?
• When do you start dextrose and how much?
My preference is 2 liters saline followed by
D
5
0.45 saline with 40 meq KCL/liter at
250 mL/hr. Monitor electrolytes q4-8h

This Sample Clinical Guideline is a compilation of recommended best practices created by a multidisciplinary medical team whose goal is to improve the care of individuals with diabetes. This Guideline is designed to assist hospitals and providers in educating themselves and their patients on medical care to individuals with diabetes and is not intended to be a standard of practice. The legal standard of care applicable to each hospital and patient will vary depending on the circumstances. It is important to note that Federal requirements prohibit the use of standing orders except where specifically allowed and that individual plans of care must be used for each patient.
Diabetic Ketoacidosis Adult Guidelines
1.
Place patient on DKA Pathway until DKA resolved (CO
2
>18 or Venous pH >7.3 or Anion Gap <14)
2.
Diet: NPO
3.
Consult Nutritional Services for diet, so when DKA resolves patient specific subcutaneous insulin can begin
4.
Strict I &O
5.
Vital signs every 2 hr x 4 or until DKA resolved then every 4 hr
6.
Continuous cardiac monitoring
7.
Initial Labs/Diagnostics
_______ EKG if over age 40 or as indicated by: (co-morbid disease state, and/or labs and diagnostics)
_______ Complete Metabolic Profile, CBC with differential, lipid profile, venous pH, Hemoglobin A1C, & urinalysis
_______ If temp is greater than 101°F or greater than 20% Bands present in CBC, obtain blood cultures x 2, urine C&S, and Chest
X-ray
_______ Other Labs/Diagnostics: _________________________________________________________
8.
Follow up Lab/Diagnostics until DKA resolved:
_______ Basic Metabolic Profile every ___ hour
_______ Phosphorus
_______ Venous pH every ___ hour
_______ Anion gap every ___ hour
9.
IV Fluids: Administer NS 1 to 2 liters for first 4 hours (may need to adjust type & rate of fluid administration in the elderly and in patients with CHF or renal failure). Normal Na+ levels are 135-145 meq/L. For subsequent fluid infusion, please refer to the chart below.
Serum Sodium (Na+) level
Low Serum Na+
Normal Serum Na+
IV Fluid
0.9% NaCl
0.45% NaCl mEq K+ to add
See Chart Below
See Chart Below
Rate of Infusion
7-14 ml/kg/hr based on hydration status
7-14 ml/kg/hr based on hydration status
High Serum Na+ 0.45% NaCl See Chart Below 7-14 ml/kg/hr based on hydration status
When plasma BG reaches a level of 250mg/dl or less, begin D5/ ½ NS at 100-200ml/hr (as stated in the IV infusion standing order set)
Initial IV Fluid__________________________ with ______________mEq K+ at _____________ ml/hr
(see No. 9 above) (see No. 10 below) (see No. 9 above)
10.
Serum Potassium (K+) (If there is persistent acidosis due to hyperchloremia, consider using Potassium Phosphate instead of
Potassium Chloride)
Serum K+ mEq K+ To Administer
Greater than 5.4 mEq/L DO NOT GIVE K+ but check level every 2 hours
Between 4.3 and 5.4 mEq/L 30 mEq K+ in each liter of IV fluid to keep level 4.0-5.0 mEq/L
Between 3.3 and 4.2 mEq/L 40 mEq K+ in each liter of IV fluid to keep level 4.0-5.0 mEq/L
Less than 3.2 mEq/L HOLD INSULIN and give 40 mEq of K+ in 1 liter of fluid over 1 hour (smaller
volume can be used only if fluid compromised).. Retest and repeat until K+ > 3.2
Notify physician if corrective measures still result in serum K+ greater than 5.4 or less than 3.2
11.
Insulin Insulin: Follow IV Insulin Protocol
12. BICARBONATE (for adult use only)
* If arterial pH is less than 7, may consider administration of 100ml NaHCO3
* Check acid-base 30 minutes later & may repeat if pH is still less than 7
* Bicarbonate should not be administered if K+ is less than 3.6
13. Continue with Insulin IV infusion standing orders inclusive of the subcutaneous insulin transition process.
14. Notify diabetes educator of admission.
Time:____________ Date:__________ MD Signature___________________________________________

What is the preferred in hospital treatment of hypoglycemia?
1.
Juice with sugar added
2.
50% IV dextrose (1 amp or 50cc)
3.
50% IV dextrose (1/2 amp or 25cc)
4.
50% IV dextrose (based on glucose level)

Treatment of hypoglycemia
• Any BG <80 mg/dL:
D50 IV = (100 - BG) x 0.4
• If eating, may use 15 gm of rapid CHO
(prefer glucose tablets)
• Do not hold insulin when BG normal

What can we do for patients admitted to the hospital?
• Protocols for all diabetes/hyperglycemic patients
• Finger stick BG AC QID on all admissions
• Check all steroid-treated patients
• Diagnose diabetes
— FBG >126 mg/dL
— Any BG >200 mg/dL

What can we do for patients admitted to the hospital?
• Document diagnosis in chart
— Hyperglycemia is diabetes until proven
— Bring to all physicians’ attention
— Note on problem list and face sheet
• Check hemoglobin A1C
• Hold metformin; Hold TZD with CHF, liver dysfunction
• Start insulin in all hospitalized patients with BG
>140 mg/dL

Defining and Identifying Hyperglycemic Patients
Goal: Studies have proven that the outcomes of hospitalized patients are greatly enhanced when
steps are taken to improve the patient’s glycemic state. Therefore, all patients presenting with
hyperglycemia will be identified using the patient’s initial “basic metabolic profile.”
Patient Presents with Hyperglycemia
Previously diagnosed DM
Diabetic Ketoacidosis
Hyperglycemic Crisis
Follow DKA Protocol
No Previous Diagnosis DM
And BG > 140
Begin BG testing
Modification of therapy
And referral for dietary
And educational consult
BG is >140 for a critically ill patient, notify physician for consideration to initiate therapy
BG is > 180 for a non- , critically ill patient, notify physician for initiation of
Subcutaneous therapy
When adult blood glucose levels > 140 still occur after initiation/modification of therapy, consideration should be given to begin IV insulin infusion (see patient and departmental special consideration listed below).
Insulin Pump
Pregnancy
Peri-Operative
ICU
Pediatrics
DKA
Abrupt or unplanned alteration of pump regimen can result in rapid deterioration of metabolic control resulting in acute complications, (DKA, hypoglycemia) and adverse outcome.
Accordingly, any change in regimen should only be ordered by or in consultation with the primary diabetes physician.
Lack of optimal glycemic control in pregnancy has been shown to cause significant and life-threatening complications for both mother and child. Consultation should be obtained with any admissions of pregnant patient with diabetes.* Preprandial BG goal of 60-90 and post-prandial BG goal of
<120 has been shown to enhance outcomes of this populace.
Optimal glycemic control will reduce post-operative complications and therefore patients with hyperglycemia may benefit from consultation and the use of IV insulin infusion.
Maintaining BG levels of 80-140 has been shown to be effective in this setting.
Optimal glycemic control reduces both morbidity and mortality rates in the ICU setting. Maintaining BG levels of
80-110 have been shown to benefit patients in the ICU area of care.
The tendency toward labile blood sugars and special considerations related to managing diabetes in pediatric patients may result in compromised outcomes and therefore may well benefit from consultation.
Since DKA is a serious condition which requires intensive management, consultation with the patient’s primary diabetes physician should be considered.*

Protocol for insulin in hospitalized patient
• Treat any patient with BG >140 mg/dL with insulin
— Treat any BG >140 mg/dL with rapid-acting insulin (BG-100) / (3000 / wt [kg]) or 1700 / total daily insulin
— Treat any recurrent BG >180 mg/dL with IV insulin if failing SC therapy or >140 mg/dL if
NPO, acute MI, perioperative, ICU, or >100 mg/dL if pregnant
• If >0.5 U/h IV insulin required, start long-acting insulin

Protocol for insulin in hospitalized patient
• Daily total: Pre-admission or weight (kg) x 0.5 U
— 50% as glargine (basal)
— 50% as total rapid-acting insulin (bolus)
• Give in proportion to meal’s CHO eaten
• BG >140 mg/dL: (BG-100) / CF
— CF = 1700 / total daily insulin or 3000 / wt (kg)
• Do not use sliding scale as only diabetes management

What can we do for patients admitted to the hospital?
• Get diabetes education consult
• Instruct patient in monitoring and recording
— See that patient has meter on discharge
• Decide on case-specific program for discharge
• Arrange early follow-up with PCP

• For a copy or viewing of these slides, contact or hospital protocols, go to: www.adaendo.com
www.gha.org