Management of Inpatient
Blood Glucose at
Temple
Housestaff Orientation
2014
Hyperglycemia is Associated with
Morbidity and Mortality in Inpatients
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ICU
Ward
Surgical
Medical
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Endocarditis
Pneumonia
Renal transplantation
COPD exacerbation
Post-MI
Stroke
Infection
Wound healing
2
Glycemic Control Targets
in Non–ICU Patients
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Premeal BG <140 mg/dL
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Random BG <180 mg/dL
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To avoid hypoglycemia (BG <70 mg/dl),
reassess insulin if BG levels fall below 100
mg/dL
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Estimating Insulin Requirement
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Home insulin regimen
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Weight-based dose
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Recent insulin given (as inpatient)
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Clinical status (hypoglycemia and insulin
resistance factors)
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Hypoglycemia and insulin
resistance factors
Hypoglycemia risk factors
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Type 1 diabetes
Renal dysfunction
Severe cardiac
dysfunction
Severe hepatic
dysfunction
Advanced age
Insulin resistance factors
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Obesity
Infection
Open wounds
Steroids
Glucotoxicity
 BG > ~300 mg/dl
 A1c > ~10%
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Continuing home insulin
program in hospital
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Must fully assess
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Glucose control at home
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Hypoglycemia, hyperglycemia, A1c
Compliance (confirm meds/doses)
 Does the regimen make sense?
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Consider along with weight-based
estimate to calculate dose: use clinical
judgment
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Weight-based SC insulin dosing
1.
Estimate Total Daily Dose (TDD, U/kg)
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0.3 U/kg if high risk of hypoglycemia
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0.4 – 0.5 U/kg average type 2 diabetes
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0.6 U/kg if insulin resistant
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How to dose SC insulin
2.
TDD = 50% basal insulin + 50% bolus insulin
3.
Basal insulin =
Lantus (glargine) qHS or NPH q12 h
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4.
Do not hold for NPO (give 50-80%)
Bolus (nutritional, prandial) insulin =
Humalog (lispro) qAC
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Given with meal (or tube feeds)
Given as long as premeal BG >70 mg/dl
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Case: 78 yo woman, type 2 DM on metformin
1000mg BID + glargine 20units qHS
admitted for COPD, BG is 320 mg/dl, A1c is 9%
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Hypoglycemia risk factors: age, Cr 1.6
Insulin resistance factors: steroids, hyperglycemia
Estimated TDD = 0.5 units/kg/day
TDD = 66 kg x 0.5 U/kg = 33 units
50% basal = 33/2 = 16 units glargine qHS
50% bolus = 16/3 meals
= 5 units lispro qAC
STOP all oral diabetes meds
Assess glucose and titrate daily
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What about correction insulin?
150-200 2U
201-250 4U
251-300 6U…
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Sensitivity Factor
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The expected drop in glucose after
administering 1 unit of insulin
HIS SF= 10
HER SF = 50
AVERAGE SF= 30
This scale assumes SF=25
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2 units for 50 mg/dl intervals
150-200 2U
201-250 4U
251-300 6U…
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Correction Scales at TUH
Insulin Correction Scale
BG mg/dl
#1
#2
#3
#4
151-200
1
2
3
4
201-250
2
4
6
8
251-300
3
6
9
12
301-350
4
8
12
16
351-400
5
10
15
20
50
25
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12.5
SF
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Rule of 1500
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SF = 1500/TDD
From prior ex., TDD = 33
SF = 1500/33 = 45
Use correction scale #1
Better to use lower-dose scale if SF is
between scales
Rubin DJ, Golden SH. Hypoglycemia in non-critically ill, hospitalized patients with
diabetes: evaluation, prevention, and management. Hosp Pract (1995). 2013
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A complete insulin program
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Basal + Bolus + Correction
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Correction is given regardless of nutrition
status (NPO)
Should be ordered for:
All type 1 diabetes
 Most type 2 diabetes
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Except diet-controlled and BGs <140 mg/dL
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Key Points
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Inpatient blood glucose is important
Non-ICU BG targets:
<140 premeal, <180 random
Do not use sliding scale alone
Stop oral diabetes meds
Order a complete SC insulin program
Check A1c on every diabetic or BG >140
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TUH Diabetes Protocols
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Located in SharePoint
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Hypoglycemia protocol
MIS Diabetes orderset instructions
Prandial insulin hold Guideline
DKA/HHS Guideline
Critical Care IV Insulin Guideline
Transitioning IV to SC insulin
Insulin instructions for discharge
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How to access SharePoint
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From any TUH computer,
type “diabetes” in web browser
How to access SharePoint
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From any TUHS network computer or
via Citrix, use SharePoint directory
Select “SharePoint site directory”
Select
“TUH Glycemic Control”
Hypoglycemia algorithm
Diabetes Orderset
Diabetes Orderset
Diabetes Orderset
Diabetes Orderset
Diabetes Orderset
Diabetes Orderset
Prandial Insulin Hold Guideline
“Hold” parameters for Prandial/nutritional/bolus
insulin, i.e., Humalog (lispro) or Regular insulin
􀂆 Do not give dose if blood glucose <70 mg/dL
􀂆 Give ½ the ordered dose if blood glucose is 70-99 mg/dL
􀂆 Give all of the ordered dose if blood glucose is ≥100 mg/dl
DKA/HHS Guideline
DKA/HHS Guideline
Critical Care Insulin Infusion
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Applies to all patients in all ICUs except
 DKA or HHS or expected transfer out of unit
within 24 hrs
Start when 2 BG >160 mg/dl
within 24-48 hr
 Target 120-160 mg/dl
 Nurses titrate
 Give SC insulin (usually glargine) 2 hrs
before stopping insulin drip
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Transitioning IV to SC Insulin
Transitioning IV
to SC Insulin
Transitioning IV to SC Insulin
Insulin
Discharge
Instructions
Order HBA1C in Common Lab Tests Menu