Building and Implementing Effective Subcutaneous Insulin Orders and Protocols - PowerPoint PPT Presentation


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Building and Implementing Effective Subcutaneous Insulin Orders and Protocols


Building and Implementing Effective Subcutaneous Insulin Orders and Protocols Greg Maynard MD, MS Professor of Clinical Medicine and Chief, Division of Hospital Medicine – PowerPoint PPT presentation

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Title: Building and Implementing Effective Subcutaneous Insulin Orders and Protocols

Building and Implementing Effective Subcutaneous
Insulin Orders and Protocols
  • Greg Maynard MD, MS
  • Professor of Clinical Medicine and Chief,
    Division of Hospital Medicine
  • University of California, San Diego

Insulin Terminology
  • Basal insulin
  • Long-acting, all Type 1 and most Type 2 DM
    patients should have basal insulin whether they
    are eating or not (insulin glargine, insulin
    detemir, or NPH)
  • Nutritional or pre-meal / prandial insulin
  • Short-acting insulin given with meals in
    anticipation of carbohydrate load glycemic spike
    (scheduled insulin aspart, insulin lispro,
    insulin glulisine, regular insulin)
  • Correction or supplemental insulin
  • Short-acting insulin given to cover high glucose
    if substantial use, it should drive adjustment of
    basal and nutritional insulins

Insulin Terminology
  • Sliding scale insulin
  • This is a dirty word we dont use dirty words at
  • Mindless medicine, paralysis of thought,
    action without benefit, insulin insanity
  • Evidence does not support this technique without
    basal insulin unacceptably high rates of
  • Hyperglycemia
  • Hypoglycemia and insulin stacking
  • Iatrogenic DKA in patients with type 1 DM

Umpierrez G et al. J Hosp Med. 2006 1141-4.
Steps for Successful Implementation
  • Identify best practices and preferred regimens
  • Integrate into a protocol, summarize in one page.
  • Place protocol guidance into flow of work
  • Structured order sets, documentation tools,
  • Use high reliability design, layer on other
    improvement methods (including special teams)
  • Proactively identify and mitigate outliers.
    Refine and redesign your educational efforts,
    order set design, and implementation strategies

Integrate Best Practice into protocols, order
sets, documentation
  • Actionable glycemic target
  • Constant carbohydrate / dietary / consult
  • A1c
  • Specify hyperglycemic diagnosis
  • Education plan
  • Hypoglycemia protocol
  • Guidance for transitions (linked protocols)

Integrate Best Practice into protocols, order
sets, documentation
  • Coordinated insulin / nutrition / monitoring.
  • Insulin preferred - DC oral agents
  • Basal / Nutrition / Correction terminology
  • Dosing adjustment guidance
  • Specific regimens for different situations
  • NPO
  • Eating
  • Tube feeds
  • Steroids, etc

Problems with Oral Agents in the Hospital
  • Sulfonylureas (e.g., glyburide, glipizide, etc.)
  • Hypoglycemia (long acting)
  • ? CAD
  • Metformin
  • Lactic acidosis risk
  • Renal insufficiency, hypotension, heart failure)
  • Gastrointestinal
  • Nausea, abdominal pain, diarrhea
  • Thiazolidinediones (TZDs or glitazones) (e.g.,
  • Possible liver toxicity
  • Fluid overload, heart failure
  • Inability to titrate (very slow onset of action)

Physiologic Insulin SecretionBasal-Bolus
Nutritional (prandial) insulin
Insulin (µU/mL)
Suppresses glucose production
between meals and overnight
Basal insulin
Breakfast Lunch Supper
Nutritional glucose
The 50/50 rule (or maybe 40/60)
Glucose (mg/dL)
Basal glucose
Time of Day
Which Patients Need Basal Insulin in the Hospital?
  • Insulin-deficient patients should always have
    basal insulin (even NPO)
  • Type 1 DM or DKA, pancreatic insufficiency
  • A history of type 2 DM for 10 years or more
  • On any insulin for 5 years or more
  • Wide fluctuations of glucose values
  • Preprandial glucose gt ?130, 150 mg/dL
  • Any glucose gt 180 mg/dL

Constructing a Profile for Scheduled Subcutaneous
Insulin .
Glulisine Lispro Aspart
Glargine Detemir
6 am 12 pm 6 pm 12 am
SHM Glycemic Control Task ForcePreferred Insulin
  • See handout
  • In interest of standardization, narrow down
  • Eliminating other acceptable choices, but also
    many unacceptable ones!
  • Allow variation, while encouraging standardization

Common Features Increasing Risk of Hypoglycemia
in an Inpatient Setting
  • Malnutrition and low body weight
  • Chronic renal failure
  • Decreased oral intake, failure to provide
    nutrition or dextrose infusion
  • Advanced age
  • Liver disease
  • Beta-blockers
  • Iatrogenic Risk Factors SSI, distractions, poor
    regimens disconnect between testing,
    administration of insulin, and nutrition

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Calculating Insulin Dosage (Total Daily Dose)
  • Calculate from insulin infusion amount
  • Recent steady state hourly rate x 20, for example
  • Add up insulins taken at home, adjust for
    glycemic control and other factors
  • Calculate from weight, body habitus, other factors

Starting Basal-Bolus from Scratch
  • Calculate starting total daily dose (TDD)
  • 0.3 units/kg/day (hypoglycemia risk factors,
    naïve patient)
  • 0.4 units/kg/day (conservative for most
  • 0.5 0.6 units/kg/day (overweight to obese)
  • Adjust TDD up or down based on
  • Past response to insulin
  • Presence of hyperglycemia inducing agents, stress
  • This Is very conservative and safe (adjust up as
  • Basal insulin 40-50 of TDD
  • Glargine q HS or q AM, detemir in 1 or 2 doses
  • Goal FBS and pre-meal glucose 80-110 mg/dL

Case 1 Initiating Subcutaneous Insulin in an
obese patient eating regular meals
  • 56 year old man admitted with diabetic foot
    infection, eating regular meals.
  • Obese, weighs 100 kg
  • Home regimen
  • 2 OHGs and 20 units of NPH q HS
  • Baseline Control
  • HbA1c of 10, POC glucose in ED 240 mg/dL
  • What are your initial orders for insulin?
  • What change would you make if he had to go to the
    OR the next morning?

Eating Patient (or Bolus TF)
Case 1 Solutions for Obese, eating patient
  • Accuchecks AC and HS
  • TDD 100 kg x 0.6 units/kg/day 60 units
  • Glargine (Lantus) Alternative
  • Basal Glargine 30 units q HS
  • Nutritional Lispro 10 units q ac
  • Correction Lispro per scale q ac and HS
  • For NPO p MN and OR the next AM
  • Hold nutritional dose, continue adjustment dose
  • Give the full dose of Glargine q HS No change.

Adjust, Adjust, Adjust
  • If glucoses going lt 70 mg / dL, use 80 of TDD as
    next days TDD
  • If glucose readings gt 150 and no hypoglycemic
    values, use 120 of yesterdays total as new TDD
    (or 130, depending on the uniformity and degree
    of poor control)

Case 2 Patient in IMU on Continuous TF
  • 65 year old you are seeing for the first time in
    the IMU, no outpatient history available except
    on insulin. Glucose gt 200 in ED, HbA1C pending.
  • 80 kg overweight woman started on continuous TF
    yesterday (HD3), with serum glucose in 200-250
    mg/dL range
  • What would you order?

TPN or Continuous Tube Feedings
Continuous Tube Feeding Insulin Regimen
Case 2 Solutions in a patient on continuous TF
or TPN
  • Accuchecks q 6 hours
  • TDD is 0.5 units/kg/day x 80 kg 40 units
  • Basal Glargine 16 units q hs (or q am)
  • Nutritional 6 units regular insulin q 6 h
  • Correction regular insulin q 6 h per scale
  • Patients being started on TPN do better with
    separate insulin infusions initially (with y
    connector) to find dose.
  • Conversion then can be made to insulin in TPN
    (80 of TDD), or subcutaneous regimen.

Case 3 Transition from IV to subcutaneous
  • 60 yo man with DM 2, well controlled in ICU on
    insulin infusion and continuous TF at 40 ml/hour.
  • Insulin Infusion rate 80 units in the last 24
    hours, 3 units / hour over last 6 hours.
  • Prior to hospitalization, baseline HbA1c was 8.7
    on 40 units of 70/30 insulin per day and OHGs.
  • Plan Transfer to ward, continue enteral
  • How do you transition this patient to a
    subcutaneous insulin regimen?

Stepwise approach to moving from IV to SC insulin
  • Calculate how much IV insulin the patient has
    been requiring. Modify down for safety cushion.
  • Was this insulin supplying Basal requirements, or
    Basal and Nutritional requirements? Translate
    into the subcutaneous regimen.
  • Consider any nutritional changes that may be
    implemented at the time of the transition off of
    the drip
  • Make sure SC insulin is given before
    discontinuation of the IV insulin

Case Transition to subcutaneous insulin(enteral
nutrition to continue)
  • Safe Estimate of 24 hour requirement
  • 3 units / hour x 20 60 units
  • 60 units represents the TDD Basal and
    nutritional insulin
  • 5050 Rule Example
  • Glargine 30 units Basal
  • Regular 7 units q 6 h Nutritional
  • Correction dose of regular insulin also given
    along with nutritional dose as needed.
  • Glargine / Nutritional should be given BEFORE IV
    insulin stopped

What if??? Enteral to PO
  • Instead of continuing enteral nutrition on the
    floor, you opt to stop enteral nutrition and
    start patient on a mechanical soft diet?
  • Glargine 30 units Basal
  • RAA 10 units q AC Nutritional / Prandial
  • (IF you expect them to eat a full meal! )
  • If po intake suspect at first, use CHO counting,
    or empirically reduce nutritional RAA dose and
    give the dose just AFTER the meal instead of just
    BEFORE the meal.
  • CORRECTION dose RAA insulin also needed.

Have a Discharge PlanTailored to Patient!
  • Diabetes and insulin education, survival skills
    START EARLY and repeat
  • Follow up and community resources
  • Covered by insurance
  • Patient and family can understand
  • Reconcile medications
  • Language, health literacy, and cultural barriers
  • Use HbA1c
  • Insulin requirement may decrease post discharge