Lake Forest Hospital
Non-ICU Glucose Management
Non-ICU Glucose Management
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Notify/Consult Endocrinology:
Insulin pump, DKA/HHS, type 1 diabetes, U-500, tube feeds, high dose steroids,new onset diabetes, severe insulin resistance, severe hyperglycemia, hypoglycemia < 54 mg/dl, hypoglycemia unawareness, admission for symptomatic or severe hyperglycemia (A1c > 11%) Check A1c (if none in 90 days and no transfusions) Stop all oral agents Default: check POC glucose before meals and bedtime Consider 3AM check: bedtime correction, high dose steroids, risk of hypoglycemia, unstable glucose patterns Never stop basal insulin in DM1 (DKA risk) Limit or avoid sliding scale use Document and assess home regimen: hypoglycemia, hyperglycemia, total daily dose of insulin (units/kg/day) Goal blood glucose: fasting/pre-meal 100-140 mg/dl, random or post-meal < 180 mg/dl
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Calculate Total Daily Insulin Dose (TTD) by weight
Patient category per table, multiply factor by weight in Kg Divide TTD into 50% basal and 50% mealtime (divide with 3 meals) If patient on insulin at home (basal, basal-meal, 70/30): Compare calculated dose with 80% of total home dose and always use the LOWER of 2 doses Preexisting diabetes: Insulin orders
long-acting +meal rapid acting (as appropriate) + Correction Correction alternative: 1-5 units per 100 mg/dl starting with glucose > 150 mg/dl 1:100 (1) 1:50 (2) 1:35 (3) 1:25 (4) 1:20 (5) |
Value |
LOW (1:50) |
MEDIUM (1;30) |
HIGH (1:20) |
CONFIGURABLE 1:100, 1:75, 1:15, 1:10,1:5 |
150-199 |
1 |
1 |
2 |
*** |
200-249 |
2 |
3 |
4 |
*** |
250-299 |
3 |
5 |
7 |
*** |
300-349 |
4 |
7 |
10 |
*** |
350-399 |
5 |
9 |
13 |
*** |
> 400 |
See severe protocol |
- |
- |
- |
ADJUST INSULIN DAILY
Watch BG trends:
IF BG> 140 mg/dl fasting OR > 180 mg/dl random, increase TTD 10-20%
If BG < 100 mg/dl, decrease 10-20%
Increase mealtime insulin if BG values elevated at pre-lunch, pre-dinner, or bedtime
Increase basal insulin: If fasting BG > 140 mg/dl AND BG drops less than 50mg/dl from bedtime to fasting
Alternative: Take 50% of prior 24 hours correctional insulin, 1/2 basal, 1/2 with meals
Insulin sensitivity factor estimate: 1500/TTD (1500-1800/TTD)
Insulin: carbohydrate ratio estimate: 500/TTD (300-500/TTD)
SPECIAL NUTRITIONAL SITUATIONS
NPO or clear liquids
Do not hold basal insulin (especially DM1)
Consider decreasing basal insulin by 20% (DM1), up to 50% (DM2) (see preoperative protocol)
Use weight based TTD per table, give 40% as basal
Do NOT give mealtime insulin, use appropriate correction scale
Meals
Default is consistent carbohydrate of 60-75g
Carbohydrate counting: Insulin: carbohydrate ratio (number of units per g carbohydrate
Example: 1:10 I:C ratio: 6 units to cover 60g of carbohydrate, male default 1:10, female default 1:15)
Tube feeds:
Nocturnal: Basal 1/d, rapid with start cycle, add correction, BG 4/day
Bolus: Basal 1-2/daily, rapid 3-4/day (hold NPO), BG 4/day: add rapid correction
Continuous: Basal 1-2/day, regular Q6(hold NPO), rapid Q4, BG 4/d, add rapid correction
SEVERE HYPERGLYCEMIA > 400 mg/dl
Hold food, encourage non-glucose containing fluids (unless fluid restricted)
Rule out DKA/HHS (stat basic chemistry, beta-hydroxybutyrate): transfer ICU if confirmed, sustained glucose > 600 mg/dl
Assess for spurious result, assess for causative factors (stress, high carbohydrate intake)
Check steroid use: see steroid protocol
Option 1: Give correction of rapid acting insulin 5-10% of weight based TTD per table (peaks in 1-2 hours)
Avoid stacking by separating doses by at least 3 hours
Can check at 1 hour (check at least 10% drop)
Option 2: starting glucose-110/correction factor (at least one step up from current correction scale)
Example: Glargine 24 units, meals, 8 lispro per meal, medium dose correction (1:30-35), Glucose 460 mg/dl
480-110/25 (high dose scale correction) = 350/25 =14 units rapid acting insulin SQ
STEROID-INDUCED HYPERGLYCEMIA
Convert steroid to prednisone equivalent:
prednisone 20mg = methylprednisolone 16mg = Dexamethasone 3mg
Prednisone > 100mg daily, consider endocrinology consult
Insulin naive or prednisone < 40mg
If steroid dosed daily: Add NPH 10 units with steroid dose
If steroid doses multiple times daily, add rapid acting insulin e.g. lispro 3 units with each meal
Adjust dose 10-20% daily as needed
Insulin resistant or prednisone dose > 40 mg
Prednisone equivalent(mg)-20/20 x 0.1 units x body weight (Kg)
Maximum initial single dose: 20 units, insulin naive, 40 units insulin experienced
Give NPH with each steroid dose
If giving evening steroid, order 3AM glucose check
Alternatives:
1.Basal-bolus-correction (weight based TTD: 50-50% basal + meals (1/3 per meal) + correction
2. OR give 30% basal, 70 % meals (20-40-40%) + correction
Total daily dose 0.5-0.6 (or higher: 0.7-1.2+ U/kg/day)
Adjust at least 10-20% daily
Option 3 Prednisone 10mg NPH 0.1 u/kg/day, 20mg=0.2, 30mg=0.3, >40mg 0.4 u/kg/d
Option 4 use 130% of home insulin dose initially, frequent adjustments as needed
Watch BG trends:
IF BG> 140 mg/dl fasting OR > 180 mg/dl random, increase TTD 10-20%
If BG < 100 mg/dl, decrease 10-20%
Increase mealtime insulin if BG values elevated at pre-lunch, pre-dinner, or bedtime
Increase basal insulin: If fasting BG > 140 mg/dl AND BG drops less than 50mg/dl from bedtime to fasting
Alternative: Take 50% of prior 24 hours correctional insulin, 1/2 basal, 1/2 with meals
Insulin sensitivity factor estimate: 1500/TTD (1500-1800/TTD)
Insulin: carbohydrate ratio estimate: 500/TTD (300-500/TTD)
SPECIAL NUTRITIONAL SITUATIONS
NPO or clear liquids
Do not hold basal insulin (especially DM1)
Consider decreasing basal insulin by 20% (DM1), up to 50% (DM2) (see preoperative protocol)
Use weight based TTD per table, give 40% as basal
Do NOT give mealtime insulin, use appropriate correction scale
Meals
Default is consistent carbohydrate of 60-75g
Carbohydrate counting: Insulin: carbohydrate ratio (number of units per g carbohydrate
Example: 1:10 I:C ratio: 6 units to cover 60g of carbohydrate, male default 1:10, female default 1:15)
Tube feeds:
Nocturnal: Basal 1/d, rapid with start cycle, add correction, BG 4/day
Bolus: Basal 1-2/daily, rapid 3-4/day (hold NPO), BG 4/day: add rapid correction
Continuous: Basal 1-2/day, regular Q6(hold NPO), rapid Q4, BG 4/d, add rapid correction
SEVERE HYPERGLYCEMIA > 400 mg/dl
Hold food, encourage non-glucose containing fluids (unless fluid restricted)
Rule out DKA/HHS (stat basic chemistry, beta-hydroxybutyrate): transfer ICU if confirmed, sustained glucose > 600 mg/dl
Assess for spurious result, assess for causative factors (stress, high carbohydrate intake)
Check steroid use: see steroid protocol
Option 1: Give correction of rapid acting insulin 5-10% of weight based TTD per table (peaks in 1-2 hours)
Avoid stacking by separating doses by at least 3 hours
Can check at 1 hour (check at least 10% drop)
Option 2: starting glucose-110/correction factor (at least one step up from current correction scale)
Example: Glargine 24 units, meals, 8 lispro per meal, medium dose correction (1:30-35), Glucose 460 mg/dl
480-110/25 (high dose scale correction) = 350/25 =14 units rapid acting insulin SQ
STEROID-INDUCED HYPERGLYCEMIA
Convert steroid to prednisone equivalent:
prednisone 20mg = methylprednisolone 16mg = Dexamethasone 3mg
Prednisone > 100mg daily, consider endocrinology consult
Insulin naive or prednisone < 40mg
If steroid dosed daily: Add NPH 10 units with steroid dose
If steroid doses multiple times daily, add rapid acting insulin e.g. lispro 3 units with each meal
Adjust dose 10-20% daily as needed
Insulin resistant or prednisone dose > 40 mg
Prednisone equivalent(mg)-20/20 x 0.1 units x body weight (Kg)
Maximum initial single dose: 20 units, insulin naive, 40 units insulin experienced
Give NPH with each steroid dose
If giving evening steroid, order 3AM glucose check
Alternatives:
1.Basal-bolus-correction (weight based TTD: 50-50% basal + meals (1/3 per meal) + correction
2. OR give 30% basal, 70 % meals (20-40-40%) + correction
Total daily dose 0.5-0.6 (or higher: 0.7-1.2+ U/kg/day)
Adjust at least 10-20% daily
Option 3 Prednisone 10mg NPH 0.1 u/kg/day, 20mg=0.2, 30mg=0.3, >40mg 0.4 u/kg/d
Option 4 use 130% of home insulin dose initially, frequent adjustments as needed
Prednisone dose |
NPH: insulin naive or sensitive |
NPH: insulin resistant or experiences |
40mg |
20 |
40 |
30mg |
15 |
30 |
20mg |
10 |
20 |
10mg |
5 |
10 |
5mg |
2 |
5 |
INSULIN PUMP:
Notify endocrinology
Do NOT use if: unstable, no supplies, mental status changes, suicidal, psychosis, not proficient
Use signed contract/waiver when implemented (see updated policy)
Hypoglycemia: Rx < 70 mg/dl, incident report < 40 mg/dl, with adverse clinical effects
15g carb (4 Oz. juice,soda, 8 oz. non-fat milk, 3-4 glucose tablets), recheck Q20 mins until > 70 mg/dl. If unable to take PO: 25 ml of D50 IV = 25g (consider glucagon, D10)
Ultra long acting insulin: Toujeo(U-300 glargine), Tresiba(degludec)-adjusted every 3-4 days. Optimal dose adjustment prior to surgery not clearly defined
Care with SGL2i (Cana-dapa-empa-gliflozins) as associated with (euglycemic) DKA
Perioperative/NPO: Insulin treated diabetes cut basal 80% night before (type 2 diabetes with poor oral intake consider 50%), 50% basal on day of surgery (unless ultra long axcting)
Critical illness: Glucose goals: 140-180, IV insulin protocol, Check glucose hourly (use lab or blood gas glucose for poor perfusion, pressors)
High risk Surgery: Check A1c. Check glucose before, during or just after surgery, before PACU Discharge. Correction insulin for glucose > 150mg/dl. Basal-meal-correction after surgery. See detailed protocol
Discharge planning/transition of Care: meter, test strips, insulin (affordable: NPH, regular, 70/30=~$25 range), syringes and/or pen needles, glucose tablets, urine ketone strips, alert ID, follow up.
Notify endocrinology
Do NOT use if: unstable, no supplies, mental status changes, suicidal, psychosis, not proficient
Use signed contract/waiver when implemented (see updated policy)
Hypoglycemia: Rx < 70 mg/dl, incident report < 40 mg/dl, with adverse clinical effects
15g carb (4 Oz. juice,soda, 8 oz. non-fat milk, 3-4 glucose tablets), recheck Q20 mins until > 70 mg/dl. If unable to take PO: 25 ml of D50 IV = 25g (consider glucagon, D10)
Ultra long acting insulin: Toujeo(U-300 glargine), Tresiba(degludec)-adjusted every 3-4 days. Optimal dose adjustment prior to surgery not clearly defined
Care with SGL2i (Cana-dapa-empa-gliflozins) as associated with (euglycemic) DKA
Perioperative/NPO: Insulin treated diabetes cut basal 80% night before (type 2 diabetes with poor oral intake consider 50%), 50% basal on day of surgery (unless ultra long axcting)
Critical illness: Glucose goals: 140-180, IV insulin protocol, Check glucose hourly (use lab or blood gas glucose for poor perfusion, pressors)
High risk Surgery: Check A1c. Check glucose before, during or just after surgery, before PACU Discharge. Correction insulin for glucose > 150mg/dl. Basal-meal-correction after surgery. See detailed protocol
Discharge planning/transition of Care: meter, test strips, insulin (affordable: NPH, regular, 70/30=~$25 range), syringes and/or pen needles, glucose tablets, urine ketone strips, alert ID, follow up.
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Lake Forest Hospital DKA/HHS Management 2018:
See Policy and order sets Notify: Endocrinology (Page 1-9755), Nephrology for ARF, advanced CKD, ESRD DKA Prevention: NEVER omit basal insulin in type 1 diabetes/DKA prone/insulin pumps Diagnosis of DKA/HHS: Diabetic Ketoacidosis (DKA), Hyperosmolar hyperglycemic state (HHS)can overlap: Look for triggers-infection ischemia, non-adherence, social factors, pump problems DKA glucose usually > 200 mg/dl, pH <7.3, C02 < 15 MeQ/l, Anion Gap > 12, Beta hydroxybutyrate > 3.0 Meq/L, ketones positive (moderate pH < 7.24, severe < 7.0) HHS BG> 540-600, pH > 7.3, Bicarb> 18, BHB <3.0, ketones small-zero, mOSm/kg > 320 Predicted fluid and potassium deficits: Water deficit DKA 7-14 Liters HHS 10-22 Liters!! Potassium deficit DKA 210-350 mmol/kg HHS 350-1050 mmol/kg DKA Initial Studies: HbA1c, Basic chemistry, Magnesium, Calcium, Phosphate, Blood gas (venous or arterial) Beta Hydroxybutyrate (or ketones): rapid turn around approved CBC, Amylase/Lipase Osmolarity, Urinalysis (others-toxicology, troponin, beta HCG, EKG) Maintenance studies: BCP, magnesium, phosphorus q3-4 hours Potassium Management: K < 3.3 Meq/l correct BEFORE starting insulin infusion (rule out anuria) Anticipate total body depletion (unless advanced CKD, ARF, ESRD) DKA Fluid management: Start IVF 0.9% saline 10-20 ml/kg in 1st hour, then per MD orders Adjust IVF for shock, ESLD, ESRD, ARF, CHF DKA insulin management: Start insulin 0.1 u/kg IV bolus, 0.1 u/kg/hour IV infusion (See titration tablets over) Once glucose < 250mg/dl: Change to D5 0.45% NS suggested rate 125-200 cc/hour Consider no insulin bolus with HHS Oral intake: May eat if alert and no aspiration risk. Provide SQ rapid acting insulin: Rapid acting SQ 0.3 u/kg divided ⅓ with meals or default insulin: carbohydrate ratio 1:15 male, 1:10 males DKA resolution: Anion gap <=12, Bicarbonate > 18 Meq/l, pH > 7.3, BHB=0 HHS: IVF: Start with 0.9% NaCl 1-1.5L, switch to 0.45% if osmolarity not falling on 0.9% 1-2 L/hour 0.9% NaCl for shock otherwise 500 ml/hour x 4 hours, then 250 ml/hour Insulin: start 0.1 u/kg/hour once osmolarity stops falling with IVF, double if not falling 50-70 mg/dl/hour, decrease 0.02-0.05 u/hour glucose <250-300 mg/dl OR per order sets Water deficit: current TBW x (serum Na/140-1). TBW 50% range lean body weight Corrected sodium: Serum Na Meq/L + glucose (mg/dl)/18 Lower sOsm 3 Mosm/kg/hour. Glucose 50-90 mg/dl/hour maximum Chronic hypernatremia (no hyperglycemia): goal lower by 10Meq/L in 24 hours Transition from IV insulin: DKA resolution, stable infusion for at least 4 hours preferable Basal: Check home dose, 50%** of 24 hour stable infusion rate (minimum 4 hours) OR consider 0.3 u/kg/day glargine, stop IV 2 hours after SQ basal. Total daily dose 0.5-0.8+ u/kg (Alternative: Stop IV infusion after basal PLUS 10% of basal dose as rapid acting SQ) Meal insulin: =basal dose ⅓ with each meal OR insulin: carbohydrate ratio (Default 1:10 males 1:15 females) (** Some centers use 80% of stable insulin infusion rate as basal dose.) |
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