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How Is Insulin Sliding Scale Used?

Glycemic Control In Hospitalized Patients Not In Intensive Care: Beyond Sliding-scale Insulin

Glycemic Control In Hospitalized Patients Not In Intensive Care: Beyond Sliding-scale Insulin

Glycemic control in hospitalized patients who are not in intensive care remains unsatisfactory. Despite persistent expert recommendations urging its abandonment, the use of sliding-scale insulin remains pervasive in U.S. hospitals. Evidence for the effectiveness of sliding-scale insulin is lacking after more than 40 years of use. New physiologic subcutaneous insulin protocols use basal, nutritional, and correctional insulin. The initial total daily dose of subcutaneous insulin is calculated using a factor of 0.3 to 0.6 units per kg body weight, with one half given as long-acting insulin (the basal insulin dose), and the other one half divided daily over three meals as short-acting insulin doses (nutritional insulin doses). A correctional insulin dose provides a final insulin adjustment based on the preprandial glucose value. This correctional dose resembles a sliding scale, but is only a small fine-tuning of therapy, as opposed to traditional sliding-scale insulin alone. Insulin sensitivity, nutritional intake, and total daily dosing review can alter the physiologic insulin-dosing schedule. Prospective trials have demonstrated reductions in hyperglycemic measurements, hypoglycemia, and adjusted hospital length of stay when physiologic subcutaneous insulin protocols are used. Transitions in care require special considerations and attention to glycemic control medications. Changing the sliding-scale insulin culture requires a multidisciplinary effort to improve patient safety and outcomes. In the United States, the prevalence of diabetes mellitus is now 10.8 percent of adults 20 years and older, and 23.1 percent of adults 60 years and older.1 An estimated one in five U.S. health care dollars is spent caring for someone with diabetes.2 Over the past 10 years, the Agency fo Continue reading >>

Insulin Sliding Scale

Insulin Sliding Scale

Use this sliding scale as an example only Adjust per patient weight and activity or Disability Delays Insulin until Hyperglycemia appears Cover as units per Glucose 50 mg/dl over 150 mg/dl Renal Failure ( Insulin 50% renal excreted) V. Protocol 1: Based on Insulin sensitivity Estimate sensitivity using "rule of 1800" BG change per unit Insulin = 1800/total Insulin daily Example of 60 units/day: 1 unit drops BG 30 mg/dl Protocol (uses rapid acting Insulin , e.g. Lispro ) Using sensitivity, how many units to drop 50 mg/dl For example above, ~1 unit to drop BG 50 mg/dl BG 150-199: 1 unit Bolus Insulin (regular or RA) Based on per carbohydrate when Glucose >60 mg/dl Use for Type I Diabetes , consider for Type II Example: For 3 carbohydrate meal, add 3 units VI. Protocols: Sliding Scales (contact provider if maximum Glucose is exceeded) BG 150-199: 0.5 unit Bolus Insulin (regular or rapid-acting) Schnipper (2009) J Hosp Med 4(1): 16-27 [PubMed] Images: Related links to external sites (from Bing) These images are a random sampling from a Bing search on the term "Insulin Sliding Scale." Click on the image (or right click) to open the source website in a new browser window. Search Bing for all related images Related Studies (from Trip Database) Open in New Window Therapeutic or Preventive Procedure (T061) esquema de insulina con escala variable (rgimen/tratamiento), esquema de insulina con escala variable (rgimen/terapia), Sliding scale insulin regime, Sliding scale insulin regime (regime/therapy), esquema de insulina con escala variable Derived from the NIH UMLS ( Unified Medical Language System ) FPnotebook.com is a rapid access, point-of-care medical reference for primary care and emergency clinicians. Started in 1995, this collection now contains 6546 interlinked topic pag Continue reading >>

Sliding Scale Therapy

Sliding Scale Therapy

Sliding scale therapy approximates daily insulin requirements. The term "sliding scale" refers to the progressive increase in pre-meal or nighttime insulin doses. The term “sliding scale” refers to the progressive increase in the pre-meal or nighttime insulin dose, based on pre-defined blood glucose ranges. Sliding scale insulin regimens approximate daily insulin requirements. Common sliding scale regimens: Long-acting insulin (glargine/detemir or NPH), once or twice a day with short acting insulin (aspart, glulisine, lispro, Regular) before meals and at bedtime Long-acting insulin (glargine/detemir or NPH), given once a day Regular and NPH, given twice a day Pre-mixed, or short-acting insulin analogs or Regular and NPH, given twice a day The general principles of sliding scale therapy are: The amount of carbohydrate to be eaten at each meal is pre-set. The basal (background) insulin dose doesn’t change. You take the same long-acting insulin dose no matter what the blood glucose level. The bolus insulin is based on the blood sugar level before the meal or at bedtime Pre-mixed insulin doses are based on the blood sugar level before the meal The sliding scale method does not accommodate changes in insulin needs related to snacks or to stress and activity. You still need to count carbohydrates. Sliding scales are less effective in covering a pre-meal high blood sugar, because the high blood glucose correction and food bolus cannot be split. Points To Remember! Sliding scale regimens may include a bedtime high blood sugar correction. As the nighttime scale only considers the amount of insulin required to drop your blood sugar level back into the target range, it should not be used to cover a bedtime snack. When using a sliding scale, eat the same amount of carbohydrat Continue reading >>

Sliding-scale Insulin

Sliding-scale Insulin

More evidence needed before final exit? Sliding-scale regular insulin (SSI) in the management of patients with diabetes was the standard practice as early as 1934 (1) and was also used in the hyperglycemic emergency diabetic ketoacidosis (2). These earlier studies used urine glucose for sliding scale, but with demonstration of inaccuracy of urine glucose (3), blood glucose replaced urine glucose for sliding scale in diabetic ketoacidosis (4). SSI is widely used in health institutions (5,6) because it is easy and convenient, but it has the disadvantage of not delivering insulin in a physiologic manner, thereby leading to fluctuations in glycemic levels (7–9). Despite these drawbacks, the use of SSI has survived for >70 years, through many generations of physicians. Retrospective (6,9) and prospective (5) cohort studies, as well as observations and commentaries (10), have concluded that SSI should be discouraged because it has not been shown to be an effective means of achieving much-needed optimal glycemic control in hospitalized patients. However, the issue of SSI has never been settled because of the lack of data on prospective, randomized, controlled studies. Hence, the studies reported in this issue by Umpierrez et al. (11) are a welcome addition based on which future studies could finally settle the controversies of SSI (12). Umpierrez et al. reported on a prospective, randomized, open-label, two-center study in which two groups of relatively similar insulin-naive patients admitted to general medical wards were compared regarding efficacy of basal-bolus insulin (glargine once a day plus glulisine before meals and at bedtime) versus SSI (before each meal and at bedtime if patients were able to eat or every 6 h if they were unable to eat). Although blood glucose was Continue reading >>

Insulin Sliding Scale

Insulin Sliding Scale

This sliding scale should NOT to be used to treat people with: Diabetic Ketoacidosis (DKA) Hyperglycaemic Hyperosmolar State (HHS) / Hyperosmolar Non-Ketotic Coma (HONC) See individual guidelines for the management of these conditions. This sliding scale can be used to manage glucose levels in people with diabetes mellitus. It can be used in surgical patients with diabetes mellitus undergoing operations however local anaesthetic departments may have their own scales. Prior to using the scale below, discuss with local anaesthetists that they are happy for it to be used. This scale can also be used in medical patients with diabetes mellitus in whom regulation of glucose is deemed important. The principles of the sliding scale are: Desired glucose control is achieved and maintained Avoidance of hypoglycaemia Avoidance of ketosis by providing adequate carbohydrate and insulin Maintenance of fluid and electrolyte balance. Before starting on the sliding scale it is important to specify the target glucose level and whether intravenous fluids are to be given with insulin. Urea and electrolytes should be checked before starting the sliding scale to guide potassium administration. If patient is already on a background insulin (eg Insulatard®, Lantus® or Levemir®), administer at the usual time whilst using sliding scale, unless advised not to by Diabetes team or anaesthetist. Insulin Preparation: Add 50units of soluble insulin (Actrapid® or Humulin S®), drawn up using an insulin syringe, to 50ml of 0.9% sodium chloride in a 50ml syringe. Infuse IV using a syringe pump and adjust according to sliding scale below, which is an initial guide. Please review insulin rate and blood glucose response on a regular basis (see supplementary notes below) and amend if need be to achieve ta Continue reading >>

What Is Insulin Sliding Scale?

What Is Insulin Sliding Scale?

Sliding scale insulin is sometimes used by doctors to help regulate a patient's blood sugar levels. Although it can be helpful for some, its effectiveness is questionable, and a good deal of controversy surrounds its use. Definition Sliding scale insulin is generally defined as a set of instructions for administering insulin dosages based on specific blood glucose readings. Some sliding scales are in the form of general charts that are used for many different patients with doses given based on the patient's weight and activity level. Other sliding scales are individualized with guidelines and doses calculated for the individual patient by a doctor based on the patient's specific needs and medical history. Uses Sliding scale insulin is often used short-term during periods of insulin adjustment, illness, hospitalization or any other time when acute management of insulin becomes necessary. It can also be ordered as a standing order backup to an ongoing glucose management plan (i.e. give 2 additional units if blood sugar level goes above 200) or as the sole means of insulin management where blood glucose checks are done at regular intervals and sliding scale insulin is given each time based on the results. This method is not recommended for the long term. Advantages A sliding scale allows patients and nurses to administer insulin doses based on blood sugar readings without needing to consult with the doctor each and every time. It can also be helpful in the treatment of very brittle or unstable diabetics that can have sudden or unexpected blood sugar level spikes and need immediate dosing. (See Reference #1, #2, #3) Disadvantages Because insulin dosages are dependent on individual blood glucose readings, the sliding scale is a reactive approach to insulin management versus Continue reading >>

Sliding Scale Insulin Therapy

Sliding Scale Insulin Therapy

Insulin is the foundation of treatment for many people with diabetes. If you’re a diabetic, your body either can’t produce enough insulin or can’t use insulin efficiently. People with type 1 diabetes, and some with type 2 diabetes, have to take several injections of insulin per day. The insulin keeps blood sugar in a normal range and prevents high blood sugar levels. This can help prevent complications. The amount of insulin you should take can be determined in several different ways: Fixed-Dose Insulin With this method, you take a certain set amount of insulin units at each meal. For example, you may take 6 units at breakfast and 8 at dinner. The numbers don’t change based on your blood sugar readings or the amount of food you eat. While this may be easier for people just starting insulin, it doesn’t account for pre-meal blood sugar levels. It also doesn’t factor in the varying amounts of carbohydrates in a given meal. Carbohydrate to Insulin Ratio In this method, you take a certain amount of insulin for a certain amount of carbohydrates. For example, if your breakfast carb to insulin ratio is 10:1 and you eat 30 grams of carbohydrates, you would take 3 units before breakfast to cover your meal. This method also includes a “correction factor” that accounts for your pre-meal blood sugar. For example, let’s say you want your blood sugar to be under 150 mg/dL before meals, but it’s at 170. If you’ve been told to take 1 unit of insulin for every 50 you’re over, you would take 1 additional unit of insulin before your meal. While this takes a lot of practice and knowledge, people who can manage this method can keep better control of their post-meal blood sugar levels. Sliding-Scale Insulin Therapy (SSI) In the sliding-scale method, the dose is based o Continue reading >>

Diabetes Sliding Scale & Insulin Administration

Diabetes Sliding Scale & Insulin Administration

Diabetes is a condition of inappropriate glucose metabolism causing glucose, or blood sugar, to remain in the blood in higher than normal levels. Under normal conditions, your pancreas releases insulin to control glucose levels. In diabetes, your pancreas either does not produce any or not enough insulin to keep blood glucose at the desired level. If left uncontrolled, diabetic complications can affect your eyes, heart and kidneys. Video of the Day Your body functions best when your blood sugar is less than 126. A diagnosis of diabetes is made when your fasting blood glucose is over this value. according to the American Diabetes Association. Type 1 diabetes is associated with a pancreas which does not produce any insulin. Type 2 diabetes is the most common type and is characterized by insufficient production of insulin. Your physician will initially recommend lifestyle changes should you be found to have type 2 diabetes. Should diet and activity changes not be effective in controlling blood sugar, oral anti-diabetic medication may be prescribed. If you continue to have difficulty managing your type 2 diabetes, or if you have type 1 diabetes, your physician will order scheduled doses of injected insulin. There are many types of insulin used in treatment. The types differ in how quickly they act to lower blood glucose and the duration of action. In order to determine the most effective regimen, your physician most likely will have you to check your blood sugar up to four times a day. Based on the results, he may order that you take a consistent dose of insulin up to four times a day. For example, your insulin administration regimen may be 5 units of insulin in the morning and 3 units in the evening. Another option your physician may employ to keep your blood glucose level Continue reading >>

Insulin Sliding Scale

Insulin Sliding Scale

Also known as VRIII or CVRIII (continuous variable rate intravenous insulin infusion). An insulin sliding scale involves intravenous administration of a standard insulin to tightly regulate blood glucose levels. Blood glucose levels are monitored using bedside, finger-prick capillary glucose monitoring machines. The rate of infusion of insulin is titrated according to the glucose level, which is ideally monitored every 1-2 hours. Insulin given intravenously has a short half-life of a few minutes. A variation of the insulin sliding scale is the Alberti regime, also known as a GKI infusion (glucose, potassium and insulin). This emphasizes that potassium follows glucose into cells under insulin stimulation and patients need such issues to be addressed. Often such regimes will have trigger points based on blood glucose after initial loss of control, where a transition is made from one supplementary intravenous fluid such as 0.9% saline (with potassium added as indicated) to 5% glucose (with potassium added as indicated). Contents [hide] 1 Indications 2 Criticisms 3 Alternatives 4 Practicalities 4.1 Preparing the Syringe 4.2 Prescribing 5 References Indications Peri-operative glycaemic control in fasting patients or those with unpredictable food intake. A form of sliding scale is sometimes used for diabetic ketoacidosis. The 'standard' sliding scale should not be used for initial treatment. Hyperkalaemia (glucose infusion simultaneously) The principle of adjusting insulin dosage to a rapidly changing glycaemic state is sound in that it attempts to mimic the body's homeostatic mechanisms. The difficulty is that an intravenous sliding scale may fail on the two essential components to a negative feedback system: detection and feedback adjustment. Firstly, accurate monitoring ca Continue reading >>

Sliding Scale Insulin: How It Works

Sliding Scale Insulin: How It Works

Taking insulin on a sliding scale means the size of an insulin dose depends on a person’s current glucose reading. The number of prescribed insulin units "slides" up as your blood sugar level rises. Sliding scale doses are typically taken just prior to meal time, and sometimes at bedtime, to correct for elevated blood sugar. The type of insulin used on a sliding scale is often regular or fast-acting, but there are different sliding scale regimens - using a variety of insulin - to address different diabetic needs. A Sliding Scale Prescription Here is an example of a doctor’s insulin order for Ms. Doe: Monitor blood sugar twice each day - at 9 am and 5 pm; Take regular insulin for glucose above 200 mg/dl at 9 am and 5 pm according to the following sliding scale: Blood Sugar (mg/dl) . . . .Regular Insulin below 70 . . . . . . . . . . . . . . follow rule of 15, notify MD 70 - 200 . . . . . . . . . . . . . . . none 201 - 250 . . . . . . . . . . . . . . 4 units subcutaneously 251 - 300 . . . . . . . . . . . . . . 6 units subcutaneously 301 - 350 . . . . . . . . . . . . . . 8 units subcutaneously over 351 . . . . . . . . . . . . . . .call MD Reading the sliding scale: The left column is where Ms. Doe looks after taking her 5 pm fingerstick. Her blood sugar reading of 220 mg/dl falls between 201 and 250, so she takes 4 units of insulin. The next morning at 9 am, Ms. Doe has a glucose level of 260 mg/dl which lies between 251 and 300. She takes a 6 unit dose of insulin. Later, at 5 pm, Ms. Doe’s glucose is 180 mg/dl and she takes no units of insulin. Many individuals with a sliding orders also have a prescription for a fixed or unchanging background dose of long-lasting insulin. Sliding Scale Considerations The sliding scale has some disadvantages. It does not accommodate Continue reading >>

Meta-analysis Sliding-scale Insulin Used For Blood Glucose Control: A Meta-analysis Of Randomized Controlled Trials

Meta-analysis Sliding-scale Insulin Used For Blood Glucose Control: A Meta-analysis Of Randomized Controlled Trials

Abstract Sliding-scale insulin has been widely used in treating inpatient hyperglycemia. A systematic review and meta-analysis of randomized controlled trials (RCTs) was conducted to evaluate the efficacy and possible adverse effects of sliding-scale insulin in hospitalized patients. PubMed, EMBASE, Cochrane Library, Scopus, and ClinicalTrials.gov registry were searched for studies published up to May 2015. Individual effect sizes were standardized, and a meta-analysis was performed to calculate a pooled effect size using random effects models. Eleven RCTs containing a total of 1322 patients were identified. Among eight studies in which the RISS was compared with other regimens, no significant difference was observed in the percentage of patients who achieved the mean blood glucose level between the two groups, which was determined according to the numbers of blood samples (RR: 2.84; 95% CI: 0.94 to 8.59) and patients (RR: 1.75; 95% CI: 0.86 to 3.55). The mean blood glucose level (weighted mean difference = 27.33, 95% CI: 14.74 to 39.92) and incidence of hyperglycemic events were significantly higher in the RISS group than in the non-sliding-scale group. No significant difference in the incidence of severe hypoglycemia and length of hospitalization between the groups was identified. The overall results of the meta-analysis indicated that applying the RISS alone or in combination with other antidiabetic medications did not provide any benefits in blood glucose control, but was accompanied by an increased incidence of hyperglycemic events. Therefore, we suggest that the use of sliding-scale insulin be discontinued in hospitals. Continue reading >>

Sliding Scale Insulin Therapy: How It Works, Doses, Alternatives

Sliding Scale Insulin Therapy: How It Works, Doses, Alternatives

A healthy pancreas releases a burst of insulin as a person begins to eat. This prepares the body for the intake of glucose that is to come. For people who have type 1 diabetes or insulin-deficient type 2 diabetes, these bursts must be recreated through insulin injections either before or after a meal. The sliding scale is one way of working out how much insulin to take before each meal. Most doctors advise against the sliding scale approach. In fact, the American Diabetes Association have pushed for this treatment method to no longer be used. How the sliding scale works The "sliding scale" is actually a chart of insulin dosages. A doctor creates this chart based on how the patient's body responds to insulin, their daily activity, and an agreed-upon carbohydrate intake. As one moves along the chart, insulin dosage changes depending on two factors: Pre-meal blood glucose level This is usually plotted from low to high, down the chart's left-most column. As one slides from top to bottom, insulin dosage increases. This is because more insulin is needed to manage greater amounts of blood glucose. Mealtime This is usually plotted along the chart's top row. As one moves from breakfast to lunch to dinner within the same blood glucose level, dosage may vary. This is because insulin sensitivity, the way the body responds to insulin, can change throughout the day. The fat content of meals can also change through the day, and the doctor may have taken that into consideration. To work out the right dosage using a sliding scale, people should: test their blood glucose level find the matching blood glucose value along the chart's left-hand column slide horizontally along that value's row, until the current meal is reached take a dosage that matches the number where the two values meet Continue reading >>

Understanding The Sliding Scale In Diabetes Care

Understanding The Sliding Scale In Diabetes Care

One of the tools physicians use to help people who take insulin keep their blood glucose in control is a sliding scale. There are many reasons your health care provider may prescribe this type of insulin regimen for you but foremost it has to do with how much involvement you are able to have and want to have in figuring out your insulin needs. Some people want to spend as little time and effort as possible with their insulin and are willing to follow a structured, time-bound meal plan. For these folks a fixed dose (taking the same amount of insulin at each meal regardless of their blood glucose level or the type or amount of food they are eating) is a good choice. On the other end of the spectrum is matching insulin to carbohydrate. This requires a strong commitment to carb counting and following a mathematical algorithm at meals. The sliding scale falls smack in the middle. No math to do, meal timing isn’t as important but carbohydrate content at meals does need to be standardized. When people hear the term “sliding scale,” they might picture a balance scale with weights tumbling off one end. Now there is no physical object to slide; rather it is a chart that tells you how much insulin to give yourself at meals based on your blood glucose levels The chart is divided into a series of columns. The column farthest to the left lists blood glucose ranges starting from below 70mg/dl to 400mg/dl or more, increasing in increments of anywhere from 20 mg to 50 mg/dl. The other columns correspond to breakfast, lunch and dinner, and, if necessary, bedtime. The columns may have you take different amounts of insulin at different times of the day at the same blood glucose level. This may be because your sensitivity to insulin changes throughout the day or because your meals ten Continue reading >>

Use Of A Standardized Protocol To Decrease Medication Errors And Adverse Events Related To Sliding Scale Insulin

Use Of A Standardized Protocol To Decrease Medication Errors And Adverse Events Related To Sliding Scale Insulin

Go to: Abstract Sliding scale insulin (SSI) is frequently used for inpatient management of hyperglycemia and is associated with a large number of medication errors and adverse events including hypoglycemia and hyperglycemia. Observational before and after study evaluating the impact of implementation of a standardized SSI protocol and preprinted physician order form. Guidelines for the use of SSI were created by an interdisciplinary committee and implemented in non‐intensive care units. In addition, a preprinted physician order sheet was developed which included the guidelines and an option for ordering one of three standardized insulin sliding scales or a patient specific scale. One year after implementation the physician order form was used for 91% of orders and, overall, 86% of SSI orders followed the guidelines. The number of prescribing errors found on chart review was reduced from 10.3 per 100 SSI patient‐days at baseline to 1.2 at 1 year (p = 0.03). The number of hyperglycemia episodes 1 year after implementation decreased from 55.9 to 16.3 per 100 SSI patient‐days. The protocol was readily accepted by hospital staff and was associated with decreased prescribing errors and decreased frequency of hyperglycemia. Keywords: insulin, medication errors, hyperglycemia, practice guidelines Sliding scale insulin (SSI) is commonly used to manage hospitalized patients with and without diabetes mellitus.1,2,3 Monotherapy with SSI often leads to erratic fluctuations of glucose control because it tries to retrospectively “treat” hyperglycemia rather than prospectively “prevent” it.1,4,5,6,7,8,9,10 In the hospital setting, use of supplemental short acting insulin in addition to scheduled basal and preprandial insulin for patients with type 1 diabetes is recommende Continue reading >>

Diabetes Mellitus

Diabetes Mellitus

Correct preoperative management depends on : Diabetic patients should be first on the operative list Major surgery involves a general anaesthetic and therefore a period of fasting ; Minor surgery does not. Start 1 litre of 'Solution 18' + 20 mEq KCL + 2/9 of total daily dose of insulin over 8 hrs; repeat till eating and drinking. - Glucose meter readings 1-4 hourly; aim at readings of 6-10 mmol/L. - Supplemental insulin can be given s.c. (4 hourly); then the amount of insulin added to the next litre adjusted appropriately. An intravenous insulin infusion pump is essential in the treatment of DKA, major illness or major surgery. The advantages are (1) ability to tightly control BG levels (2) separation of insulin and fluid regimes. 50 units of Short Acting insulin (Actrapid, Humulin S etc) in 50 mls of N. Saline (0.9%) conveniently results in units/hr=mls/hr. Glucometers are checked hourly initially and 2 hourly when stable. Continue i.v regime until patient is taking normal diet post-operatively. Calculate s.c. dose from i.v. insulin requirement in previous 24 hours. The first dose of s.c. insulin is given thirty minutes (unless a short acting analogue) prior to stopping the i.v. insulin infusion. Patient then eats a normal meal. Minor Surgery : Omit breakfast and oral hypoglycaemic agents. Resume diet and medication post op. if feasible; if not, start i.v. regime using Soln.18+KCL+Short Acting insulin as above. Patient fasted from 12 MN the night prior to surgery. i.v. regime commenced at 07.00 hours on day of surgery as for Type 1. Insulin requirement is approximately 0.5 u/kg/day - approximately 4-10 units per litre initially. (Obese patients may require more). Supplemental sliding scale of Short Acting Insulin may be used, checking glucose meters 1-4 hourly. 1. Nev Continue reading >>

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