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What Insulin Is Used For Sliding Scale

The Abcs Of Insulin

The Abcs Of Insulin

Insulin is a naturally occurring hormone produced by the pancreas. Insulin is required to move sugar from the blood into the body’s cells, where it can be used for energy. For the symptoms of high blood sugar and low blood sugar, see Tables 1 and 2. Type 1 diabetes (T1D) is a chronic condition in which the pancreas produces little or no insulin. Only 5% of patients with diabetes have this form of the disease, according to the American Diabetes Association. Type 2 diabetes (T2D) is much more common; the risk factors are listed in online table 3. Individuals with T2D make insulin, but their bodies don’t respond well to it, a condition known as insulin resistance. Treatment of T2D usually begins with dietary and lifestyle changes, as well as oral medications. Over time, as the pancreas struggles to make an adequate amount of insulin to overcome insulin resistance, patients may require insulin supplementation. Insulin therapy must be individualized and balanced with meal planning and exercise. When a patient begins using insulin to manage diabetes, the initial dose is just a starting point. Over time, insulin requirements are affected by factors such as weight gain or loss, changes in eating habits, and the addition of other medications. The need for insulin often increases, and the dose must be readjusted to meet the new requirements. Insulin is injected subcutaneously, meaning not very deep under the skin. Common injection sites include the stomach, buttocks, thighs, and upper arms. By rotating the site of injection, patients can avoid lipohypertrophy, a slight increase in the growth or size of fat cells under the skin. When lipohypertrophy occurs, a soft pillowy growth may form at the repeated-use injection site. Therefore, for reliable absorption rates and cosmetic 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 >>

Sliding-scale Insulin: An Ineffective Practice

Sliding-scale Insulin: An Ineffective Practice

By Mark D. Coggins, PharmD, CGP, FASCP Aging Well Vol. 5 No. 6 P. 8 In the United States, approximately 26 million people have diabetes mellitus, including 10.9 million adults aged 65 or older.1 The number of those newly diagnosed with diabetes continues to rise, and the Agency for Healthcare Research and Quality reports that over the past decade there has been a 26% increase in the number of patients discharged from hospitals with a primary diagnosis of diabetes. The overall costs related to diabetes treatment place a tremendous burden on the healthcare system, with one in five US healthcare dollars being spent on the condition. Patients with diabetes typically have medical expenses that are 2.3 times higher than those of nondiabetics,1 and families with a child who has diabetes reportedly spend as much as 10% of their income on the disease.2 Beyond the financial cost, diabetes can have a tremendous negative impact on patients and their families due to associated intangibles that are more difficult to measure, such as pain, depression, anxiety, inconvenience, and a lower quality of life. Diabetes Complications The primary goal of diabetes management is to achieve a level of glycemic control that closely mimics that of nondiabetic patients in an effort to prevent the long- and short-term complications associated with the disease. Inadequate blood glucose control over an extended period of time can result in significant long-term complications affecting multiple organ systems with reduced quality of life and increased mortality and morbidity (see Table 1 below). Short-term complications related to the failure to control glycemic levels can result in symptoms associated with periods of hyperglycemia. Issues related to hypoglycemia, when severe and left untreated, can lead 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 >>

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 >>

Insulin Regular Human (rx, Otc)

Insulin Regular Human (rx, Otc)

Dosage Forms & Strengths injectable solution Type 1 Diabetes Mellitus Initial: 0.2-0.4 units/kg/day SC divided q8hr or more frequently Maintenance: 0.5-1 unit/kg/day SC divided q8hr or more frequently; in insulin-resistant patients (eg, due to obesity), substantially higher daily insulin may be required Approximately 50-75% of the total daily insulin requirements are given as intermediate- or long-acting insulin administered in 1-2 injections; rapid- or short-acting insulin should be used before or at mealtimes to satisfy the remainder balance of the total daily insulin requirements Premixed combinations are available that deliver rapid- or short-acting components at the same time as the intermediate- or long-acting component Type 2 Diabetes Mellitus Type 2 diabetes inadequately controlled by diet, exercise, or oral medication: Suggested beginning dose of 10 units/day SC (or 0.1-0.2 unit/kg/day) in evening or divided q12hr Severe Hyperglycemia (Diabetic Ketoacidosis) 0.1 unit/kg/hr IV continuous infusion; if serum glucose does not fall by 50 mg/dL in the first hour, check hydration status; if possible, double the insulin hourly until glucose levels fall at the rate of 50-75 mg/dL/hr; decrease infusion to 0.05-0.1 unit/kg/hour when blood sugar reaches 250 mg/dL Dosing Considerations Dosage of human insulin, which is always expressed in USP units, must be based on the results of blood and urine glucose tests and must be carefully individualized to optimal effect Dose adjustments should be based on regular blood glucose testing Adjust to achieve appropriate glucose control Look for consistent pattern in blood sugars for >3 days Same time each day: Compare blood glucose levels with previous levels found at that time of day For each time of day: Calculate blood glucose range Continue reading >>

Basal/bolus Versus Sliding Scale Insulin In Hospitalized Patients With Type 2 Diabetes

Basal/bolus Versus Sliding Scale Insulin In Hospitalized Patients With Type 2 Diabetes

High blood glucose levels in hospitalized patients with diabetes are associated with increased risk of medical complications. Improved glucose control with insulin injections may improve clinical outcome and prevent some of the hospital complications. It is not known; however, what is the best insulin regimen in hospitalized patients. The use of repeated injections of regular insulin (known as sliding scale regimen) is one of the most commonly used insulin regimen for glucose control in hospitalized patients with diabetes. Recently, the combination of basal and rapid acting insulins has been shown to improve glucose control with lower rate of hypoglycemia (low blood sugar). This study will compare how well regular insulin will compare to glargine (Lantus®) once daily plus glulisine (Apidra®) insulin before meals in hospitalized patients with type 2 diabetes and elevated blood glucose (sugar) levels. Lantus is a long-acting insulin which is given subcutaneously (under the skin) once daily. Apidra is a rapid-acting insulin which is given subcutaneously several times a day and frequently before meals. Regular insulin is a short-acting insulin in clinical use for more than 20 years that is also given subcutaneously several times per day. Lantus, Apidra and regular insulins are approved for use in the treatment of patients with diabetes by the FDA. This investigator-initiated research will be conducted at Grady Memorial Hospital, Atlanta and at Jackson Memorial Hospital, Miami. Dr. Umpierrez designed the study and will serve as principal investigator. A total of 65 patients will be recruited at Grady and 65 patients at the Jackson Memorial Hospital. This study is supported by Sanofi-Aventis Pharmaceuticals. Study Type : Interventional (Clinical Trial) Actual Enrollment : 1 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 >>

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 >>

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 >>

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 >>

Sliding Scale Insulin Use And Rates Of Hyperglycemia

Sliding Scale Insulin Use And Rates Of Hyperglycemia

In their recent study of the effects of sliding scale insulin use on rates of hyperglycemia in hospitalized patients, Queale et al1 found no less hyperglycemia in patients using sliding scale regimens than in those not treated with sliding scale regimens. In an accompanying editorial, Sawin then concluded that sliding scales "offer no benefit to sick patients with diabetes."2 Continue reading >>

Getting Your Patients Off The Sliding-scale Insulin Roller Coaster

Getting Your Patients Off The Sliding-scale Insulin Roller Coaster

Published in the January 2006 issue of Today’s Hospitalist While the patient was admitted to the hospital with chest pain and ended up needing bypass surgery, the real trouble came in managing her diabetes. The patient had a long history of type 1 diabetes, but the condition had always been well-controlled, in part because she was very diligent about her diabetes care. The surgery went smoothly, but when she was discharged from the ICU to the wards on sliding scale insulin only, she experienced ketoacidosis, lengthening her hospital stay by several days. According to Thomas Donner, MD, director of the Joslin Diabetes Center at the University of Maryland School of Medicine, the above case, which involved one of his patients, illustrates a simple but critical point: For many diabetics admitted to the hospital, sliding scale insulin doesn’t do an adequate job of controlling glucose. In a presentation on inpatient diabetes management at the Fall 2005 Hospitalist CME Series, Dr. Donner said that countless studies have shown that poorly controlled glucose is associated with many problems, from infections to mortality. He also pointed to research that has found that sliding scale insulin, an approach that is still common at many hospitals, leads to more hyperglycemia and hypoglycemia. During the meeting, which was held in cooperation with Today’s Hospitalist magazine, Dr. Donner outlined some easy-to-use strategies to implement a standardized glucose regimen that will better control your inpatients’ glucose levels. The trouble with sliding scale insulin Dr. Donner acknowledged that tightly controlling the glucose levels of hospitalized patients is not always easy. He noted that some of the more obvious challenges include high levels of cortisol in inpatients, unpredict Continue reading >>

Safe And Effective Use Of Intravenous Sliding Scale Insulin

Safe And Effective Use Of Intravenous Sliding Scale Insulin

1. Indications 1.1 Background National Patient Agency Alert. 2010 - RRR013 Identifies insulin as a high risk drug. Intravenous sliding scale insulin prescription charts have been reviewed and updated to simplify and increase the safety with this practice. This guideline is for intravenous sliding scale insulin, it is to be used in conjunction with the NEW 2 day intravenous sliding scale insulin prescription chart. Intravenous sliding scale insulin should be used in acutely unwell patients with raised blood glucose levels and patients with diabetes managed with sub-cutaneous insulin who are nil by month. NB: Subcutaneous sliding scale insulin MUST NOT be used within the Trust. 1.2 Aim/purpose To ensure safe and effective use of intravenous sliding scale insulin. 1.3 Patient/client group. Adult patients with diabetes who are acutely unwell with raised blood glucose levels as follows: Patients who are unwell with diabetes out of control, which cannot be controlled by adjusting their normal therapy. Patients with diabetes who are N.B.M. and unable to take their normal therapy. Patients with diabetes who are having surgery. - See surgical protocol on ICID . Patients with diabetes who are in D.K.A. or H.O.N.K. - See protocol on ICID. 1.4 Exceptions/ contraindications This policy does NOT apply to children. Patients in Coronary Care Unit may be managed without intravenous fluids Intensive Care Unit follows a separate protocol for the management of diabetes. 2. Clinical Management 2.1 Staff & Equipment Two registered nurses will check and prepare the sliding scale insulin infusion as per the 2-day intravenous sliding scale insulin prescription chart. 50 units of Actrapid insulin (O.5ml of 100 units/ml insulin drawn up in an insulin syringe) to be added to 49.5ml of Sodium Chlor Continue reading >>

Evidence For Basal–bolus Insulin Versus Slide Scale Insulin

Evidence For Basal–bolus Insulin Versus Slide Scale Insulin

Abstract Greater understanding of hyperglycemia and its control in non-ICU patients has become ever more urgent given the high and increasing prevalence of diabetes in the general population and, hence, in hospitalized patients. It is well accepted that hyperglycemia in hospitalized patients is common and associated with profound medical consequences, longer lengths of stay, high healthcare costs, and adverse outcomes. It is a marker for poor clinical outcome and mortality. Although evidence that supports intensive glycemic control in critically ill patients is strong, glycemic control is often overlooked or insufficient in patients on general medicine and surgery services. In the face of strong evidence that glycemic control helps to improve outcomes in non-ICU patients, it is critical to consider how best to manage hyperglycemia in medical and surgical patients to develop optimum strategies for maintaining glycemic control. Currently available strategies for glycemic control include sliding-scale insulin and basal–bolus regimens. The principal difference between the two strategies is that sliding-scale insulin does not deliver adequate glycemic control to patients and addresses hyperglycemia after it has occurred, whereas a basal–bolus regimen is directed at preventing hyperglycemia. This paper explores the rationale for and implementation of a basal–bolus insulin regimen in non-critically ill hospitalized patients and in addition reviews best practices for transitions of care and discharge planning. Notes Compliance with Ethics Guidelines This paper was underwritten in part by a grant from Sanofi to the Hospital Quality Foundation to support the writing group’s efforts, including travel. All authors report receiving consulting fees from Sanofi. This article d Continue reading >>

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