diabetestalk.net

Which Insulin Is Used For Sliding Scale

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 >>

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 >>

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 >>

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 >>

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 Vs. Individualized Insulin Therapy

Sliding Scale Insulin Vs. Individualized Insulin Therapy

The prevalence of diabetes has been growing steadily in the geriatric population of the United States. In a 2014 report from the Centers for Disease Control and Prevention (CDC), 27% of Americans aged 65 and older have diabetes. It is estimated that one-third of elderly people admitted to nursing home facilities are affected by diabetes. In the nursing home setting, the annual costs of care for a person with diabetes are estimated to be $56 billion. In a disease with such a high cost and high disease burden for the patient, it is important to effectively treat diabetes and prevent complications. Sliding scale insulin (SSI) has been used for many years to manage diabetes, but evidenced-based guidelines and studies show that benefits of this therapy are lacking and discourage SSI use, instead encouraging individualized insulin therapy. SSI may cause prolonged periods of hyperglycemia in residents instead of preventing hyperglycemia from occurring. This can lead to costly micro- and macrovascular complications such as coronary artery disease, retinopathy, and nephropathy leading to more medications and increased hospitalizations. Residents who have a shorter life expectancy can also benefit from individualized insulin therapy. Better diabetes management reduces the risk of falls, infections, dehydration, and cognitive dysfunction. From a regulatory standpoint, the American Geriatrics Society 2012 Beers Criteria Update lists SSI as something to be avoided in older adults due to a higher risk of hypoglycemia without improvement in hyperglycemia management. Facilities using SSI therapies may risk a standard of care citation at survey time. Changing patients from SSI regimen to an individualized insulin regimen provides benefit by better controlling blood sugar, improving over Continue reading >>

Sliding-scale Insulin Regimens Questioned

Sliding-scale Insulin Regimens Questioned

Sliding-scale insulin regimens used in hospital patients to control blood sugar may be ineffective, say clinicians from Johns Hopkins Medical Institutions (Baltimore, MD, USA). Indeed, in the absence of a standing dose of intermediate-acting insulin, such regimens may be associated with an increased rate of hyperglycaemic episodes. Continue reading >>

Insulin (medication)

Insulin (medication)

"Insulin therapy" redirects here. For the psychiatric treatment, see Insulin shock therapy. Insulin is used as a medication to treat high blood sugar.[3] This includes in diabetes mellitus type 1, diabetes mellitus type 2, gestational diabetes, and complications of diabetes such as diabetic ketoacidosis and hyperosmolar hyperglycemic states.[3] It is also used along with glucose to treat high blood potassium levels.[4] Typically it is given by injection under the skin, but some forms may also be used by injection into a vein or muscle.[3] The common side effect is low blood sugar.[3] Other side effects may include pain or skin changes at the sites of injection, low blood potassium, and allergic reactions.[3] Use during pregnancy is relatively safe for the baby.[3] Insulin can be made from the pancreas of pigs or cows.[5] Human versions can be made either by modifying pig versions or recombinant technology.[5] It comes in three main types short–acting (such as regular insulin), intermediate–acting (such as NPH insulin), and longer-acting (such as insulin glargine).[5] Insulin was first used as a medication in Canada by Charles Best and Frederick Banting in 1922.[6] It is on the World Health Organization's List of Essential Medicines, the most effective and safe medicines needed in a health system.[7] The wholesale cost in the developing world is about US$2.39 to $10.61 per 1,000 iu of regular insulin and $2.23 to $10.35 per 1,000 iu of NPH insulin.[8][9] In the United Kingdom 1,000 iu of regular or NPH insulin costs the NHS 7.48 pounds, while this amount of insulin glargine costs 30.68 pounds.[5] Medical uses[edit] Giving insulin with an insulin pen. Insulin is used to treat a number of diseases including diabetes and its acute complications such as diabetic ketoacid Continue reading >>

What Does A Sliding Scale Refer To In The Context Of Insulin?

What Does A Sliding Scale Refer To In The Context Of Insulin?

A sliding scale is a slightly old fashioned (but functional) approach to fixing high blood sugars. The scale has two columns, the first shows ranges of blood sugar; and the second shows units of insulin. So for instance—and I just pulled these numbers out of thin air so for Peat's sake, don’t use them—the scale might look like this: For blood sugar of 151 to 200 take 2 units of insulin For blood sugar of 201 to 250 take 3 units of insulin For blood sugar of 251 to 300 take 4 units of insulin A sliding scale is a slightly old fashioned (but functional) approach to fixing high blood sugars. The scale has two columns, the first shows ranges of blood sugar; and the second shows units of insulin. So for instance—and I just pulled these numbers out of thin air so for Peat’s sake, don’t use them—the scale might look like this: For blood sugar of 151 to 200 take 2 units of insulin For blood sugar of 201 to 250 take 3 units of insulin For blood sugar of 251 to 300 take 4 units of insulin It's called a sliding scale because as the blood sugar numbers increase, so too do the units of insulin. The amount of insulin you need is variable—it slides—depending on your blood sugar. Everyone needs a different, personalized scale that takes into account both their insulin sensitivity and insulin resistance. The bigger problem with sliding scale is that it is trying to close the gate after the horse has gotten out of the barn and the barn has burnt to the ground. It is a reactive therapy, trying to fix problems after they happen. More modern approaches focus on trying to calculate insulin needs beforehand. Key to this modern approach is "carb counting," a method of estimating the blood sugar impact of a meal proactively and taking insulin to cover the meal before the first 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: 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 >>

Sliding-scale Versus Basal-bolus Insulin In The Management Of Severe Or Acute Hyperglycemia In Type 2 Diabetes Patients: A Retrospective Study

Sliding-scale Versus Basal-bolus Insulin In The Management Of Severe Or Acute Hyperglycemia In Type 2 Diabetes Patients: A Retrospective Study

Abstract Sliding-scale and basal-bolus insulin regimens are two options available for the treatment of severe or acute hyperglycemia in type 2 diabetes mellitus patients. Although its use is not recommended, sliding-scale insulin therapy is still being used widely. The aims of the study were to compare the glycemic control achieved by using sliding-scale or basal-bolus regimens for the management of severe or acute hyperglycemia in patients with type 2 diabetes and to analyze factors associated with the types of insulin therapy used in the management of severe or acute hyperglycemia. This retrospective study was conducted using the medical records of patients with acute or severe hyperglycemia admitted to a hospital in Malaysia from January 2008 to December 2012. A total of 202 patients and 247 admissions were included. Patients treated with the basal-bolus insulin regimen attained lower fasting blood glucose (10.8±2.3 versus 11.6±3.5 mmol/L; p = 0.028) and mean glucose levels throughout severe/acute hyperglycemia (12.3±1.9 versus 12.8±2.2; p = 0.021) compared with sliding-scale insulin regimens. Diabetic ketoacidosis (p = 0.043), cardiovascular diseases (p = 0.005), acute exacerbation of bronchial asthma (p = 0.010), and the use of corticosteroids (p = 0.037) and loop diuretics (p = 0.016) were significantly associated with the type of insulin regimen used. In conclusion, type 2 diabetes patients with severe and acute hyperglycemia achieved better glycemic control with the basal-bolus regimen than with sliding-scale insulin, and factors associated with the insulin regimen used could be identified. Figures Citation: Zaman Huri H, Permalu V, Vethakkan SR (2014) Sliding-Scale versus Basal-Bolus Insulin in the Management of Severe or Acute Hyperglycemia in Type 2 Diabe 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 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 >>

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 >>

More in insulin