Sliding scale insulin

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DRshooter

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Why is it that every chief that I've ever had insists that I put my type one diabetics on a sliding scale post op without any basal coverage?
The next day, when the patients sugar keeps rising, they increase the sliding scale to "aggressive", yet the sugars keep rising!!
I understand that the patient is NPO!! but they need basal insulin either way...
Then...we consult endo...and guess what they do.... start basal insulin(70/30 or lantus) like I tried to do in the first place.

What really annoys me is that when I try to explain my point.... it's like talking to a wall....

It's very hard to bottom someone out on long acting insulin that doesn't peak

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Why is it that every chief that I've ever had insists that I put my type one diabetics on a sliding scale post op without any basal coverage?
The next day, when the patients sugar keeps rising, they increase the sliding scale to "aggressive", yet the sugars keep rising!!
I understand that the patient is NPO!! but they need basal insulin either way...
Then...we consult endo...and guess what they do.... start basal insulin(70/30 or lantus) like I tried to do in the first place.

What really annoys me is that when I try to explain my point.... it's like talking to a wall....

It's very hard to bottom someone out on long acting insulin that doesn't peak

Because people are to afraid of "bottoming" people out. Its easier to just let people be high. I recently had an intern "explain" to me, when i wrote an order to Page HO for blood sugar >200, that the nurses will keep calling if you don't write the sliding scale up to 400. He didn't quite grasp that avoiding pages wasnt the point of a sliding scale.
 
Hypoglycemia kills. Relative hyperglycemia can elevate the risk of wound infections, but nobody finds a patient dead from an Accucheck of 240.
 
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Hypoglycemia kills. Relative hyperglycemia can elevate the risk of wound infections, but nobody finds a patient dead from an Accucheck of 240.

That being said, I tend to manage the glucose of my patients relatively tight. I frequently use long acting insulins, usually Lantus, for their basal insulin requirements, and then either a supplemental (if I know they're going to eat well) or a sliding scale. If I DO use a sliding scale, I want them to have a low threshold to call me.

Obviously, on the critically ill patients, I do an insulin gtt with a target of 80-110.

I guess I buy into all the recent literature stressing tight glycemic control.
 
I agree that aggressive management of glucose is important, especially in critically ill patients. I personally don't start things like Lantus unless it's a home med -- I'm just not familiar enough with it to feel comfortable with that. My point was that traditionally surgeons have worried a whole lot more about the morbidity/mortality of HYPOglycemia and have been less worried by a glucose of 160. I don't manage that many inpatients anymore -- if there's someone whose home regimen of insulin isn't doing the trick, they're going to get a Medicine consult.
 
I agree that aggressive management of glucose is important, especially in critically ill patients. I personally don't start things like Lantus unless it's a home med -- I'm just not familiar enough with it to feel comfortable with that. My point was that traditionally surgeons have worried a whole lot more about the morbidity/mortality of HYPOglycemia and have been less worried by a glucose of 160. I don't manage that many inpatients anymore -- if there's someone whose home regimen of insulin isn't doing the trick, they're going to get a Medicine consult.

You're absolutely right. There's nothing worse than almost killing an otherwise stable patient because you got over-aggressive with glucose management. I've ironically seen this happen on medicine patients more than anywhere else.....

Plastics-specific question: I don't know how much graft work you do, but do you ever keep your skin graft recipients that are poorly controlled diabetics in the hospital for a few days so you (or a consultant) can tightly monitor their glucose?
 
This is what the diabetes NP's are for. If I have to write anything more than regular insulin on a sliding scale then the NP's are getting called. Especially with the amount of recon stuff we do it needs to be well managed. Plus with our head and neck wacks they're all on tube feeds because they can't swallow and we usually feel obliged to throw in some decadron for good measure.

Interesting side note. At our hospital the BS's are in the computer and the endocrine NP's get notified by some system if a pt has consistent sugars out of range and they will then see the patient automatically. Anyone else have anything like this?
 
We do lots of flaps and grafts at our place. If someone had totally out of control glucoses, I suppose I might consider admitting them for better glycemic control. It hasn't really been an issue that I've encountered, though. While poorly controlled sugars can have a deleterious effect on graft take, I think the biggest problem with graft take is related to technique.
 
I'm an intern trying to get a good feel for the sliding scale orders, anyone like to share how you write your sliding scale orders?
 
I'm an intern trying to get a good feel for the sliding scale orders, anyone like to share how you write your sliding scale orders?

I think the most important thing is to start conservative/less aggressive, and then find your comfort level.

Also, you should always have a low threshold for calls. I think it's unacceptable to write a scale up to 400-500. If the sugars are that high, you should know about it. Also, you should either change your treatment or consult someone who will.

Sliding scales with fixed q4 or q6 accuchecks don't really work if the pt is eating. If they're eating, you should be checking qac/qpc sugars and treating accordingly. For me, I always throw an 0200 check in there, because as someone else mentioned, hypoglycemia kills.

If you are treating the qpc, some people might argue that you are chasing your sugars inappropriately, so I often will write more of a supplemental scale, based on their qac sugar.

Here is a typical Sliding scale for an NPO patient, but keep in mind that this may be insufficiently treating a patient.

Accuchecks q4 or q6
<60 -------1/2 amp D50 IV (or juice if they're allowed) and call MD
61-150-----do nothing
151-180----2 units regular insuling subQ
181-210----4 units
211-240----6 units
241-270----8 units
271+----10 units and call MD

If sugars are low on this, back off a little, or vice versa if they are high.


I personally start treating at 120, and have nurses call me if over 250 or so. Other people will make broader ranges like 150-200, 200-250, etc. Really, it depends on your comfort level. It's like any call parameters. What do you really want to be called about?

Also, I incorporate long acting insulin, usually Lantus, so that the patients aren't really getting above 200 very often. You can calculate their requirements based on how much regular insulin they received from your sliding scale the previous day.


I am not an expert. so please don't use this as the absolute best way to treat people, but you can use it as a starting point, and then develop your own system as you get more comfortable.
 
Wound infections don't get show up until a week or so post op....but what you do before that period does have an effect on your rate of infection.
There is a study (Providence St. Vincent Medical Center, Portland, Oregon, USA.) where the compared tight glycemic control with insulin gtt vs. standard sliding scale in the immediate post op period on CTS patients.
They have followed those patients years out after surgery, and the impressive finding is that further out you take the study, the more difference in outcome.


Clinical effects of hyperglycemia in the cardiac surgery population: the Portland Diabetic Project
Endocr Pract. 2006 Jul-Aug;12 Suppl 3:22-6.
 
You can tightly manage the glucose with basal/SSI, but what's the point? Most of these folks aren't going to be in house longer than a week, and wound infections won't really get going until a week or so post op, so what really matters is what they're going home on, not what you do.

Hyperglycemia's effect on wound healing starts immediately after you reapproximate the tissue, and continues into your magical "wound infection week."

It's not like there's a window of time where it doesn't matter, and then after a week, all of a sudden it causes wound infections.
 
Yeah, duh.

My point is that I watch all these folks futting around with SSI regimens, changing Lantus dose every day, meanwhile ignoring the fact that the patient was on maxed out on metformin and glipizide at home . . . gosh, I wonder why we can't get their sugars under control?

Plus, half the time they have sugars locked down on the Lantus/SSI combo, then send them out the door on POD#3 with the standard "resume home meds". How will their sugars do at home? Will they still be anorexic and end up hypoglycemic in the ER? Or will the stress state persist, and they'll end up coasting in the 200s for another week? No one knows, since no one is tracking it.

It doesn't take much more than a little common sense to restart their diabetic meds ASAP, then by the time you send them out, you at least have a feel for what their sugars will do at home, and whether or not you need to adjust anything prior to discharge.

I have to agree there. It's extremely frustrating to adjust a patient's regimen, get them under control, and then have them come back to clinic with a BS of 500.

Hopefully most of the patients that are restarted on their home regimen are somewhat through the perioperative stress hyperglycemia/insulin resistance by the time they hit the door, and start to normalize.......
 
I'm an intern trying to get a good feel for the sliding scale orders, anyone like to share how you write your sliding scale orders?

Sliding Scale Novolog (BG-100)/* for BG >140
* is the amount that one unit of insulin will decrease blood glucose
start at 40 to be conservative
if they are on home insulin (basal/bolus) then add up their total daily insulin dose and divide that number by 1700 to get an accurate "correction factor"

example pt on 45 units lantus qHS and 15 units Novolog with meals = 90 units total daily insulin dose
1700/90 = 18.8
so if you wrote an "aggressive" sliding scale, BG-100/20 would cover them
I wrote for BG-100/25 today for this patient
I'm allowed to just write the formula, but you can use this to calculate out the scale if necessary
-tw
 
Well, there are some positive reasons to use Novolog sliding scale. I am of my Nurse friend shared this article with me which I think explains in a better way but about controlling the A1C level I think the information given here is not correct. Check it out

Solid bump! I'm sure that the people discussing this in 2008 will like the contribution!
 
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Well, there are some positive reasons to use Novolog sliding scale. I am of my Nurse friend shared this article with me which I think explains in a better way but about controlling the A1C level I think the information given here is not correct. Check it out
Great job! Excellent work premed! Thank you for correcting us, anything else your nursing friend can bless upon us dumb surgeons? Perhaps that colace/senna/miralax encourages the poopoo?
 
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