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INSULIN THERAPY AND INSULIN THERAPY AND NUTRITIONAL MANAGEMENT NUTRITIONAL MANAGEMENT IN PATIENTS WITH DIABETES IN PATIENTS WITH DIABETES
MELLITUS IN THE MELLITUS IN THE PERIOPERATIVE PERIODPERIOPERATIVE PERIOD
Josephine Carlos-Raboca MD FPCP Josephine Carlos-Raboca MD FPCP Gabriel V. Jasul MD FPCP FPSEMGabriel V. Jasul MD FPCP FPSEMRosa Allyn G. Sy MD FPCP FPSEMRosa Allyn G. Sy MD FPCP FPSEM
Leilani B. Mercado-Asis, M.D., Ph.D.FPCP Leilani B. Mercado-Asis, M.D., Ph.D.FPCP FPSEMFPSEM FPSEMFPSEM
Insulin Therapy Insulin Therapy and and
Hyperglycemia in Hyperglycemia in Hospitalized Hospitalized
PatientsPatients
Dr. Josephine Carlos-Dr. Josephine Carlos-RabocaRaboca
Dr. Leilani B. Mercado-AsisDr. Leilani B. Mercado-Asis
GENERAL OBJECTIVES:GENERAL OBJECTIVES: To review general guidelines and treatment To review general guidelines and treatment
approaches in diabetes management in approaches in diabetes management in surgical patients, including in-hospital surgical patients, including in-hospital glycemic targets and intravenous and glycemic targets and intravenous and subcutaneous insulin regimens.subcutaneous insulin regimens.
To review treatment guidelines on To review treatment guidelines on nutritional management of diabetic nutritional management of diabetic patients in the perioperative period, in patients in the perioperative period, in particular, routes of feeding and insulin particular, routes of feeding and insulin therapy adjustments in relation to therapy adjustments in relation to nutritional provision.nutritional provision.
To apply these guidelines through case-To apply these guidelines through case-based discussion and to formulate practical based discussion and to formulate practical treatment plans in the management of treatment plans in the management of diabetic patients undergoing surgery.diabetic patients undergoing surgery.
CaseCase
VS, 62M VS, 62M Type 2 DM X3 yrsType 2 DM X3 yrs
– Rx: Glibenclamide 5 mg OD Rx: Glibenclamide 5 mg OD
Metformin 500 mg BID Metformin 500 mg BID
admitted due to abdominal admitted due to abdominal painpain
HistoryHistory
2 days PTA 2 days PTA crampy LLQ paincrampy LLQ pain
increasing in severity increasing in severity
anorexia and vomitinganorexia and vomiting
(-)fever(-)fever
(-)diarrhea,constipation (-)diarrhea,constipation ADMISSION
CASE
Physical ExaminationPhysical Examination
Conscious, coherentConscious, coherent BP: 130/70; CR: 89: RR: 23/min; T: 36.8CBP: 130/70; CR: 89: RR: 23/min; T: 36.8C Wt: 80kg, Ht: 178cm BMI: 25Wt: 80kg, Ht: 178cm BMI: 25 Neck: (+)curvilinear scar, no palpable Neck: (+)curvilinear scar, no palpable
thyroidthyroid Heart and lungs were unremarkableHeart and lungs were unremarkable Abdomen: flabby, normoactive bowel Abdomen: flabby, normoactive bowel
sounds, no organomegaly, (+) direct sounds, no organomegaly, (+) direct tenderness on the left lower quadrant tenderness on the left lower quadrant area.area.
Extremities: (-)edema nor cyanosisExtremities: (-)edema nor cyanosis
CASE
Course at the ERCourse at the ER
Stat CBGStat CBG 357mg/dl357mg/dl Serum ketonesSerum ketones NegativeNegative ABGABG Compensated Compensated
metabolic acidosismetabolic acidosis
Repeat CBGRepeat CBG 260mg/dl260mg/dl
IVF: Plain NSS at 30gtts/min
Regular Insulin 10u/SC
CASE
11stst Hospital Day Hospital Day
Scout film of the abdomenScout film of the abdomen– localized ileuslocalized ileus– rule out a localized fluid collection or an rule out a localized fluid collection or an
inflammatory process. inflammatory process. CBC CBC
– leukocytosis with predominance of segmenters leukocytosis with predominance of segmenters (WBC: 20.90, seg: 0.96). (WBC: 20.90, seg: 0.96).
Urinalysis Urinalysis – (+1) albumin.(+1) albumin.
Ultrasound of the abdomen Ultrasound of the abdomen – hyperechoic lesion (2.0X1.8X2.2cm) right lobe of hyperechoic lesion (2.0X1.8X2.2cm) right lobe of
the liverthe liver HbA1c: 7%; FBS: 345 mg/dlHbA1c: 7%; FBS: 345 mg/dl Creatinine: 0.98; Na:131mg/dl; K:3.2; SGPT: Creatinine: 0.98; Na:131mg/dl; K:3.2; SGPT:
28.1.28.1.
CASE
Initial OrdersInitial Orders
Keep on NPOKeep on NPO Serial abdomen exam Serial abdomen exam IVF: D5 NM1L + 20meqs KCl X IVF: D5 NM1L + 20meqs KCl X
30gtts/min30gtts/min Refer to Endocrine serviceRefer to Endocrine service
CASE
11stst Hospital Day Hospital Day
Persistent abdominal painPersistent abdominal pain (+) Rebound tenderness, LLQ (+) Rebound tenderness, LLQ
areaarea Surgery consult: Surgery consult:
– For exploratory LaparotomyFor exploratory Laparotomy– Endocrine clearanceEndocrine clearance
CASE
Endocrine ConsultEndocrine Consult D5NSS X 100cc/hrD5NSS X 100cc/hr Stat CBG: 245mg/dlStat CBG: 245mg/dl 6units Regular Insulin/SC stat6units Regular Insulin/SC stat CBG monitoring q4hCBG monitoring q4h Standing insulin: Glargine Insulin10u SC Standing insulin: Glargine Insulin10u SC
ODOD Supplemental scale: Supplemental scale:
CBGCBG Regular Insulin/SCRegular Insulin/SC
180 – 250180 – 250 4u4u
251 – 350251 – 350 6u6u
>350>350 8u 8u
CASE
CBG MONITORING CBG MONITORING SHEETSHEET
2AM (ER)2AM (ER) 3am (ER)3am (ER) 8am (Ward)8am (Ward) 12nn 12nn
(Ward)(Ward)
BGBG Insulin/Insulin/
routerouteBGBG Insulin/Insulin/
routerouteBGBG Insulin/Insulin/
routerouteBGBG Insulin/Insulin/
routeroute
357357 10u/10u/
SCSC260260 ---- 245245
GlarginGlargine 10 u e 10 u SC +SC +
4u HR/4u HR/
SCSC
301301 ??
CASE
Admission To OR
REVIEW GENERAL PRINCIPLES OF REVIEW GENERAL PRINCIPLES OF PERIOPERATIVE MANAGEMENT OF DIABETES PERIOPERATIVE MANAGEMENT OF DIABETES MELLITUS, INCLUDING NUTRITION SUPPORT, MELLITUS, INCLUDING NUTRITION SUPPORT, CHOICE OF TYPE AND ROUTE OF INSULIN CHOICE OF TYPE AND ROUTE OF INSULIN ADMINISTRATION, FREQUENCY OF ADMINISTRATION, FREQUENCY OF MONITORING AND FLUID MANAGEMENTMONITORING AND FLUID MANAGEMENT
REVIEW GENERAL PRINCIPLES OF PERIOPERATIVE REVIEW GENERAL PRINCIPLES OF PERIOPERATIVE MANAGEMENT OF DIABETES MELLITUS, INCLUDING MANAGEMENT OF DIABETES MELLITUS, INCLUDING CHOICE OF, TYPE AND ROUTE OF INSULIN CHOICE OF, TYPE AND ROUTE OF INSULIN ADMINISTRATION, FREQUENCY OF MONITORING ADMINISTRATION, FREQUENCY OF MONITORING AND FLUID MANAGEMENTAND FLUID MANAGEMENT
Objective # 3
GENERAL PRINCIPLES OF GENERAL PRINCIPLES OF PERIOPERATIVE MANAGEMENT OF PERIOPERATIVE MANAGEMENT OF DIABETES MELLITUSDIABETES MELLITUS Oral agents may be contraindicatedOral agents may be contraindicated Dose adjustment of oral agents may Dose adjustment of oral agents may
require time and may be ineffectiverequire time and may be ineffective Stress, intravenous dextrose, and Stress, intravenous dextrose, and
enteral feedings, may increase dose enteral feedings, may increase dose requirements for exogenous insulinrequirements for exogenous insulin
Pattern of carbohydrate exposure may Pattern of carbohydrate exposure may change, necessitating pattern change, necessitating pattern adjustment of insulin therapyadjustment of insulin therapy
Nutritional assessment is importantNutritional assessment is important
SLIDING SCALE IS NOT SLIDING SCALE IS NOT RECOMMENDEDRECOMMENDED
..
6 12 6 12
NPH
6 12 6 12
Regular at least 50 % - - - -
Glargine not more than 50 %
Regular ~ 33 % (hold if low) - - -
NPH ~ 67 % —
q 6 – 8 h
Prolonged NPO Status
CHOICE OF TYPE AND ROUTE OF CHOICE OF TYPE AND ROUTE OF INSULIN ADMINISTRATIONINSULIN ADMINISTRATION
Established basal therapy with peakless long-acting insulin analog
6 am 12 pm 6 pm 12 am
Glargine Doses
yesterday’s today’s
Procedures, brief NPO status, or anesthesia < 1hr
8 12 6 10
Lispro or Aspart
Glargine
Endocrine Follow upEndocrine Follow up
Patient cleared for surgeryPatient cleared for surgery Perioperative orders:Perioperative orders:
– Hold standing and supplemental insulinHold standing and supplemental insulin– Give 10u Regular insulin/IV now thenGive 10u Regular insulin/IV now then– Insulin drip: Plain NSS 100cc + 50 units Insulin drip: Plain NSS 100cc + 50 units
Regular Insulin – flush 20cc thru the Regular Insulin – flush 20cc thru the tubings before hooking to patient. Start tubings before hooking to patient. Start at 10cc/hr via infusion pump (5u/hr)at 10cc/hr via infusion pump (5u/hr)
– CBG monitoring q1hCBG monitoring q1h
CASE
Review rationale for intensive Review rationale for intensive glucose control in hospitalized glucose control in hospitalized patients and in particular, in patients and in particular, in surgical patientssurgical patients
Objective # 1
1.What is the rationale for 1.What is the rationale for intensive glucose control in intensive glucose control in hospitalized patients?hospitalized patients?
Insulin is anti-inflammatory, anti-Insulin is anti-inflammatory, anti-oxidant, profibrinolytic, anti-platelet, oxidant, profibrinolytic, anti-platelet, vasodilatory, anti-apoptotic and vasodilatory, anti-apoptotic and cardioprotective.cardioprotective.
Glucose is pro-inflammatory, pro-Glucose is pro-inflammatory, pro-oxidant, prothrombotic, platelet pro-oxidant, prothrombotic, platelet pro-aggregatory, worsens prognosis in aggregatory, worsens prognosis in AMIAMI
Proposed Mechanisms of Poor Proposed Mechanisms of Poor Outcomes in Patients with Outcomes in Patients with Uncontrolled HyperglycemiaUncontrolled Hyperglycemia
Immune systemImmune system– Glucose >200mg/dl impairs leukocyte functionGlucose >200mg/dl impairs leukocyte function
ThrombosisThrombosis– Reduced fibrinolytic activity, increased platelet Reduced fibrinolytic activity, increased platelet
reactivityreactivity Vascular endothelial dysfunctionVascular endothelial dysfunction
– Increased permeability, inflammation and Increased permeability, inflammation and thrombosisthrombosis
Oxidative stressOxidative stress– Cell and tissue injuryCell and tissue injury
Poor wound healingPoor wound healing– Glycation of collagen, increased collagenase Glycation of collagen, increased collagenase
activityactivity Insulin deficiency per seInsulin deficiency per seClement S., Braithwaite SS, Magee MF, et al (ADA Diabetes in
Hospitals Writing Committee). Management of diabetes and yperglycemia in hospitals. Diabetes Care. 2004;27:533-591
Benefits of Intensive Blood Benefits of Intensive Blood Glucose Control in Critically Ill Glucose Control in Critically Ill PatientsPatients Whole blood glucose levels at 80-Whole blood glucose levels at 80-
100%100%mortality by 34%mortality by 34%
sepsis by 46%sepsis by 46%
renal failure necessitating dialysis by renal failure necessitating dialysis by 41%41%
need for blood transfusion by 50%need for blood transfusion by 50%
critical illness related polyneuropathy critical illness related polyneuropathy by 41%by 41%
Van den Bergh G, Wouters F, et al. Intensive therapy in the critically ill patients. NEJM 2001;345:1359-1367
Increased Increased hormoneshormones– CortisolCortisol– CathecolaminesCathecolamines– GlucagonGlucagon– Growth hormoneGrowth hormone
Metabolic effectsMetabolic effects– GluconeogenesisGluconeogenesis– GlycogenolysisGlycogenolysis– LipolysisLipolysis– KetogenesisKetogenesis
Metabolic Consequences Metabolic Consequences of Surgery and of Surgery and AnesthesiaAnesthesia
DEFINE INTENSIVE GLUCOSE DEFINE INTENSIVE GLUCOSE CONTROL IN HOSPITALIZED CONTROL IN HOSPITALIZED PATIENTS AND SET GLYCEMIC PATIENTS AND SET GLYCEMIC TARGETS IN THE SURGICAL PATIENTSTARGETS IN THE SURGICAL PATIENTS
Objective # 2
Target Blood Glucose LevelsTarget Blood Glucose LevelsADA 2006ADA 2006
Critically illCritically ill– BG as close to 110mg/dl as possible BG as close to 110mg/dl as possible
and generally <180mg/dland generally <180mg/dl Noncritically illNoncritically ill
– Premeal: 90 – 130mg/dlPremeal: 90 – 130mg/dl– Postprandial: <180mg/dlPostprandial: <180mg/dl
Glycemic TargetsGlycemic Targets AACE 80-110 mg/dlAACE 80-110 mg/dl
ADA as close to 110 mg/dl as possible, and generally <180 ADA as close to 110 mg/dl as possible, and generally <180 mg/dlmg/dl
Yale New Haven Hospital 90-120 mg/dlYale New Haven Hospital 90-120 mg/dl
ACC/AHA ST elevation MI(STEMI) guidelineACC/AHA ST elevation MI(STEMI) guideline Class I recommendation ”an insulin infusion to normalize BG Class I recommendation ”an insulin infusion to normalize BG
for patients with STEMI and complicated course for patients with STEMI and complicated course “(level evidence “(level evidence B)B)
Class IIa recommendation; :During the acute phase (first 24-48 Class IIa recommendation; :During the acute phase (first 24-48 hours) of management of STEMI inpatients with hours) of management of STEMI inpatients with hyperglycemia, it is reasonable to administer an insulin hyperglycemia, it is reasonable to administer an insulin infusion to normalize BG in paitents with an uncomplicated infusion to normalize BG in paitents with an uncomplicated course course “(level evidence B)“(level evidence B)
Garber AJ et al Endocr Pract 2004,10.77-82ADA Diabetes Care 2006:29 (Suppl 1) 575-77
REVIEW INTRAVENOUS INSULIN REVIEW INTRAVENOUS INSULIN PROTOCOLS CURRENTLY IN USE PROTOCOLS CURRENTLY IN USE AND DETERMINE THEIR AND DETERMINE THEIR FEASIBILITY FOR USE IN OUR FEASIBILITY FOR USE IN OUR SETTINGSETTING
Objective # 4
Atlanta Multiplier methodAtlanta Multiplier method Van den Berghe (studied in critical care Van den Berghe (studied in critical care
setting)setting) Portland Protocol (used in surgical Portland Protocol (used in surgical
setting)setting) Markovitz (studied in post op heart Markovitz (studied in post op heart
surgery patients)surgery patients) Yale protocol (studied in medical Yale protocol (studied in medical
intensive care setting)intensive care setting)
Various protocolsVarious protocols
Insulin (units per hour) = multiplier × (BG - 60)
With use of this algorithm manually, the initial multiplier is set at 0.02, and a BG value is determined every hour in conjunction with calculation of the units of IV insulin therapy per hour. The multiplier is adjusted every hour by 0.01 to obtain the target BG level—if the result is less than the target, decrease by 0.01; if within target range, no change is needed; if more than the target and the BG level has not decreased by 25%, increase by 0.01. The BG is always determined hourly until stable results are achieved; then it is measured every 2 hours.
Portland Protocol for Continuous Portland Protocol for Continuous IV Insulin Infusion -- FLOOR IV Insulin Infusion -- FLOOR patientspatients Target: 80 - 120Target: 80 - 120
1.1. Surgical Patients:Surgical Patients: Start “Portland Protocol” during surgery. Continue through Start “Portland Protocol” during surgery. Continue through 7 AM of the 37 AM of the 3rdrd POD; patients who are not taking enteral nutrition on the 3 POD; patients who are not taking enteral nutrition on the 3rdrd POD POD should remain on this protocol until taking at least 50% of a soft ADA diet.should remain on this protocol until taking at least 50% of a soft ADA diet. Medical PatientsMedical Patients: Continue Portland Protocol throughout until taking soft ADA : Continue Portland Protocol throughout until taking soft ADA diet.diet.
2.2. For patients previously undiagnosed diabetes (DM) who present with For patients previously undiagnosed diabetes (DM) who present with hyperglycemia: start PDX protocol if blood glucose (BG) level > 150 mg/dl X 2 hyperglycemia: start PDX protocol if blood glucose (BG) level > 150 mg/dl X 2 consecutive readings consecutive readings OROR >175 at any one time. Consult endocrinologist for DM >175 at any one time. Consult endocrinologist for DM workup and follow-up orders.workup and follow-up orders.
3.3. Start insulin infusion via pump “piggybacked” to normal saline IV as follows:Start insulin infusion via pump “piggybacked” to normal saline IV as follows:
Furnary AP, et al. Endocr Pract. 2004;10:21–33.
Portland Protocol for Continuous Portland Protocol for Continuous IV Insulin Infusion -- FLOOR IV Insulin Infusion -- FLOOR patientspatients Target: 80 - 120Target: 80 - 120
Furnary AP, et al. Endocr Pract. 2004;10:21–33.
Blood Glucose Blood Glucose (mg/dL)(mg/dL)
Intravenous Intravenous Insulin Bolus (U)Insulin Bolus (U)
Initial Insulin Rate (Units/h) (circle Initial Insulin Rate (Units/h) (circle one)one)
Type 2 DMType 2 DM Preoperatively Preoperatively
Type 1 DMType 1 DMPreoperativelyPreoperatively
80–12080–120 00 0.50.5 11
121–180121–180 00 11 22
181–240181–240 44 22 3.53.5
241–300241–300 88 3.53.5 55
301–360301–360 1212 55 6.56.5
> 360> 360 1616 6.56.5 88
Portland Protocol for Continuous Portland Protocol for Continuous IV Insulin Infusion -- FLOOR IV Insulin Infusion -- FLOOR patients Target: 80 - 120patients Target: 80 - 120
Furnary AP, et al. Endocr Pract. 2004;10:21–33.
4.4. Test BG level by finger-stick or venous line drop Test BG level by finger-stick or venous line drop sample. sample. The frequency of BG testing is as follows:The frequency of BG testing is as follows:
a.a. If BG ≥180 or < 80 : check BG every If BG ≥180 or < 80 : check BG every 30 30 minutesminutes
b.b. If BG 80 - 179: check BG every hour.If BG 80 - 179: check BG every hour.c.c. When BG 80 – 120, with <15 mg/dl change When BG 80 – 120, with <15 mg/dl change andand
insulin rate remains unchanged x insulin rate remains unchanged x 44hr., = “stable hr., = “stable infusion rate” -- then may test q. 2 hrsinfusion rate” -- then may test q. 2 hrs
d.d. May stop q. 2 hr testing on May stop q. 2 hr testing on POD #3POD #3 in surgery in surgery patients or as noted in #1 (see items #1 & #8).patients or as noted in #1 (see items #1 & #8).
e.e. At nightAt night: Test q. 2 hr : Test q. 2 hr if BG 120 - 150if BG 120 - 150; Test q4 hr ; Test q4 hr if if BS 80 - 120 and BS 80 - 120 and “stable infusion rate” exists.“stable infusion rate” exists.
Portland Protocol for Continuous Portland Protocol for Continuous IV Insulin Infusion -- FLOOR IV Insulin Infusion -- FLOOR patients Target: 80 - 120patients Target: 80 - 120
Blood Glucose Blood Glucose (mg/dL)(mg/dL) ActionAction
< 60< 60
Stop insulin; give 25 mL D50; Stop insulin; give 25 mL D50; Recheck BG in 30 Recheck BG in 30 minutesminutes. . When blood glucose > 70, restart with rate 50% of When blood glucose > 70, restart with rate 50% of previous rate. previous rate.
60–69 60–69 Stop insulin; if previous BG >100, give 25 mL D50. Stop insulin; if previous BG >100, give 25 mL D50. Recheck BG in 30 minutesRecheck BG in 30 minutes When BG > 70, restart with rate 50% of previous rate.When BG > 70, restart with rate 50% of previous rate.
70–7970–79
If greater than last BG, continue current rate. If greater than last BG, continue current rate. If lower than last BG by 20 mg/dl or more, decrease rate If lower than last BG by 20 mg/dl or more, decrease rate by 50%by 50%If within 20 mg/dL of last BG, decrease rate by 0.5 If within 20 mg/dL of last BG, decrease rate by 0.5 units/hour. units/hour. Recheck BG in 30 minutesRecheck BG in 30 minutes
80–12080–120Same rate -- EXCELLENT! You are in the Target Range!Same rate -- EXCELLENT! You are in the Target Range!TITRATE DRIP AT WILL TO MAINTAIN BG in TITRATE DRIP AT WILL TO MAINTAIN BG in TARGET RANGETARGET RANGE
ALL Remaining ALL Remaining TitrationTitration SAME AS ICU PROTOCOLSAME AS ICU PROTOCOL
5. Insulin titration:5. Insulin titration:
Furnary AP, et al. Endocr Pract. 2004;10:21–33. 59
Portland Protocol for Continuous Portland Protocol for Continuous IV Insulin Infusion -- FLOOR IV Insulin Infusion -- FLOOR patients Target: 80 - 120patients Target: 80 - 120
6.7. -- Diet and SQ Humalog orders and titration:SAME AS IN ICU PROTOCOL
8. At protocol cessation: Restart preadmission glycemic control medication. If receiving insulin, wait 1hr after injection of short-acting insulin or 2hr after long-acting insulin before stopping IV insulin drip.Long-acting insulin: type Schedule/dose Short-acting insulin: type Schedule/dose Oral agents:
Check BG (circle)….. qAC; qHS; 90minutes PCOR……….. q ___ hours
GIK SolutionGIK Solution
500ml10% dextrose solution500ml10% dextrose solution+15u short – acting insulin+15u short – acting insulin
+ 10mmol KCl+ 10mmol KCl Infuse over 5 hours(100ml/h)Infuse over 5 hours(100ml/h)
CBG MONITORING SHEETCBG MONITORING SHEET
BGBG Insulin/Insulin/
routerouteBGBG Insulin/Insulin/
routerouteBGBG Insulin/Insulin/
routerouteBGBG Insulin/Insulin/
routeroute
1pm1pm 2pm2pm 3pm3pm 4pm4pm
Post opPost op
250250 5uR/5uR/
dripdrip247247 7uR/7uR/
dripdrip160160 7uR/7uR/
dripdrip120120 5uR/5uR/
dripdrip
CASE
Post opIntraoperative
WHEN AND HOW DO WHEN AND HOW DO YOU INITIATE YOU INITIATE NUTRITIONAL NUTRITIONAL
SUPPORT ?SUPPORT ?
The time arrives to begin eating discrete meals
8 12 6 10
Insulin requirement
Patients who are eating
Consistent carbohydrate diet order
8 12 6 10
Lispro / aspart ( ~ 50 % )Glargine ( ~ 50 % )
8 12 6 10
Lispro or aspartGlargine
( ~ 50 % )
Advanced carbohydrate counting
4. How do you shift 4. How do you shift from IV to SC insulin?from IV to SC insulin? Establish 24 hour insulin Establish 24 hour insulin
requirementrequirement Extrapolated from average over Extrapolated from average over
last 4 hours of stablelast 4 hours of stable Give 50% as basal and 50% as Give 50% as basal and 50% as
total bolustotal bolus Correction bolus for BG>140Correction bolus for BG>140
Shifting Insulin from IV to Shifting Insulin from IV to Subcutaneous RouteSubcutaneous Route
Establish 24 hour insulin requirementEstablish 24 hour insulin requirement Extrapolated from average over last Extrapolated from average over last
4 hours of stable4 hours of stable Give 50% as basal and 50% as total Give 50% as basal and 50% as total
bolusbolus Correction bolus for BG>140Correction bolus for BG>140 There should be an overlap between There should be an overlap between
IV to SQ insulin TxIV to SQ insulin Tx