Transcript No Slide Title

Sara Meltzer, MD, FRCPC, FACP
2010
In-Patient Diabetes Management
Objectives:
 Importance of Diabetes
 as a risk factor
 in hospital outcomes


Review physiology of stress and insulin needs
Aspects of glucose control in hospital






Diet and Testing,
Oral agents
Insulin use
Peri-operative care
Emergency Room management
Pump therapy – basics in case admitted
Scope of the problem…
Common and Increasing




Overall: > 8% Individuals 65+: > 15%
1 in 3 individuals born in 2000 will develop diabetes
in their lifetime
25% of DM1 & 30% of DM2 admitted each year
49%  of DM in discharge diagnoses from 1980 to
2001
Costly:
 Medical expenditures/patient 2.4x > non-diabetics
 4.6 million DM-associated admissions costs in 2001;
 17 million hospital days at > $ 40 billion (US)
May, 2008
Vascular Disease Outcomes in
Patients with or without DM:
OACIS Registry
Figure 1. Long-term clinical outcomes among
 8,013 patients with Non-diabetic and diabetic patients in the OACIS registry

95 hospitals in 6
countries (incl.
Canada)

Overall mortality
increased 57% in
presence of DM
% of patients
unstable angina or
non-Q wave MI
Malmberg, Circulation,2000
May, 2008
Canadian Acute Coronary Syndrome Registry
• 4,578 patients with acute coronary syndromes
• 9 Canadian provinces 1999-2001
Yan, JACC, 2004
May, 2008
Digami Trial - Sweden
620 patients with DM & MI;
 mean follow-up 3.4 y.
◦ 306 intensive insulin; 314 controls

One life saved for every 9 treated patients
Death Rate:
138 (44%) in controls;
102 (33%) in the int. tx group
(RR 0.72, P=0.011)
Malmberg, BMJ, 1997
May, 2008
Stoke patients…

2 - 4 x risk of CVA compared to non-diabetics
(Framingham Study, Paris Prospective Study,Whitehall
Study, MRFIT, Rancho Bernardo Study)


Hyperglycemia present in 40% of CVA admissions
Both ischemic and hemorrhagic CVA have 3X 30-day
mortality risk when admission glucose>6-8 mM
(Capes, Stroke, 2001, 32-Study Meta-Analysis)

Return to work post-CVA 76% if normal admission
glucose, vs. 43% if glucose > 6.7 mM
(Pulsinelli, Am J Med, 1983)

Persistent in-hospital glucose > 7   infarct expansion
and  functional recovery
May, 2008
In-Patient Diabetes Management
: Objectives
 Importance of Diabetes
 as a risk factor
 in hospital outcomes
Review physiology of stress and insulin
needs
 Aspects of glucose control in hospital







Diet and Testing,
Oral agents
Insulin use
Peri-operative care
Emergency Room management
Pump therapy – basic concepts in case admitted
Hyperglycaemia in the
Hospital Setting
Pathophysiology
Growth hormone
Cortisol
Catecholamines
Glucagon
Insulin
Glucose
May, 2008
Considerations in Assessment of
Peri-operative Stress
Metabolic stress response
Stress hormones & peptides
 Glucose
 Insulin
Immune dysfunction
Infection dissemination
 FFA
Ketones
Lactate
Cellular injury/apoptosis
Inflammation / Tissue damage
Altered tissue/wound repair
Acidosis / Infarction/ischemia
Prolonged hospital stay
Disability
Death
May, 2008
Reactive O2 species
Transcription factors
Secondary mediators
Clement, NEJM 2004
Optimal Insulin replacement
– Why bother?
 Surgical or illness related stress causes insulin
needs to increase
 Insulin is the BEST ANABOLIC HORMONE
we have and if the amount available is
inadequate for metabolic needs…
CATABOLISM occurs.
 Hyperglycemia increases chances of infections
 In patients severely ill in ICU, even glucose
values > 6mmol/L can be associated with
poorer outcomes.
May, 2008
Insulin secretion
Proinsulin
Insulin released in equimolar
amounts with C - peptide (90-97%)
Pro-insulin & conversion
products (3 -10 %)
Released into
portal circulation
Basal secretion is approximately 1 unit / hour
In response to food, increases 5 - 10 fold
Average
insulin release about 40 units/day
May, 2008
Insulin Needs in Hospital
Relative Proportion of Insulin Needs
Healthy
Sick - eating
Basal
Prandial
Very Sick - NPO
Nutritional
May, 2008
Correction
Surgical Site Infections
Correlation with peri-operative glucose
Surgical Site Infection without DM – 5.3%
Surgical Site Infection with DM – 11.2% Adjusted OR 1.80
Adj OR 12.1
Ata et al Arch Surg Sept. 2010 p858
May, 2008
In-Patient Diabetes Management:
Objectives
 Importance of Diabetes
 as a risk factor
 in hospital outcomes


Review physiology of stress and insulin needs
Aspects of glucose control in hospital






Diet and Testing,
Oral agents
Insulin use
Peri-operative care
Emergency Room management
Pump therapy – basic concepts in case admitted
Before the OR

Evaluate for concurrent illness and risks
related to them e.g.





Silent cardiovascular disease (women and men)
Autonomic and/or peripheral neuropathy
Hypertension/ renal disease
Co-existent other autoimmune disease in type 1’s
(hypothyroid, Addisons?)
Adjust diet to provide optimal
nutrition
May, 2008
Concept of Diet for Diabetes
Not equal to
“ Don’t eat sugar”!
Adequate for caloric and nutritional needs
 Spread carbohydrate (CHO) intake from
food throughout day
 Balance sources from fruits/vegetables and
starches with needed protein & fat
 Insulin must match carbohydrate intake

May, 2008
Diet orders…
Clarity is very important!
Order ‘diabetic diet’ once eating
 Clear fluids will often put sugars up as
well… try to have it given in 30g servings at
meal & snack times…

 eg. 6 oz apple juice or ginger ale (15g) + 1 jello (15g)

Full fluids also better served Q3H and as
30g feeds, if possible...
 e.g. 1c cream soup (15g) + 1c eggnog (15g)
May, 2008
Carbohydrate Intake Peri-operatively
If eating, must consider timing of insulin with
meals, size and frequency
If on tube feeds – continuous or interrupted?
– must plan insulin appropriately
If on IV fluids, must provide adequate calories
to avoid catabolism and ketone formation,
roughly 5g per hour
i.e. D5W or D5NS or ½ NS@100cc/h;
D10W@50cc/h (~ 2 oz of orange juice only!)
If on Total Parental Nutrition –
requirements for insulin increase as calories are
continuous and similar to when eating
May, 2008
Capillary Blood Glucose Testing
Clinical Status of Patients
Options for CBGM
Patients actively treated, often with
changes in dietary or CHO intake
Q1-4h for patients on IV insulin
Q 2-6h for patients on continuous feeds
AC meals and HS for patients eating
AC and PC meals, HS and 03h for patients
requiring excellent control e.g. pregnancy
Patients with stable diabetes on
insulin or oral agents eating
consistent meals with minimal
changes in diet plan
Routinely AC breakfast and AC supper
Once or twice weekly, AC meals and HS
Long-term care patients with
diabetes which is unstable or DM1
AC meals and HS in order to adjust insulin
dose
Long-term care patients on insulin
or oral agents who are stable
AC bkft daily; PC breakfast, lunch, supper in
rotation if on oral agents
AC meals and HS in rotation: once weekly
AC (ante-cebum ) = before meal and PC (post-cebum ) = after meal in Latin
May, 2008
Nov.
15
Humulin R
Humulin N
Nov.
16
Humulin R
Humulin N
7.2 5.4 9.3 10.5
2.7
8u 6-2 10u
4u
16u
8+2
10u
11.4
16h 2.7
OJ given
Oral Agents: Effects and
Mechanisms of Action
Diet &
Sulfonylureas
Exercise
and Glitinides
Metformin
a-Glucosidase
Agents
Adverse
Effects
0.5-2.0
Avoiding McD
Injury
1.0-2.0
Insulin
Inhibitors
1° mech ↓ insulin resist ↑ insulin secretion ↓ hepatic output ↓ CH2O absorpt
HgbA1c↓
TZD
1.0-2.0
↑ insulin sens ↑[insulin]
0.5-1.0
0.5-1.0
Glyburide
Gliclazide
Glimepiride
Repaglinide
Nateglinide
Metformin
Acarbose
Miglitol
Rosiglitazone
Pioglitzone
Hypoglycemia
GI upset
GI upset
Edema
Wt gain
Lactic acidosis
1.5-2.5
↓ glucose
Wt gain
The Stable Hospitalized
Diabetic Patient
Can sometimes continue home regimen, including
oral agents, as long as:
1. Stable or improving medical status
2. Predictable nutritional intake
3. Frequent CBG monitoring
4. Sufficient glycemic control
May, 2008
Insulin Routes of Administration

Subcutaneous
◦ variable absorption
◦ variable duration of action
◦ all formulations may be given this route

Intramuscular
◦ all can be given, hurts more, faster action

Intravenous
◦ faster action (T 1/2 = < 5 min.)
◦ very consistent action
◦ high levels of circulating insulin can be established

Intra-peritoneal
◦ used in peritoneal dialysis
◦ portal levels >> systemic - more physiologic
◦ used in implanted pumps… trouble with omental blocking
May, 2008
Regular insulin - half life

If given IV…. T ½ = 4 - 5 min.

If given IM… T ½ = 1 - 2 hours

If given IP… T ½ = 2 - 3 hours

If given SC … T ½ = 6 hours
May, 2008
Insulin Types & Action Profiles:
Short-acting
Type
Name
Rapid
Analog
Humalog
Onset
(min)
Peak
action(h)
Duration
action(h)
- lispro
Novorapid
- aspart
Apidra
10 – 15
1- 3
3-5
30 - 60
2-3
4-8
- glulisine
Regular Novolin
Human Toronto
Humulin R
May, 2008
Insulin Types & Action Profiles:
Intermediate and Long-acting
Type
Name
Onset
(h)
Peak action
(h)
Duration of
action (h)
NPH
Human
Novolin NPH
Humulin NPH 
1–3
5 – 10
16 – 18
Glargine
Lantus 
4–6
8 – 16
20 – 36
Detemir
Levemir 
2–4
6 – 12
12 - 24
May, 2008
Insulin orders... Clarity counts!
For patient on IV’s
◦ Best option = iv insulin with adjustment
◦ 2nd best option is Q6H regular SC or R ac meals and NPH at
HS
For patients who are eating but unstable:
◦ NPH @ HS and Regular pre-meal … both with adjustment
scale
For patients who are eating but unstable amounts:
◦ NPH @ HS and Regular pre-meal if needed
◦ + Rapid acting post-meal … only adjust pre-meal regular with
sliding scale
For patients who are eating and stable:
◦ Regular AC meals and NPH at HS, adjusted with sliding
scale… may be able to reduce testing frequency but should
still cover all parts of the day
May, 2008
Insulin Therapy: Temporary use...
 Pregnancy… can’t use pills!
 Surgery … increased need.
 Medication such as steroids which dramatically
increase insulin needs.
 Concurrent illness … eg. MI or CVA… better
peri-event sugar control improves morbidity and
mortality.
Good sugar control helps patients
recover and leave hospital faster!
May, 2008
Concept of
BASAL insulin needs
Any person, eating or not requires insulin to
live… 24 hours a day!
Basal needs (no food):

◦ often lower levels between 12 am and 4 am, an increase
prior to awaking until about 8 am, then often about 0.4-0.8
u/hr.
In response to food,
◦ proportion of insulin release closely relates to CHO
content of the meal +/- presence of protein & fat in it.
May, 2008
Insulin replacement for
Type 1
 In
type 1… no insulin of their
own without injections… never
leave them without insulin
coverage!
May, 2008
Insulin replacement for Type 2

Type 2 on diet: if not eating, can often keep
fasting glucose normal… may not need basal

Type 2 on oral agents: if not eating… usually
needs additional amounts of insulin to keep
normal sugars, even without eating.

Type 2 on insulin: often some remaining basal
insulin but needs coverage even if not eating to
have good glucose entry into cells.
May, 2008
Establishing “basal” needs –
i.e. amount needed if no significant carbohydrate intake

Establish known total daily dose (TDD)
i.e. sum of all insulin taken in a normal day

Determine what ½ of that amount is… approximate
amount of insulin needed if no CHO intake

Determine the necessary hourly rate of this “base need”
[i.e. [(TDD/2)]  24 = X u/h

Set up an IV insulin infusion with this hourly rate as a
starting point and allow adjustment up or down until target
range is reached
May, 2008
May, 2008
Patients taking insulin who are NPO
or Pre-op:
Items of the order sheet are based on the
following premises…
Patients should receive glucose IV at ~ 5g/h in order to
provide essential minimum calories to avoid ketosis of fasting.
Can be done using D10W at 50cc/h if fluid status is a
problem, or D5W or D5NS @100cc/h for most patients.
 Capillary blood glucose should be measured frequently
initially Q1H and subsequently decreasing frequency
depending on stability of blood sugar, with a minimum
frequency of Q4H.
 Intravenous insulin should always be REGULAR insulin
(either Humulin R or Novolin Toronto – be precise to avoid
confusion).

May, 2008
Patients taking insulin who are NPO
or Pre-op:
Premise which permits determination of the
initial insulin infusion rate:

This is usually based on a simple calculation of the basal
insulin requirements. Approximately half of the insulin
given every day covers the meals – the other half covers
the basal needs. Therefore, calculate ½ of the total daily
dose (TDD) of insulin to allow coverage of basal needs,
converted to units/hour.
i.e. ½ TDD ÷ 24 = starting insulin infusion rate.


If the infusion rate is < 1.0units/h – use 10units/250ml NS (1unit = 25ml.)
If the infusion rate is ≥ 1.0 units/h – use 25units/250ml NS (1unit / 10ml)
May, 2008
Establishment of basal infusion rate:
May, 2008
Adjustments to Insulin Infusion Rate:
If CBG (mmol/L) is:
≤ 4.0
Stop insulin infusion temporarily; continue glucose
infusion at previous rate and give 20ml of D50W IV push
over 2-3 minutes. Inform MD. Recheck CBG in10 min. &
repeat D50W until CBG ≥6mmol/L, then resume the
insulin infusion at ½ previous rate.
4.1 – 7.0 Decrease insulin infusion rate by (indicate with checkmark)
□ half of current rate (for fractions of a ml.,
decrease to nearest whole number)
□ ______ units/hr. (i.e. _______ ml/hr).
7.1 – 10.0 Continue the current insulin infusion rate.
10.1 – 14 Increase current infusion rate by ____units/hr (i.e. ___ml/hr).
14.1 – 18 Increase current infusion rate by ____units/hr. (i.e. ___ml/hr).
> 18
Increase current infusion rate by ____units/hr. (i.e. ___ml/hr).
and inform MD.
May, 2008
Post-operative orders
once ready to resume full fluids
 Re-order “diabetic diet …X….Kcal/day”
 In patients normally on oral agents, re-order once
patient is eating
 may need lower doses as intake may be poor
 may need “insulin adjustment scale” or “sliding
scale” for values above 8 or 10 mmol/L
 In patients normally on insulin, restart
subcutaneous insulin dose at least 20-30 minutes
prior to the discontinuation of the IV, even if at a
lower dose than prior to admission…
May, 2008
Returning to eating

Once patient ready to return to meals, likely not eating
well, so work in reverse…
i.e. Hourly dose given X 24 = approximate present “basal needs”
which can be distributed to be given prior to meals and HS in the
proportion of:
Time
NPH or basal
Regular/rapid


Breakfast
0
25%
Lunch
-
0
15% -
Supper
0
20% -
HS
40%
0
Use insulin adjustment scale to correct for food and
relative proportion errors
Adjust base dose daily based on previous day’s needs until
control achieved and on normal diet
May, 2008
Insulin orders – patient eating
Ordered baseline dose
(Indicate clearly type
and brand of insulin)
Breakfast
or 0600h
Lunch
or 12h
Supper
or 18h
HS or
22h
NPH/glargine/detemir
0%
0%
0%
40%
Regular/lispro/aspart/glusine
25%
15%
20%
0%
Example of insulin adjustment scale for pre-meal or HS insulin adjustment
If capillary blood glucose is:
≤ 4 mmol/L
Treat for low blood sugar; decrease ordered dose
by 4units
4.1 – 6.0 mmol/L
Decrease ordered dose by 2 units
6.1 – 10.0 mmol/L
Give ordered baseline dose
10.1 – 12.0 mmol/L
Increase ordered dose by 2 units
12.1 – 14.0 mmol/L
Increase ordered dose by 4 units
14.1 – 16.0 mmol/L
Increase ordered dose by 6 units
16.1 – 18.0 mmol/L
Increase ordered dose by 8 units
> 18.0 mmol/L
Increase ordered dose by 10 units; inform MD
November, 2010
Additional considerations once eating:

IV insulin – Regular is preferred, as analogues have
no advantage if not SC and are more expensive. Once
eating, if previously on analog insulins, can re-start.

Monitor glucose at least every 4 - 6 h; ideally, pre-meals.

In situation where changes of need may occur rapidly, use
of aspart (Novorapid®) or lispro (Humalog®) SC may be
easier, since it can be given with the meal. Rapid acting
analogs, however, only lasts 4-6h, not 6-8h as “regular”
does.

Initially CBG testing would be ordered as 0600, 1200,
1800 and 2400 but, if switched to eating, adjust timing to
meal delivery & 2200 hr.
May, 2008
Patients going for tests

Adjust timing of tests to facilitate insulin and
diet needs whenever possible.

If patient likely to be gone at a snack time or may
have lunch delays by waiting times in X-ray, etc…
send juice and a snack with them.

Reassess patient on return from test with
capillary blood glucose & adjust therapy as
needed.
May, 2008
“Sliding Scales”
– why such a bad reputation?

Inappropriately, they are used alone….as
the only insulin ordered…

To work, the sliding scale should only help fix
the “ordered dose”

The information from the adjustments used in
the sliding scale should be used to help correct
the “base dose” the next day.
May, 2008
Sliding scale in hospital
if glucose is:
(mmol/L)
R/RA before
meals
N/L/UL @ hs
< 4.0
- 4 units
- 4 units
4.1 - 6
- 2 units
- 2 units
6.1 - 10
Base dose
Base dose
10.1 - 12
+ 2 units
+ 1 u. R/RA
12.1 - 14
+ 4 units
+ 2 u. R/RA
14.1 - 18
+ 6 units
+ 3 u. R/RA
> 18
+ 8 units
+ 4 u. R/RA
if glucose above 20, give 10 units & call MD
May, 2008
Insulin adjustment scale for patients at
home or for insulin sensitive type 1
if glucose is:
(mmol/L)
R/RA before
meals
N/L/UL @ hs
< 3.0
- 3 units
- 3 units
3.1 - 4
- 2 units
- 2 units
4.1 - 5
- 1 unit
- 1 unit
5.1 - 8
Base dose
Base dose
8.1 - 10
+ 1 unit
+ 1 unit
10.1 - 12
+ 2 units
+ 2 units
12.1 - 14
+ 3 units
+ 3 units
14.1 - 18
+ 4 units
+ 4 units
> 18
+ 5 units
+ 5 units
May, 2008
In-Patient Diabetes
Management:Objectives
 Importance of Diabetes
 as a risk factor
 in hospital outcomes


Review physiology of stress and insulin needs
Aspects of glucose control in hospital




Diet and Testing,
Oral agents
Insulin use
Peri-operative care


Emergency Room management
Pump therapy – basic in case admitted
ER or Hospital Management
- Challenges to Care:





Meals are :
◦ irregular, or missed completely
◦ rarely the same as normal diet or on time
Capillary Blood Glucose Monitoring is:
◦ Done irregularly, not always in relation to meals
◦ Difficult to arrange hourly for IV infusions due to nursing
staff limitations on occasion.
Staff changes are frequent, thus less continuity of care.
Patient’s participation in self care may be severely limited.
Patient, by definition, will be ill and inter-current illness
often substantially changes insulin requirements… often
increasing them due to the psychological and physiological
stresses.
May, 2008
Evaluation in the Emergency Room….
Usual treatment often gives valuable insight
into how patient’s care should be done
 Is patient able to eat normally?
 Is patient NPO or on IV infusion?
 Does patient normally take insulin?
- If so, need to know:
 what kinds of insulin, type and exact name
 how much, and
 at what times?
DETAILED EXACT INFO needed!!!
May, 2008
ER IV insulin infusions – pros and cons
In some ER situations, due to staffing issues, hourly CPG
to adjust an IV protocol initially may not be possible.
 Use an insulin adjustment scale as one would use normally
pre-meal using ¼ of total daily dose [TDD] as top limit of
sliding scale for highest glucose values.

To calculate dosage to use for basal needs if not eating…
Calculate Total Daily Dose (TDD) divide by 2
(since ½ insulin for food)
Divide this amount over the day - 40 % overnight and the rest split
in 3 with a bit more at breakfast than lunch as regular or analogue
pre-meal or 0600, 1200, 1800 hours and NPH at HS.
e.g.
25% - 15% - 20% - 0 can be given pre-meal regular or RA
0 - 0 - 0 - 40% as longer acting evening insulinspre
May, 2008
Patient with DM in ER
Normally on diet ± oral agents
Able to eat
Not able to eat
Give consistent glucose load by
IV (~ 5 g/h) to avoid ketosis
Eg. IV D5 W or D5NS @ 100cc/h or
D10 W @ 50 cc/h if fluid an issue.
Continue usual diet
and pills
Is glucose stable
and well controlled?
YES
NO
Initiate an IV insulin infusion with
concept of giving 10 – 12 u/24 h. (or
presumption of potential total
insulin dose as 20 u/day)
Ie. IV insulin to start @ 0.4 u/h or
Base dose ac meals & HS of :
N
0-0-0-4
R/RA
4-5-4-0
with insulin adjustment scale.
Monitor glucose as needed.
Monitor glucose q 4-6 h as
needed, no other therapy
for DM likely needed.
May, 2008
Patient with DM in ER
Normally on insulin
Able to eat
Continue usual diet
and insulin if possible
YES
If type 1, initiate IV or Q4-6 SC
insulin regimen once glucose
above 6 mmol/L and check for
ketones.
NO
Breakfast
or 0600
Lunch
or 1200
Supper
or 1800
HS
or 2400
NPH/lente/ultralente
(source, brand)
0
0
0
X
Regular / Rapid acting
(source, brand)
X
X
X
0
EG. Insulin adjustment scale for rapid acting insulin before each meal:
If capillary blood glucose is:
≤4.0 mmol/L
Treat for low blood sugar;
decrease ordered dose by 4 units
4.1–6.0 mmol/L
Decrease ordered dose by 2 units
6.1–10.0 mmol/L
Give consistent glucose load by
IV (~ 5 g/h) to avoid ketosis
Eg. IV D5 W or D5NS @ 100cc/h
or D10 W @ 50 cc/h if fluid
volume is an issue.
Is glucose stable
and well controlled
(ie < 10mmol/L)?
Monitor glucose q 4-6 h as
needed, continuing
therapy as planned.
Ordered dose:
Not able to eat
Give ordered dose
10.1–12.0 mmol/L
Increase ordered dose by 2 units
12.1–14.0 mmol/L
Increase ordered dose by 4 units
14.1–18.0 mmol/L
Increase ordered dose by 6 units
>18.0 mmol/L
Increase ordered dose by 8 units
and inform physician
Initiate insulin …either as
an IV insulin infusion of base dose [total
daily dose / 2] distributed over 24 hour as
starting insulin dose for infusion… ie. IV
insulin to start …
@ (TDD/2)  = X u/h (initial rate) & adjust
or
Base dose ac meals & HS of :
N
0 - 0 - 0 - 40%
R/RA 25% - 15% - 20% - 0
with insulin adjustment scale.
Monitor glucose as needed.
May, 2008
In-Patient Diabetes Management
Objectives:
 Importance of Diabetes
 as a risk factor
 in hospital outcomes


Review physiology of stress and insulin needs
Aspects of glucose control in hospital






Diet and Testing,
Oral agents
Insulin use
Peri-operative care
Emergency Room management
Pump therapy – basic concepts in case
admitted
The dilemma of pump patients…
That patient in Bed 3 is on an insulin
pump – you take her!
No, I can’t… I don’t know anything
about pump therapy…
Well neither does the doctor who’s
on tonight – so what do we tell the
patient?
May, 2008
Core Concepts of Insulin Pump Prescriptions
(~25% of type 1’s now on pumps!)
“Basal” = Basal dose – units per hour
24 – 04h …0.6u
04–07h …1.0u
07–12h …0.8u
12–18 …0.6u
18–24h …0.7u
Bolus doses: Ratio of grams CHO covered by 1 unit of insulin
24–07h 1u/20g
07–11h 1u/8g
11–15h 1u/12g
15–20h 1u/10g
20-24h 1/15g
Correction factor – the amount of glucose lowered by 1 u (in mmols)
24–07h 1u/3
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07–11h 1u/1.5
11–15h 1u/2
15–20h 1u/2
20-24h 1/3
Basal = baseline dose = insulin amount given over 24 hours without food
Bolus = dose given to cover food intake
Total daily dose = insulin amount used as basal + bolus given for meals
Insulin Sensitivity Factor (ISF) or Correction factor indicates
mmol increments for sliding scale (often must be doubled
if ill or stressed e.g. hospital i.e. mmol denominator must be decreased)
May, 2008
The Type 1 on pump or who “carb counts”…
In order to order IV or alternative subcutaneous insulin doses …
need to know the total daily dose (TDD) – pumps have that
info in their minicomputers… ask the patient!
For Patients who don’t know/can’t tell you their Total Daily Dose
 To determine basal total: Ask them (or review basal on the
pump) to find basal rates by hour… calculate: [basal rates X
numbers of hours at each] = total basal rate
 To determine meal amounts if carbohydrate counting:
1. Ask them what their “normal” meal carbohydrate intake is, then
ask them what they usually take to cover that… will often get
relative doses for breakfast, lunch and dinner that way.
2. If they are not able to tell you their usual meal CHO intake,
assume 40g at breakfast and 50g for lunch and supper – multiply
by ratio found under bolus wizard or EZ carbs eg 1u/8g at bkft =
5units

Total Daily Dose = sum of basal rates
+ usual amount for each meal…
May, 2008
Search for “micro” complications!
Nephropathy:
◦ Check albumin/creatinine ratio
(> 2.0 men or 2.8 women = trouble)
◦ creatinine clearance by Cockcroft-Gault equation
◦ Urinalysis – for cells, protein, or signs of infection
Retinopathy
◦ Be sure patient has been seen by competent
ophthalmologist and eyes assessed within last year
Neuropathy
- Test ankle jerks + 10g monofilament on toes
- Ask about erectile dysfunction, bowel problems, excess
sense of fullness post-meal, postural hypotensive
symptoms
May, 2008
Search for “macro” risk factors
or complications
Lipid profile at least yearly
◦ evaluation of LDL and HDL cholesterols, Triglycerides,
apo-B.
Cardiac assessment
◦ ECG + / - stress test
◦ Hypertension – assess and control to < 130/85
Peripheral Vascular Disease…
◦ Vascular flow assessments with doppler PRN
◦ Assess for bruits or intimal media thickening
Foot care…
◦ Look at the foot – reflexes, monofilament, ulcers,
redness, callouses and general state of care
May, 2008
Make sure outpatient follow-up
well established
 Remember
to use entire team…
nursing, dietitian, family MD, social
worker and community services, if
needed.
 Plan appropriate steps long before day
of discharge.
 Survival booklets available in English &
French – order via Endocrinology
office…
May, 2008
Thank you for your attention…
Questions ???