10. Insulin Guidelines
Optimise diabetes management of hospital inpatients
Additional sub cut insulin algorithms
Continue regular insulin
? Adjust usual regime
Consider BG targets
IV insulin infusion orders (iio)
When?
10% glucose 80mls/hr & Actrapid 50u/50ml NaCl 0.9%
? Kcl → ileus, v & d’s, or NBM → monitoring
iio form / drug chart / fluids FBC /algorithm
Decision → surg team/anaesthetist
Poor control = RBG > 17, mean BG >11, HbA1C >73mmol/l
Preggies & paeds
11. Acute presentations
DKA
Baseline obs ?
Aims:
Correct dehydration / electrolyte slowly
IV insulin infusion / Dextrose 10% IV
? Cause – education
IV insulin / Dextrose 10%
Until ketosis clear or minimal / pH nad
Dont be in a rush to feed / Ø vomiting & stable
Regular insulin / crossover infusion
Newly dx – ref
Lantus
Paeds – Starship policy
Mod Severe
pH 7-7.24 <7.0
Serum HC03- 10-15 <10
Ketones Urine ++-+++
B hydroxybutyrate > 1.2 (0.4)
12. HHS – hyperglycaemia
hyperosmolar state
Resembles DKA
BGs usually ↑↑
Rx → as for DKA
Slow replacement fluid
Insulin infusion
Electrolyte
DVT risk
Ongoing Rx / usual regime
13. Notes →Insulin infusions
OT →Infusion starts at point of starvation
Never stop infusion in T1DM →treat / adjust
Infusion not enough prandial cover
If acidotic – keep going!
NaCl 0.9% if BG > 17 mmol/l
dedicated lines
14. Recommencing usual regimes
<24 hrs interruption usual insulin – restart next meal
Infusion overlap 1-4 hrs
>24hrs – morning with overlap 1-4 hrs
Bg’s 5-15 mmol acceptable short term
OHA – resume 1st post op meal
Consider additional s/c
15. Hyperglycaemia
Bg >17 mmol/l two or more / repeated
? options
Hypoglycaemia
Bg < 4.0 mmol/l
? Treatment
Concious
unconcious
? On insulin infusion
16. Prediabetes – intermediate
hyperglycaemia
HbA1C 41-49 mmol/l
Lifestyle management 3– 6/12
Metformin 46-49 mmol/l
No SMBG or retinopathy screening
CVD risk
Opportunistic screening
Known IHD/CVA/PVD
Hx cellulitis / PCOS
Long term steroid or antipsychotic Rx
Obese BMI ≥ 30 (27 Indo-Asian)
Family hx – Maori, PI, Indo-Asian