Principles of Sliding Scale Insulin in the Hospital Setting

In the Hospital, Everyone goes on Insulin, because we don't like the side effects of the oral meds on top of the stresses on the patient from hospital procedures. But how much of what kind to give?

Step 1: Figuring out the base insulin you will give to Patient:

For Pts on Orals outside the hospital (e.g. metformin), multiply their weight (kg) times 0.3 to get total insulin.
For Pts on Insulin with controlled glucose outside the hospital, mult. weight times 0.5 to get total insulin.
For pts on insulin with uncontrolled glucose outside the hospital, multiply wt times 0.7 to get total insulin.

Step 2: What insulin to give as a baseline

First divide total by 2. Half will be Glargine, long-acting that will cover baseline metabolic activity. Half will be untra-short-acting Lispro, which will further be divided in three for each of the three meals of the day.

Step 3: Sliding Scale

Everybody is different, and some people won't react as well as you want. Ideally you want your patient to be between 120 and 179 Serum Glucose at ALL times. You'll try using the amount of Glucose we derived from Step 2, but if their post-prandial glucose levels are out of range (measure for each of their meals), use the sliding scale.

Start with a low sliding scale, and if they are way  out of range, use a medium scale, which basically amounts to more units to be added the next day to the total insulin.

Typical scales look like this:

100-149: 0 addt'l units
150-199: 1 add'l unit
200-249: 2 add'l units
250-299: 3 add'l units
300+: 4 add'l units.

You will take each of the meals' glucose levels and add together add'l units of insulin from each meal. You will take the total add'l insulin and divide this in the same proportions as baseline insulin we calculated in Step 2, adding it to whatever we used the previous day.

Repeat as necessary, until patient is back in the normal range of 120-179 after meals.

For Example:

Let's say you have a 100 lb patient who takes oral metformin to control their diabetes who you are admitting.

Step 1: They will get a baseline of 30 units of insulin a day.

Step 2: 15 will be insulin glargine, and 15 insulin lispro divided among their 3 meals, making 5 units of lispro before every meal.

Step 3: After the first day, you note their post-prandial glucose levels are as follows:

Breakfast: 200
Lunch: 270
Dinner: 170

Using the scale above, You would then have to add 2 add'l units for breakfast, 3 for lunch and 1 for dinner, making a total of 6 units. So your insulin the next day will be 15 + 3 = 18 units of Glargine for the day, and 5 + 1 = 6 units of Lispro insulin for each meal.

DKA vs HHS Diagnosis and Management

Diagnosis: How to Tell the Difference

DKA vs HHS
Type 1 DM                                                 vs. Type 2 DM
Glucose > 250                                             vs. > 600
pH < 7.3                                                       vs. > 7.3
Bicarb < 15                                                  vs. > 15
Moderate Ketonuria                                     vs. Non-Ketotic
(Anion Gap = Na- (Cl + Bicarb)) > 12mEq vs. Osmolality > 320 mOsm/L
Abs Insulin Def.                                            vs. Profound Hyperglycemia, no significant ketones

3 Things needed to Dx DKA
Hyperglycemia
Ketosis
Systemic Acidosis

Food Poisoning Differential

Vomiting Predominant: 

Staph aureus (esp. mayo)
Bacillus cereus (esp. rice)
Noroviruses, eg Norwalk

Watery diarrhea predom:

C. perfringens
Enterotoxic E. coli
Enteric viruses
Cryptosporidium
Cyclospora
Intestinal tapeworms

Inflammatory diarrhea predominant

Salmonella (typhi and non-typhi)
Campylobacter
Shiga-toxin producing E. coli
Shigella
Enterobacter
Vibrio (usually parahaemolyticus)
Yersinia

Non-GI Symptoms

Botulism (descending paralysis)
Ciguatera toxin (paresthesia)
Scombroid (flushing, itching)
Listeria (meningitis)
V. vulnificus (cellulitis, sepsis)
Hep A (jaundice)
Brucellosis (fever, arthralgia)

Acute Cervical Adenitis in Children

Unilateral:

Staph aureus OR Strep pyogenes: erythema, tenderness

Anaerobic bacteria, eg Prevotella: Dental caries

Bartonella henselae: Papular nodularity at site of cat scratch

Mycobacterium avium: gradual onset, nontender

Bilateral:

Adenovirus: Pharyngoconjunctivitis

EBV: Mononucleosis

Seven Wise Words from Doctor Somji

1. Medicine is gray.
2. D/C patients by 9-9:30AM
3. D/C Summaries done by end of shift.
4. "I don't know" doesn't exist.
5. If it doesn't make dollars, it doesn't make sense (unless it is good medicine/good for the patient).
6. Don't regurgitate; understand.
7. Always call ED back IMMEDIATELY.
8. CHF patients get Cefepime instead of Zosyn because Zosyn has a lot of salt.

Converting A1c reading into average Glucose from last 3 months

For every point of A1c over 6, add 30 to a baseline Glucose of 120, to get the average glucose over the past 3 months.

For example, An A1c of 9, indicates an average glucose over the past 3 months of 210.

Correcting Sodium for High Glucose Values

When you've got a high glucose, sometimes it's necessary to correct sodium.

You do this by taking the recorded glucose and, if it's higher than 199, add 1 to the recorded Sodium for every additional hundred glucose, to get the actual, corrected Sodium.

So for example, your patient's Glucose is 359, and recorded Sodium is 139. You add 2, since you're in the 300s. So your corrected Sodium is 141.