View Full Screen - ADVANCE for NPs & PAs

Diabetes
and he had already eaten a meal, this
data could not be used to appropriately
calculate his subcutaneous insulin needs.
Two protocols were available: the sliding
scale insulin protocol (Table 2) and
the basal–bolus insulin protocol (Table
3). The hospitalist physician decided to
place William on the sliding scale insulin
protocol. After 4 more hours on this
protocol and another meal, the patient’s
glucose level increased to 450 mg/dL.
Table 1
DKA Insulin Infusion Protocol
Serum ketones were negative. The patient
was returned to the insulin infusion, but
this time he was placed on a general medical
unit insulin infusion protocol that
allowed for a higher number of units based
on the results of finger sticks performed
every 2 hours.
After another 4 hours, William’s blood
sugars were in the 180 mg/dL range. The
nursing staff calculated subcutaneous
insulin doses based on insulin infusion
1. Call provider before any of these orders are instituted.
2. Draw STAT basic metabolic panel, magnesium, phosphorus, serum acetone (if not yet
drawn).
3. Discontinue all previous insulin orders.
4. Give bolus human regular insulin IV ___________ units. Suggested dose 0.1 units/kg.
5. Start infusion of 150 units of human regular insulin in 150 mL 0.9% NaCl (1 unit per
mL) at appropriate insulin infusion rate. (See infusion orders below.) Run first 10–20 mL
of infusion through tubing and waste.
Insulin Infusion Protocol:
CAPILLARY or BLOOD GLUCOSE INSULIN INFUSION
> 500 14 mL/hr (14 units/hr)
401–500 10 mL/hr (10 units/hr)
351–400 8 mL/hr (8 units/hr)
301–350 6 mL/hr (6 units/hr)
251–300 4 mL/hr (4 units/hr)
201–250 3 mL/hr (3 units/hr)
151–200 2 mL/hr (2 units/hr)
100–150 1 mL/hr (1 unit/hr)
< 100 no insulin
6. Capillary or blood glucose every hour. Record on glucose monitoring record. Adjust
insulin infusion based on Insulin Infusion Protocol.
7. If insulin infusion is interrupted due to glucose < 100 mg/dL, obtain capillary or blood
glucose every hour until glucose > 100 mg/dL, then restart insulin infusion.
8. Start IV fluids: _________________________ at __________ mL/hr.
9. For signs of hypoglycemia:
A. Collect STAT capillary or blood glucose. If < 60 mg/dL and symptomatic, stop insulin
infusion and give dextrose 25 g IV (50 mL of D50W).
B. Collect STAT capillary or blood glucose. If blood glucose < 60 mg/dL and the patient is
asymptomatic, stop insulin infusion and give dextrose 12.5 g IV (25 mL of D50W).
C. Recheck capillary or blood glucose in 15–20 minutes. If blood glucose < 60 mg/dL,
repeat above procedure A or B depending on patient’s symptoms and contact physician.
10. When the capillary or blood glucose is less than 300 mg/dL, change IV fluids to D5W
______at ______mL/hr.
Consider discontinuing IV fluids when tolerating by mouth diet.
11. Ask provider about frequency of lab draw:
Electrolyte panel every ______________ Phosphate every ______________
Basic metabolic panel every __________ Serum acetone every ___________
Potassium every ________________ Arterial blood gasses every __________________
Magnesium every _______________ Other: ____________every _______
12. Before stopping insulin infusion, call provider for subcutaneous insulin orders (must
be given 30–60 minutes before insulin infusion is discontinued).
Provider Signature/ID No: _____________________________________________
Date/Time: __________________
rates over the previous 4 hours, and the
hospitalist physician started the patient
on the basal–bolus insulin protocol. The
nursing staff provided instruction about
blood glucose self-monitoring and insulin
administration, and the hospital provided
a blood glucose meter for home use. The
nurses instructed William to check his
blood sugars three times per day and to
bring his meter to the follow-up appointment
with his primary care provider
so that his doses could continue to be
adjusted. He was discharged later that
evening with a blood sugar of 203 mg/dL.
Background
Hospitalized patients with hyperglycemia
are usually categorized as being previously
diagnosed with diabetes, having unrecognized
diabetes, or having hyperglycemia
related to hospitalization. Hyperglycemia
with and without diabetes has been associated
with poor outcomes such as longer
lengths of stay. 1 The American College
of Endocrinologists recommends that
elevated glucose levels (> 140 mg/dL in
patients who are not critically ill) should
be identified in all hospitalized patients
and should be treated aggressively and
as soon as detected. 2
Previously diagnosed diabetes usually
falls into two categories: type 1 (presenting
as diabetic ketoacidosis; DKA)
or type 2 (presenting as hyperosmolar
hyperglycemia state; HHS). The diagnosis
of diabetes has become more complex.
The presentation can be misleading due
to conflicting physical and objective findings.
Often this leads to inappropriate
treatment that produces poor outcomes,
such as immunosuppression, endothelial
dysfunction, inflammation, increased
oxidative stress or thrombosis. 1
William presented to the emergency
department with symptoms similar to
those of someone with type 1 diabetes
(abrupt onset of symptoms and lack of
family history of diabetes). He also had
positive serum ketones, a status typically
present in type 1 diabetes. These
symptoms can also be present in type
2 diabetes, as in HHS. This patient did
not fit the typical physical presentation
of type 1 diabetes. He was an obese black
man with acanthosis nigricans, a condition
often found in type 2 diabetes.
26 ADVANCE for NP & PAs