ADULT Known diabetes ?

HYPERGLYCEMIA
MANAGEMENT Yes No
ALGORITHM
Q4-6h (sq SSI) or Q1h (IV SSI, > 1 level > 150 Glucose checks on admission
monitored pt. only) Glucose checks and within 24 h
& regular human insulin SSI With diabetic patients that are not on a stable PO diet:
coverage: consider continuing longer acting forms of insulin at ~ ½ of
No DM & Glucose all < 150 &
the usual dose to avoid large glucose variations on SSI; oral
100-150, not req. medically stable
SQ SSI IV SSI anti-diabetic medications may be continued on an individual
Insulin for ≥ 24h
basis w. caution; Metformin should be discontinued.
0-60 ½ Amp D50 & NHO
Physician to adjust initial SSI coverage based on weight, D/C glucose checks,
61-150 0U 0U
151-200 1- 4U 1-2U type of nutritional support (NPO, PO diet, tube feeds, TPN), resume glucose checks when patient
D/C glucose
conditions that increase insulin requirements (infection, condition changes significantly or
checks &SSI 201-250 2- 8U 2-4U
steroids) and home insulin requirements level >150 on routine labs
251-300 3-12U 3-6U
301-350 4-14U 4-8U Physician to adjust SSI coverage as needed to achieve
consistent target glucose levels 100-150
>350 5-16U 5-10U &
NHO • Always as separate infusion
• Goal glucose levels 100-150
Glucoses On maximal SSI coverage: Initiate regular human insulin drip: • Do not decrease levels by >
consistently • one glucose level > 250 100 /hour
Monitored Glucose 151-250 1U/hour
100-150, but • ≥ 3 levels > 150 / 24 hour period unit • Monitor blood glucose levels
251-350 2U/hour
req. insulin • repeated hyper/hypoglycemia q1h until in target range for
>350 3U/hour
≥ 4 consecutive hours and
Non-monitored unit patient medically stable – then
q2 hours
Medically Stable and Not on stable diet? INSULIN DRIP TITRATION: • When conditions change
Not medically stable? resume q1 hour checks
On stable PO diet ? Glucose > 150 - increase gtt. by 1 U/hour (if not controlled
- Consider restart home anti-diabetic Poorly controlled? after 2 increases, may increase by 2U/h steps)
regimen, monitor glucoses qAC&HS, & SSI any glucose level > 350,
(diabetic patients should receive ADA / glucose repeatedly > 250, 100-150 - maintain gtt. Rate
non-concentrated sweets diet) repeated hypoglycemia < 60 80- 99 - decrease gtt. by 25% & recheck glucose
q 1 hour until > 100
On stable cont. tube feeds ?
60- 79 - decrease gtt. by 50% & recheck glucose
- Consider longer lasting form of insulin
• Treatment must be individualized q 30 min until > 80
& SSI, monitor glucoses q 6 hours
< 60 - hold gtt., give ½ Amp D50 IV, recheck glucose
On stable TPN ? under close physician supervision in 15, 30, 60 min and q1hour thereafter
- Consider adding regular insulin to TPN repeat doses of ½ Amp D50 for any subsequent
(in conjunction w. surgical nutrition • Consider addition of long acting glucose < 60;
specialist) & SSI, insulin - when glucose > 100 restart gtt. with rate reduced
- monitor glucoses q 4 - 6 hours • Consider transfer to monitored by ½ of previous rate.
New diabetes/glucose intolerance ? unit for insulin gtt. therapy
Once patient medically stable, on stable insulin requirements and stable nutritional support, consider transitioning
to longer acting insulin plus SSI for enterally fed pt. or insulin in TPN plus SSI per protocol, in conjunction w.
surgical nutrition specialist and under close physician supervision;
Consider Endocrine (Joselin Diabetes Center) consult For newly diagnosed diabetes/glucose intolerance consider Endocrine consult