Makindo Medical Notes

Related Subjects: Type 1 DM | Type 2 DM | Diabetes in Pregnancy | HbA1c | Diabetic Ketoacidosis (DKA) Adults | Hyperglycaemic Hyperosmolar State (HHS) | Diabetic Nephropathy | Diabetic Retinopathy | Diabetic Neuropathy | Diabetic Amyotrophy | Maturity Onset Diabetes of the Young (MODY) | Diabetes: Complications |

Introduction

• These are a necessary evil. They are time-consuming for nurses, mean repeated finger prick testing for patient and are reactive always playing catch up to manage the blood glucose rather than proactive and tight control can cause hypoglycaemia. They have their place in the ill patient when blood glucose needs to be micromanaged to keep it within a certain value usually 4-8 mmol/l for AMI and 4-11 mmol/l in acute stroke and other conditions.
• The worry is inducing hypoglycaemia in the comatose or sedated patient which is why we run things slightly less tightly controlled on the stroke unit. Below is a sliding scale but there is no perfect sliding scale. The amount of Insulin needed by the patient for a certain glucose value depends on their Insulin resistance, dietary input, level of cortisol and other stress hormones.
• However, the scale will ratchet itself up if control is failing. Once the acute stress/illness/surgery is over try rapidly to revert to oral medication for Type 2 or regular Insulin or restart normal Insulin for a Type 1 or introduce a new diabetic to Insulin altogether.

Basic Blood Glucose Ranges (UK and US Units)

Sliding Scale - 50 units soluble Insulin in 49.5 ml of N-saline and 1L 5% Dextrose with 40 mmol KCl at 30 ml/hr given by non-reflow Y connector

Sliding scale: check with local guidelines

Starting Insulin

• Estimate Insulin need over past 12 hours on syringe driver and double
• Give 1/3rd at 10 pm as Intermediate Insulin
• Give 2/3rds as 3 doses of short-acting before each meal

Monitor

• Regular monitoring and adjustment is key
• Check BM before meals aiming for 4-7 mmol/l
• Teach patient to adjust doses to suit

Education

• Always educate never to stop Insulin when unwell and seek help promptly