Pintura a) Generalidades

Guideline: Starting insulin dose 0.2 units/kg basal insulin q 24 hr and 0.05 units/kg Novolog before each meal. It is recommended that scheduled / basal insulin be used in combination with supplemental insulin.

Basal Insulin

insulin detemir (LEVEMIR PEN) injection Subcutaneous, Nightly at bedtime, Nightly at bedtime

Scheduled Pre-Meal-Insulin

insulin aspart (NovoLOG PEN) injection - individual dose TID AC

Pre-breakfast insulin aspart (NovoLOG

PEN) injection Subcutaenous, Daily before breakfast, Daily before breakfast

Pre-lunch insulin aspart (NovoLOG PEN)

injection Subcutaenous, Daily before lunch, Daily before lunch

Pre-dinner insulin aspart (NovoLOG PEN)

injection Subcutaenous, Daily before dinner, Daily before dinner

Sliding Scale Insulin (AC, HS and 0200 Coverage)

* This order set represents a sample of what would be selected for an individual patient eating three meals each day and receiving Scale I (of Scale I, II, or III) sliding scale insulin. The complete order set found in the electronic health record also includes instructions for patients with different nutritional needs and/or receiving different sliding scale insulin amounts. The ‘General’ section (which includes when to notify the physician, nursing interventions related to diabetic ketoacidosis, and ancillary consultations) and the ‘Hypoglycemia” section were removed for brevity. All other details, including any grammatical or typographical errors, are directly quoted from END IP Insulin Subcutaneous.

insulin aspart (NovoLOG PEN) injection 0-12, Subcutaneous. 3 times daily antidiabetic, 3 times daily antidiabetic

Scale I

If BG >/= 350 mg/dL, give appropriate insulin per dose algorithm and call physician.

BG < 70 mg/dL: Follow Hypoglycemia Orders BG 70 - 110 mg/dL: No insulin BG 111 - 150 mg/dL: No insulin BG 151 - 200 mg/dL: 2 units BG 201 - 250 mg/dL: 4 units BG 251 - 300 mg/dL: 6 units BG 301 - 350 mg/dL: 8 units

BG 351 - 400 mg/dL: 10 units (Call physician) BG > 400 mg/dL: 12 units (Call physician)

insulin aspart (NovoLOG PEN) injection 0-6, Subcutaneous, Bedtime and 0200 scheduled, Bedtime and 0200 scheduled

Scale I

If BG >/= 350 mg/dL, give appropriate insulin per dose algorithm and call physician.

Check 0200 BG for patients who received insulin at dinner and/ or bedtime, or patient who have had ANY hypoglycemia (BG <70) in the past 24 hours.

BG < 70 mg/dL: Follow Hypoglycemia Orders BG 70 - 110 mg/dL: No insulin BG 111 - 150 mg/dL: No insulin BG 151 - 200 mg/dL: 1 unit BG 201 - 250 mg/dL: 2 units BG 251 - 300 mg/dL: 3 units BG 301 - 350 mg/dL: 4 units

BG 351 - 400 mg/dL: 5 units (Call physician) BG > 400 mg/dL: 6 units (Call physician)

Appendix E

Protocol: Transition from IV to SQ Insulin Draft 4, 4/3/2018

Patient Recommendations:

* All patients have minimally variable IV insulin infusion rate for 6 hours * Blood glucose is at goal rate per John Muir policy for 6 hours

• _{Goal for Cardiac Surgery Patients: BG 110 - 150} • _{Goal for non-cardiac patients: BG 140 – 180} • _{Goal for DKA patients: BG 150-200}

Timing of the transition:

• _{Give initial basal dose at 0900}

• _{Stop IV insulin drip at least two hours after first dose of basal insulin.} • _{Give pre-meal and/or sliding scale insulin before lunch}

• _{For patients requiring > 50 U/day of basal insulin, split the dosing of the basal} • _{Give half of the daily basal dose at 0900}

• _{Give half of the daily basal dose at 2100 the night before transition to} basal/bolus insulin.

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1. Patients with history of diabetes or requiring ≧ 1.5 units/hour

• _{Determine the patient’s total daily dose (TDD) of SQ insulin:}

a. Determine the total units of IV insulin infusion over previous 6 hours

b. Multiply this total by 4 to calculate total average daily IV insulin infusion dose c. Multiply the total average daily IV insulin infusion dose by any factor between

0.6 - 0.8 to convert to a safe SQ dosage

▪ Patients will receive between 60% - 80% of IV insulin infusion dose, as determined by the provider

Math: Total SQ Dosage (units/day) =

Minimum: = (insulin infusion total over 6 hours) x (4) x (0.6) Maximum: = (insulin infusion total over 6 hours) x (4) x (0.8)

• _{Basal Insulin: Give 50% of TDD as long acting glargine (Lantus) or detemir (Levemir)} insulin

• _{Give regardless of oral intake}

• _{Give at least 2 hours prior to discontinuation of IV insulin infusion} • _{Bolus Insulin}

• _{Patient on PO intake:}

o Give 50% of TDD as scheduled pre-meal insulin in 3 evenly divided doses ▪ insulin aspart (NogoLOG pen)

o If patient is transitioning to clear liquids, give 0 - 50% of TDD as scheduled pre-meal insulin in 3 evenly divided doses.

▪ Increase the premeal insulin dose over time, based on patient intake.

o Hold scheduled insulin if patient is NPO.

o Administer correction sliding scale insulin PRN per John Muir protocol for BG outside of goal range

▪ Scale I: sensitive, thin, elderly; <40 units insulin/day ▪ Scale II: average weight; 40 - 80 units insulin/day

▪ Scale III: resistant, obese, steroids, or continued infection; >80 units insulin/day

• _{Patient on Continuous Tube Feed:}

o Give 50% of TDD as scheduled insulin in 6 evenly divided doses, every 4 hours

o If tube feedings are stopped, hold scheduled insulin.

o Administer correction sliding scale insulin PRN per John Muir protocol for BG outside of goal range

▪ Scale I: sensitive, thin, elderly; <40 units insulin/day ▪ Scale II: average weight; 40 - 80 units insulin/day

▪ Scale III: resistant, obese, steroids, or continued infection; >80 units insulin/day

2. Patients without history of diabetes and requiring < 1.5 units/hour

• _{No basal dose of insulin is needed}

• _{Order correction sliding scale insulin PRN per John Muir protocol for BG outside} of goal range

o Scale I: sensitive, thin, elderly; <40 units insulin/day

o Scale II: average weight; 40 - 80 units insulin/day

o Scale III: resistant, obese, steroids, or continued infection; >80 units insulin/day