Further to the excellent presentation supporting the eradication of Insulin Sliding Scales by Dr George Xidos, this post highlights the Canadian Guidelines on inpatient Diabetes management. This will form the framework for a new ED Orderset to be used when admitting patients who have diabetes.
Step 1:
• Estimate the patient’s total daily dose (TDD) of insulin
• If previously on insulin, use patient’s current TDD
• If not previously on insulin, use patient’s weight (in kg) times 0.4 – 0.5
Step 2:
• Order the basal insulin (insulin type, time of day, dose)
• Basal insulin type will be NPH, glargine, or detemir
• Basal insulin is typically given at bedtime
• Basal insulin dose will be TDD times 0.4 – 0.5
Step 3:
• Order the bolus, sometimes called prandial, insulin (insulin type, time of day, dose)
• Rapid acting insulin analogues (aspart, glulisine, lispro) are the preferred type of bolus insulin in hospital, but regular insulin can also be used
• Bolus insulin is typically given before each meal
• Bolus insulin dose will be TDD minus the basal insulin dose, evenly divided between the 3 meals or; TDD times 0.2 at each meal
• Bolus insulin should be held in patients who are temporarily not eating
Step 4:
• Order the supplemental or correction insulin (insulin type, time of day, dose)
• The supplemental insulin should be the same type as the bolus insulin; so usually a rapid acting insulin analogue.
• Supplemental insulin, if necessary, is typically given before each meal; it can also be given at bedtime
• The dose of supplemental insulin is added to the dose of bolus insulin and the two doses are given together. The supplemental insulin will typically only be given when the blood glucose is greater than 8 or 10 mmol/L; examples are shown in “Tools”.
Step 5:
• Review the patient’s diabetes and insulin record daily and make changes according to the blood glucose pattern(s).
Insulin Ordersets
Adult Inpatient Orderset
Acute Coronary Syndrome Orderset
Critical Care Orderset
DKA Orderset
Hypoglycaemia Orderset
Full CDA Document
