Bruce W. Bode, MD FACE

Susan S. Braithwaite, MD FACE R. Dennis Steed, MD

Paul C. Davidson, MD FACEDecember 15, 2003

IV Insulin Infusion Therapy: Indications,

Thresholds and Target Range Glucose,

Protocols and Methodology

Transition to Subcutaneous Insulin,

Diabetic ketoacidosis

Non-ketotic hyperosmolar state

Critical care illness (surgical)

Myocardial infarction or cardiogenic shock

Post-operative period following heart surgery

Indications for IV Insulin Infusion

Critical care illness (medical)

NPO status in type 1 diabetes

General pre-, intra- and post- operative care

Organ transplantation

TPN

Exacerbated hyperglycemia

during high dose glucocorticoid

therapy

Indications for IV Insulin Infusion

Stroke

Dose finding strategy, anticipatory to initiation or

re-initiation of SC insulin in type 1 or type 2

diabetes

Labor and delivery

Other acute illness requiring prompt glycemic

control

Indications for IV Insulin Infusion

Thresholds for Initiation and Targets of IV Insulin Infusion Therapy

0

2

4

6

8

10

12

14

16

<150 150-175 175-200 200-225 225-50 >250

Average Post-operative glucose (mg/dl)

Mo

rtali

ty

Cardiac-related mortalityNoncardiac-related mortality

Mortality of DM Patients Undergoing CABG

Furnary et al J Thorac Cardiovasc Surg 2003;123:1007-21

Glycemic Threshold in CABG

Portland data suggest BG:

< 150 mg/dl for mortality

< 175 mg/dl for infection

< 125 mg/dl for atrial fibrillation

Furnary et al J Thorac Cardiovasc Surg 2003;123:1007-21

0

5

10

15

20

25

30

35

40

45

0 50 100 150 200 250

Days after inclusion

Cum

ulat

ive

% M

orta

lity

(in h

ospi

tal d

eath

)

P=0.0009

P=0.026

BG<110

110<BG<150

BG>150

Surgical ICU MortalityEffect of Average BG

Van den Berghe et al (Crit Care Med 2003; 31:359-366)

In this observational study of 531 ICU patients, glucose results were time- weighted for analysis.Shown as proportions of the whole admission, are percentages of admissions spent in bands of glucose.

Survivors Nonsurvivors111-144

200

Reduction of mortality below threshold glucose of 144- 200 mg/dL, with speculative upper limit of target range at about 145 mg/dL

Finney SJ et al JAMA 2003;290(15):2041-47

Glycemic threshold in Surgical ICU

BG < 110 mg/dl or < 145 mg/dl

Van den Berghe et al Crit Care Med 2003; 31(2):359-66

Finney SJ et al JAMA 2003;290(15):2041-47

What About Medical Patients?

Glycemic Threshold in Acute MI and Intervention (PTCA)

DIGAMI supports BG < 180 mg/dl

Minimal other data:

- PTCA reflow better with BG 159 than 209 mg/dl

Iwakura K: JACC 2003; 41:1-7

Malmberg BMJ 1997;314:1512Malmberg BMJ 1997;314:1512

Other Medical Conditions

Infection data supports BG < 130 mg/dl

Hartford ICU study 125 mg/dl vs 179 mg/dl 10X decrease in infections

Stroke data supports BG < 140 mg/dl

Pregnancy data supports BG < 100 mg/dl

Stamford CT ICU Study (Retrospective): Description of Patient Subgroups (N = 1826)

Cardiac (medical): 28.6% (540)

Pulmonary: 15.8% (289)

Septic Shock: 5.0% (92)

Other Medical: 14.9% (272)

Neurological: 13.2% (241)

Surgical: 7.1% (313)

Trauma: 4.3% (79)

Krinsley JS: Mayo Clin Proc 2003; 78: 1471-1478

05

1015202530354045

80-99 100-119

120-139

140-159

160-179

180-199

200-249

250-299

>300

Average ICU glucose (mg/dl)

Mo

rtal

ity

%

Hyperglycemia and Hospital Mortality1826 consecutive ICU patients 10/99 thru 4/02, Stamford CT

Krinsley JS: Mayo Clin Proc 78: 1471-1478, 2003

Glycemic Threshold for Medical Patients

< 140 mg/dl if IV Insulin is mandated by condition

Acute MI, NPO, Gastroparesis, etc

< 180 mg/dl for patients failing SC therapy

Threshold blood glucose in mg/dL for starting IV insulin infusion

Peri-operative care: > 140

Surgical ICU care: > 110 - 140 *

Non-surgical illness: > 140 - 180 * *

Pregnancy > 100

* Van den Berghe’s study supports 110; Finney’s study supports 145

* * If drip indication is failure of SQ therapy, use 180 ;

if indication is specific condition ( DM 1/ NPO, MI, etc ), use 140

Target blood glucose in mg/dL during IV insulin infusion

80 – 110 in Surgical ICU patients

90 – 140 in other Surgical and Medical Patients

70 – 100 in Pregnancy

Methods For Managing Hospitalized Persons with Diabetes

Take Diabetes out of the equation.

Control glucose!!!

Diabetes in Hospitalized Diabetes in Hospitalized

Patients .Patients . Psychology Psychology

Patients expect good glycemic control as part of Patients expect good glycemic control as part of

hospital carehospital care

They strive for recommended goals at homeThey strive for recommended goals at home

Difficult to understand staff’s casual approach to Difficult to understand staff’s casual approach to

BG’s >150BG’s >150

Methods For Managing Hospitalized Persons with Diabetes

Continuous Variable Rate IV Insulin Drip

Major Surgery, NPO, ICU, Unstable, MI, DKA, Hyperglycemia, Steroids, Gastroparesis, Delivery, etc

Basal / Bolus Therapy (MDI)

GIK (Reserved for euglycemic patients)

The Ideal IV Insulin Protocol

Easily ordered (signature only)

Effective (Gets to goal quickly)

Safe (Minimal risk of hypoglycemia)

Easily implemented

Able to be used hospital wide

Components of IV Insulin Therapy

IV line with minimal flow (> 40 ml/l)

Glucose inflow kept constant

Potassium must be given

Regular insulin in a 1 U/ml or 0.5 U/ml concentration

Infusion controller adjustable in 0.1 U doses

Accurate bedside BG monitoring done hourly (and if stable, every 2 hours)

Essentials of a good IV Insulin Algorithm

Easily implemented by nursing staff

Able to seek BG range via:

- Hourly BG monitoring

- Adjusts to the insulin sensitivity of the patient

All three have IV insulin protocolsComplexRequire ICU housing (exception Furnary)Specially trained nursesDedicated supervisionConsequently not widely accepted

IV Insulin Based StudiesDIGAMI, Portland, Leuven

Protocol of Van den Berghe and colleaguesTest Result Action

Measure glucose on entry to ICU

BG > 220 mg/dL Start insulin 2 - 4 IU/h

BG 220 - 110 mg/dL Start insulin 1 - 2 IU/h BG < 110 mg/dL Do not start insulin but

continue BG monitoring every 4 h

Measure glucose every 1 -2h until within normal range

BG > 140 mg/dL Increase insulin dose by 1 -2 IU/h

BG 110 - 140 mg/dL Increase insulin dose by 0.5- 1 IU/h

BG approaching normal range

Adjust insulin dose by 0.1 -0.5 IU/h

Measure glucose every 4 h BG approaching normal range

Adjust insulin dose by 0 .1-0.5 IU/h

BG normal Insulin dose unchanged BG falling steeply Reduce insulin dose by half

and check more frequently BG 60 - 80 mg/dL Reduce insulin dose and

check BG within 1 h BG 40 - 60 mg/dL Stop insulin infusion, assure

adequate baseline glucose intake and check BG within

1 h BG < 40 mg/dL Stop insulin infusion, assure

adequate baseline glucose intake, administer glucose per 10 g IV boluses and check BG within 1 h

Van den Berghe et al, NEJM 2001;345(19):1359

ICU Survival

Blood glucose control in Intensive Group:

Mean AM 103 mg/dl

BG < 40 mg/dl 5.2% (39)

Van den Berghe et al, NEJM 2001;345(19):1359

In no instance was hypoglycemia considered to be a serious event

1. Start Portland protocol during surgery and continue through 7 AM of the third POD. Patients who are not receiving enteral nutrition on the third POD should remain on this protocol until receiving at least 50% of a full liquid or soft American Diabetes Association diet.

2. For patients with previously undiagnosed DM who have hyperglycemia, start Portland protocol if blood glucose is greater than 200 mg/dL. Consult endocrinologist on POD 2 for DM workup and follow-up orders.

3. Start infusion by pump piggyback to maintenance intravenous line as shown in Appendix Table 1. 4. Test blood glucose level by finger stick method or arterial line drop sample. Frequency of blood glucose testing is as follows:

a. When blood glucose level greater than 200 mg/dL, check every 30 minutes. b. When blood glucose level is less than 200 mg/dL, check every hour. c. When titrating vasopressors, (eg, epinephrine) check every 30 minutes. d. When blood glucose level is 100 to 150 mg/dL with less than 15 mg/dL change and insulin rate remains unchanged for 4 hours (“stable

infusion rate”), then you may test every 2 hours. e. You may stop testing every 2 hours on POD 3 (see items 1 and 8). f. At night on telemetry unit, test every 2 hours if blood glucose level is 150 to 200 mg/dL; test every 4 hours if blood glucose level is less than

150 mg/dL and “stable infusion rate” exists.5. Insulin titration according to blood glucose level is performed as follows

a. When blood glucose level is less than 50 mg/dL, stop insulin and give 25 mL 50% dextrose in water. Recheck blood glucose level in 30 minutes. When blood glucose level is greater than 75 mg/dL, restart with rate 50% of previous rate.

b. When blood glucose level is 50 to 75 mg/dL, stop insulin. Recheck blood glucose level in 30 minutes; if previous blood glucose level was greater than 100 then give 25 mL 50% dextrose in water. When blood glucose level is greater than 75 mg/dL, restart with rate 50% of previous rate. c. When blood glucose level is 75 to 100 mg/dL and less than 10 mg/dL lower than last test, decrease rate by 0.5 U/h. If blood glucose level is

more than 10 mg/Dl lower than last test, decrease rate by 50%. If blood glucose level is the same or greater than last test, maintain same rate. d. When blood glucose level is 101 to 150 mg/dL, maintain rate. e. When blood glucose level is 151 to 200 mg/dL and 20 mg/dL lower than last test, maintain rate. Otherwise increase rate by 0.5 U/h. f. When blood glucose level is greater than 200 mg/dL and at least 30 mg/dL lower than last test, maintain rate. If blood glucose level is less than 30 mg/dL lower than last test (or is higher than last test), increase rate by 1 U/h and, if greater than 240 mg/dL, administer intravenous bolus

of regular insulin per initial intravenous insulin bolus dosage scale (see item 3). Recheck blood glucose level in 30 minutes. g. If blood glucose level is greater than 200 mg/dL and has not decreased after three consecutive increases in insulin, then double insulin rate. h. If blood glucose level is greater than 300 mg/dL for four consecutive readings, call physician for additional intravenous bolus orders.

6. American Diabetes Association 1800-kcal diabetic diet starts with any intake by mouth. 7. Postmeal subcutaneous Humalog insulin supplement is given in addition to insulin infusion when oral intake has advanced beyond clear liquids.

a. If patient eats 50% or less of servings on breakfast, lunch, or dinner tray, then give 3 units of Humalog insulin subcutaneously immediately after that meal.

b. If patient eats more than 50% of servings on breakfast, lunch, or supper tray, then give 6 units of Humalog insulin subcutaneously immediately after that meal.

8. On third POD, restart preadmission glycemic control medication unless patient is not tolerating enteral nutrition and is still receiving an insulin drip.

Portland ProtocolFurnary et al J Thorac Cardiovasc Surg 2003;123:1007-21

Two Specific IV Insulin Infusion Algorithms

Markovitz, Braithwaite and colleagues

- Tabular form

Davidson, Steed and Bode

- Computerized system called “Glucommander”

Protocol of Markovitz and colleagues, as modifiedColumn 1 Column 2 Column 3 Column 4 Column 5 Column 6 CBG units/hr CBG units/hr CBG units/hr CBG units/hr CBG units/hr CBG units/hr <70 off <70 off <70 off <70 off <70 off <70 off 70- 79 off 70- 79 off 70- 79 off 70- 79 off 70- 79 0.5 70- 79 1 80- 89 off 80- 89 off 80- 89 off 80- 89 0.5 80- 89 1 80- 89 1.5 90- 99 off 90- 99 off 90- 99 0.5 90- 99 1 90- 99 1.5 90- 99 2 100-109 off 100-109 0.5 100-109 1 100-109 1.5 100-109 2 100-109 3 110-129 0.5 110-129 1 110-129 1.5 110-129 2 110-129 3 110-129 4 130-149 1 130-149 1.5 130-149 2 130-149 3 130-149 4 130-149 6 150-179 1.5 150-169 2 150-179 3 150-169 4 150-179 6 150-169 8 170-189 2.5 170-189 5 170-189 10 180-209 2 190-209 3 180-209 4 190-209 6 180-209 8 190-209 12 210-269 3 210-254 4 210-239 5 210-229 7 210-239 10 210-229 14 240-269 6 230-269 8 240-269 12 230-249 16 270-329 4 255-299 5 270-299 7 270-309 10 270-299 14 250-269 18 300-345 6 300-329 8 310-349 12 300-329 16 270-309 20 330-389 5 330-359 9 330-359 18 310-349 24 346-389 7 360-389 10 350-389 14 360-389 20 350-389 28 390 6 390 8 390 11 390 16 390 22 390 32

Markovitz LJ et al Endocrine Practice 2002; 8(1):10-18

Formula for Markovitz Protocol

Hourly insulin rate

= hourly maintenance rate + ( BG – 150 ) / ISF

Formula for Markovitz Protocol

Hourly insulin rate

= hourly maintenance rate + ( BG – 150 ) / ISF

• To create a table, the upper target of 150

can be replaced with any upper target,

and the insulin sensitivity factor ( ISF )

may be calculated by a rule of 1500 or 1700.

• The hourly maintenance rate for target range control

for a given patient is discovered during

treatment by response to column

assignments .

The tabular insulin drip protocol now has been adapted to achieve glycemic targets lower than initially published

The glycemic management protocol damped the variability of glycemic control

Markovitz. 2002

any glucose < 70

percent of patient days

mean > 250 mean > 200

before and withprotocol

< 100 off

100-109 0.5

110-129 1.0

130-149 1.5

150-169 2.0

170-189 2.5

190-209 3.0

210-254 4.0

255-299 5.0 etc.

Check BG every 1 hr and adjust rate

The default insulin drip column

< 100 off

100-109 0.5

110-129 1.0

130-149 1.5

150-169 2.0

170-189 2.5

190-209 3.0

210-254 4.0

255-299 5.0 etc.

Suppose the patientstarts with CBG = 254 mg/dLbut after 2 hours the CBGremains about the same

The default insulin drip column

80- 89 off

< 100 off 90- 99 0.5

100-109 0.5 100-109 1.0

110-129 1.0 110-129 1.5

130-149 1.5 130-149 2.0

150-169 2.0 150-179 3.0

170-189 2.5 180-209 4.0

190-209 3.0 210-239 5.0

210-254 4.0 240-269 6.0

255-299 5.0 270-299 7.0

The next columnThe default column

Shifting between several algorithms allows the nurse to discover the insulin requirement that maintains normoglycemia

Instructions about modified Markovitz protocol

Default: start with column 2; use priming bolus

Switch to next higher column if:

BG 200 x 1h, falling < 30 mg/dL over the past 1h

BG 150 x 2h, falling < 60 mg/dL over the past 2h

Test BG q 1h if drip turned off by protocol

After drip interruption for low BG, resume when BG > 109

Switch to next lower column if:

interrupted for low BG, but now resuming

on column 4, 5 or 6 for past 8 hr and within target

A System for the Maintenance of Overnight Euglycemia and the Calculation of Basal Insulin Requirements in Insulin-Dependent Diabetics

Practical Closed Loop Insulin Delivery

1/slope = Multiplier = 0.02

0

1

2

3

4

5

6

0 100 200 300 400

Glucose (mg/dl)

Insulin Rate (U/hr)

NEIL H. WHITE, M.D., DONALD SKOR, M.D., JULIO V. SANTIAGO, M.D.; Saint Louis, Missouri

Ann Int Med 1982 ;97:210-214

Historical Perspective

IV Insulin Algorithm– Insulin (u/h) = (BG-60) x Multiplier

“White’s” Multiplier Not Applicable

for Majority– Based on Type 1 Pediatric Pump Patients– IV Insulin Used Frequently in Stressed Type 2

• Only 14% Stabilized at 0.02

0.00%2.00%4.00%6.00%8.00%

10.00%12.00%14.00%16.00%18.00%20.00%

00.

040.

060.

08 0.1

0.12

0.15

0.17

0.19

Multiplier

Glucommander Multipliers

N=2364 Runs

White = 0.02

Continuous Variable Rate IV Insulin Drip (Davidson 1982)

Mix Drip with 125 units Regular Insulin into

250 cc NS Starting Rate Units / hour = (BG – 60) x 0.02

where BG is current Blood Glucose

and 0.02 is the multiplier Check glucose every hour and adjust drip Adjust Multiplier to keep in desired glucose

target range (100 to 140 mg/dl)

Continuous Variable Rate IV Insulin Drip (Davidson 1982)

Adjust Multiplier (initially 0.02) to obtain glucose in target range

If BG > 140 mg/dL and not falling by 50mg/dl,

increase by 0.01

If BG < 100 mg/dL, decrease by 0.01

If BG 100 to 140 mg/dL, no change in current multiplier

If BG is < 80 mg/dL, Give IV D50 cc = (100 – BG) x 0.3

Give continuous rate of Glucose in IVF’s

Once eating, continue drip till 2 hour post SQ insulin

Glucommander AN ADAPTIVE, COMPUTER-DIRECTED SYSTEM FOR IV INSULIN, SHOWN TO BE SAFE, SIMPLE, AND EFFECTIVE IN 120,618 HOURS OF OPERATION

Invented in 1984 Davidson and Steed

19 Years Experience with this Computer Based Algorithm for the Administration of IV Insulin

Currently used as a software program housed in lap top computer in over 60 U.S. hospitals

Glucommander

1. Obtain initial Blood Glucose and each time the Glucommander beeps and enter the value into the Glucommander. (This is necessary so the multiplier will be adjusted)

2. Diet:______ Non-caloric __________ NPO 3. DO NOT FEED FOOD CONTAINING CALORIES UNLESS

ADDITIONAL MEALTIME INSULIN IS ORDERED. (Continuous enteral or IV feeding is an exception to this order.)

4. Mix IV Insulin Drip: Normal Saline 250ml with 125 units of Regular Insulin (this

making a 0.5Units Insulin/ml mixture). Place IV Insulin Drip on controller. DO NOT USE FILTER ON LINE

5. Low Target Blood Glucose: 100 mg/dl (or ____________)

6. High Target Blood Glucose: 140 mg/dl (or ____________) 7. Multiplier: 0.02 (or_____________)

8. Max Minutes between Blood Glucose Readings: 120 minutes (or ____________)

Note: Glucommander will beep for new blood glucose more frequently until glucose is stabilized. Obtain and enter BG value EVEN if the insulin drip is at 0 units/hr. The insulin drip will need to be restarted if the BG has increased above low target range.

9. Hypoglycemia Treatment: If BG < 80 mg/dl administer D50 according to the formula: (100 – BG) x 0.4 = __________ cc D50 IV Push

Glucommander Orders

GlucommanderPrinciples

0123456789

10

0 100 200 300 400 500

Insu

lin

Un

its

/ H

ou

r

Glucosemgm / dl

Cumulative Runs

0

1000

2000

3000

4000

5000

6000

7000

Glucommander

5802 Runs and 120,618 BG’s 1985-1998

Glucose Management System (GMS)

In 1997, MiniMed and Roche purchased the marketing rights to the Glucommander

Changed the name to GMS

Multicenter U.S. trials done for FDA approval

Useful and Safe for Any Application of IV Insulin

Shelved Pending FDA Approval of IV Use of Insulin

Glucose Management System

Glucommander .

Complete Data Set 1985 to 1998 Beyond Data Analyzed by Boehringer Manheim/MiniMed in 1995

13 years of data from Glucommander.

5802 Runs over 120,618 hours.

Correction of hyperglycemia:

Mean starting BG=259 mg/dL (SD 127).

Mean stable <150 after three hours.

Subsequent stability in target range for 60 hrs.

Hypoglycemia:

BG’s <50 were 0.6% of total BG’s.

2.6% all runs had one BG <40. All were immediately corrected to 100 with IV glucose

No severe hypoglycemia.

0

50

100

150

200

250

300

350

400

Hours

Glu

cose

m

g/d

lm

ean

-sd

Glucommander

Average and Standard Deviation of of All Runs1985 to 1998; 5808 runs, 120,618 BG’s

Glucommander .

Summary of PerformanceGlucose Averages for 3404 Patients

Glucose mg/dl

50

Pe

rce

nti

les

90

10

Hours

Pe

rce

nti

les

y = 0.7013x + 36.878

R2 = 0.9237

8090

100110120130140150160170180

80 100 120 140 160 180

Glucommander Target Mean

Aver

age

of B

G M

eter

Tes

ts

Conformity of Blood Glucose to Glucommander Target

0

1

2

3

4

5

6

7

0 10 20 30 40 50 60

0

0.01

0.02

0.03

0.04

0.05

0.06

50

100

150

200

250

300

350

400

Hours

Glucose

Multiplier

Mu

ltip

lier

Insu

lin

Insulin

Glu

cose

Typical Glucommander Run

Hi

Low

2.67.8

16.5

30

44.9

05

10152025303540455055

40 50 60 70 80

Blood Glucose mg/dl

% R

un

s w

ith

BG

bel

ow

val

ue

Leuven

<40 mg/dl

5.2%

Hypoglycemia on Glucommander5772 Runs

Protocol for Insulin in Hospitalized PatientProtocol for Insulin in Hospitalized Patient

Treatment of HypoglycemiaTreatment of Hypoglycemia

Any BG <80 mg/dl: D50 = (100-BG) x 0.4 ml IVAny BG <80 mg/dl: D50 = (100-BG) x 0.4 ml IV

Do not treat with oral CHO Do not treat with oral CHO

Do Not Hold Insulin When BG NormalDo Not Hold Insulin When BG Normal

20

40

60

80

100

120

140

160

Glu

cose

Correction of Hypoglycemia with Glucose100-BG X 0.2 Grams

Before After

Richardson Diabetes 1999 50:A200

100-BG X 0.15 Grams

N = 827

0123456789

10

0 100 200 300 400 500

InsulinUnits / Hour

Glucosemgm / dl

Glucommander 33 u

ADA 38 u

IV DRIP 38 u

MARKOVITZ 33 u

GlucommanderSimilar Systems

Features in CommonEarly high doseDecrease in parallel with BGEnd up at common doseSimilar total dose

0

50

100

150

200

250

300

0 5 10 15 20 25Time (hours)

Glu

cose

(m

g/dl

)

Glucommander .

Surgical SeriesCompared to Watts Algorithm

Watts

Glucommander

Watts et al Diab Care 1987 10:722-728

0

2

4

6

8

10

12

0 5 10 15 20 25Time (hours)

Insu

lin R

ate

(U

nits

/hr)

Glucommander .

Surgical SeriesCompared to Watts Algorithm

Glucommander

Watts

How has the Glucommander been used?

Treatment of ketoacidosis Hyperosmolar non-ketotic state Perioperative glucose management Labor and delivery Myocardial infarction Critically ill patients in ICU Hyperalimentation Gastroparesis with intractable nausea and vomiting Estimating a patient’s insulin sensitivity

– A guide for dosing insulin

• Estimating total insulin dose, correction factor, CHO/Ins

Clinical Experience with Glucommander

Simple, safe, and effective method for maintaining glycemic control thru out the hospital

Extensively studied

Standardized treatment method applicable in a wide variety of conditions

Available for review, www.glucommander.com

Transitioning off IV Insulin Infusion Therapy

Converting to SC insulin

If More than 0.5 u/hr IV insulin required with If More than 0.5 u/hr IV insulin required with normal BG, start long-acting insulin (glargine)normal BG, start long-acting insulin (glargine)

Must start SC insulin at least 2 hours before Must start SC insulin at least 2 hours before stopping IV insulinstopping IV insulin

Some centers start long-acting insulin on initiation Some centers start long-acting insulin on initiation of IV insulin or the night before stopping the drip of IV insulin or the night before stopping the drip

Intravenous insulin infusion under basal conditions correlates well with subsequent subcutaneous insulin requirement.

Units SQ

Units IV

Overwrite

Hawkins et al Endocrine Practice: 1995; 1(6) 385-389

A nurse-managed overnight insulin infusion predicts insulin dose requirement in a wide range of otherwise well patients having poorly controlled diabetes

insulin dose

predictedactual

Pre and post blood glucose

Mao et al. JCEM 1997;82:2466-70

Converting to SC insulin

Establish 24 hr Insulin Requirement

– Extrapolate from average over last 6-8 hours if stable

Give One-Half Amount As Basal

Give p.c. Boluses Based on CHO Intake

– Start at CHO/Ins 1 CHO = 1.5 units Rapid-acting

Monitor a.c. tid, hs, and 3 am

Supplement All BG >140 mg/dl

– (BG-100)/(1700/Daily Insulin Requirement)

• Prescription for insulin therapy includes:

• Basal Insulin (BI)

• Carbohydrate-to-Insulin Ratio (CIR)

• Correction Factor (CF)

•1801 Records from Pump Patients Studied

•Data from best-controlled of 591 pump patients

• Analyzed for optimum parameters

•Resulting formulae used as model for others

• The Accurate Insulin Management (AIM) formulae

The Accurate Insulin Management (AIM) Formulae

Davidson PC et al Diabetes Tech & Ther 2003; 5:327

The Accurate Insulin Management (AIM) Formulae

Accurate Insulin Management

(AIM) formulaeCarbohydrate-to-Insulin Ratio:

CIR=2.8*BW#/TDDCorrection Factor:

CF=1700/TDDBasal Insulin:

Basal=0.48*TDD

Davidson PC et al Diabetes Tech & Ther 2003; 5:327

Questions that need further study

What is the glucose threshold and target glucose for IV insulin in acute MI, pre-CABG, other states, etc?

<110 mg/dl or <140 mg/dl ? What is the best IV insulin infusion protocol?

What is the best way to transition to SC?

Conclusion

All hospital patients should have normal glucose

The Paradigm for the MilleniumThe Paradigm for the MilleniumHyperglycemia: A “Mortal” SinHyperglycemia: A “Mortal” Sin

A blood glucose over 110 in a hospitalized patient A blood glucose over 110 in a hospitalized patient causes increased morbidity and mortality.causes increased morbidity and mortality.

In the 21st Century In the 21st Century

Neglecting BG >200 Neglecting BG >200

Is MalpracticeIs Malpractice

For a copy or viewing of these slides

– Contact

• www.adaendo.com

How can I get use of Glucommander?

– Available for review on internet,

• www.glucommander.com

– Contact us:

• Glucommander@adaendo.com