For decades, a axiom was anesthetized bottomward by bookish physicians to trainees and agents as a guideline for inpatient affliction of patients with diabetes. That bit of acumen captivated that it is best to “keep the accommodating a little sweet.” The Diabetes Ascendancy and Complications Trial1 and the U.K. -to-be Diabetes Study2 showed the adeptness of agitated ascendancy to abate microvascular complications of diabetes. Despite the added accident of hypoglycemia, these trials afflicted convenance patterns in ambulant settings in favor of accession of diabetes therapy. Amid ailing patients, a accord of adverse outcomes to hyperglycemia was adapted by abounding empiric studies that appear on mortality,3–7 communicable complications,8–11 breadth of stay,12 and added findings. Nevertheless, analysis connected to be apparent by abounding practitioners as aloof a brusque break during which bound glycemic ascendancy was chancy and additionally extraneous to the abiding abundance of patients with diabetes.
Two randomized, -to-be trials application intravenous insulin analysis now accept revolutionized our cerebration about inpatient affliction of diabetes and hyperglycemia by d the adeptness of accelerated insulin analysis of alarmingly ill ailing patients to abate bloodshed afterwards accretion anguish due to hypoglycemia.13,14 The aboriginal abstraction alleged for acceptance of an beverage of glucose and insulin in the ambience of myocardial infarction and aimed at a ambition glucose of 126–180 mg/dl.13,15,16 The additional acclimated intravenous insulin beverage in the surgical accelerated affliction assemblage to accomplish a ambition glucose of 80–110 mg/dl.14,17 Ascendancy of hyperglycemia or insulin analysis per se apparently adeptness abate risks for ailing patients by acclimation mechanisms of abrasion such as neutrophil dysfunction, aberrant activation of cytokines and the anarchic pathway, cardiac reperfusion injury, endothelial dysfunction, thrombotic tendency, cataism, and hyperglycemia-induced oxidative accent with resultant tissue injury.18 Although the allegation of the inpatient trials cannot be connected confidently aloft the populations that were studied, practitioners and able organizations now accept accepted a position in favor of hospital normoglycemia.18,19
The ambition ranges for claret glucose in the hospital are:
Deciding whether to beforehand a patient’s ambulant analysis plan while the accommodating is in the hospital usually is not difficult. In general, metformin will be contraindicated. Changes in renal activity put patients at accident for hypoglycemia during glyburide therapy. All articulate agents crave abiding ascertainment amid dosage adjustments. Insulin provides the greatest adaptability to accommodated rapidly about-face requirements. Therefore, best patients, if they charge antihyperglycemic analysis to beforehand target-range control, are best served by acting about-face to subcutaneous or intravenous insulin analysis or by accession of insulin to those articulate agents that are safe to use beneath altitude of hospitalization.
In accustomed physiology, the pancreatic achievement of insulin is disconnected about appropriately into basal and prandial components. The basal basic can be anticipation of as the bulk of insulin all-important to anticipate boundless or afield timed about-face of accumulator forms of activity into fuels (i.e., the bulk of insulin all-important to anticipate absolved postprandial or abnegation gluconeogenesis and ketogenesis and the bulk all-important to anticipate abnegation hyperglycemia). The prandial basic is the bulk bare in affiliation to accustomed commons to beforehand about-face of digested nutrients into accumulator forms of activity (i.e., the bulk of insulin all-important to awning commons afterwards development of postprandial hyperglycemia).
Patients with blazon 2 diabetes sometimes can accommodated the physiological needs for insulin through the autogenous assembly of insulin. If they already adapted exogenous insulin, the dosage claim may change depending on caloric assimilation and anatomy weight, or it may abandon entirely. Patients with blazon 1 diabetes, in contrast, accept an complete claim for exogenous insulin, and, in the absence of medical accent or aloft affairs changes, the claim is appreciably abiding over time.
Intravenous beverage of insulin is the alone insulin analysis activity accurately developed for use in the hospital. Indications for intravenous insulin beverage board diabetic ketoacidosis; nonketotic hyperosmolar state; analytical affliction illness; myocardial infarction or cardiogenic shock; the post-operative aeon afterward affection surgery; patients on NPO cachet in blazon 1 diabetes; accepted pre-, intra- and postoperative care; agency transplantation; achievement (possibly); affronted hyperglycemia during high-dose glucocorticoid therapy; use as a dose-finding activity avant-garde to acceptance or reinitiation of subcutaneous insulin in blazon 1 or blazon 2 diabetes; activity and delivery; and added astute affliction for which active glycemic ascendancy is advised important to recovery, such as blockage or analysis of infection.
A cardinal of protocols accept been appear anecdotic the conduct of intravenous insulin infusion.6,17,20–23 Glucose ecology by nursing agents initially charge be provided on an alternate basis. Afterwards stabilization of glycemic control, some protocols admittance the abundance of glucose ecology to abatement to every 2 hours or every 4 hours. Computerization of an algorithm for affirmation of the bare bulk of insulin infusion, engineering of the charge system, and approaching developments in glucose ecology are adequate to abridge analysis for the staff.24
Outside of the analytical affliction or step-down unit, best ailing patients astute insulin accept subcutaneous therapy. Afore an intravenous beverage of insulin is stopped, subcutaneous analysis should be started and abounding time anesthetized for the accommodating to acquaintance acceptance of action.
Assuming a accommodating requires exogenous insulin, a dieting of subcutaneous insulin analysis charge accommodated basal requirements (basal insulin). Aloft the basal requirement, insulin analysis adequate to accommodated caloric acknowledgment charge be assigned (nutritional insulin), either to awning detached commons (prandial insulin) or to awning abiding caloric exposure. By accouterment in beforehand for insulin administering adequate in bulk to awning both basal and comestible requirements and adapted in timing (scheduled insulin, programmed insulin), the ambition of subcutaneous insulin analysis (i.e., the blockage of hyperglycemia) can be met.25,26
Small added doses of approved insulin or rapid-acting analog acknowledging to hyperglycemia additionally can be assigned (correction dosage therapy).23 For acutely ill patients, about-face doses of approved insulin or rapid-acting analog may be accustomed every 4 or 2 hours, respectively. The bulk acclimated as about-face dosage analysis may be a adviser to bare changes of appointed insulin. About-face dosage analysis differs from sliding calibration monotherapy in that about-face doses are commensurable to circadian claim and are offered as a supplement to, not a backup for, appointed therapy.
The use of sliding calibration as monotherapy is ineffective.27,28 All too often, patients backpack a sliding calibration with them, inscribed on their medication administering almanac (MAR), and borne throughout the hospital from accepted breadth to preoperative captivation areas, briefly replaced with intravenous us analysis in the operating room, and afresh agitated to the postoperative accretion breadth and aback afresh to the accepted ward. Breadth about-face orders may artlessly state, “Resume sliding scale.”
For patients possibly accepting blazon 1 diabetes, by far the added astute charge is that, wherever such patients go, their MAR should backpack a basal insulin regimen, the basic of their insulin analysis that charge never be stopped. What is basal insulin? Already in the blood, of course, insulin is insulin. Bold the absence of insulin allergy, it is not the best of pharmacological alertness that counts, but instead the bulk and the agenda for administration, which charge be advised to beforehand continuously and uninterruptedly the bare claret levels of insulin to accommodated the physiological basal requirement.
For patients in the hospital who eat detached commons and do not accept carbohydrate amid meals, it is accessible and able to appoint appointed insulin as abstracted basal and prandial components. Abounding patients with blazon 2 diabetes do able-bodied with premixed or split-mixed NPH and approved insulin acclimated to awning both basal and prandial needs. However, in both blazon 1 and blazon 2 diabetes, insulin analysis is easiest to administer effectively, and the accident of hypoglycemia about is lowest, with analysis affairs that advance average or long-acting peakless insulin for the basal basic of analysis and a rapid-acting analog akin to the carbohydrate agreeable of commons for prandial therapy.29–32 About-face doses afresh are accustomed as baby doses of a rapid-acting analog aback hyperglycemia occurs.
Many patients ahead advised with alloyed NPH and approved insulin are beholden to go home on such a regimen, with the achievement of hypoglycemia abridgement and the abeyant that the analysis dieting offers for abandon in the timing and agreement of meals. Outpatient aftereffect about avant-garde carbohydrate counting is desirable.
For patients who are not accustomed with the use of an insulin-to-carbohydrate arrangement and who are not practicing self-management in the hospital, physicians should appoint a constant carbohydrate diet.33 Carbohydrate may be assigned in increments of about 15 g, the bulk historically advised to be “one serving.” Typical orders would board for 45, 60, or 75 g (3–5 servings) of carbohydrate at anniversary aloft meal and 15–30 g (1–2 servings) at snacks, additional any added diet specifications, such as “soft diet,” alkali restriction, or low phosphorus. The diet or comestible account of the hospital should apparatus the consistent-carbohydrate adjustment and sometimes should be asked to appraise patients’ absolute intake.
Fine-tuning through modification of the appointed insulin dieting is adapted aback glucose after-effects are aing to ambition ambit control. However, aback starting, it is adapted to bisect the basal and prandial apparatus of circadian analysis about equally. The absolute circadian dosage of insulin (TDDI) is estimated. About 50% of the TDDI is accustomed as basal therapy, and the actual 50% is disconnected amid the aloft commons to bout the carbohydrate agreeable of the meals.
Following is a sample consistent-carbohydrate meal plan adjustment with basal, prandial, and about-face insulin orders for a accommodating who does not yet adding carbohydrate:
Capillary claret glucose circadian afore commons and at bedtime
Consistent carbohydrate diet: 60 g at breakfast, lunch, and supper and 30 g at bedtime
Lispro insulin, 6 units, afore breakfast, lunch, and supper
Glargine insulin, 18 units, at bedtime.
For patients accepting corticosteroids, the admeasurement may acceptance 30% basal and 70% prandial. If prednisone is accustomed alone in the morning, the prandial requirements may be greatest at cafeteria and supper.
Many patients in the hospital do not eat detached commons or do accept caloric acknowledgment amid meals. Patients may “graze” on capricious meal plans, or they may accept between-meal comestible supplements, intravenous dextrose, enteral feedings, absolute parenteral nutrition, connected renal backup therapy, or added exposures to dextrose. There may be planned interruptions of caloric acknowledgment as with brief cycling of enteral feedings, or interruptions of enteral feedings for charge of drugs such as phenytoin. There may be adventitious interruptions, as with obstruction of the enteral agriculture tube or array of venous acceptance for connected renal backup therapy. Application adroitness accompanying with a adeptness of the acceptance and continuance of activity of accessible insulin products, the caregiver should devise a analysis plan that will board connected appointed insulin advantage to accommodated the comestible needs during the hours of the day aback connected caloric acknowledgment is occurring.34
Often it is not adorable to assay the physiological requirements for basal and comestible insulin analysis abnormally with specific pharmacological affairs of insulin. For connected comestible coverage, rapid-acting analogs are beneath able than longer-acting insulins, including mixtures, such as approved and NPH insulin accustomed at 6-, 8- or 12-hour intervals. Basal needs can be met with the aforementioned affairs or with long-acting or peakless insulin.
As a affirmation anticipation adjoin brusque interruptions of comestible assimilation or caloric exposure, the bulk of long-acting insulin or peakless insulin should not beat the basal requirements of the patient. For the aforementioned reason, to abbreviate risks in the accident of brusque abeyance of caloric exposure, to awning the comestible needs it may be bigger to appoint accepted baby doses of intermediate-acting or approved insulin than exceptional beyond doses of insulin. For example, to awning the comestible needs of a accommodating accepting connected enteral feedings, an antecedent plan for baby doses of alloyed NPH and approved insulin, accustomed every 6–8 hours, may be safer than a plan for beyond doses of NPH accustomed every 12 hours.
Physicians additionally can address “hold” orders for the approved insulin basic of analysis beneath a accustomed threshold, such as 100 mg/dl.
The absorbed of a “hold” adjustment is to board a absorber adjoin hypoglycemia in case of antecedent overestimation or bottomward trending of the insulin claim and to assure adjoin connected insulin administering aback comestible assimilation adeptness aback change. “Alert” or “call” ambit are advised to active application of a afterlight of continuing orders. For example, orders for a accommodating accepting connected enteral feedings adeptness be:
Capillary claret glucose every 6 hours
NPH insulin, 8 units, every 6 hours
Regular insulin, 4 units, every 6 hours
Hold approved insulin if glucose is < 100 mg/dl
Hold approved insulin if tube feeds are interrupted
Call me for glucose < 80 mg/dl or > 240 mg/dl or abeyance of tube feeds.
One of the best arduous questions about insulin analysis is, absolutely simply: “How much?” Or, to be added exact, the catechism is initially, “How abounding to alpha with?” and later, “How abounding for today?”
Having a bright almanac of the pre-admission analysis plan, such as that apparent in Figure 1, is consistently accessible to acceptance providers. For blazon 2 diabetes advised with insulin monotherapy, d there is no affirmation for accessible over-treatment or under-treatment and d the accommodating will be eating, an adapted starting appraisal is about the TDDI afore admission. As an alternative, one can appraisal TDDI based on a patient’s anatomy weight by starting with about 0.3 units/kg anatomy weight, of which about 0.15 units/kg would board basal coverage.35–38 Such an appraisal usually charge bound be revised upward, however.
If comestible assimilation is acutely reduced, the claim for exogenous insulin may abandon for a accommodating with blazon 2 diabetes. Aback caregivers are ambiguous whether hyperglycemia will abide in a accommodating with blazon 2 diabetes, it may be safest to abstain appointed insulin to see what arrangement emerges.
For blazon 1 diabetes, the bare TDDI usually is already known. In blazon 1 diabetes, the bare bulk of basal insulin is about 40–50% of the TDDI, as bent during accustomed bloom aback the accommodating is bistro accustomed meals. If a afterlight is adapted and the caregiver wishes to “start over,” a reasonable abode to alpha is with a TDDI of about 0.5 units/kg anatomy weight, ciphering the basal claim to be about 0.25 units/kg/day.
If patients who were advised with insulin monotherapy afore acceptance are affected potentially to accept blazon 1 diabetes and are maintained on basal insulin in adapted dosage throughout their hospitalization, there is little likelihood of harm. Aback the analysis of blazon 2 diabetes is doubtable in a heavy-set accommodating but allocation is ambiguous and a accommodation is fabricated to amusement as if the accommodating adeptness accept blazon 1 diabetes, the antecedent adding for basal insulin may be as little as 0.15 units/kg.
Estimates of insulin claim may prove to be boundless for patients who accept a activity predisposing to hypoglycemia, such as renal failure, or if the estimated insulin dosage was acquired from observations fabricated during periods of overnutrition. If medical accent is severe, on the added hand, or during corticosteroid analysis for patients with either blazon 1 or blazon 2 diabetes, the preadmission dosage of insulin is adequate to be too low. In such cases, there is adequate to be an access in appointed insulin claim that may be apportioned, for patients who are eating, amid the basal and prandial apparatus of therapy.
Some patients are anew advised with insulin as an intravenous beverage in the analytical affliction setting. At the time of abeyance of intravenous insulin infusion, for analytic abiding patients not accepting pressors and not apparent to dextrose, the alternate insulin beverage bulk all-important to accomplish brief abnegation glucose ascendancy during intravenous insulin analysis can be acclimated to appraisal the basal insulin requirements during subcutaneous therapy. Based on accommodating acknowledgment to subcutaneous therapy, any appraisal of basal insulin claim should be reassessed 12–24 hours afterwards cessation of intravenous insulin analysis and circadian thereafter.
At the time of about-face from a analytical affliction unit, as afterwards affection surgery, or at added times during hospitalization, the basal insulin requirements may be high, and the aliment assimilation may be doubtful. The prandial insulin afresh can be estimated as aloof 1–2 units of rapid-acting analog per 15 g of carbohydrate at meals, starting with 1 assemblage per 15 g or 3–5 units at anniversary meal, with instructions to nursing agents to bear the insulin alone if the accommodating has eaten at atomic bisected of the tray. Over several canicule during recovery, the basal claim about falls, and the prandial claim rises. If the accommodating will not accept detached meals, but rather receives intravenous dextrose or connected comestible support, about 1 assemblage of insulin for every 10 g of carbohydrate is a reasonable antecedent appraisal of circadian claim for comestible insulin coverage.39 For example, D5-containing fluids administered at 83 cc/hour would bear 2 liters or 100 g of dextrose circadian and adeptness initially be covered by about 10 units of appointed subcutaneous insulin aloft basal requirements. The antecedent dosage about abundantly underestimates the charge that eventually will be approved during comestible support.40–43
To beforehand glucose levels in the ambition range, the bulk of appointed subcutaneous insulin should be revised already or active daily. There should be a analysis of the absolute bulk of insulin absolutely administered over the above-mentioned 24 hours, including supplements and decrements, and the after-effects of glucose monitoring. It is additionally important to attending aback over several canicule to agenda any advancement or bottomward trending of glucose after-effects and insulin requirements and to appraise for attendance of altitude that adeptness affect insulin requirements. A reasonable dose-finding activity for the aing 24 hours is:
Determine yesterday’s absolute insulin dosage absolutely administered
Review yesterday’s glycemic control
Calculate today’s appointed insulin dose, as follows:
If some glucoses were < 80 mg/dl, use 80% of yesterday’s total
If glucoses were 80–179 mg/dl, use 100% of yesterday’s total
If some glucoses were ≥ 180 mg/dl, and none were < 80 mg/dl, use 110% of yesterday’s total.
Unlike the bearings for abounding patients accepting blazon 2 diabetes, abeyance of comestible assimilation does not accept a cogent appulse on the basal insulin claim for patients accepting blazon 1 diabetes. The charge to appraisal and abide accouterment the basal insulin claim is a bulk of life-saving accent in blazon 1 diabetes. Luckily, it is not difficult.
The absolute circadian basal insulin can be delivered in one of the afterward ways: glargine accustomed already daily; appropriately disconnected amounts of NPH accustomed every 6–12 hours, mixtures of NPH and approved insulin accustomed every 6–8 hours, or approved insulin accustomed subcutaneously every 4 hours (for patients with renal failure, every 6 hours may work); connected subcutaneous infusions of rapid-acting analog by pump; or intravenous approved insulin.
For example, a accommodating with blazon 1 diabetes who has balmy abiding renal abortion may accept taken 70/30 insulin afore admission, 20 units in the morning and 10 units at supper. In the hospital, if there will be abeyance of accustomed meals, it would be advisable to devise a new plan. Application 12 units, or 40% of the outpatient TDDI, as the estimated basal requirement, it would be adequate to activate one of the afterward schedules for basal insulin, or addition alternative, not to be withheld for normoglycemia:
12 units glargine, already daily
6 units NPH every 12 hours
4 units of 70/30 NPH/regular premixed insulin every 8 hours
3 units of approved insulin every 6 hours
When the basal basic of analysis is active as the account of hypoglycemia or as the account of bottomward trending of glucose creating a accident for hypoglycemia, afresh the hypoglycemia is treated, and basal analysis is rewritten to bear a lower bulk over 24 hours. The dosage reductions are hardly > 20% at a time. In blazon 1 diabetes, adjustments are fabricated afterwards brusque abeyance of basal insulin.
Fear of hypoglycemia is apparently the arch barrier to accomplishment of normoglycemia. Best cases of astringent insulin-induced hypoglycemia apparently appear on accepted wards, not in the accelerated affliction unit. On accepted wards, glucose ecology is beneath intense, and the avenue of insulin administering provides best continuance of action.44
Most episodes of hospital hypoglycemia amid insulin-treated patients are anticipated and accordingly should be preventable. Although abounding abstract about analysis of hypoglycemia exists,45 there is little appear advice about prevention. A proactive activity of blockage requires that physicians in their order-writing charge be acquainted of the development or attendance of renal insufficiency, malnutrition, alarmist disease, sepsis, shock, malignancy, dementia, congestive affection failure, stroke, about-face of patients’ adeptness to self-report symptoms, cone-shaped of glucocorticoids, denial of appointed doses of insulin, episodes of hypoglycemia that accept already occurred, or added predisposing altitude that advance the charge for active prescribing.46
Many cases of hypoglycemia amid ailing insulin-treated patients aftereffect from a conflict amid administered caloric assimilation and comestible insulin therapy.47 If diet ceases to be provided, comestible insulin advantage should be interrupted. If comestible insulin already has been given, blockage usually consists of 1) acquainted a triggering accident for hypoglycemia, 2) accretion the acuteness of glucose ecology for the continuance of activity of ahead administered insulin (for archetype to every 2 hours), and 3) administering carbohydrate by an addition avenue afore the claret glucose becomes low (for example, in this setting, 50% dextrose for glucose < 120 mg/dl).48
There should be ward-based protocols or hospital behavior that admittance adapted nursing responses to triggering events. Triggering contest board busline off breadth causing meal delay, new NPO status, abeyance of intravenous dextrose, abeyance of absolute parenteral nutrition, abeyance of enteral feedings, or abeyance of connected renal backup therapy.
Patients who are competent to abide self-management in the hospital deserve every accomplishment by their caregivers and the hospital to board their ambition and to admit their above adeptness to do so. To accommodated centralized and alien authoritative requirements that are bounden on the hospital pharmacy, the point-of-care testing program, nursing standards, and the medical accessories blank board of the hospital, it is accessible to authorize a multidisciplinary board that can assignment calm with the hospital affection affirmation affairs to authorize an enabling policy. Aboriginal and foremost, the affirmation of patients charge be assured. This aftereffect is about best achieved, afterwards appraisal of competency, by acceptance adapted patients to abide self-management.
Patients are about absolved on a new diabetes analysis regimen, sometimes additionally with adapted agency function, anatomy weight, or comestible assimilation compared to their preadmission status. Hypoglycemia sometimes occurs anon afterwards discharge.49 The acquittal affairs should board alarm ambit that would ambush a bottomward or advancement trend of claret glucose. A acknowledgment appointment anon afterwards acquittal to altercate diabetes ascendancy and advancing outpatient apprenticeship is appropriate.
When boundless numbers of active ambit and codicillary statements are absolute in physician orders, and aback there is airheadedness amid prescribers, afresh the accident of confounding and absurdity increases.
In general, the safe and able affliction of ailing patients accepting hyperglycemia requires institutional and physician charge to affection ascendancy and a multidisciplinary aggregation accomplishment in devising hospital procedures.50 Ward-based protocols or hospital-wide behavior can annihilate the charge for authoritative appropriate accoutrement in anniversary set of doctors’ orders, such as adeptness be adapted for the analysis or blockage of hypoglycemia. Well-designed protocols, as for intravenous insulin beverage or about-face of hyperglycemia, can accommodate the all-important complication and yet be ordered with a distinct signature.51 The best protocols can be accomplished by nursing agents afterwards astute nurses to accomplish algebraic calculations or to assay consecutive events. Standardized adjustment sets, with blanks for specific accommodating variables, can accustom the agents with the accomplishments of insulin and with accepted analysis plans.52 Direct physician adjustment access by computer added reduces error.53
Not alone hypoglycemia, but additionally hyperglycemia is a accommodating affirmation factor. Ambition ambit glucose is 80–110 mg/dl during analytical affliction in a surgical accelerated affliction unit, < 110 mg/dl afore commons (if eating), and < 180 mg/dl aiguille postprandial (or if accepting connected intravenous dextrose or comestible support). Good affliction involves analysis and advancing afterlight of circadian insulin dosage to alter about-face analysis with appointed insulin.
Fear of hypoglycemia is the arch barrier to normoglycemia. Hypoglycemia in the hospital is mostly preventable (by agency added than undertreatment of diabetes). Patients who are competent, eating, and accomplished in self-management should abide self-management in the hospital. Nationwide opportunities for advance board abetment of insulin dribble therapy, acclimation of diabetes adjustment sets and about-face dosage algorithms, protocols for blockage of hypoglycemia, accommodating apprenticeship and acquittal planning, and hospital behavior on accommodating self-management.
Sample pre-admission analysis plan.
Kristen B. Campbell, PharmD, is a cardiology specialty citizen in the Department of Pharmacy at the University of North Carolina–Chapel Hill. Susan S. Braithwaite, MD, is a analytic assistant of anesthetic at the University of North Carolina–Chapel Hill with adroitness convenance area at the Diabetes Affliction Center of the University of North Carolina–Chapel Hill in Durham, N.C.
Note of disclosure: Dr. Braithwaite has accustomed honoraria for speaking engagements from Aventis and analysis abutment from Bristol-Myers Squibb. These companies accomplish biologic articles for the analysis of diabetes.
The DCCT Analysis Group: The aftereffect of accelerated analysis of diabetes on the development and progression of abiding complications in insulin-dependent diabetes mellitus. N Engl J Med 329:977–986, 1993
U.K. -to-be Daibetes Abstraction Group: Accelerated blood-glucose ascendancy with sulphonylureas or insulin compared with accepted analysis and accident of complications in patients with blazon 2 diabetes (UKPDS 33). Lancet 352:837–853, 1998
Stagnaro-Green A, Barton MK, Linekin PL, Corkery E, deBeer K, Roman SH: Bloodshed in ailing patients with hypoglycemia and astringent hyperglycemia. Mount Sinai J Med 62:422–426, 1995
Capes S, Hunt D, Malmberg K, Gerstein H: Accent hyperglycaemia and added accident of afterlife afterwards myocardial infarction in patients with and afterwards diabetes: a analytical overview. Lancet 355:773–778, 2000
Umpierrez GE, Isaacs SD, Bazargan N, You X, Thaler LM, Kitabchi AE: Hyperglycemia: an absolute brand of in-hospital bloodshed in patients with undiagnosed diabetes. J Clin Endocrinol Metab 87:978–982, 2002
Furnary AP, Gao G, Grunkemeier GL, Wu Y, Zerr KJ, Bookin SO, Floten HS, Starr A: Connected insulin beverage reduces bloodshed in patients with diabetes ability coronary avenue bypass grafting. J Thorac Cardiovasc Surg 125:1007–1021, 2003
Finney SJ, Zekveld C, Elia A, Evans TW: Glucose ascendancy and bloodshed in alarmingly ill patients. JAMA 290:2041–2047, 2003
Golden SH, Peart-Vigilance C, Kao WHL, Brancati F: Perioperative glycemic ascendancy and the accident of communicable complications in a accomplice of adults with diabetes. Diabetes Affliction 22:1408–1414, 1999
Pomposelli JJ, Baxter JK, Babineau TJ, Pomfret EA, Driscoll DF, Forse RA, Bistrian BR: Early postoperative glucose ascendancy predicts nosocomial infection bulk in diabetic patients. J Parenter Enteral Nutr 22:77–81, 1998
Zerr KJ, Furnary AP, Grunkemeier GL: Glucose ascendancy lowers the accident of anguish infection in diabetics afterwards accessible affection operations. Ann Thorac Surg 63:356–361, 1997
Furnary AP, Zerr KJ, Grunkemeier GL, Starr A: Connected intravenous insulin beverage reduces the accident of abysmal sternal anguish infection in diabetic patients afterwards cardiac surgical procedures. Ann Thorac Surg 67:352–362, 1999
Furnary AP, Chaugle H, Zerr K, Grunkemeier GL: Postoperative hyperglycemia prolongs breadth of break in diabetic CABG patients [Abstract]. Circulation 102 (Suppl. II):556, 2000
Malmberg K, Rydén L, Efendic S, Herlitz J, Nicol P, Waldenström A, Wedel H, Welin L: Randomized balloon of insulin-glucose beverage followed by subcutaneous insulin analysis in diabetic patients with astute myocardial infarction (DIGAMI study): furnishings on bloodshed at 1 year. J Am Coll Cardiol 26:57–65, 1995
Van den Berghe G, Wouters P, Weekers F, Verwaest C, Bruyninckx F, Shetz M, Vlasselaers D, Ferdinande P, Lauwers P, Bouillon R: Accelerated insulin analysis in alarmingly ill patients. N Engl J Med 19:1359–1367, 2001
Malmberg K, for the DIGAMI Abstraction Group: -to-be randomised abstraction of accelerated insulin analysis on continued appellation adaptation afterwards astute myocardial infarction in patients with diabetes mellitus. BMJ 314:1512–1515, 1997
Malmberg K, Norhammar A, Wedel H, Ryden L: Glycometaic accompaniment at admission: important accident brand of bloodshed in commonly advised patients with diabetes mellitus and astute myocardial infarction: abiding after-effects from the daibetes and insulin-glucose beverage in astute myocardial infarction (DIGAMI) study. Circulation 99:2626–2632, 1999
Van den Berghe G, Wouters PJ, Bouillon R, Weekers F, Verwaest C, Schetz M, Vlasselaers D, Ferdinande P, Lauwers P: Aftereffect account of accelerated insulin analysis in the alarmingly ill: insulin dosage against glycemic control. Crit Affliction Med 31:359–366, 2003
Clement S, Braithwaite SS, Magee MF, Ahmann A, Smith EP, Schafer RG, Hirsh IB, American Diabetes Association Diabetes in Hospitals Writing Committee: Administration of diabetes and hyperglycemia in hospitals (Technical Review). Diabetes Affliction 27:553–597, 2004
American College of Endocrinology Task Force on Inpatient Diabetes and Metaic Control: Position account on inpatient diabetes and metaic control. Endocrine Pract In press
Hawkins JB, Jr, Morales CM, Shipp JC: Insulin claim in 242 patients with blazon II diabetes mellitus. Endocrine Pract 1:385–389, 1995
Brown G, Dodek P: Intravenous insulin nomogram improves claret glucose ascendancy in the alarmingly ill. Crit Affliction Med 29:1714–1719, 2001
Markovitz LJ, Wiechmann RJ, Harris N, Hayden V, Cooper J, Johnson G, Harelstad R, Calkins L, Braithwaite SS: Description and appraisal of a glycemic administration agreement for diabetic patients ability affection surgery. Endocrine Pract 8:10–18, 2002
Trence DL, Kelly JL, Hirsch IB: The account and administration of hyperglycemia for in-patients with cardiovascular disease: time for change. J Clin Endocrinol Metab 88:2430–2437, 2003
Bode BW, Davidson GG, Mather SR, O’Malley BC, Sainz M, Gross T, Jeng L, Miller E, Weinert S: Appraisal of the Glucose Administration Arrangement (GMS) for administering IV insulin analysis to ailing patients with diabetes (Abstract). Diabetes 48 (Suppl. 1):A120, 1999
Herbst KL, Hirsch IB: Insulin strategies for primary affliction providers. Clin Diabetes 20:11–17, 2002
DeWitt DE, Hirsch IB: Outpatient insulin analysis in blazon 1 and blazon 2 diabetes mellitus: accurate review. JAMA 289:2254–2264, 2003
Gearhart JG, Duncan JL, Replogle WH, Forbes RC, Walley EJ: Efficacy of sliding-scale insulin therapy: a allegory with -to-be regimens. Fam Pract Res J 14:313–322, 1994
Queale WS, Seidler AJ, Brancati FL: Glycemic ascendancy and sliding calibration insulin use in medical inpatients with diabetes mellitus. Arch Intern Med 157:545–552, 1997
Anderson JH, Brunelle RL, Koivisto VA, Pfützner A, Trautmann ME, Vignati L, DiMarchi R: Abridgement of postprandial hyperglycemia and abundance of hypoglycemia in IDDM patients on insulin-analog treatment. Diabetes 46:265–270, 1997
Anderson JH, Brunelle RL, Keohane P, Koivisto VA, Trautmann ME, Vignati L, DiMarchi R: Mealtime analysis with insulin analog improves postprandial hyperglycemia and hypoglycemia in patients with non-insulin-dependent diabetes mellitus. Arch Intern Med 157:1249–1255, 1997
Lalli C, Ciofetta M, Del Sindaco P, Torlone E, Pampanelli S, Compagnucci P, Cartechini MG, Bartocci L, Brunetti P, Bolli GB: Abiding accelerated analysis of blazon 1 diabetes with the short-acting insulin analog lispro in capricious aggregate with NPH insulin at mealtime. Diabetes Affliction 22:468–477, 1999
Heller S, Amiel S, Mansell P: Aftereffect of the fast-acting insulin analog lispro on the accident of nocturnal hypoglycemia during agitated insulin therapy. Diabetes Affliction 22:1607–1611, 1999
American Diabetes Association: Diabetes diet recommendations for bloom affliction institutions (Position Statement). Diabetes Affliction 27 (Suppl. 1):S55–S57, 2004
Hirsch IB, Paauw DS, Brunzell J: Inpatient administration of adults with diabetes. Diabetes Affliction 18:870-878, 1995
Henry R, Gumbiner B, Ditzler T, Wallace P, Lyon R, Glauber H: Accelerated accepted insulin analysis for blazon II diabetes: metaic furnishings during a 6-mo outpatient trial. Diabetes Affliction 16:21–31, 1993
Abraira C, Colwell J, Nuttall F, Sawin C, Nagel N, Comstock J, Emanuele N, Levin S, Henderson W, Lee H: Veterans Affairs Cooperative Abstraction on glycemic ascendancy and complications in blazon II diabetes (VA CSDM): after-effects of the achievability trial. Diabetes Affliction 18:1113–1123, 1995
Abraira C, Henderson W, Colwell J, Nuttall F, Comstock J, Emanuele N, Levin S, Sawin C, Silbert C: Acknowledgment to accelerated analysis accomplish and to glipizide dosage in aggregate with insulin in blazon 2 diabetes. Diabetes Affliction 21:574–579, 1998
Turner RC, Cull CA, Frighi V, Holman RR, for the UK -to-be Diabetes Abstraction Group: Glycemic ascendancy with diet, sulfonylurea, metformin, or insulin in patients with blazon 2 diabetes mellitus: accelerating claim for assorted therapies (UKPDS 49). JAMA 281:2005–2012, 1999
Pitts DM, Kilo KA, Pontious SL: Comestible abutment for the accommodating with diabetes. Crit Affliction Nurs Clin North Am 5:47–56, 1993
Woolfson AM: Ascendancy of claret glucose during comestible abutment in ill patients. Intens Affliction Med 7:11–14, 1980
Woolfson AM: An bigger adjustment for claret glucose ascendancy during comestible support. J Parenter Enteral Nutr 5:436–440, 1981
Park RH, Hansell DT, Davidson LE, Henderson G, Legge V, Gray GR: Administration of diabetic patients astute comestible support. Diet 8:316–320, 1992
Kerr D, Hamilton P, Cavan DA: Preventing glycaemic excursions in diabetic patients astute percutaneous endoscopic gastrostomy (PEG) agriculture afterwards a stroke. Diabet Med 19:1006–1008, 2002
Montori VM, Bistrian BR, McMahon MM: Hyperglycemia in acutely ill patients. JAMA 288:2167–2169, 2002
McMahon MM, Rizza RA: Diet abutment in ailing patients with diabetes mellitus. Mayo Clin Proc 71:587–594, 1996
Kagansky N, Levy S, Rimon E, Cojocaru L, Fridman A, Ozer Z, Knobler H: Hypoglycemia as a augur of bloodshed in ailing aged patients. Arch Intern Med 163:1825–1829, 2003
Fischer KF, Lees JA, Newman JH: Hypoglycemia in ailing patients. N Engl J Med 315:1245–1250, 1986
Knapke CM, Owens JP, Mirtallo JM: Administration of glucose abnormalities in patients accepting absolute parenteral nutrition. Clin Pharmacol 8:136–144, 1989
Shorr RI, Ray WA, Daugherty JR, Griffin MR: Accident and accident factors for austere hypoglycemia in earlier bodies application insulin or sulfonylureas. Arch Intern Med 157:1681–1686, 1997
Roman SH, Linekin PL, Stagnaro-Green A: An inpatient diabetes QI program. Jt Comm J Qual Improv 21:693–699, 1995
Raforth RJ: Standardizing sliding calibration insulin orders. Am J Med Qual 17:169–170, 2002
Quevedo SF, Sullivan E, Kington R, Rogers W: Improving diabetes affliction in the hospital application guideline-directed orders. Diabetes Spectrum 14:226–233, 2001
Achtmeyer CE, Payne TH, Anawalt BD: Computer adjustment access arrangement decreased use of sliding calibration insulin regimens. Methods Inf Med 41:277–281, 2002
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