Date______________ time________ physician/provider signature____________________________

PROTOCOL ORDER
INPATIENT GLYCEMIC CONTROL TEAM
PATIENT LABEL
119.PL01 Revised 11/02/11 Approved 07/24/09
PHARMACY THERAPEUTICS
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Page 1 of 1. Please write firmly with a ball-point pen.
Orders with  must be checked to initiate.
All other orders in effect unless crossed out.

For use in Adult patients only Glycemic goal (general medical/surgical floors): pre-prandial 100 - 140 mg/dL, maximum post-prandial <180 mg/dL and reassess the insulin regimen if blood glucose is <100 mg/dl. Glycemic goal (Critical Care): 110 - 180 mg/dL. • HbA1C (if not documented as done in last 30 days) Hold diabetic medications at the discretion of the glycemic control team If diet is advanced within 24 hours of surgery, remove dextrose from IV solution When diet advances beyond clear liquids, patient shall receive an ADA diet Utilize Critical Care Adult Insulin Infusion orders: (111.P45) in ICU/CVICU Utilize Adult Insulin Infusion orders (111.P50) on non-ICU/CVICU units Utilize Glycemic Control and Cardiac Surgery (103.P39) orders for patients who have had cardiac surgery Transition to Subcutaneous Insulin orders (111.P46) as diet advanced Utilize guidelines (see backer on 111.P45 & 111.P03) for transition to subcutaneous insulin orders or when changing between the 6 column insulin infusion and the 4 column insulin infusion. Subcutaneous Insulin orders (111.P46) with following guidelines: • If the patient is eating (has at least a full liquid tray ordered – may need to consider percent of tray eaten) If Insulin use prior to admission, then resume usual home dose + correction insulin
OR
If no prior insulin use, then basal insulin + prandial dose + correction dose based on patient’s weight
and oral intake
If the patient is NPO or on a clear liquid diet: If insulin use prior to admission, then resume usual home basal insulin dose + correction insulin
OR
If no prior use of insulin, then basal insulin + correction insulin based on patient’s weight
T ORDER SHEET
An insulin infusion shall be initiated for patients with uncontrolled blood sugars at the discretion of the glycemic control team (see order 111.P45 or 111.P50) Type I diabetics who are NPO require scheduled basal long acting insulin to avoid ketoacidosis Patients taking metformin or metformin containing medications (Glucophage®, Glucovance®, Metaglip®, Actosplus Met ®, Avandamet®, ): • BMP if no serum creatinine is available post operatively Hold medication until serum creatinine determined to be within normal limits and diet is resumed Hypoglycemia
Initiate hypo/hyperglycemic protocol (111.PL01) New Diagnosed Diabetic Patients and Uncontrolled Diabetic (HbA1C > 8%)
•
Refer to PCP or PeaceHealth Southwest Diabetes Clinic Consider changing regimen or starting therapy prior to discharge INPATIENT GLYCEMIC CONTROL TEAM
SPECIAL NUTRITIONAL SITUATIONS:
NPO
NPO status prolonged, consider an insulin infusion.
Brief NPO periods: continue detemir (Levemir®) at full dose. No prandial dose, but use scheduled correction dose
insulin. NPH: decrease total dose by 1/3 to 1/2.
Type II diabetic patients previously on oral diabetic medications and currently NPO: hold oral diabetic medications and
consider using basal insulin based on weight of patient plus correction insulin, or correction insulin alone initially. Add
scheduled insulin based on the previous days correction doses the patient received.
Perioperative
Night before surgery: full dose of detemir (Levemir®) or NPH.
Day of surgery: ½ dose of NPH in am. No prandial until regular diet resumed. Use correction dose insulin and resume
prior basal insulin dose.
As diet resumes, give aspart (Novolog®) after meals, dependent upon amount eaten in addition to correction dose
insulin: < 50% meal = 2 unit, 50 – 75 %: 4 units, > 75%: 6 units.
Continuous Enteral Feeds
Total Daily Dose (TDD) ratio should be basal 40% / prandial 60%. Prandial dose should be q
insulin.
TPN
Initiate an insulin infusion on day 1 in order to determine insulin requirements. Add 70 – 80 % of insulin used on first
day of TPN to next TPN bag added as regular insulin. Continue insulin infusion or use correction dose regular insulin q
6 hours. Add 50% of correction insulin dose used in previous 24 hours to insulin dose already in TPN for next TPN bag.
When TPN discontinues, transition to subcutaneous insulin.
SPECIAL SITUATIONS FOR ALL DIABETIC PATIENTS:
Transition from Insulin Infusion:
TDD = average hourly rate of insulin infusion over last 6 hours x 20.
Patient receiving nutrition: divide TDD basal 50% / prandial 50%
Patient receiving minimal nutrition: TDD = basal. Prandial insulin added as oral intake increases.
Give basal insulin detemir (Levemir®) or NPH 2 hours before stopping insulin infusion.
Initiating Insulin Therapy:
Total Daily Dose: 0.2 units/kg of body weight.
50% basal insulin detemir (Levemir®) qhs or NPH bid + 50% prandial (evenly divided between 3 meals)
Insulin Management:
Adjust detemir (Levemir®) dose based on fasting blood sugar. If fasting glucose within range but AC and HS blood
glucose are high, continue same detemir (Levemir®) dose and increase prandial doses.
Correction Dose Guidelines:
Insulin requirement < 40 unit/day or BMI < 25 = mild scale
Insulin requirement 40 – 80 units/day or BMI 25 - 30 = moderate scale
Insulin requirement > 80 units/day or BM > 30 = aggressive scale
Patients at Risk for Hypoglycemia:
Significant renal insufficiency, liver failure, age >65 or unsure of how much patient is eating:
Basal: 0.15 units/kg body weight
Prandial: 1 unit/10gm carbohydrate
(1800 caloric diabetic diet at SWMC has 60 gm carbohydrate at each meal)

Patients on Steroids:
TDD basal 40% / prandial 60%. Prandial dose may need to be progressively increased from breakfast to lunch to
dinner.

Source: http://www.wsha.org/files/177/Peacehealth_Protocol_Inpatient_GlycemicControlTeam.pdf