The document discusses the use of sliding-scale insulin (SSI) as monotherapy for glycemic control in hospitalized patients. It notes that while SSI is commonly used, evidence shows it is ineffective at preventing hyperglycemia and may be harmful. Studies have found basal-bolus insulin regimens are more effective at controlling blood glucose levels without increasing hypoglycemia risk. The document recommends using basal insulin plus nutritional insulin rather than SSI alone based on current guidelines.
The document discusses safety concerns with insulin use in the inpatient setting and outlines the pharmacist's role in ensuring safe use. It identifies key areas the pharmacist should understand, such as treatment goals, options, protocols, and methods to reduce medication errors. Common types of errors with insulin therapy include transcription errors, dispensing errors, and administration errors. The document provides recommendations to standardize insulin therapy and operations, such as using single insulin concentrations and protocols, educating staff, and developing a hypoglycemia treatment protocol.
The document discusses safety concerns with insulin use in the inpatient setting and outlines the pharmacist's role in minimizing errors. It identifies insulin as a high-alert medication that is commonly implicated in adverse events. Some key responsibilities for pharmacists include developing treatment protocols, formulary decisions, and educating patients prior to discharge. The document also discusses common insulin errors like transcription mistakes, dispensing errors, and administration errors that can lead to hyperglycemia or hypoglycemia. It provides recommendations for standardizing insulin orders, concentrations, protocols, and operations to reduce errors and improve safety.
This document provides information on inpatient management of hyperglycemia and glycemic control in hospitalized patients. It defines diabetes and its classifications. The prevalence and healthcare impact of diabetes are increasing dramatically. The document reviews considerations on patient admission, glycemic targets, and the risks of both hyperglycemia and hypoglycemia. It describes options for subcutaneous insulin therapy including basal, bolus, and correction components. Insulin is the preferred treatment in hospitals, while orals have limited roles.
Dr. Shahjada Selim organized a task force to develop insulin guidelines for Bangladesh considering local resource availability and circumstances. The guidelines cover insulin initiation and intensification, delivery methods, storage, and use in hospital and ICU settings. Insulin should be initiated at low doses and gradually increased based on blood glucose monitoring. In hospitals, insulin protocols aim for blood glucose between 7.8-10 mmol/L, using basal insulin with meals rather than sliding scales in general wards, and IV infusions in ICUs.
The document discusses management of hyperglycemia in the ICU setting. It provides an overview of glycemic control in critically ill patients, noting that some trials have shown improved outcomes with intensive control while others found increased mortality. It discusses strategies for successful implementation of tight glycemic control programs, including designating champions, developing protocols and order sets, providing education, and tracking metrics. Key aspects of intravenous insulin therapy and protocols are outlined, along with emphasizing the importance of preventing hypoglycemia.
Basal bolus insulin therapy resulted in improved glycemic control compared to sliding scale insulin therapy for hospitalized patients with type 2 diabetes, according to the RABBIT 2 trial. The mean daily blood glucose was 27 mg/dL lower in patients receiving basal glargine plus prandial glulisine compared to those receiving sliding scale regular insulin. Both regimens resulted in a similar rate of hypoglycemia and length of hospital stay. Basal bolus insulin provided better glycemic control and achieved target blood glucose levels under 140 mg/dL in more patients than sliding scale insulin alone.
This document provides guidelines for managing diabetes care in the hospital. The goals are to prevent hyperglycemia and hypoglycemia, promote short hospital stays, and ensure effective care transitions. It recommends using computerized order sets for glucose control and ordering an HbA1c test on admission. Target blood glucose levels are outlined for critically ill and non-critically ill patients. Insulin therapy guidelines, treating hypoglycemia, and managing special situations like steroids or enteral feeding are also covered.
The document discusses safety concerns with insulin use in the inpatient setting and outlines the pharmacist's role in ensuring safe use. It identifies key areas the pharmacist should understand, such as treatment goals, options, protocols, and methods to reduce medication errors. Common types of errors with insulin therapy include transcription errors, dispensing errors, and administration errors. The document provides recommendations to standardize insulin therapy and operations, such as using single insulin concentrations and protocols, educating staff, and developing a hypoglycemia treatment protocol.
The document discusses safety concerns with insulin use in the inpatient setting and outlines the pharmacist's role in minimizing errors. It identifies insulin as a high-alert medication that is commonly implicated in adverse events. Some key responsibilities for pharmacists include developing treatment protocols, formulary decisions, and educating patients prior to discharge. The document also discusses common insulin errors like transcription mistakes, dispensing errors, and administration errors that can lead to hyperglycemia or hypoglycemia. It provides recommendations for standardizing insulin orders, concentrations, protocols, and operations to reduce errors and improve safety.
This document provides information on inpatient management of hyperglycemia and glycemic control in hospitalized patients. It defines diabetes and its classifications. The prevalence and healthcare impact of diabetes are increasing dramatically. The document reviews considerations on patient admission, glycemic targets, and the risks of both hyperglycemia and hypoglycemia. It describes options for subcutaneous insulin therapy including basal, bolus, and correction components. Insulin is the preferred treatment in hospitals, while orals have limited roles.
Dr. Shahjada Selim organized a task force to develop insulin guidelines for Bangladesh considering local resource availability and circumstances. The guidelines cover insulin initiation and intensification, delivery methods, storage, and use in hospital and ICU settings. Insulin should be initiated at low doses and gradually increased based on blood glucose monitoring. In hospitals, insulin protocols aim for blood glucose between 7.8-10 mmol/L, using basal insulin with meals rather than sliding scales in general wards, and IV infusions in ICUs.
The document discusses management of hyperglycemia in the ICU setting. It provides an overview of glycemic control in critically ill patients, noting that some trials have shown improved outcomes with intensive control while others found increased mortality. It discusses strategies for successful implementation of tight glycemic control programs, including designating champions, developing protocols and order sets, providing education, and tracking metrics. Key aspects of intravenous insulin therapy and protocols are outlined, along with emphasizing the importance of preventing hypoglycemia.
Basal bolus insulin therapy resulted in improved glycemic control compared to sliding scale insulin therapy for hospitalized patients with type 2 diabetes, according to the RABBIT 2 trial. The mean daily blood glucose was 27 mg/dL lower in patients receiving basal glargine plus prandial glulisine compared to those receiving sliding scale regular insulin. Both regimens resulted in a similar rate of hypoglycemia and length of hospital stay. Basal bolus insulin provided better glycemic control and achieved target blood glucose levels under 140 mg/dL in more patients than sliding scale insulin alone.
This document provides guidelines for managing diabetes care in the hospital. The goals are to prevent hyperglycemia and hypoglycemia, promote short hospital stays, and ensure effective care transitions. It recommends using computerized order sets for glucose control and ordering an HbA1c test on admission. Target blood glucose levels are outlined for critically ill and non-critically ill patients. Insulin therapy guidelines, treating hypoglycemia, and managing special situations like steroids or enteral feeding are also covered.
Blood glucose monitoring helps identify patterns in fluctuations and better manage diabetes. It plays a vital role in self-management education and treatment. Regular monitoring through intermittent glucometers or continuous monitors allows for individualized control and adjustment of medications. The frequency of monitoring depends on the treatment regimen but commonly includes before meals and at bedtime. Both methods have advantages and disadvantages such as cost and reliability. Laboratory testing also evaluates long-term control through A1C levels. Maintaining stable blood glucose through effective self-monitoring and medical consultation can reduce risks of short and long-term complications.
This document provides clinical practice guidelines for inpatient management of diabetes and hyperglycemia in adults. It recommends intensive insulin therapy to maintain blood glucose at or below 110 mg/dL to reduce morbidity and mortality. It establishes a multidisciplinary team at each hospital to develop protocols focused on glycemic control. It also encourages diabetes patient self-management when appropriate and provides discharge planning guidelines.
This document discusses diabetes education in the Arab world. It begins by outlining several barriers to patient education in the region, including negative attitudes from administrators, healthcare professionals, and patients; a lack of education programs, trained personnel, and premises for education; economic barriers; and high illiteracy rates. It then recommends developing strategic plans to address all barriers. It states that any healthcare professional can provide diabetes education but that training more professionals in education is needed due to current lack of trained personnel. The document calls for action to establish national diabetes programs and start educational initiatives in Arab countries.
Revised Approach to the Inpatient Management of Diabetes 2016 June 14 2016.ppttuan nguyen
This document provides guidance on managing diabetes in the inpatient setting. It discusses targeting lower blood glucose levels to reduce mortality. It recommends using basal-bolus insulin regimens over sliding scales for better control. Basal insulin should be reduced by 20-50% for patients who are NPO. It also covers adjusting insulin for steroids and using correction doses. The key recommendations are to use basal-bolus regimens with target levels of 110-180 mg/dL for non-ICU patients and 140-200 mg/dL for ICU patients to improve outcomes.
The document discusses the perioperative management of diabetes mellitus. It provides criteria for diagnosing diabetes, discusses how surgery and diabetes affect metabolism, and outlines recommendations for preoperative evaluation and glycemic control in the perioperative period. The goals are to maintain good glycemic control, prevent complications, and shift patients back to their usual diabetes medications and diet as quickly as possible after surgery.
- Insulin therapy is eventually required for many patients with type 2 diabetes as pancreatic function continues to decline over time. Basal insulin therapy is usually initiated first to control fasting blood glucose, with the addition of prandial insulin if A1C levels remain high.
- Guidelines recommend starting basal insulin when A1C is ≥8.5% or if the total daily basal insulin dose nears 1 unit/kg/day. Prandial insulin should be added if the daily basal dose exceeds 0.5 units/kg/day or to control post-meal blood glucose excursions.
- Insulin regimens can include basal-bolus therapy with long or intermediate acting basal insulin plus rapid-acting pr
The nursing care plan addresses a patient at risk of fetal injury due to prolonged labor. Key interventions include monitoring vital signs, fetal heart rate, and labor progress closely. Oxytocin is prescribed to increase contraction strength if needed. The plan aims to progress labor safely without signs of fetal distress through nursing support and medical treatment.
This document provides treatment guidelines for diabetes mellitus. It discusses the types of diabetes, symptoms, complications, goals of treatment, and treatment options. Treatment involves lifestyle changes like diet and exercise. Pharmacological treatment starts with metformin for type 2 diabetes and insulin for type 1 diabetes. Insulin therapy is initiated at 0.4-1.0 units/kg/day for type 1 diabetes. Additional agents may be added if blood sugar levels remain uncontrolled. The goal of treatment is to achieve a hemoglobin A1c level below 7% through lifestyle management and medication adjustments.
International journal-of-diabetes-and-clinical-research-ijdcr-5-083Marwan Assakir
This document reviews different insulin initiation regimens for patients with type 2 diabetes. It discusses starting patients on basal insulin like NPH or long-acting analogues like glargine or detemir, administered once or twice daily. Insulin can be initiated at 10 units/day or 0.1-0.2 units/kg/day and titrated up every 1-2 weeks based on fasting plasma glucose levels. Premixed insulins are also reviewed for initiation, starting at 10 units/once daily or 0.3-0.5 units/kg/day. A basal-bolus regimen adding rapid-acting insulin before meals is discussed for intensifying treatment if targets are not met with basal insulin alone
This document discusses the use of insulin in managing hyperglycemia during pregnancy. It begins by defining failure to manage blood glucose levels through medical nutrition therapy alone as an indication for insulin therapy. Guidelines recommend starting insulin if targets are not met within 2 weeks of nutrition management or if safety and growth parameters like weight gain are not being met. The document reviews types of insulin including human and analog varieties, providing evidence that various insulins can safely achieve targets when used as part of a basal-bolus regimen individualized to the patient's condition and blood glucose levels. The overall goal of insulin therapy in pregnancy is to maintain blood glucose within defined targets to support fetal and maternal health.
This case discusses a 62-year-old woman with type 1 diabetes and hypoglycemia unawareness who underwent professional continuous glucose monitoring on two occasions. The initial monitoring revealed no overnight hypoglycemia but significant hyperglycemia throughout the day. Therapy was adjusted based on these results. Follow-up monitoring showed fewer post-meal excursions but continued hyperglycemia after high-fat dinners. Examination of the patient's diary revealed she had been inaccurately recording her blood glucose levels. Professional CGM was useful in identifying patterns of hyperglycemia and informing changes to the patient's insulin regimen and dietary advice.
Intensification Options after basal Insulin RevisitedUsama Ragab
Intensification Options revisited
By Dr. Usama Ragab Youssif
Add an OAD
Add a short-acting insulin at mealtime
Switch to premixed insulins
Novel insulin combinations
Basal insulin/GLP-1 RA combinations
This document summarizes a clinical presentation on the basal insulin degludec and barriers to achieving optimal glycemic control. It discusses that hypoglycemia and glucose variability are barriers, and that current basal insulins have limitations like needing to be dosed at the same time daily and intra-patient variability. Insulin degludec was developed to address these barriers with properties like an ultra-long half-life of over 25 hours, very low day-to-day variability in glucose-lowering effect, and the ability to reach steady-state in 3 days. Large clinical trials showed degludec was as effective as glargine at reducing A1c and had a similar or lower risk of hyp
A survey of 855 healthcare providers found gaps in their understanding of how hypoglycemia impacts patient behavior and physician treatment approaches compared to published findings from the GAPP study. Only 30% of providers correctly identified how often patients miss insulin doses, and most overestimated this frequency. While fear of hypoglycemia was the top reason for non-adherence in GAPP, providers here most often cited other reasons. Providers also believed physicians were less aggressive in treatment to avoid hypoglycemia less often than reported in GAPP. The results present opportunities for education by field medical teams to increase provider awareness of these challenges patients face.
Diabetes mellitus and diabetes insipidusShweta Sharma
This document provides information on diabetes mellitus and diabetes insipidus. It discusses the types, causes, signs and symptoms, diagnostic evaluation, and management of both conditions. Diabetes mellitus is characterized by high blood glucose levels due to insufficient insulin production or action. Diabetes insipidus is caused by a deficiency of antidiuretic hormone, resulting in excessive urine production and thirst. The document outlines the different etiologies, pathophysiology, clinical presentation, and treatment approaches for diabetes mellitus and diabetes insipidus.
This document describes a study examining the effects of a low-carbohydrate diet (70-90g per day) in 22 patients with type 1 diabetes who had poor blood glucose control. The results showed that after 3 and 12 months on the diet, the patients had significantly fewer episodes of hypoglycemia per week, lower HbA1c levels, and lower daily insulin requirements. Triglyceride levels also decreased significantly. The diet was found to be an effective long-term alternative for improving glycemic control in type 1 diabetes.
TEST BANK For An Introduction to Brain and Behavior, 7th Edition by Bryan Kol...rightmanforbloodline
TEST BANK For An Introduction to Brain and Behavior, 7th Edition by Bryan Kolb, Ian Q. Whishaw, Verified Chapters 1 - 16, Complete Newest Versio
TEST BANK For An Introduction to Brain and Behavior, 7th Edition by Bryan Kolb, Ian Q. Whishaw, Verified Chapters 1 - 16, Complete Newest Version
TEST BANK For An Introduction to Brain and Behavior, 7th Edition by Bryan Kolb, Ian Q. Whishaw, Verified Chapters 1 - 16, Complete Newest Version
Blood glucose monitoring helps identify patterns in fluctuations and better manage diabetes. It plays a vital role in self-management education and treatment. Regular monitoring through intermittent glucometers or continuous monitors allows for individualized control and adjustment of medications. The frequency of monitoring depends on the treatment regimen but commonly includes before meals and at bedtime. Both methods have advantages and disadvantages such as cost and reliability. Laboratory testing also evaluates long-term control through A1C levels. Maintaining stable blood glucose through effective self-monitoring and medical consultation can reduce risks of short and long-term complications.
This document provides clinical practice guidelines for inpatient management of diabetes and hyperglycemia in adults. It recommends intensive insulin therapy to maintain blood glucose at or below 110 mg/dL to reduce morbidity and mortality. It establishes a multidisciplinary team at each hospital to develop protocols focused on glycemic control. It also encourages diabetes patient self-management when appropriate and provides discharge planning guidelines.
This document discusses diabetes education in the Arab world. It begins by outlining several barriers to patient education in the region, including negative attitudes from administrators, healthcare professionals, and patients; a lack of education programs, trained personnel, and premises for education; economic barriers; and high illiteracy rates. It then recommends developing strategic plans to address all barriers. It states that any healthcare professional can provide diabetes education but that training more professionals in education is needed due to current lack of trained personnel. The document calls for action to establish national diabetes programs and start educational initiatives in Arab countries.
Revised Approach to the Inpatient Management of Diabetes 2016 June 14 2016.ppttuan nguyen
This document provides guidance on managing diabetes in the inpatient setting. It discusses targeting lower blood glucose levels to reduce mortality. It recommends using basal-bolus insulin regimens over sliding scales for better control. Basal insulin should be reduced by 20-50% for patients who are NPO. It also covers adjusting insulin for steroids and using correction doses. The key recommendations are to use basal-bolus regimens with target levels of 110-180 mg/dL for non-ICU patients and 140-200 mg/dL for ICU patients to improve outcomes.
The document discusses the perioperative management of diabetes mellitus. It provides criteria for diagnosing diabetes, discusses how surgery and diabetes affect metabolism, and outlines recommendations for preoperative evaluation and glycemic control in the perioperative period. The goals are to maintain good glycemic control, prevent complications, and shift patients back to their usual diabetes medications and diet as quickly as possible after surgery.
- Insulin therapy is eventually required for many patients with type 2 diabetes as pancreatic function continues to decline over time. Basal insulin therapy is usually initiated first to control fasting blood glucose, with the addition of prandial insulin if A1C levels remain high.
- Guidelines recommend starting basal insulin when A1C is ≥8.5% or if the total daily basal insulin dose nears 1 unit/kg/day. Prandial insulin should be added if the daily basal dose exceeds 0.5 units/kg/day or to control post-meal blood glucose excursions.
- Insulin regimens can include basal-bolus therapy with long or intermediate acting basal insulin plus rapid-acting pr
The nursing care plan addresses a patient at risk of fetal injury due to prolonged labor. Key interventions include monitoring vital signs, fetal heart rate, and labor progress closely. Oxytocin is prescribed to increase contraction strength if needed. The plan aims to progress labor safely without signs of fetal distress through nursing support and medical treatment.
This document provides treatment guidelines for diabetes mellitus. It discusses the types of diabetes, symptoms, complications, goals of treatment, and treatment options. Treatment involves lifestyle changes like diet and exercise. Pharmacological treatment starts with metformin for type 2 diabetes and insulin for type 1 diabetes. Insulin therapy is initiated at 0.4-1.0 units/kg/day for type 1 diabetes. Additional agents may be added if blood sugar levels remain uncontrolled. The goal of treatment is to achieve a hemoglobin A1c level below 7% through lifestyle management and medication adjustments.
International journal-of-diabetes-and-clinical-research-ijdcr-5-083Marwan Assakir
This document reviews different insulin initiation regimens for patients with type 2 diabetes. It discusses starting patients on basal insulin like NPH or long-acting analogues like glargine or detemir, administered once or twice daily. Insulin can be initiated at 10 units/day or 0.1-0.2 units/kg/day and titrated up every 1-2 weeks based on fasting plasma glucose levels. Premixed insulins are also reviewed for initiation, starting at 10 units/once daily or 0.3-0.5 units/kg/day. A basal-bolus regimen adding rapid-acting insulin before meals is discussed for intensifying treatment if targets are not met with basal insulin alone
This document discusses the use of insulin in managing hyperglycemia during pregnancy. It begins by defining failure to manage blood glucose levels through medical nutrition therapy alone as an indication for insulin therapy. Guidelines recommend starting insulin if targets are not met within 2 weeks of nutrition management or if safety and growth parameters like weight gain are not being met. The document reviews types of insulin including human and analog varieties, providing evidence that various insulins can safely achieve targets when used as part of a basal-bolus regimen individualized to the patient's condition and blood glucose levels. The overall goal of insulin therapy in pregnancy is to maintain blood glucose within defined targets to support fetal and maternal health.
This case discusses a 62-year-old woman with type 1 diabetes and hypoglycemia unawareness who underwent professional continuous glucose monitoring on two occasions. The initial monitoring revealed no overnight hypoglycemia but significant hyperglycemia throughout the day. Therapy was adjusted based on these results. Follow-up monitoring showed fewer post-meal excursions but continued hyperglycemia after high-fat dinners. Examination of the patient's diary revealed she had been inaccurately recording her blood glucose levels. Professional CGM was useful in identifying patterns of hyperglycemia and informing changes to the patient's insulin regimen and dietary advice.
Intensification Options after basal Insulin RevisitedUsama Ragab
Intensification Options revisited
By Dr. Usama Ragab Youssif
Add an OAD
Add a short-acting insulin at mealtime
Switch to premixed insulins
Novel insulin combinations
Basal insulin/GLP-1 RA combinations
This document summarizes a clinical presentation on the basal insulin degludec and barriers to achieving optimal glycemic control. It discusses that hypoglycemia and glucose variability are barriers, and that current basal insulins have limitations like needing to be dosed at the same time daily and intra-patient variability. Insulin degludec was developed to address these barriers with properties like an ultra-long half-life of over 25 hours, very low day-to-day variability in glucose-lowering effect, and the ability to reach steady-state in 3 days. Large clinical trials showed degludec was as effective as glargine at reducing A1c and had a similar or lower risk of hyp
A survey of 855 healthcare providers found gaps in their understanding of how hypoglycemia impacts patient behavior and physician treatment approaches compared to published findings from the GAPP study. Only 30% of providers correctly identified how often patients miss insulin doses, and most overestimated this frequency. While fear of hypoglycemia was the top reason for non-adherence in GAPP, providers here most often cited other reasons. Providers also believed physicians were less aggressive in treatment to avoid hypoglycemia less often than reported in GAPP. The results present opportunities for education by field medical teams to increase provider awareness of these challenges patients face.
Diabetes mellitus and diabetes insipidusShweta Sharma
This document provides information on diabetes mellitus and diabetes insipidus. It discusses the types, causes, signs and symptoms, diagnostic evaluation, and management of both conditions. Diabetes mellitus is characterized by high blood glucose levels due to insufficient insulin production or action. Diabetes insipidus is caused by a deficiency of antidiuretic hormone, resulting in excessive urine production and thirst. The document outlines the different etiologies, pathophysiology, clinical presentation, and treatment approaches for diabetes mellitus and diabetes insipidus.
This document describes a study examining the effects of a low-carbohydrate diet (70-90g per day) in 22 patients with type 1 diabetes who had poor blood glucose control. The results showed that after 3 and 12 months on the diet, the patients had significantly fewer episodes of hypoglycemia per week, lower HbA1c levels, and lower daily insulin requirements. Triglyceride levels also decreased significantly. The diet was found to be an effective long-term alternative for improving glycemic control in type 1 diabetes.
TEST BANK For An Introduction to Brain and Behavior, 7th Edition by Bryan Kol...rightmanforbloodline
TEST BANK For An Introduction to Brain and Behavior, 7th Edition by Bryan Kolb, Ian Q. Whishaw, Verified Chapters 1 - 16, Complete Newest Versio
TEST BANK For An Introduction to Brain and Behavior, 7th Edition by Bryan Kolb, Ian Q. Whishaw, Verified Chapters 1 - 16, Complete Newest Version
TEST BANK For An Introduction to Brain and Behavior, 7th Edition by Bryan Kolb, Ian Q. Whishaw, Verified Chapters 1 - 16, Complete Newest Version
TEST BANK For Basic and Clinical Pharmacology, 14th Edition by Bertram G. Kat...rightmanforbloodline
TEST BANK For Basic and Clinical Pharmacology, 14th Edition by Bertram G. Katzung, Verified Chapters 1 - 66, Complete Newest Version.
TEST BANK For Basic and Clinical Pharmacology, 14th Edition by Bertram G. Katzung, Verified Chapters 1 - 66, Complete Newest Version.
TEST BANK For Basic and Clinical Pharmacology, 14th Edition by Bertram G. Katzung, Verified Chapters 1 - 66, Complete Newest Version.
TEST BANK For Basic and Clinical Pharmacology, 14th Edition by Bertram G. Katzung, Verified Chapters 1 - 66, Complete Newest Version.
These lecture slides, by Dr Sidra Arshad, offer a quick overview of the physiological basis of a normal electrocardiogram.
Learning objectives:
1. Define an electrocardiogram (ECG) and electrocardiography
2. Describe how dipoles generated by the heart produce the waveforms of the ECG
3. Describe the components of a normal electrocardiogram of a typical bipolar lead (limb II)
4. Differentiate between intervals and segments
5. Enlist some common indications for obtaining an ECG
6. Describe the flow of current around the heart during the cardiac cycle
7. Discuss the placement and polarity of the leads of electrocardiograph
8. Describe the normal electrocardiograms recorded from the limb leads and explain the physiological basis of the different records that are obtained
9. Define mean electrical vector (axis) of the heart and give the normal range
10. Define the mean QRS vector
11. Describe the axes of leads (hexagonal reference system)
12. Comprehend the vectorial analysis of the normal ECG
13. Determine the mean electrical axis of the ventricular QRS and appreciate the mean axis deviation
14. Explain the concepts of current of injury, J point, and their significance
Study Resources:
1. Chapter 11, Guyton and Hall Textbook of Medical Physiology, 14th edition
2. Chapter 9, Human Physiology - From Cells to Systems, Lauralee Sherwood, 9th edition
3. Chapter 29, Ganong’s Review of Medical Physiology, 26th edition
4. Electrocardiogram, StatPearls - https://www.ncbi.nlm.nih.gov/books/NBK549803/
5. ECG in Medical Practice by ABM Abdullah, 4th edition
6. Chapter 3, Cardiology Explained, https://www.ncbi.nlm.nih.gov/books/NBK2214/
7. ECG Basics, http://www.nataliescasebook.com/tag/e-c-g-basics
8 Surprising Reasons To Meditate 40 Minutes A Day That Can Change Your Life.pptxHolistified Wellness
We’re talking about Vedic Meditation, a form of meditation that has been around for at least 5,000 years. Back then, the people who lived in the Indus Valley, now known as India and Pakistan, practised meditation as a fundamental part of daily life. This knowledge that has given us yoga and Ayurveda, was known as Veda, hence the name Vedic. And though there are some written records, the practice has been passed down verbally from generation to generation.
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Muktapishti is a traditional Ayurvedic preparation made from Shoditha Mukta (Purified Pearl), is believed to help regulate thyroid function and reduce symptoms of hyperthyroidism due to its cooling and balancing properties. Clinical evidence on its efficacy remains limited, necessitating further research to validate its therapeutic benefits.
Here is the updated list of Top Best Ayurvedic medicine for Gas and Indigestion and those are Gas-O-Go Syp for Dyspepsia | Lavizyme Syrup for Acidity | Yumzyme Hepatoprotective Capsules etc
1. @JHospMedicine | #TWDFNR
Choosing Wisely®:
Things We Do
for No Reason™
Sliding-Scale Insulin as Monotherapy for
Glycemic Control in Hospitalized Patients
Based on Ambrus DB, O’Connor MJ. Sliding-Scale Insulin as
Monotherapy for Glycemic Control in Hospitalized Patients. J. Hosp.
Med. 2019 February;14(2):114-116.
2. @JHospMedicine | #TWDFNR
Clinical Scenario
• 60-year-old man presented to the emergency department with one
week of myalgias and fever up to 103.5°F (39.7°C). He had no
localizing symptoms, and physical examination was unrevealing,
except for a small scab from a tick bite sustained two weeks prior
to symptom onset.
• Past Medical History: obesity and type II diabetes, managed with
metformin 1,000 mg BID
• On arrival, his blood sugar level was 275 mg/dL.
• The admitting resident decides to hold the patient’s metformin, but
wonders whether to replace it with insulin per a sliding scale or a
basal/bolus regimen
3. @JHospMedicine | #TWDFNR
Background
• The basic premise of sliding-scale insulin (SSI) is to correct
hyperglycemia through the frequent administration of short-acting
insulin dosed according to a patient’s blood glucose level with the
help of a prespecified rubric.
• When blood glucose levels are low, patients receive little or no
insulin, and when blood glucose levels are high, higher doses are
given.
• This approach to inpatient blood glucose management was first
popularized by Joslin in 19341
4. @JHospMedicine | #TWDFNR
Why You Might Think This is Necessary
• Use of SSI is common
• 2007 survey of 44 hospitals showed that 43% of all noncritically ill patients with hyperglycemia were
treated with SSI alone.2
• A single-center study showed that 30% of clinicians continued to use SSI as monotherapy even after
the implementation of order sets designed to limit this practice.3
• Guidelines suggest that certain patients should be screened periodically for hyperglycemia (blood
glucose persistently >180 mg/dL) and that hyperglycemia should be treated.4
• By pairing finger-stick glucose monitoring with SSI, the diagnosis and treatment—although not the
prevention—of hyperglycemia can be accomplished simultaneously.
• Avoiding hypoglycemia
• SSI as monotherapy is sometimes viewed as a cautious approach as insulin is administered only if
the blood sugar level is high.
• Convenience
• Hospitals may have ready-made order sets for SSI that are easier to prescribe than patient-specific
regimens
• In one single-center survey, physicians and staff were found to favor convenience over perceived
efficacy when asked about their attitudes toward inpatient glycemic control.5
5. @JHospMedicine | #TWDFNR
Why This Is Unnecessary and Potentially Harmful
• SSI does not prevent hyperglycemia6
• Adding SSI to oral antihyperglycemic medications resulted in no difference in rates of hyperglycemia.7
• 84% of administered SSI doses failed to correct hyperglycemia.8
• Adding basal insulin is more effective and does not increase the risk of hypoglycemia
• Randomized trial of SSI vs basal-bolus insulin in diabetic long-term care residents (already on SSI at baseline) found that the
basal-bolus group experienced lower average blood glucose levels without an increase in adverse glycemic events.9
• RABBIT 2 multicenter trial (2007) - randomized hospitalized, insulin-naïve diabetics to weight-based regimen of basal-
prandial insulin or SSI only.10
Rates of hypoglycemia and length of stay did not differ between the groups
66% of patients receiving basal-prandial insulin achieved glycemic control target vs 38% of patients on SSI only
SSI group required more total insulin.
• RABBIT 2 – surgery (2011) – randomized diabetic patients admitted for elective surgery to SSI or weight-based, basal-bolus
strategy11
Basal-bolus strategy was similarly effective, without causing severe hypoglycemia, even for patients who could not
maintain consistent oral alimentation.
On post-hoc analysis, basal-bolus insulin was associated with fewer surgical complications and produced a cost
savings of $751 per day.12
• SSI alone may be harmful
• For type 2 diabetics and nondiabetics, hyperglycemia is a marker for adverse outcomes among hospitalized patients13
SSI monotherapy is associated with a three-fold higher risk of hyperglycemia compared with the use of a sliding
scale plus other forms of insulin.14
• SSI is associated with a significantly increased length of stay compared with proactive insulin dosing.15
6. @JHospMedicine | #TWDFNR
When you might consider using SSI as monotherapy
• The use of SSI as monotherapy as a short-term approach has not
been well studied.
• “Dose finding” – withhold basal insulin for the first 24 hours in
insulin-naïve patients at risk for adverse glycemic events and use
the amount of SSI received in this time to inform subsequent
insulin dosing
• Consider if the medication reconciliation or other key components of
the history are in doubt, or if there are risk factors for hypoglycemia
such as a history of bariatric surgery.
• This method has not been validated in the literature.
• If a patient without type 1 diabetes is felt to be at high risk for a
severe hypoglycemic event, it may be prudent to withhold long-
acting insulin. However, in that situation, adding SSI to finger-stick
monitoring is unlikely to be beneficial.
7. @JHospMedicine | #TWDFNR
What You Should Do Instead
• Current guidelines recommend against the prolonged use of SSI as monotherapy and
support the use of basal plus correctional insulin with the addition of nutritional insulin
for patients with consistent oral intake16,17
• How to determine a basal/bolus insulin regimen4
• Calculate a weight-based total daily dose of insulin
RABBIT 2 protocol for known type 2 diabetics used total daily dose of 0.4 units/kg
for patients presenting with blood sugar levels ≤200 mg/dL and 0.5 units/kg for
those with higher initial glucose levels
• Give half of the total daily dose as basal insulin
• Give the remainder with meals along with correctional insulin as needed to account for
premeal hyperglycemia.
• Caution with insulin dosing may be required in patients aged >70 years, in those with
impaired renal function, and in situations in which steroid doses are fluctuating.
• The Society of Hospital Medicine has formulated an online insulin order
implementation guideline, eQUIPS, that can be a helpful resource18
8. @JHospMedicine | #TWDFNR
Recommendations
• Instead of using SSI monotherapy for hospitalized patients who
require insulin, add basal and prandial insulin, using a weight-
based approach for insulin-naive patients.
• Engage with leadership at your center to learn how inpatient
hyperglycemia protocols and blood sugar management teams can
help provide evidence-based and individualized treatment plans for
your patients.
• If no infrastructure exists at your center, the Society of Hospital
Medicine offers training and guidance through its eQUIPS inpatient
hyperglycemia management program.
9. @JHospMedicine | #TWDFNR
Conclusions
• Using SSI as monotherapy for hyperglycemia is a common
practice, but it is ineffective and possibly dangerous
• Continued efforts must be made to address the gap between
guidelines and suboptimal practice patterns locally and nationally.
• The patient should be started on a combination of basal and
prandial insulin as determined by his weight and current renal
function as opposed to monotherapy with SSI.
Case Scenario
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References
Based on Ambrus DB, O’Connor MJ. Sliding-Scale Insulin as Monotherapy for Glycemic Control in Hospitalized Patients. J. Hosp. Med. 2019 February;14(2):114-116
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11. @JHospMedicine | #TWDFNR
Citation
To cite this teaching tool:
Lu EP, Ambrus DB, O’Connor MJ. Sliding-Scale Insulin as Monotherapy for Glycemic
Control in Hospitalized Patients. Tool published at