Inpatient Insulin Management

Critical Care Setting

Continuous intravenous insulin infusion is the most effective method for achieving glycemic targets in critically ill patients 1
Infusions should be administered using validated written or computerized protocols that allow for predefined adjustments based on glycemic fluctuations 1, 2
For diabetic ketoacidosis (DKA) and hyperglycemic hyperosmolar state (HHS), continuous intravenous insulin infusion is recommended 1

Basal insulin or a basal plus correction insulin regimen is preferred for patients with poor or no oral intake 3, 1, 2
NPH insulin administered twice or three times daily (every 8 or 12 h) is recommended for patients on enteral nutrition 4
Correctional insulin should be administered subcutaneously every 6 h using human regular insulin or every 4 h using rapid-acting insulin 4
An insulin regimen with basal, prandial, and correction components is preferred for patients with adequate nutritional intake 3, 1, 2
Insulin injections should align with meals for patients who are eating 3
Point-of-care glucose testing should be performed immediately before meals 3
If oral intake is poor, administer prandial insulin immediately after the patient eats, with the dose adjusted to the amount ingested 3, 2

An insulin regimen with basal and correction components is necessary for all hospitalized patients with type 1 diabetes, even when NPO 3, 1
Basal insulin should never be held for patients with type 1 diabetes, especially during care transitions 1
For patients receiving enteral feedings, calculate insulin for nutritional component as 1 unit per 10-15g carbohydrate in the formula 4
For continuous feedings, consider NPH insulin every 8-12 hours 4
For bolus feedings, give approximately 1 unit of regular human insulin or rapid-acting insulin per 10-15g carbohydrate before each feeding 4

Prolonged use of sliding scale insulin alone is strongly discouraged as it results in poorer glycemic control and increased complications 3, 1, 2
Premixed insulin formulations are not routinely recommended for in-hospital use due to increased risk of hypoglycemia 3
Monitor for hypoglycemia, especially during overnight hours (midnight to 6:00 A.M.) when risk is highest 4
Implement a standardized hospital-wide hypoglycemia prevention and management protocol 3, 1
Ensure meal delivery and nutritional insulin coverage are coordinated to prevent hyper/hypoglycemic events 4

SGLT2 inhibitors should be discontinued 3-4 days before surgery and avoided during hospitalization 4, 2
Metformin should be withheld on the day of surgery 4