Sliding scale

#1

Why are some people on ratios and others on sliding scales? Maybe it’s my OCD but I don’t like this sliding scale at all. Why not be more exact?

They had my dad on a fixed dose at the hospital. 15 units per meal. He bottomed out in the middle of the night after only eating jello for dinner.

The next day my mom told them that it didn’t make sense to get the same amount of insulin for a huge plate of spaghetti as he did for a bowl of jello. They then started him on the sliding scale.

My mom asked why they couldn’t just do ratios like her grandson does and was told that Type 1 and Type 2 are different and they don’t have the same treatment. What?

#2

I see sliding scale insulin dosing as an attempt to guarantee hyperglycemia and relieve the medical staff of responsibility, legal and otherwise. The writers and administrators of this policy know what they are doing and feel completely justified. They’d much rather you die of a hyperglycemic related cause than a serious hypo. Almost all medical staff are unreasonably hyper-phobic about hypoglycemia.

Short term hyperglycemia usually doesn’t have any short-term consequences but in a hospital that risk goes way up. Patients with hyperglycemia do not heal well from injury or surgery. In addition, hyperglycemia is a fertile environment for the lethal super bacteria found in hospitals. These bacteria do not respond to any known antibiotic.

I am fearful about spending any time in a hospital for this reason. I am currently attempting to craft a plan, with the help of my daughter, to mitigate the deficient typical glycemic care received in most hospitals. If I am cognitively and physically able, I will not allow hospital staff to manage my blood sugar.

The hospital’s answer to this question is nonsense. Insulin to carbohydrate ratio-based insulin dosing is a tactic appropriate for T1D and T2D.

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#3

Whatever else is going on, @Terry4 is right about hospitals. No end of horror stories about how bad they are with this stuff. They practically forced me back onto R/NPH when I was in for several days after surgery, and I was shocked. Wouldn’t stand for it, but it was a struggle.

What I was told is that the rules and regs require that if you’re in the hospital, you can’t administer your own medication, even if it’s totally unrelated to whatever you’re in there for. They HAVE to do it. And that means they have to do the carb counting and calculations and whatnot, and they’re just not prepared for that. We eventually worked out a deal where I did the calculations and dialed in the dose, but then let them give me the shot. Stupid, but better than the alternative.

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#4

Fixed-dose or sliding scale dosing only makes any kind of reasonable sense in two scenarios: The patient eats exactly the same macro-nutrients at every meal, so dosing reasonable remains constant, or the patient and his/her caregiver(s) are not capable to manage more precise dosing with any kind of accuracy – these methods reduce “error” (even though they are inherently flawed).

Hospitals SHOULD be able to manage dosing precisely; however, overworked staff tends to look for an easier “CYA” approach to handling complex tasks - like insulin dosing. They set things up to avoid hypoglycemia with can be threatening much quicker than hyperglecemia, and don’t worry about the effects of the others.

When my mother was in the hospital, they did use a sliding scale; however, the approach they used was modified. They tested her BG before and after meals, administering insulin whenever there were number above a certain threshold. What helped, however, was that they kept the carb content of meals in the hospital down, so that errors were smaller and less hazardous.

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#5

I think this is a reasonable accommodation, one that should be offered to any diabetic patient at the outset of care. The plan I prefer is if cognitively and physically able, I will do all insulin dosing and BG checking and will report to them the details of every treatment I make.

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#6

I know that some people have, in the past, enlisted the assistance of their endo to bypass those rules. You solution is a good one, though. Regardless - staying away from hospitals as much as possible is always a good thing!

#7

I thought so! I thought maybe it was ignorance when the nurse’s eyes glazed over as I was asking questions. Seeing as he is recovering from open heart surgery…I figure we need to be as exact as we can.

All of his diabetes needs are currently being controlled by cardiology. We only have one endocrinologist in town who isn’t able to see him for 3 months. He had to have bypass surgery because of what hyperglycemia has done to his heart.

Thanks for the input.

#8

Amen. Amen². Amen³.

See above.

The key word there is “should”. It’s certainly well within their intellectual capabilities; these are highly trained people, after all. But in fact, that extensive training doesn’t include much about day to day management of diabetes. Medical and nursing curricula spend only a token amount of time on the subject and most of that is devoted to memorizing rote rules, e.g., sliding scale. So while they should be easily capable of doing it correctly, most of them actually don’t know how. Consequently they rely on fixed policies instituted by administrators who know even less, and which always err on the side of hyperglycemia.

Considering the prevalence of diabetes and the frequency with which they encounter it, that’s absurd/ridiculous/[your adjective here]. But . . . there it is.

#9

I agree. When my son was diagnosed T1 the same hospital admitted they didn’t know how to treat him. Which I appreciate. They called Riley Children’s Hospital for instructions and sent him there by ambulance.

I would appreciate them being honest instead of convincing my mom that a more precise method isn’t right for my dad.

My parents are the only people other than myself who learned to fully manage my son’s T1. They keep him almost every Saturday and are completely capable of figuring food doses and managing highs and lows.

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#10

Of course. It requires some real work and effort and it’s not an exact science—but it isn’t rocket science, either. And considering what’s at stake, IMHOP there is no valid excuse for not taking the trouble to learn it.

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#11

My guess is that nurses are smart enough to do this but liability adverse lawyers will not allow it.

There is a large element of experience involved in insulin dosing. A nurse that doesn’t know you like you do can dose insulin based on ratios that you provide but doesn’t know the seat of the pants part and can be wrong. Any lawyer sees that as a nightmare

#12

To play devil’s advocate a little bit: for them to handle this requires relying on precise medical data–carb ratio, active insulin time, correction factors–that is different for everyone, and they are just not institutionally set up to grant authority to such information coming from a non-medical source. If it’s a planned hospital stay, @Thas’s suggestion that you involve your endo or pcp ahead of time would probably be the right way to head off those hard-wired reflexes. My experience was the only time I’ve been in-patient for something non-D related, and I’d been doing this stuff for better than 20 years so it never even occurred to me there might be any question about it. If I have to do it again, I’ll definitely be looping my endo into it on an official level.

ETA: My experience was back on Lantus-Novolog MDI. I think the whole business may be side-stepped if you use a pump, since that’s all pre-programmed, presumably under the guidance of a physician. But even so, getting your endo in the loop seems like a good idea.

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#13

Funny(ish) story. When my son was born, my wife had a terribly difficult delivery (i.e., 96 hours in labor and then a C-section). We were in hospital for seven days total, and I stayed the entire time. When the nursing staff realized I was diabetic, they freaked out! They started bringing me all kinds of carby “snacks” and goodies and ignoring my meal selections, because they were terrified I was going to have an insulin reaction (even though I wasn’t on insulin). I wasn’t even a patient!

Long story short, I had my Dad bring me enough low-carb food to subsist on, but I still managed to lose about 4 pounds that week ;/

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#14

This is from the American Diabetes Association 2018 Standards of Medical Care in Diabetes

08 AM

I believe the use of a sliding scale for insulin dosing is slowly movings towards prohibition. By the way that bolded “A” at the end of both bullet points indicate that the evidence that supports it is at the highest and strongest level.

Here’s the strength of evidence table.

14 PM
Screen Shot 2018-01-29 at 12.15.14 PM.png707×705 32.1 KB

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#15

Terry, what do they mean by “with the addition of nutritional insulin…?” I get basal plus bolus (that makes sense), but is that last bit trying to get at patients using whatever diet is already working for them?

#16

I stumbled over that, too. So, one can bolus to correct high BGs and separately bolus to metabolize food. They are two different types of boluses.

In this context, someone might be able to get by with basal insulin and BG corrections while another person may need basal + corrections + meal insulin.

Some patients in the hospital don’t eat for various reasons, so nutritional insulin is not needed.

#17

Aha, that actually makes sense. Basal + Bolus + Correction seems obvious… the “nutritional insulin” was throwing me for a loop, mostly just due to language.

Cheers

#18

In an ideal world, yes. But few of us get to inhabit one of those. In my case, I can’t involve my endo for the simple reason that I don’t have one. And my PCP isn’t even faintly conversant with the way I manage day-to-day, or my ratios and sensitivities, etc. He just knows that he likes the numbers I put up and so trusts me to get it right. So that suggestion works great for some and isn’t applicable for others.

My bottom line is as stated earlier: I will control my dosing—full stop. It’s not a negotiation.

As good as that sounds, it’s from the ADA, not the AMA. The hospital administrators I have known (three in all), weren’t aware of any explicit ADA guidelines, and definitely did not include any in their approved internal procedures. So it may be changing, but probably not as quickly as you hope.

#19

I had a similar experience recently when my mom was in the hospital – As soon as they found out I was diabetic (and on insulin), I had an endless supply of candy, soda, juice…

#20

When I was in hospital my daughter complained about my high carb meal, said it was not suitable for a diabetic. Turned out it was a diabetic meal (!) but they had a ‘terribly strict’ diabetic meal I could have, most diabetics did not want this level of low carb meal. I gladly signed up for low carb meals, but never actually had one as I was sent home before the next meal time. Breakfast was the real problem, cereal, toast, orange juice, coffee. And after having fasted for an operation I was so hungry.