...The bolus dose is meant to prevent post-prandial hyperglycemia from developing after the meal, while the sliding scale dose is meant to treat the hyperglycemia already present going into the meal.
If the pre-dinner sugar is 260, then using the example sliding scale from the video, you would give the patient a one time additional 6 units of short-acting insulin added to whatever was scheduled for the bolus dose. If the patient consistently (i.e. more days than not) has an elevated pre-dinner sugar, a modest increase of the AM basal dose (if on NPH) would be appropriate.
Sir, please make more such videos! Need faculties like you who can spread light on how to do inpatient management. It's really very necessary. Most of us are deprived of such quality education. These are the things I yearn for. So please make more such videos! Absolutely loved this video of yours! I hope that u make many more in the future.!
There aren't guidelines per se ("official" guidelines on inpatient diabetes control are relatively vague, consistent with our lack of definitive knowledge of the subject), however references that suggest TDD of 0.3 u/kg/d for the elderly include Metabolism 62:326-36 (PMID 22999713) and Endocrinol Metab Clin North Am 41:175-201 (PMID 22575413). There are others as well, but these are among the most recent.
Thank you so much! About to start my inpatient internal medicine med school rotation and diabetes management has been a black box for me up until this point.
Hi strongdoctor Thats a fantastic video, can you make a followup video to update if anything has been changed in terms of guidelines for managing in-pt diabetes, since video was posted in 2012. Or we can still follow it? Would really appreciate it.
icemanaxs, both great questions. First, in the RABBIT 2 trial, the basal bolus regimen actually included a sliding scale. In other words, both arms of the trial received a sliding scale, with one arm receiving nothing in addition, and the other receiving the basal bolus in addition. So optimally, for a patient on a basal bolus regimen (which actually is basal/long-acting + bolus/scheduled + s.s.), the premeal insulin should be the scheduled bolus dose plus the amount according to the s.s.
I very much the clarity with which you present this topic. Some of the adjustments in insulin therapy I would have done differently, such as possibly increasing the pre-lunch insulin dose to correct pre-dinner hyperglycemia in the example cited. Also, if the basal dose should maintain blood glucose levels stable when there is no exogenous glucose entry (i.e. in the fasting state); as such I would generally maintain the same basal dose if the patient is placed NPO for a short period of time (i.e. has sufficient glycogen stores to maintain hepatic glucose output). For adults with type 1 diabetes the usual outpatient insulin dose ranges between 0.4 to 0.7 units/kg/day; I am concerned that while a 0.3 u/kg/day recommendation will definitely prevent hypoglycemia, it may not be sufficient to control hyperglycemia in many of them. For those with type 1 diabetes that do well self-managing their diabetes, I would favor letting them maintain control of their insulin regimen in the in-patient setting as long as there is no significant cognitive or physical impairment to doing so.
very thorough and practical lecture I hope that you make another lecture on the IV insulin glucose infusion protocol that is used for ICU and critically ill patients It would be of a great help
Some people will add up the units of insulin given per sliding scale over a 24 hr period, and provided there has been no hypoglycemia, will divide that sum up evenly into the basal insulin. Although this is very common, and not necessarily wrong, I find it to be a little inelegant, and this approach takes longer to establish euglycemia than one where the clinician micromanages the regimen a little more.
I suppose the terminology could potentially vary based on geography, but in my experience (which I think is consistent with general usage in literature), "correction scale" is a less commonly used synonym for "sliding scale" (even though I think correction scale is a better and more descriptive term for it).
Sir kindly make a complete video on fever and how to approach it and please include malaria and tb in the lecture bcoz it is a basic problem in asian countries
Thank you for the quick reply and for clearing up my doubts regarding inpatient diabetes treatment. All your videos have been very helpful to me, in fact i'm just going through your current lecture series on antibiotics, keep up the good work.
Dear Dr. Strong, I have a question. If the pt is on basal-bolus (glargine-aspart) plus sliding scale regimen, and his pre-dinner insulin is high, why can we not increase the pre-lunch bolus insulin?
Really nicely done. Well explained with examples. I would love that if you could add peri-operative diabetic management. There aren't much proper materials to follow.
I have a question. How can I manage the of the scaling insulin and fixexed doses, I mean if I give regular insulin with each meal, when should I measure the RBG ACC To sliding manner?
Great Video Can you kindly explain 'rule of 1500' and 'rule of 1800'? I'm pretty confused as to how these rules work and how useful they are. Thank you.
Some of these videos exist in a form that can be easily converted to pdfs (e.g. this one, antibiotics, electrolytes, cardiac auscultation, hypertension). Send me an email and let me know which one(s) you want: estrong@stanford.edu
Thanks for the lecture,great as always;but i had a few questions: 1. Didn't the RABBIT 2 trial show the superiority of the basal bolus regimen over the sliding scale regimen?, so is it really necessary to put the patient on the sliding scale when he or she is already on the basal bolus regimen? 2. If the pt is on both regimens, does that mean the pre-meal insulin dose will be the calculated bolus dose + the dose according to the sliding scale?
thank you sir..... i ve to ask u 1 more thing dat how to use mixtard 30:70 insulin in a pt taking fixed basal bolus reginen..... means how to adjust doses????
What exactly is the difference between the Aspart Correction Scale and Aspart Sliding Scale ? I've heard that the correction scale should "always" be used in patients who are taking PO, since it corrects before hyperglycemia occurs. While sliding scale treats only after hyperglycemia has already happened. Many nurses (and doctors as well) seem to be familiar only with the sliding scale.
When you say increase in AM bolus dose for patients with consistently high sugars pre-lunch, do you mean increasing the dose before breakfast or before lunch?
sorry bt i dont understand 1 thing... how to add tht correcive dose in basal bolus regimen... if around 7 pm b4 dinner pt sgar is 260... thn whether we hv to add 6 unit in pm bolus as corrective dose or we hv to adjust am basal dose.... if basal dose should be adjusted thn wht is the use of sliding scale....
Oral hypoglycemics is on my list of topics to cover, but unfortunately, I can't make any estimate right now of when I might get to it. Too many other competing suggestions...
I have a video on vasculitis available on the main channel page. Unfortunately, I don't have any on connective tissue diseases yet (e.g. SLE), but I'm planning on making one at some point. Unfortunately, I am so far behind on viewer requests that I can't estimate when exactly that might be.
▬▬► Hi friеnds. If уou or a loved оne nееds helр with drugs or alcohol aaаddiсtion CАLL ►►► *1-888-966-2616* (Toll-Free) Don't wаit until its tоo late where there is life there is hope ppреаce and blessings!
Wish the mg/dL and mmol etc is universal in the world.. Apple and Android.. hope you include other countries metrics.. Amazing Simple Marvelous Lecture.. my fear of prescribing Insulin whipped out in 22⁵³ minutes !
I appreciate the feedback. Were there specific abbreviations that you found unfamiliar? I tried to use abbreviations only if I thought they were relatively universal (e.g. DKA = diabetic ketoacidosis, AM = morning, NPO = nil per os / nothing by mouth, etc...), or else I defined them, but admittedly, I don't always know which terms are used where.
Not sure if you are being serious, but if so, I occasionally use the term "provider" to acknowledge that there are many non-physicians who watch these videos, and "provider" is a more inclusive term. I know that it annoys some docs, so more recently I've been preferring "health care professional", which seems less controversial. However, in general, it's strikes me as a small thing to get worked up about regardless - there are so many bigger issues in the modern American healthcare system for physicians to get upset about (e.g. excessive emphasis of QI and LEAN management over personalized patient care, ABIM/MOC, declining reimbursement, increased costs of education, unjust labor practices by every residency program in the country, etc...)
This video is pure gold, the example at the end connects everything up, thankyou for the amazing lecture!
Wow very good
...The bolus dose is meant to prevent post-prandial hyperglycemia from developing after the meal, while the sliding scale dose is meant to treat the hyperglycemia already present going into the meal.
If the pre-dinner sugar is 260, then using the example sliding scale from the video, you would give the patient a one time additional 6 units of short-acting insulin added to whatever was scheduled for the bolus dose. If the patient consistently (i.e. more days than not) has an elevated pre-dinner sugar, a modest increase of the AM basal dose (if on NPH) would be appropriate.
This is the best video on DM management I have ever watched. Thank you Eric for being a blessing to us.
Sir, please make more such videos! Need faculties like you who can spread light on how to do inpatient management. It's really very necessary. Most of us are deprived of such quality education. These are the things I yearn for. So please make more such videos! Absolutely loved this video of yours! I hope that u make many more in the future.!
Thank you so much! I am an IMG already in residency in Canada who has finished medical school 15 years ago! Your lectures really inspired me!
There aren't guidelines per se ("official" guidelines on inpatient diabetes control are relatively vague, consistent with our lack of definitive knowledge of the subject), however references that suggest TDD of 0.3 u/kg/d for the elderly include Metabolism 62:326-36 (PMID 22999713) and Endocrinol Metab Clin North Am 41:175-201 (PMID 22575413). There are others as well, but these are among the most recent.
Awesome video.. Don't understand how Dr. Eric presents such complex topics such lucidly
Really Amazing, thanks so much Dr.Strong.
Very clearly elucidated. Could you please point out if there are any changes seven years later?
Thank you so much! About to start my inpatient internal medicine med school rotation and diabetes management has been a black box for me up until this point.
Hi strongdoctor
Thats a fantastic video, can you make a followup video to update if anything has been changed in terms of guidelines for managing in-pt diabetes, since video was posted in 2012.
Or we can still follow it?
Would really appreciate it.
thank you Dr Strong , i seem to pick up more from second time listening . Thanks very much.
you are the best, Dr. Strong. Thank you.
icemanaxs, both great questions. First, in the RABBIT 2 trial, the basal bolus regimen actually included a sliding scale. In other words, both arms of the trial received a sliding scale, with one arm receiving nothing in addition, and the other receiving the basal bolus in addition. So optimally, for a patient on a basal bolus regimen (which actually is basal/long-acting + bolus/scheduled + s.s.), the premeal insulin should be the scheduled bolus dose plus the amount according to the s.s.
sir your lectures are simple and so easy to understand.
great effort
This was extremely well done. Thank you Dr. Strong.
Thank you for this well-explained video!
If youTube have given out Emmeys this video would have definitely won a one!!
Superb. An excellent presentation on a very common and complicated topic. 👏👏👏
I very much the clarity with which you present this topic. Some of the adjustments in insulin therapy I would have done differently, such as possibly increasing the pre-lunch insulin dose to correct pre-dinner hyperglycemia in the example cited. Also, if the basal dose should maintain blood glucose levels stable when there is no exogenous glucose entry (i.e. in the fasting state); as such I would generally maintain the same basal dose if the patient is placed NPO for a short period of time (i.e. has sufficient glycogen stores to maintain hepatic glucose output). For adults with type 1 diabetes the usual outpatient insulin dose ranges between 0.4 to 0.7 units/kg/day; I am concerned that while a 0.3 u/kg/day recommendation will definitely prevent hypoglycemia, it may not be sufficient to control hyperglycemia in many of them. For those with type 1 diabetes that do well self-managing their diabetes, I would favor letting them maintain control of their insulin regimen in the in-patient setting as long as there is no significant cognitive or physical impairment to doing so.
it was a great learning experience Dr. Strong. I hope you provide us more educational videos on different inpatient cases.
very thorough and practical lecture
I hope that you make another lecture on the IV insulin glucose infusion protocol that is used for ICU and critically ill patients
It would be of a great help
As an intern, this is an excellent presentation
Extra ordinary summary, great job, carry on
Some people will add up the units of insulin given per sliding scale over a 24 hr period, and provided there has been no hypoglycemia, will divide that sum up evenly into the basal insulin. Although this is very common, and not necessarily wrong, I find it to be a little inelegant, and this approach takes longer to establish euglycemia than one where the clinician micromanages the regimen a little more.
I never leave any comments on youtube, but thank you for your hardwork! Lots of love ❤️❤️❤️
I suppose the terminology could potentially vary based on geography, but in my experience (which I think is consistent with general usage in literature), "correction scale" is a less commonly used synonym for "sliding scale" (even though I think correction scale is a better and more descriptive term for it).
Sir kindly make a complete video on fever and how to approach it and please include malaria and tb in the lecture bcoz it is a basic problem in asian countries
Thank you for the quick reply and for clearing up my doubts regarding inpatient diabetes treatment.
All your videos have been very helpful to me, in fact i'm just going through your current lecture series on antibiotics, keep up the good work.
Dear Dr. Strong, I have a question. If the pt is on basal-bolus (glargine-aspart) plus sliding scale regimen, and his pre-dinner insulin is high, why can we not increase the pre-lunch bolus insulin?
Really nicely done. Well explained with examples. I would love that if you could add peri-operative diabetic management. There aren't much proper materials to follow.
An awesome lecture. Better than lectures in med schools
thank u so much for this informative easily explained lecture
Excellent sir.. thanks a lot👏🙏
Thank you for this amazing video on diabetes inpatient..
Sir can u plz do a video on converting inpatient regimen to outpatient regimen..
Brilliant and very useful.
Excellent video, thank you so much!
Could you expand the section on hypoglycemia more? Thank you.
I have a question.
How can I manage the of the scaling insulin and fixexed doses, I mean if I give regular insulin with each meal, when should I measure the RBG ACC To sliding manner?
Great Video
Can you kindly explain 'rule of 1500' and 'rule of 1800'? I'm pretty confused as to how these rules work and how useful they are.
Thank you.
Thank you so much Dr. Strong ❤️
Really helped alot.Thanks Dr Eric for such an amazing work.
Thank you very much for all your medical lectures, may we have slides handout ???
Some of these videos exist in a form that can be easily converted to pdfs (e.g. this one, antibiotics, electrolytes, cardiac auscultation, hypertension). Send me an email and let me know which one(s) you want: estrong@stanford.edu
Very well done.
Wonderful lecture sir how to adjust mixtard insulin becoz most of time we use mixtard insulin kindly guide us
Thanks for the lecture,great as always;but i had a few questions:
1. Didn't the RABBIT 2 trial show the superiority of the basal bolus regimen over the sliding scale regimen?, so is it really necessary to put the patient on the sliding scale when he or she is already on the basal bolus regimen?
2. If the pt is on both regimens, does that mean the pre-meal insulin dose will be the calculated bolus dose + the dose according to the sliding scale?
Nicely explained
thank you sir.....
i ve to ask u 1 more thing dat how to use mixtard 30:70 insulin in a pt taking fixed basal bolus reginen..... means how to adjust doses????
What exactly is the difference between the Aspart Correction Scale and Aspart Sliding Scale ? I've heard that the correction scale should "always" be used in patients who are taking PO, since it corrects before hyperglycemia occurs. While sliding scale treats only after hyperglycemia has already happened. Many nurses (and doctors as well) seem to be familiar only with the sliding scale.
Kindly upload diabetes outpatient management...
When you say increase in AM bolus dose for patients with consistently high sugars pre-lunch, do you mean increasing the dose before breakfast or before lunch?
The dose of scheduled preprandial short-acting insulin before breakfast.
Thank you so much for the wonderful explanations. When you have time, can you pls explain how to calculate for the sliding scale.
Thank you again Dr. Strong. Great Lecture.
most doctors failed to assist patients with dietary support for glycemic target control
sorry bt i dont understand 1 thing... how to add tht correcive dose in basal bolus regimen... if around 7 pm b4 dinner pt sgar is 260... thn whether we hv to add 6 unit in pm bolus as corrective dose or we hv to adjust am basal dose.... if basal dose should be adjusted thn wht is the use of sliding scale....
Concise and great for an intern.
thank you very much sir
please make a video about oral hypoglycemic drugs,,,,which o be choosen intially.....
Oral hypoglycemics is on my list of topics to cover, but unfortunately, I can't make any estimate right now of when I might get to it. Too many other competing suggestions...
Thank you Dr.Strong, great job!!!!!
Thank you
It is a gold video i love it
BEST EVER! Thank you doctor
Thank you 🙏🏾
which guidelines suggests a TDD of 0.3 u/kg/d for geriatrics?
Awesomely informative and perfectly explained! Thank you so much! 😊😊 14/9/2019
Good more interesting
Lots of love and respect 💜💜💜❤❤❤
rheumatology is laking !!! may we have about SLE ?
I have a video on vasculitis available on the main channel page. Unfortunately, I don't have any on connective tissue diseases yet (e.g. SLE), but I'm planning on making one at some point. Unfortunately, I am so far behind on viewer requests that I can't estimate when exactly that might be.
▬▬► Hi friеnds. If уou or a loved оne nееds helр with drugs or alcohol aaаddiсtion CАLL ►►► *1-888-966-2616* (Toll-Free) Don't wаit until its tоo late where there is life there is hope ppреаce and blessings!
Strong Medicine
So many Thans
Shoaib Mahbub
So Many Thanks
fantastic! Would help Canadian viewers if mmol /l also included.
Thanks for the feedback. I'll plan on including multiple systems of units for future videos.
Wish the mg/dL and mmol etc is universal in the world.. Apple and Android.. hope you include other countries metrics.. Amazing Simple Marvelous Lecture.. my fear of prescribing Insulin whipped out in 22⁵³ minutes !
I didn’t get the sliding scale thing?
I mean is it additional dose or you fix dose acc to this scale?
ياخ شكرا ليك كتييييييييييييييييييييييييييييييييييييييييييييييييييير (thank you vvvvvvveeeeeeeerrrrrrrrrrrrrrrryyyyyyyyyy much
Thanks!
Really helpful
Wonderful!
Thanks
Great! Thanks
thank youuuuu, much needed!
what is NPO?
It's a medical term that means "nothing by mouth" (i.e. a patient is "not allowed" to eat or drink anything). It's from the Latin, "nil per os".
@@StrongMed thank you
Tks you so much!!
Thanky so much.
Very Smart Doc, Eric! Good on ya, mate! I really like your presentation. See... I've given you thumbs up!! :)
Best
Good queen's
great video but barely audible.
Nice
I love you
Thanks for the video! Its a pity you use so many abbreviations while speaking though.. it makes the lesson less helpful for foreign viewers.
I appreciate the feedback. Were there specific abbreviations that you found unfamiliar? I tried to use abbreviations only if I thought they were relatively universal (e.g. DKA = diabetic ketoacidosis, AM = morning, NPO = nil per os / nothing by mouth, etc...), or else I defined them, but admittedly, I don't always know which terms are used where.
Had to unsubscribe. Can't stand when physicians use the AANP-promoted political term "Provider"
Not sure if you are being serious, but if so, I occasionally use the term "provider" to acknowledge that there are many non-physicians who watch these videos, and "provider" is a more inclusive term. I know that it annoys some docs, so more recently I've been preferring "health care professional", which seems less controversial. However, in general, it's strikes me as a small thing to get worked up about regardless - there are so many bigger issues in the modern American healthcare system for physicians to get upset about (e.g. excessive emphasis of QI and LEAN management over personalized patient care, ABIM/MOC, declining reimbursement, increased costs of education, unjust labor practices by every residency program in the country, etc...)
Reverse Diabetes with a “Pаnccсreаs Jumрstart” twitter.com/db7128550dfc15ed0/status/822776868130521089 Inpаtiеnt Diabetеs Manаgement
it was a great learning experience Dr. Strong. I hope you provide us more educational videos on different inpatient cases.
Thanks
Thanks