West Virginia University School of Medicine, Eastern Division, Harpers Ferry, WV, USA.
Am Fam Physician. 2010 May 1;81(9):1130-5.
Glycemic control in hospitalized patients who are not in intensive care remains unsatisfactory. Despite persistent expert recommendations urging its abandonment, the use of sliding-scale insulin remains pervasive in U.S. hospitals. Evidence for the effectiveness of sliding-scale insulin is lacking after more than 40 years of use. New physiologic subcutaneous insulin protocols use basal, nutritional, and correctional insulin. The initial total daily dose of subcutaneous insulin is calculated using a factor of 0.3 to 0.6 units per kg body weight, with one half given as long-acting insulin (the basal insulin dose), and the other one half divided daily over three meals as short-acting insulin doses (nutritional insulin doses). A correctional insulin dose provides a final insulin adjustment based on the preprandial glucose value. This correctional dose resembles a sliding scale, but is only a small fine-tuning of therapy, as opposed to traditional sliding-scale insulin alone. Insulin sensitivity, nutritional intake, and total daily dosing review can alter the physiologic insulin-dosing schedule. Prospective trials have demonstrated reductions in hyperglycemic measurements, hypoglycemia, and adjusted hospital length of stay when physiologic subcutaneous insulin protocols are used. Transitions in care require special considerations and attention to glycemic control medications. Changing the sliding-scale insulin culture requires a multidisciplinary effort to improve patient safety and outcomes.
住院患者的血糖控制在非重症监护病房仍不尽如人意。尽管专家一直建议停止使用，但美国医院仍广泛使用胰岛素调整剂量方案。经过 40 多年的使用，目前仍缺乏有关胰岛素调整剂量方案有效性的证据。新的生理皮下胰岛素方案使用基础、营养和校正胰岛素。使用 0.3 至 0.6 单位/公斤体重的系数计算初始每日总剂量皮下胰岛素，其中一半作为长效胰岛素（基础胰岛素剂量），另一半每天分为三餐作为短效胰岛素剂量（营养胰岛素剂量）。校正胰岛素剂量根据餐前血糖值提供最终胰岛素调整。这种校正剂量类似于调整剂量方案，但只是对治疗进行微调，而不是传统的单独使用胰岛素调整剂量方案。胰岛素敏感性、营养摄入和每日总剂量的回顾可以改变生理胰岛素给药方案。前瞻性试验表明，使用生理皮下胰岛素方案可降低高血糖测量值、低血糖和调整后的住院时间。护理过渡需要特别考虑和注意血糖控制药物。改变胰岛素调整剂量方案文化需要多学科努力，以提高患者安全性和治疗效果。
