When to intubate in GCS?

GCS ≤ 8 requires intubation for airway protection. The patient cannot protect their own airway at this level of consciousness. Motor score is the most prognostically important component.

What is the best initial fluid for sepsis resuscitation?

Lactated Ringer's (LR) is the preferred resuscitation fluid. The SMART trial (2018) showed balanced crystalloids reduced death, new renal failure, and persistent renal dysfunction compared to normal saline.

When to start vasopressors in septic shock?

Start norepinephrine (first-line vasopressor) if MAP remains < 65 mmHg after initial 30 mL/kg crystalloid resuscitation, or earlier if patient is profoundly hypotensive. Do not delay pressors to complete full fluid resuscitation.

Why can serum uric acid be normal during acute gout?

During acute inflammation, IL-6 increases renal urate excretion and redistributes urate from plasma to tissues. Up to 40% of acute gout flares have normal serum uric acid. Joint aspiration with polarized microscopy is needed for definitive diagnosis.

How do you distinguish lupus flare from infection in SLE?

Key clues: CRP is low/normal in flare but elevated in infection. Complement (C3/C4) drops in flare but is normal/elevated in infection. Procalcitonin is elevated in bacterial infection but normal in flare. Anti-dsDNA rises in flare, stable in infection.

What is the difference between DKA and HHS?

DKA features acidosis (pH 600), hyperosmolality (> 320), and minimal ketosis -typically in Type 2 DM. DKA requires insulin drip; HHS requires aggressive fluid resuscitation first.

When to give tPA in acute ischemic stroke?

IV alteplase (tPA) can be given within 4.5 hours of last known well time in eligible patients. CT head must rule out hemorrhage first. For large vessel occlusion, mechanical thrombectomy can be performed up to 24 hours with favorable imaging.

What antibiotics for community-acquired pneumonia?

Inpatient non-ICU: ceftriaxone + azithromycin. ICU: ceftriaxone + azithromycin (add vancomycin if MRSA risk). Outpatient healthy: amoxicillin. Outpatient with comorbidities: augmentin + azithromycin or respiratory fluoroquinolone. Duration: 5 days if clinically stable for 48 hours.

How to interpret iron studies?

Iron deficiency: low ferritin (< 30), high TIBC, low iron, low transferrin saturation (< 20%). Anemia of chronic disease: normal/high ferritin (acute phase reactant), low TIBC, low iron. A ferritin of 50-100 in an inflamed patient may still represent iron deficiency.

What is the correction rate for hyponatremia?

Correct sodium no more than 8 mEq/L in 24 hours to avoid osmotic demyelination syndrome (ODS). For symptomatic severe hyponatremia with seizures, give 3% hypertonic saline 100-150 mL bolus over 10-20 minutes. If overcorrected, use D5W + DDAVP rescue protocol.

When to start antibiotics in meningitis?

Within 30-60 minutes. Do NOT delay antibiotics for LP or CT. Draw blood cultures, start empiric antibiotics (vancomycin + ceftriaxone ± ampicillin if > 50 or immunocompromised), then perform LP when possible. Dexamethasone should be given before or with the first antibiotic dose.

DOACs vs warfarin in antiphospholipid syndrome?

DOACs are contraindicated in APS. The TRAPS trial (2018) showed rivaroxaban was inferior to warfarin with more thrombotic events in triple-positive APS patients. Warfarin with INR target 2-3 is the standard for APS, indefinitely.

How to manage scleroderma renal crisis?

ACE inhibitors (captopril) are life-saving -start immediately and titrate aggressively. Do NOT hold for rising creatinine. Steroids > 15 mg prednisone per day precipitate scleroderma renal crisis. ARBs are NOT a substitute -evidence is only for ACEi.

What are the 4 pillars of heart failure treatment?

Guideline-directed medical therapy (GDMT) for HFrEF: (1) ARNI or ACEi/ARB, (2) beta-blocker (carvedilol, metoprolol succinate, or bisoprolol), (3) MRA (spironolactone or eplerenone), (4) SGLT2 inhibitor (dapagliflozin or empagliflozin). All four should be initiated and titrated to target doses.

RoundsRx

Dashboard

Overview

Recent

Rotations

Quick Reference

Antibiotic Guide Analgesia Guide Sedation Guide Bowel Regimen Electrolyte Replacement Pain Management & Conversions Drug Interactions Anticoag Reversal IV Fluid Guide Inotropes Guide Vasopressors Insulin Guide Code Blue & Rapid Response Procedures Guide ECG Interpretation Lab Interpretation Radiology Quick Ref GCS Pocket Card Admission Orders & I-PASS Landmark Trials

Tools

💎 Clinical Pearls 🧠 Pimp Me Quiz 🧮 Clinical Calculators 📰 What's New 🎓 Intern Survival Guide ✅ Rounding Checklists 🩺 Procedure Guides ⚡ Electrolyte Replacement 💧 IV Fluids Guide 🩸 Transfusion Guide 💓 ECG Pattern Guide 🧪 Lab Interpretation Guide 📱 QR Poster 🔗 Resources 🎙️ Channels & Podcasts 🎮 Medical Games 🏛️ Famous Cases 🎬 Media Library

ℹ️ About

Available offline

Endocrinology / Wards

Inpatient Diabetes Management

Basal-bolus insulin is SUPERIOR to sliding scale alone. Target 140-180 mg/dL in ICU, 100-180 on wards. NEVER hold basal insulin just because a patient is NPO. Sliding scale alone is outdated and reactive, basal-bolus is proactive.

🔍 Overview

Overview

Inpatient hyperglycemia is extremely common and associated with increased mortality, infections, and length of stay. The landmark NICE-SUGAR, 2009 trial showed that targeting 140-180 mg/dL in ICU patients reduces mortality compared to tight glucose control (81-108). For non-ICU patients, the ADA 2026 recommends 100-180 mg/dL. Initiate or intensify insulin for persistent BG ≥180 mg/dL confirmed on two occasions.

ADA 2026 Inpatient Updates:
• Perioperative: A1c goal <8% within 3 months of elective surgery. Target BG 100–180 mg/dL perioperatively. Do NOT postpone surgery based on A1c alone
• CGM in hospital: Hospital-owned CGM devices show feasibility for detecting nocturnal/asymptomatic hypoglycemia (no devices FDA-approved for inpatient use yet)
• Discharge planning: Initiate CGM prior to discharge to facilitate follow-up. Prescribe glucagon at discharge for patients with severe hypoglycemia or impaired awareness
• Cancer treatment hyperglycemia (NEW): Metformin first-line for PI3K/mTOR inhibitor-induced hyperglycemia. Insulin reserved for severe/crisis-level. Close monitoring for immune checkpoint inhibitor patients

Updated Practice: Sliding scale alone is OUTDATED and inferior. RABBIT 2, 2007 showed basal-bolus achieves better glycemic control with LESS hypoglycemia. Sliding scale = reactive (chasing highs). Basal-bolus = proactive (preventing highs).

Glycemic Targets

ICU patients: 140-180 mg/dL (NICE-SUGAR, 2009)
Non-ICU patients: 100-180 mg/dL (pre-meal <140, random <180)
Avoid hypoglycemia: <70 mg/dL is harmful. <54 = clinically significant. <40 = severe.

🚨 Management

Step 1 -Calculate Total Daily Dose (TDD)

Patient Type	TDD Calculation
Already on insulin at home	Use 80% of home TDD (reduce for illness-related decreased intake)
Insulin-naive, Type 2	0.4-0.5 units/kg/day (start conservatively). Elderly / CKD eGFR < 30 / thin → 0.3 units/kg/day.
Type 1	0.4-0.6 units/kg/day. NEVER hold basal completely.
On steroids	↑ TDD by 20-40% (prednisone causes afternoon/evening hyperglycemia). Increase nutritional insulin at lunch/dinner more than basal.

Step 2 -Split Into Components (50/50)

50% as basal: Glargine (Lantus) or Detemir (Levemir) once daily (usually at bedtime or in the morning). Covers fasting glucose / hepatic glucose output.
50% as bolus (nutritional): Divided into 3 equal doses before each meal, Lispro (Humalog) or Aspart (NovoLog) before meals. Skip if NPO or not eating.
Correction factor: 1700 / TDD = how many mg/dL 1 unit of insulin will drop glucose. Add correction to mealtime dose. Example: TDD 32 → 1700/32 ≈ 53 mg/dL per unit.

Step 3 -Adjust Daily

Fasting glucose high? → increase basal by 10-20%
Pre-lunch / dinner / bedtime high? → increase prior meal's nutritional dose by 10-20%
Hypoglycemia (< 70)? → reduce the responsible component by 20%. If nocturnal → reduce basal.
NPO? → continue basal (reduce by 20-50% if concerned), hold nutritional, use correction-only sliding scale
Tube feeds? → basal + correction q6h, OR 70/30 insulin BID for continuous feeds

NEVER hold basal insulin just because a patient is NPO. Basal insulin controls hepatic glucose output, not meal glucose. Hold or reduce MEALTIME doses only. Holding basal leads to DKA in type 1 and dangerous hyperglycemia in type 2. If NPO, reduce basal by 20-50% but never hold it entirely.

ICU -Insulin Drip and Drip-to-SubQ Transition

Continuous insulin infusion for critically ill patients (DKA, postoperative, unstable PO intake, persistent BG > 180 despite SubQ).
Regular insulin drip: start 0.5-1 unit/hr, titrate to target 140-180 mg/dL.
Check BG q1h until stable, then q2h.
Transitioning to SubQ -the overlap rule: calculate 24-hr drip total (last 6-8 h average × 24), give 80% of that as daily basal. Give the SubQ basal dose 2-4 hours BEFORE stopping the drip -basal needs time to reach steady-state.
- Glargine overlap = 4 hours (slower onset)
- Detemir overlap = 2 hours
Why the overlap matters: if you stop the drip before SubQ basal reaches therapeutic level, there's a 2-4 h gap with no effective insulin → rebound hyperglycemia in T2DM, DKA in T1DM.

🔄 Updated Practice: Old teaching (Van den Berghe, 2001): tight glucose control (80-110 mg/dL) in ICU improves mortality. OVERTURNED by NICE-SUGAR, 2009 -intensive insulin INCREASED mortality due to hypoglycemia. Current target: 140-180 mg/dL in ICU. Avoid both hyperglycemia AND hypoglycemia. Sliding-scale-only is also outdated -basal-bolus is superior (RABBIT 2, 2007).

Special Situations

Steroid-Induced Hyperglycemia

Prednisone causes AFTERNOON/EVENING hyperglycemia (peaks 4-8h after morning dose). The key is to match insulin to the glycemic pattern:

Add NPH insulin with the morning prednisone dose, NPH peak matches prednisone glycemic peak.
Starting dose: 0.1-0.2 units/kg. Uptitrate daily based on afternoon/evening glucose readings.
When steroids are tapered, taper the NPH proportionally (or hyperglycemia will resolve and you risk hypoglycemia).

TPN (Total Parenteral Nutrition)

Start with regular insulin IN the TPN bag at 1 unit per 10 g dextrose.
Adjust daily based on glucose readings.
Supplement with correction scale insulin SQ for persistent hyperglycemia.
Roll 80% of previous day's correction insulin into the next TPN bag.

Hypoglycemia Protocol

Glucose <70 mg/dL: If able to eat, 15 g oral glucose (juice box, glucose tabs). If NPO or unable, D50 25 mL (12.5 g) IV push.
Recheck glucose in 15 minutes. Repeat if still <70.
If recurrent hypoglycemia: reduce insulin dose by 20%, investigate cause (missed meals, renal clearance, adrenal insufficiency).

Clinical Example: A 65-year-old man with T2DM (A1c 9.2, weight 80 kg) is admitted for cellulitis. He was on metformin + glipizide at home. TDD = 0.4 x 80 = 32 units. Basal: glargine 16 units at bedtime. Bolus: lispro 5 units before each meal (~16 units total divided by 3). Correction factor: 1700/32 = ~53, so 1 unit drops glucose by ~53 mg/dL. Hold home metformin and glipizide while inpatient.

🧪 Workup

Assessment on Admission

A1c, if not checked in past 3 months. Reflects 3-month average. Guides discharge planning.
Home insulin regimen, detailed medication reconciliation. What type, how much, when?
Type 1 vs Type 2, critical distinction. Type 1 patients MUST have basal insulin at all times (DKA risk). Check C-peptide if unclear.
Point-of-care glucose (POC), AC (before meals) and HS (bedtime) = 4x/day for eating patients. Q6h if NPO.
Renal function, CKD increases hypoglycemia risk (reduced insulin clearance). Reduce TDD by 25-50% if eGFR <30.
Nutritional status, is the patient eating? NPO? On TPN? On tube feeds? This drives your insulin strategy.

Daily Glucose Review

Review all 4 POC glucose values from the past 24h
Identify patterns: fasting highs = increase basal. Pre-dinner highs = increase lunch bolus. Overnight lows = reduce basal.
Adjust insulin doses by 10-20% increments daily

💊 Medications

Medications

Drug	Type	Onset / Peak / Duration	Notes
Glargine (Lantus)	Basal (long-acting)	2-4h / peakless / 20-24h	Once daily. Provides baseline insulin coverage. Do NOT hold when NPO (reduce by 20-50%).
Detemir (Levemir)	Basal (long-acting)	1-2h / 6-8h / 18-24h	May need BID dosing. Slight peak compared to glargine.
NPH	Intermediate-acting	1-3h / 4-12h / 12-18h	Key for steroid-induced hyperglycemia. Give with morning prednisone. Peak matches steroid glycemic peak.
Lispro (Humalog)	Rapid-acting (bolus)	15 min / 1-2h / 3-5h	Give 0-15 min before meals. Hold if NPO. Correction scale uses this.
Aspart (NovoLog)	Rapid-acting (bolus)	15 min / 1-2h / 3-5h	Equivalent to lispro. Interchangeable.
Regular insulin	Short-acting	30-60 min / 2-4h / 6-8h	Used in IV insulin drips (ICU) and added to TPN bags. Give 30 min before meals if used SQ.
D50 (Dextrose 50%)	Hypoglycemia rescue	25 mL (12.5g) IV push	For glucose <70 when patient cannot eat. Recheck in 15 min.

🏥 Rounds

Pimp Questions

❓ Why should you NOT hold basal insulin in NPO patients?

Basal insulin controls hepatic glucose output (gluconeogenesis and glycogenolysis), NOT meal-related glucose. Even when fasting, the liver continuously produces glucose. Without basal insulin, Type 1 patients will develop DKA and Type 2 patients will have dangerous hyperglycemia. The correct approach: reduce basal by 20-50% but never hold it. Hold MEALTIME insulin only.

❓ How do you dose NPH for steroid-induced hyperglycemia?

Give NPH with the morning prednisone dose, NPH has a peak at 4-12h that matches the glycemic peak from prednisone (4-8h after dose). Start at 0.1-0.2 units/kg. Uptitrate daily based on afternoon and evening glucose values. When steroids are tapered, taper NPH proportionally to prevent hypoglycemia.

❓ What is the correction factor formula?

1700 / TDD = correction factor (also called insulin sensitivity factor). This tells you how many mg/dL 1 unit of rapid-acting insulin will lower the blood glucose. Example: TDD 40 units → 1700/40 = 42.5, so 1 unit drops glucose by ~43 mg/dL. For a glucose of 280 with target 150: (280-150)/43 = ~3 units of correction insulin added to mealtime dose.

❓ Why did NICE-SUGAR change ICU glucose targets?

NICE-SUGAR, 2009: 6,104 ICU patients randomized to tight glucose control (81-108 mg/dL) vs conventional (140-180). Tight control increased 90-day mortality (27.5% vs 24.9%) and severe hypoglycemia 13-fold. Likely mechanism: repeated hypoglycemic episodes → adrenergic surges, cardiac arrhythmias, cerebral glucose deprivation. Overturned the prior Van den Berghe 2001 tight-control paradigm. Current ICU target: 140-180 mg/dL.

❓ Why must you overlap basal insulin with the drip when transitioning to SubQ?

Long-acting basal insulin takes several hours to reach therapeutic levels after SubQ injection. Glargine ~4 h to steady state; detemir ~2 h. If you stop the drip and give SubQ basal simultaneously, there's a several-hour gap with no effective insulin → rebound hyperglycemia → DKA risk (especially T1DM, who can ketogenesise within hours of insulin gap). The fix: give SubQ basal 2-4 h BEFORE stopping the drip, write it as an explicit nursing order.

❓ Why is sliding-scale-only insulin especially dangerous in T1DM?

Type 1 diabetics produce ZERO endogenous insulin. Without basal insulin, they develop DKA within 6-12 hours regardless of whether they're eating. Sliding-scale insulin is only correctional (reactive) -treats hyperglycemia after it happens, contains no basal component. A T1DM on sliding-scale-only will: (1) have persistent hyperglycemia (corrected q6h then rises again), (2) develop ketogenesis between checks, (3) progress to DKA within a day. T1DM ALWAYS needs scheduled basal insulin -never hold it completely.

❓ Patient on 40 units of glargine at home is admitted NPO for surgery. What do you do with the insulin?

Give 60-80% of home basal dose (24-32 units glargine). NEVER hold basal insulin entirely in T1DM (DKA risk) or insulin-dependent T2DM (severe hyperglycemia). Hold all mealtime bolus while NPO. Use correction scale q4-6 h PRN. Resume full home basal once eating regularly.

Clinical Examples

📋 Case 1, Initiating Basal-Bolus for Insulin-Naive T2DM

Patient: 70M with T2DM (A1c 9.8), admitted for cellulitis. Home meds: metformin + glipizide. Weight 85 kg. Glucose 280-380 on sliding scale alone × 24h.

Key findings: Sliding scale alone is failing. Patient needs basal-bolus insulin. Home orals (metformin, glipizide) are held inpatient, metformin risk with IV contrast/AKI, glipizide unpredictable when eating is variable.

Management:

Calculate TDD: 0.4 U/kg × 85 kg = 34 U/day (conservative for insulin-naive)
Basal (50%): glargine 17 U at bedtime
Bolus (50% ÷ 3): lispro 5-6 U before each meal (hold if NPO)
Correction factor: 1700/34 = 50 → 1 unit drops glucose ~50 mg/dL. Add correction to mealtime dose
Adjust daily: increase basal by 2-4 U if fasting glucose > 180; increase bolus by 1-2 U if pre-meal values high

Teaching point: The "50/50 split" is the foundation: 50% basal (covers liver glucose output) + 50% bolus (covers meals). Never hold basal in T1DM. Reduce basal by 20-50% in NPO patients but never to zero, the liver never stops making glucose.

📋 Case 2, Steroid-Induced Hyperglycemia

Patient: 65F with no diabetes history, admitted for COPD exacerbation. Started prednisone 40 mg daily. Day 2: glucose pattern, fasting 118, pre-lunch 162, pre-dinner 298, bedtime 264.

Key findings: Classic steroid hyperglycemia pattern: morning glucose near-normal, peaks in afternoon/evening (prednisone peaks at 4-6h → hyperglycemia at 6-12h). Fasting glucose is relatively spared because steroid effect wears off overnight.

Management:

NPH insulin with AM prednisone dose: start 0.15 U/kg = ~10 U (NPH peaks at 6-8h, matching steroid peak)
Correction lispro with lunch and dinner only (where the peaks are)
Do NOT add glargine (flat profile → overnight hypoglycemia while missing afternoon peaks)
Titrate NPH by 2-4 U daily based on pre-dinner and bedtime glucose
When prednisone tapered: reduce NPH proportionally, halve insulin when steroid dose is halved

Teaching point: NPH is the ideal match for once-daily prednisone because its pharmacokinetic profile parallels the hyperglycemic pattern. Glargine is the WRONG choice, its flat 24h profile causes overnight hypoglycemia while under-covering the afternoon peak. Always co-taper insulin with steroids.

📋 Case 3, Transitioning Insulin Drip to SubQ in T1DM

Patient: 25M with T1DM, admitted in DKA (now resolved). Insulin drip at 2.5 U/hr × last 8h. Eating well. AG closed. Team ready to transition to SubQ.

Key findings: T1DM = zero endogenous insulin. The drip-to-SubQ transition is the highest-risk moment, any gap in insulin coverage → DKA recurrence within hours. The "2-hour overlap" is mandatory.

Management:

Calculate: 2.5 U/hr × 24h = 60 U/day → give 80% = 48 U as daily basal
Give glargine 48 U SubQ NOW, continue drip for 2 more hours (overlap period for SubQ absorption)
After 2h overlap: stop drip. Start mealtime lispro 8 U before each meal + correction scale
Check glucose before each meal + bedtime + 3 AM for first 24h (catch overnight hypo or hyperglycemia)
If patient was on home insulin: use their home regimen if A1c was reasonable (< 8); use drip-calculated dose if home regimen was clearly inadequate

Teaching point: The 2-hour overlap saves lives. Glargine takes ~4h to reach steady state, giving it 2h before stopping the drip ensures no insulin gap. In T1DM, even a 2-hour gap without insulin can trigger ketogenesis. Write the overlap as an explicit nursing order.

Sample Presentation

Mr. Garcia is a 58-year-old man with T2DM (A1c 8.7) admitted for community-acquired pneumonia. He is on prednisone 40 mg daily for severe COPD exacerbation. Home regimen: metformin 1000 mg BID + glipizide 10 mg BID. Weight 90 kg. Admission glucose 280. We transitioned to basal-bolus: TDD 0.4 x 90 = 36 units. Glargine 18 units QHS, lispro 6 units AC meals, correction scale. For steroid-induced hyperglycemia: added NPH 10 units (0.1 u/kg) with morning prednisone. Yesterday's glucoses: AM 145, pre-lunch 168, pre-dinner 242, HS 198. The pre-dinner spike confirms steroid effect, increasing NPH to 14 units. Metformin and glipizide held inpatient.

Key Points: Basal-bolus is superior to sliding scale. Added NPH to match prednisone glycemic peak (afternoon). Adjust NPH daily based on afternoon/evening glucoses. When prednisone is tapered, taper NPH proportionally. Will need discharge diabetes plan based on A1c and response to therapy.

Monitoring

POC glucose AC + HS (before meals and bedtime) = 4 checks/day for eating patients
POC glucose q6h for NPO patients
Q1h glucose for patients on IV insulin drip (ICU)
Hypoglycemia alerts: <70 requires intervention. <54 = clinically significant. <40 = severe, consider dose reduction and workup.
Daily insulin adjustment: review all 4 values, identify patterns, adjust by 10-20% per day.
BMP daily, monitor K+ (insulin shifts K+ intracellularly), renal function (affects insulin clearance).
A1c on admission, guides discharge insulin planning (A1c >9 likely needs insulin at discharge, A1c <8 may resume oral agents).

📋 Summary

Summary

Target

140-180 mg/dL (ICU). 100-180 (non-ICU). NICE-SUGAR, 2009

Protocol

Basal-bolus: TDD 0.4-0.5 u/kg. 50% basal (glargine) + 50% bolus (lispro AC meals). RABBIT 2, 2007

NPO Rule

NEVER hold basal. Reduce by 20-50%. Hold mealtime doses only.

Steroids

NPH with morning prednisone. Start 0.1-0.2 u/kg. Peak matches steroid glycemic peak.

Correction

1700 / TDD = how much 1 unit drops glucose (mg/dL).

Hypoglycemia

<70: D50 25 mL IV if NPO, or 15 g PO glucose. Recheck in 15 min.