Insulin infusion protocol Appendix 11
PURPOSE & INDICATIONS:
To standardise use of insulin infusions in ICU patients where insulin is NOT being used for the management of Diabetic Ketoacidosis or Hyperglyaemic Hyperosmolar State. Such patients are excluded from this protocol.
Patients requiring insulin in ICU do not need a previous diagnosis of diabetes.
Target range of blood glucose in ICU patients is 7.1-10.0 mmol/L
To standardise use of insulin infusions in ICU patients where insulin is NOT being used for the management of Diabetic Ketoacidosis or Hyperglyaemic Hyperosmolar State. Such patients are excluded from this protocol.
Patients requiring insulin in ICU do not need a previous diagnosis of diabetes.
Target range of blood glucose in ICU patients is 7.1-10.0 mmol/L
PRECAUTIONS & RISKS:
Insulin infusions increase risk of hypoglycaemia; risk higher in unconscious/sedated patients. Patients with type I diabetes always need some insulin - discuss with medical staff before ceasing insulin for >1 hour. Insulin infusions may cause hypokalaemia; monitoring via venous or arterial blood gas is sufficient and may require supplementation.
Insulin infusions increase risk of hypoglycaemia; risk higher in unconscious/sedated patients. Patients with type I diabetes always need some insulin - discuss with medical staff before ceasing insulin for >1 hour. Insulin infusions may cause hypokalaemia; monitoring via venous or arterial blood gas is sufficient and may require supplementation.
PROCESS:
1) Measure Blood Glucose Level (BGL) by finger prick or arterial/venous blood gas sampling
2) Insulin infusion required if two consecutive blood glucose levels >10.0 mmol/L more than 2 hours apart or any single level ≥16.0 mmol/L
3) Make up insulin infusion by diluting 50 units of Novarapid in 50 mL of normal (0.9%) saline so that 1 mL contains 1 unit of insulin
4) Do not given an initial insulin bolus unless requested by an ICU doctor
5) Medical staff to prescribe insulin infusion in regular section of medication chart
5) Commence the infusion as per Table 1
6) Adjust & maintain the infusion as per Table 2
7) Only stop this protocol as per stopping instructions below
1) Measure Blood Glucose Level (BGL) by finger prick or arterial/venous blood gas sampling
2) Insulin infusion required if two consecutive blood glucose levels >10.0 mmol/L more than 2 hours apart or any single level ≥16.0 mmol/L
3) Make up insulin infusion by diluting 50 units of Novarapid in 50 mL of normal (0.9%) saline so that 1 mL contains 1 unit of insulin
4) Do not given an initial insulin bolus unless requested by an ICU doctor
5) Medical staff to prescribe insulin infusion in regular section of medication chart
5) Commence the infusion as per Table 1
6) Adjust & maintain the infusion as per Table 2
7) Only stop this protocol as per stopping instructions below
*stable is considered 3 consecutive BGL within 7.1-10 mmol/L target range provided trend not decreasing. If BGL falls dramatically
(>2 mmol/L/hour) then consider dose reduction outside this protocol. Discuss as needed with ICU ACNM or medical staff.
Insulin infusion rates should not exceed 20 u/hr without specific instructions from senior medical staff
(>2 mmol/L/hour) then consider dose reduction outside this protocol. Discuss as needed with ICU ACNM or medical staff.
Insulin infusion rates should not exceed 20 u/hr without specific instructions from senior medical staff
WHEN TO STOP:
• When indicated in Table 2
• If nasogastric feed or TPN is stopped in a non-diabetic patient, stop the insulin infusion
• If nasogastric feed or TPN is stopped in a diabetic patient, halve or stop the infusion depending on BGL
• If BGL ≥10.0 mmol/L then halve the infusion rate. If BGL ≤10.0 then stop
• If insulin infusion continues, monitor BGL hourly initially
• When transitioning to subcutaneous insulin, as guided by ICU medical staff
• When indicated in Table 2
• If nasogastric feed or TPN is stopped in a non-diabetic patient, stop the insulin infusion
• If nasogastric feed or TPN is stopped in a diabetic patient, halve or stop the infusion depending on BGL
• If BGL ≥10.0 mmol/L then halve the infusion rate. If BGL ≤10.0 then stop
• If insulin infusion continues, monitor BGL hourly initially
• When transitioning to subcutaneous insulin, as guided by ICU medical staff