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VOLUME 9 NUMBER 2 • JUNE 2012
95
SA JOURNAL OF DIABETES & VASCULAR DISEASE
HANDS ON
Table 4.
Tight glycaemic control for all patients in the ICU.
Date
Time
Adult insulin infusion protocol
1. Discontinue all previous insulin orders (including sliding scale), and all other insulin protocols.
2. Run IV of:
• Normal saline 0.9% to run at _____ml/h. Use only if patient is eating or on TPN, IVF or enteral feed.
• Dextrose 5% in water to run at _____ ml/h.
• Dextrose 5% in water and normal saline 0.45% to run at _____ ml/h.
3. Insulin drip: rapid-acting insulin 100 units/100 ml 0.9% normal saline. Deliver via infusion device, prime the tubing when initiating, and
must be changed every 24 hours. There is no need to use glass bottles for the insulin.
4. Titrate insulin infusion to blood glucose goal of: (select one)
regular control: 6.1–8 mmol/l (recommended for most patients).
OR
tight control (limited to ICU/CCU): 5.6–6.1 mmol/l mg/dl (recommended for unstable, critically ill patients, e.g. cardiothoracic surgery, receiving
glucorticoids or vasopressors, or known diabetics on more than 80 units of insulin daily as an outpatient). May transfer to floor once patient is
stabilised, requiring less Accuchecks.
5. Begin initial insulin infusion with: (select one)
• Algorithm 1 (recommended for most patients).
OR
• Algorithm 2 (recommended for unstable, critically ill patients, e.g. cardiothoracic surgery, receiving glucorticoids or vasopressors or
known diabetics on more than 80 units of insulin daily as an outpatient).
Algorithm 1
Algorithm 2
Algorithm 3
Algorithm 4
Blood glucose
Insulin
Blood glucose
Insulin
Blood glucose
Insulin
Blood glucose
Insulin
(mmol/l)
(units/h)
(mmol/l)
(units/h)
(mmol/l)
(units/h)
(mmol/l)
(units/h)
< 6
off
< 6
off
< 6
off
< 6
off
6.1–7.9
1
6.1–7.9
1
6.1–7.9
2
6.1–7.9
4
8–9.9
2
8–9.9
2
8–9.9
4
8–9.9
6
10–11.9
4
10–11.9
4
10–11.9
6
10–11.9
8
12–13.9
6
12–13.9
6
12–13.9
8
12–13.9
10
14–15.9
8
14–154.9
8
14–15.9
10
14–15.9
12
> 16– < 360
10
> 16– < 360
10
> 16– < 360
12
> 16– < 360
14
6. When starting insulin infusion, begin with hourly capillary blood glucose until ordered goal is obtained. If possible use arterial sample.
• If patient not at goal and blood glucose does not change (decrease) at least 4 mmol/l within one hour, move to next higher algorithm and
notify ordering physician.
• For blood glucose that is not at goal after four consecutive hours, contact the ordering physician; look for cause and adjust treatment,
e.g. parenteral nutrition.
7. Once goal is achieved and maintained for four consecutive hours, monitor blood glucose as follows:
Regular control: monitor glucose levels every four hours, given blood glucose is at goal and the patient is clinically stable. Any change in orders
for diet, IV rate or composition or the patient becomes clinically unstable; begin again at number 6 above, unless ordered differently by the doctor.
OR
Tight control: monitor glucose levels every two hours. Note: critically ill patients may require hourly monitoring for other reasons even if they
have stable blood glucose (e.g. vasopressor titration).
8. Notify the ordering physician promptly of:
• Any blood glucose changes up or down greater than 6 mmol/l or any blood glucose level greater than 16 mmol/l that is persistent.
• Whenever patient moves from one algorithm to another or the infusion is restarted.
• When the patient has received IV insulin infusion for three days.
9. Any time blood glucose is between 5.6 and 6.1 mmol/l, stop insulin infusion and begin repeating glucoes levels every 30 minutes.
• Once blood glucose is greater than 6.1 mmol/l × two samples, restart same algorithm and begin again at number 8 above.
• For a blood glucose less than 6.1 mmol/l within four hours after resuming the same algorithm, move to next lower algorithm and begin
again at step number 6 above.
• For patient already on algorithm 1, contact ordering physician for further orders.
10. Blood glucose less than 5.6 mmol/l
• Stop insulin infusion.
• For awake patient – check if glucose required.
• For patient that is NOT awake – give dextrose 50% 50 ml (1 ampule) IV push/central line preferably.
• Recheck blood glucose Accucheck every 30 minutes. For blood glucose less than 5.6 mmol/l and patient awake, repeat dextrose 50%
25 ml (½ ampule) or for patient not awake repeat dextrose 50% 50 ml (1 ampule) IVP.
• Once blood glucose is greater than 6.1 mmol/l × two; restart insulin infusion, move to next lower algorithm and begin again at step
number 6 above.
• For patient already on algorithm 1, contact ordering physician for further orders.
• Notify the ordering physician after each dosing of dextrose 50% given and when algorithm restarted.
Adjustment for meals and/or tube feedings:
Once the patient is consuming 50% or more of his/her last two meals (other than clear liquids) and/or is receiving bolus tube feelings:
• Increase the insulin infusion rate two steps within the same algorithm for one hour and recheck blood glucose.
• Adjust insulin infusion within same algorithm according to blood glucose level.
• Repeat blood glucose in one hour.
• For blood glucose between 6.1 and 8 mmol/l, turn insulin infusion off and go back to step number 9. If less than 5.6 mmol/l, go back to
step number 10.
TPN, total parenteral nutrition; CCU, coronary care unit; ICU, intensive care unit; IV, intravenous infusion; IVF, intravenous fluids.