iv insulin - final

University of Maryland Medical Center

Guidelines for Hyperglycemia Management

in Adult Patients

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Contents

I. Exclusions to guidelines

II. Definitions

III. Hyperglycemia Management in non-monitored units

A. Monitoring

1. Patients with diabetes

2. Patients without diabetes

3. TPN patients

B. Sliding scale insulin Order

C. Hyperglycemia management



3. TPN patients

4. For poorly controlled blood glucose

IV. Hyperglycemia management in monitored units

A. Monitoring



3. TPN patients

B. Sliding scale insulin Order

C. Hyperglycemia management



3. TPN patients

4. Criteria for intravenous insulin therapy initiationD. Insulin drip initiation, monitoring, and titrationE. Transitioning off insulin dripF. Management of diabetic ketoacidosis and hyperosmolar coma

V. Hyperglycemia management abbreviated algorithm

VI. Insulin drug information

VII. Contact Information

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I. EXCLUSIONS TO GUIDELINES:

Exclusions to guidelines

Any patient admitted under a specific pathway that includes blood glucose monitoring, such as new post-op liver transplant, pancreas transplant, or islet cell transplant patients. Are excluded from these guidelines. Patients with diabetic ketoacidosis or hyperglycemic hyperosmolar state (HHS) are addressed in a specific section at the end of the document and are excluded from the general hyperglycemia management guidelines.

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II. DEFINITIONS

1. Monitored unit:- A patient care area such as an intensive care unit (ICU) or intermediate care unit (IMC) with adequate nursing to patient ratio and designated to administer intravenous (IV) insulin.

2.Non-monitored unit:- A patient care area such as a regular medical or surgical floor or a unit that is not designated to administer IV insulin.

3.Hyperglycemia requiring treatment during hospitalization:- Any single serum or finger stick glucose level > 250 mg/dl.- Repeated serum or finger stick glucose levels > 150 mg/dl.

4. Goal blood glucose level:- The target range for blood glucose levels (serum or finger stick) for any adult patient under the monitoring guidelines is 100 – 150 mg/dl.

5. Medically stable patient:- A patient who for the past 24 hours has had no significant changes in the amount or route of nutritional support and there are no anticipated changes in the next 24 hours and - For the past 24 hours has had:

blood glucose levels within target range no evidence of active/worsening sepsis or an inflammatory process not requiring significant doses of pressor/inotrope medications not receiving hyperbaric oxygen therapy not receiving stress-dose glucocorticoids or a steroid taper not on continuous renal replacement therapy.

6. Insulin:- Only regular human insulin can be used safely via the intravenous route.- In the following document the use of the term “insulin” (in conjunction with intravenous or subcutaneous administration) will always refer to regular human insulin unless otherwise specified.- Sliding scale (SSI): interval dosing of insulin (subcutaneous or intravenously, as specified) based on most recent glucose level.- Insulin drip (gtt): continuous intravenous insulin administration with dose titration according to most recent glucose level.

7. Patient with diabetes:- Any patient that has a documented medical history of diabetes mellitus (Type

1 or Type 2 diabetes mellitus or other form of diabetes mellitus). This includes: -Any patient on a modified diet to control blood glucose levels. -Any patient on oral anti-diabetic agents or any form of insulin therapy.

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III. Hyperglycemia Management in non-monitored units

A. Monitoring

1. Patients with diabetes should receive a (finger stick or serum) glucose level on admission and every 6 hours if patient is NPO or receiving continuous nutrition or qac and qhs for po and bolus tube fed patients.- Patients with documented prior need for high doses of insulin, frequent dosing, large fluctuations in glucose levels, active infections, sepsis, or currently receiving stress dose glucocorticoids may need their glucose levels checked every 4 hours to maintain glucose in target range.- All patients with diabetes should have appropriate sliding scale insulin (SSI) coverage ordered on admission (see SSI section below).

2. Patients without diabetes admitted to a patient care unit should receive a (finger stick or serum) glucose level check on admission and again within 24 hours.- If the initial and within 24 hour follow up glucose levels are < 150 mg/dl glucose monitoring may be discontinued.- If the initial or any glucose level within the next 24 hours is > 150 mg/dl, begin q 6 hour (or qac and qhs for po and bolus tube fed patients) glucose checks and initiate sliding scale coverage (see SSI section below).- If over the following 24 hours subsequent glucose levels are < 150 mg/dl and patient did not require SSI coverage, glucose checks may be discontinued.- Resume glucose monitoring in any patient with glucose levels >150 mg/dl on routine laboratory evaluation.

3. Patients receiving total parenteral nutrition (TPN) should receive glucose checks initially every 6 hours. All patients receiving TPN should have appropriate sliding scale insulin (SSI) coverage ordered upon initiation of TPN therapy.

B. Sliding Scale Insulin order (SSI)

1. Sliding scale coverage for subcutaneous injection:

Glucose level (mg/dl): SSI coverage:

0- 60 ½ amp D50 IV & NHO1

61-150 0 units 151-200 1 - 4 units201-250 2 - 8 units251-300 3 -12 units301-350 4 -14 units >350 5 -16 units & NHO

- 1 If patient is alert and able to take po , can treat hypoglycemia with 4 oz. soda (non-diet), 4-6 oz. fruit juice, or 2-4 glucose tablets

- NOTE: the following recommendations are based on a 70 kg patient- The initial sliding scale coverage should be ordered based on the patient’s

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weight, previous (home) insulin requirements, concomitant therapies and disease states that may influence insulin requirements (e.g.: steroid or TPN use, active pancreatitis, infection / sepsis, etc.) and adjusted as needed based on patient response

- Patients with end stage renal disease, hepatic disease, or cachexia may be more sensitive to insulin. Use of the lower range of the sliding scale is recommended.

- Subcutaneous SSI coverage may be given no more frequently than every 4 to 6 hours due to the half life of subcutaneous regular insulin.

- IV SSI and insulin drip therapy can only be given in monitored units.

2. Adjustment of SSI coverage:The sliding scale should be reevaluated daily by the prescribing physician for adequacy of coverage and should be adjusted when:- Patient has had documented hypoglycemia < 60mg/dl.- Current SSI not adequately maintaining blood glucose in target range over past 24 hours.

C. Hyperglycemia management in non-monitored units

1. Patients with diabetes not receiving TPN, that are NPO or are receiving changing amounts of nutrition– consider continuing longer acting forms of insulin at approximately ½ their usual home dose to avoid large glucose variations on SSI alone. Oral anti-diabetic agents may be continued on an individual basis with caution. Metformin should be discontinued. Continue with q 4 to 6 hour glucose checks and subcutaneous SSI coverage. SSI coverage and long acting insulin should be titrated to maintain glucose in target range. If problems controlling glucose persist, consider endocrine consult.- Medically stable patients receiving a PO diet or bolus tube feeds at predictable, stable amounts (breakfast, lunch, dinner, and bedtime) may be continued on their home anti-diabetic regimen. Review regimen especially if patient admitted for hyperglycemia. On admission, metformin should be stopped on all patients. Continue with q 4 to 6 hour glucose checks and subcutaneous SSI coverage.- Patients receiving continuous tube feedings, consider longer acting forms of insulin and continue with q 4 to 6 hour glucose checks and subcutaneous SSI coverage.- For subsequent management, initiation of, or transition to longer acting forms of insulin or oral anti-diabetic agents must be individualized for each patient under close supervision of the patient’s physician. Once stable, patients without contraindications to the use of metformin (renal disease or dysfunction, Creatinine <1.4 for women and <1.5 for men, cardiovascular collapse, respiratory failure, acute myocardial infarction, acute congestive heart failure, septicemia, acute or chronic metabolic acidosis, or any patient undergoing radiologic studies involving the intravascular administration of iodinated contrast materials) may be restarted on this medication.

2. Patients without diabetes should have sliding scale insulin ordered to cover any blood glucose level > 150 mg/dl. The sliding scale should be titrated to

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maintain blood glucose in goal range. If hyperglycemia persists, consider endocrine consult.

3. TPN patients **NOTE: Not all patients are appropriate candidates for addition of insulin to TPN. Patients who are not medically stable (see definitions) and therefore may experience rapidly changing insulin requirements are not able to be safely managed with insulin in the TPN bag. Also, many patients without large insulin requirements may be managed with SSI alone.

a. Patients that do not require insulin at home1. Before starting TPN, begin monitoring BG levels every 4-6

hours and initiate SSI coverage.2. If BG levels not in target range, adjust SSI.3. Initiate TPN when BG levels maintained routinely < 150

mg/dl.4. Start TPN at no more than 1 liter of the standard low

carbohydrate solution at 42ml/hr over 24 hours.5. Do not advance TPN to goal unless BG maintained

consistently < 150 mg/dl.6. If BG levels not in target range and patient requires 20 or

more units of SSI coverage over 24 hours and patient is medically stable, consider addition of insulin to TPN with ½ to 2/3 of previous 24 hour SSI coverage requirement. If patient not medically stable and hyperglycemia persists consider transfer to a monitored unit for more aggressive management with an insulin drip.

b. Patients with diabetes requiring insulin at home.1. Before starting TPN, begin monitoring BG levels every 4-6 hours and initiate SSI coverage.2. Adjust SSI as needed.3. Do not initiate TPN until BG levels routinely < 150 mg/dl.4. Discontinue all previous standing orders for insulin (regular and

long-acting) except for SSI.5. Start TPN at no more than 1 liter of the standard low carbohydrate

solution (D20W = 200gm CHO) at 42ml/hr over 24 hours. Add 0.1 unit of insulin per gram dextrose provided (e.g.: 200gm CHO = 20 units insulin) to initial TPN bag.

6. Do not advance TPN until BG levels consistently < 150 mg/dl.c. Titration of insulin in TPN

-Goal BG level between 100-150 mg/dl, through the combined use of subcutaneous sliding scale insulin and insulin in the TPN bag.

If BG level > 150 mg/dl more than once for the previous 24 hours- add ½ to 2/3 of the previous days sliding

scale insulin coverage to next TPN bag. If BG level between 100-150 mg/dl and patient stable

- maintain amount of insulin in bag. If BG level < 100 mg/dl more than once for the previous 24 hours

- decrease insulin in next bag 1/3 to ½.

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If BG level < 60 mg/dl - discontinue TPN and start D10W at the same

rate as the TPN for a maximum of 4 to 8 hours, then change to D5W 0.45NS with 20meq/liter KCl or other appropriate fluid. Check BG levels q4h and continue SSI. - For the next TPN order decrease insulin by 1/3 to ½.

- Continue sliding scale insulin coverage and titrate as needed- NOTE: Decrease insulin in bag during steroid tapers, resolution of infection, or any other changes in clinical condition that potentially decreases insulin requirements.

D. For poorly controlled blood glucose

For all patients, if BG levels are poorly controlled: - one BG level > 350 mg/dl,- glucose repeatedly > 250 mg/dl,- repeated hypoglycemia < 60 mg/dl.

Treatment must be individualized under close physician supervision. If patient only on sliding scale and not receiving TPN, consider addition of long acting insulin. If patient still poorly controlled, consider transfer of patient to a monitored unit for more intensive management using an insulin drip.

III. Hyperglycemia Management in monitored units

A. Monitoring

1. Patients with diabetes should receive a (finger stick or serum) glucose level on admission and every 6 hours if patient is NPO or receiving continuous nutrition or qac and qhs for po and bolus tube fed patients.- Patients with documented prior need for high doses of insulin, frequent dosing, large fluctuations in glucose levels, active infections, sepsis, or currently receiving stress dose glucocorticoids may need their glucose levels checked every 4 hours to maintain glucose in target range.

- All patients with diabetes should have appropriate sliding scale insulin (SSI) coverage ordered on admission (see SSI section below).

2. Patients without diabetes admitted to a patient care unit should receive a (finger stick or serum) glucose level check on admission and again within 24 hours.- If the initial and within 24 hour follow up glucose levels are < 150 mg/dl glucose monitoring may be discontinued.- If the initial or any glucose level within the next 24 hours is > 150 mg/dl, begin q 6 hour (or qac and qhs for po and bolus tube fed patients) glucose checks and initiate sliding scale coverage (SSI, see section below on SSI).- If over the following 24 hours subsequent glucose levels are < 150 mg/dl and patient did not require SSI coverage, glucose checks may be discontinued.- Resume glucose monitoring in any patient with glucose levels >150 mg/dl on routine laboratory evaluation.

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3. Patients receiving total parenteral nutrition (TPN) should receive glucose checks initially every 6 hours. All patients receiving TPN should have appropriate sliding scale insulin (SSI) coverage ordered upon initiation of TPN therapy.

B. Sliding Scale Insulin order (SSI)

a. Subcutaneous SSI- Preferred route of SSI administration in most patients- Relative contraindications: - Generalized skin infection or inflammatory skin condition - Large body surface wounds or burn (involving standard injection sites) - Anasarca - Hemodynamic instability requiring significant inotrope / pressor doses or other conditions associated with significant cutaneous hypoperfusion (CHF, severe vascular disease)

Sliding scale coverage for subcutaneous injection:


0- 60 ½ amp D50 IV & NHO1

61-150 0 units 151-200 1 - 4 units201-250 2 - 8 units251-300 3 -12 units301-350 4 -14 units >350 5 -16 units & NHO

1 If patient is alert and able to take po , can treat hypoglycemia with 4 oz. soda (non-diet), 4-6 oz. fruit juice, or 2-4 glucose tablets

- NOTE: the above recommendations are based on a 70 kg patient- Medically stable* patients, patients with diabetes without an insulin requirement at home, and patients on stable enteral nutrition may require lower doses and q 6 hour monitoring.- Infected patients, patients on steroids or high doses of home insulin may require higher doses and q 4 hour monitoring.-Patients with Type 2 DM are usually on higher doses of insulin than patients with Type 1 DM due to factors such as obesity and insulin resistance. Higher doses of home insulin do not mean that patient is unstable. More likely, Type 2 DM patient is on high doses due to obesity and insulin resistance and their BG levels fluctuate less than Type 1 patients on low doses of insulin.

- Patients with End stage renal disease, hepatic disease, or cachexia may be more sensitive to insulin. Use of the lower range of the sliding scale is recommended.

- Subcutaneous SSI coverage may be given no more frequently than every 4 to 6 hours due to the half life of subcutaneous regular insulin.

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b. Intravenous SSI- Preferred route of SSI administration in patients with presence of contraindications to subcutaneous SSI administration.- Can only be given to patients in monitored units.

Sliding scale coverage for intravenous (push) administration:


0- 60 ½ amp D50 IV & NHO 61-150 0 units151-200 1 - 2 units201-250 2 - 4 units251-300 3 - 6 units301-350 4 - 8 units

>350 5 -10 units & NHO

- NOTE: the above recommendations are based on a 70 kg patient- Monitor glucose levels q 1 hour, until patient is medically stable* and monitoring frequency may be adjusted by the patient’s physician to every 2 hours.

c. Adjustment of SSI coverage:The sliding scale should be reevaluated daily by the prescribing physician for adequacy of coverage and should be adjusted when: - Patient has had documented hypoglycemia (BG < 60).- Current SSI not adequately maintaining blood glucose in target range over past 24 hours.

C. Hyperglycemia management in monitored units

1. Patients with diabetes not receiving TPN, that are NPO or are receiving changing amounts of nutrition– consider continuing longer acting forms of insulin at approximately ½ their usual home dose to avoid large glucose variations on SSI alone. Oral anti-diabetic agents may be continued on an individual basis with caution. Metformin should be discontinued. Continue with q 4 to 6 hour glucose checks and subcutaneous SSI coverage.- Medically stable patients receiving a PO diet or bolus tube feeds at predictable, stable amounts (breakfast, lunch, dinner, and bedtime) may be continued on their home anti-diabetic regimen. Review regimen, especially if patient admitted for hyperglycemia. On admission, metformin should be stopped on all patients. Continue with q 4 to 6 hour glucose checks and subcutaneous SSI coverage.- Patients receiving continuous tube feedings, consider longer acting forms of insulin and continue with q 4 to 6 hour glucose checks and subcutaneous SSI coverage.- For patients with diabetes, initiation of / transition to longer acting forms of insulin or oral anti-diabetic agents must be individualized for each patient under close supervision of the patient’s physician. Once stable, patients without contraindications to the use of metformin (renal disease or dysfunction, Creatinine <1.4 for women and <1.5 for men, cardiovascular collapse, respiratory failure, acute myocardial infarction, acute congestive heart failure, septicemia, acute or

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chronic metabolic acidosis, or any patient undergoing radiologic studies involving the intravascular administration of iodinated contrast materials) may be restarted on this medication.

2. Patients without diabetes should have sliding scale insulin ordered to cover any blood glucose level > 150 mg/dl. The sliding scale should be titrated to maintain blood glucose in goal range. If hyperglycemia persists, consider endocrine consult.

3. TPN patients should have sliding scale insulin ordered to cover any blood glucose level > 150 mg/dl. The sliding scale should be titrated to maintain blood glucose in goal range. If criteria met for insulin drip initiation, insulin drip therapy should always be initially given as separate infusion and not added to TPN.

D. Criteria for intravenous insulin therapy initiation

For all patients, SSI coverage and all other forms of insulin and oral anti-diabetic agents should be discontinued and IV insulin drip therapy begun for:

- Any initial or (on SSI) subsequent glucose level > 350 mg/dl. - If greater than one subsequent glucose levels > 250 mg/dl on maximal SSI coverage

- If 3 consecutive glucose levels > 150 mg/dl on maximal SSI coverage - Recurrent hyperglycemia / hypoglycemia with SSI coverage that is not resolved with adjustment of SSI.

E. Insulin drip initiation, monitoring and titration.

1. Insulin drip initiation:

- Initial insulin infusion rate based on initial glucose level

Glucose level (mg/dl) Initial insulin drip rate

151-250 1 unit/hr 251-350 2 units/hr >350 3 units/hr

2. Insulin drip monitoring and titration:- Check glucose level every 1 hour until level within goal range (100 – 150

mg/dl) for 4 consecutive hours and patient is medically stable*, then monitor q 2 hours.

- If the patients condition changes or glucose levels no longer in goal range, resume q 1 hour BG checks.

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- Goals: decrease glucose levels by 50-100 mg/dl/hour to target range of 100 to 150 mg/dl.

If BG 100 - 150 mg/dl - maintain drip at current rate. If BG > 150 mg/dl - increase drip rate by 1 unit/hr.

- recheck BG in one hour.- if BG not decreasing by 50-100 mg/dl/hour after two 1 unit/hr incremental increases – increase drip rate by 2 units/hr increments.

If BG 80 - 99 mg/dl - decrease drip rate by 25%. - check BG every 1 hour

until BG level is > 100 mg/dl. If BG 60 - 79 mg/dl - decrease drip rate by 50%.

- increase BG monitoring to q 30 minutes until BG level is > 80 mg/dl.

If BG < 60 mg/dl - hold insulin drip and give 25ml D50 IV. - Recheck BG in 15 minutes, 30 minutes, and every

hour thereafter. - Give additional 25ml D50 IV for any subsequent

BG < 60 mg/dl.- Once BG level > 100 mg/dl restart drip at 1/2 to 2/3

of the previous infusion rate

*NOTE: The above recommendations are suggested guidelines for titration of IV insulin therapy to safely achieve BG levels in target range in a reasonable amount of time and are not meant to replace the clinical judgement of any healthcare provider.

F. Transitioning off insulin drip therapy

1. Longer acting subcutaneous insulin plus SSI coverage for enterally fed patients:- patients must be medically stable*- THE FIRST DOSE OF LONG ACTING SUBCUTANEOUS INSULIN SHOULD BE GIVEN AT LEAST 2 HOURS BEFORE DISCONTINUATION OF THE INSULIN DRIP.- If blood glucose levels repeatedly are very high (> 250 mg/dl) or low (<100 mg/dl) in 24 hour period, adjust the appropriate dose of long acting insulin under supervision of the patient’s physician and continue close glucose monitoring.– Type2 patients that previously required low dose subcutaneous insulin or who were on oral anti-diabetic agent(s) prior to admission, once medically stable*, should be evaluated for continued need for insulin therapy vs. restarting or initiating an oral anti-diabetic agent.

a. Type 1 patients with diabetes:

Receiving PO diet or bolus tube feeds at predictable, stable amount (breakfast, lunch, dinner, and bedtime) - Restart home insulin regimen.

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- If patient admitted for hyperglycemia, reevaluate insulin regimen. - Patients should be on at least a 3 injection/day regimen. - Monitor glucose levels before meals and at bedtime (qac and qhs).- SSI coverage (see subcutaneous SSI section).- Adjust insulin doses as needed until glucose levels are consistently at goal.

On continuous enteral nutrition - Give ½ to 2/3 of previous 24 hours IV insulin requirement as NPH insulin divided equally q 12 hours or as one dose of evening Lantus insulin.- Monitor glucose levels q 6 hours.- SSI coverage (see subcutaneous SSI section).- On the following day add ½ to 2/3 of previous days SSI insulin to NPH regimen; continue to adjust dose until patients BG level is consistently at goal.

b. Type 2 patients with diabetes and patients with new onset hyperglycemia (not type 1 diabetes):

Receiving PO diet or bolus tube feeds at predictable, stable amount (breakfast, lunch, dinner, and bedtime) and previously on insulin- restart home insulin regimen or if patient admitted for hyperglycemia, reevaluate insulin regimen. - SSI coverage (see subcutaneous SSI section).- Monitor BG before meals and at bedtime (qac & qhs). - Adjust insulin doses as needed until glucose levels are consistently at goal.

Receiving PO diet or bolus tube feeds at predictable, stable amount (breakfast, lunch, dinner, and bedtime) with no prior insulin requirement - If patient previously on home oral anti-diabetic agent, consider restarting agent, if appropriate or- give ½ to 2/3 of previous 24 hour IV insulin requirement as NPH insulin dividing the dose to 2/3 in the morning and 1/3 at bedtime. - SSI coverage (see subcutaneous SSI section).- Monitor glucose levels before meals and at bedtime (qac & qhs). - On the following day add ½ to 2/3 of previous days sliding scale coverage to NPH regimen; continue to adjust dose until glucose levels are consistently at goal. May also need standing dose of short acting insulin to achieve this goal.

On continuous enteral nutrition - give ½ to 2/3 of previous 24 hour IV insulin requirement as NPH insulin dividing the dose equally q 12 hours or as a single dose of evening Lantus insulin. - SSI coverage (see subcutaneous SSI section).- Monitor glucose levels q 4 to 6 hours. - On the following day add ½ to 2/3 of previous days sliding scale insulin

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coverage to NPH regimen; continue to adjust dose until glucose levels are consistently at goal.

2. Transitioning to insulin added to parenteral nutrition solutions (TPN)

- Patients must be medically stable* and transfer to an unmonitored unit is anticipated.

- Insulin in TPN is ordered by the patient’s physician on the standard TPN order sheet.

a. Initial Insulin dosing recommendation:

- Add 1/2 to 2/3 the amount of previous 24 hours insulin drip requirement to the next TPN bag.

- Discontinue the insulin drip when the new TPN bag is hung (standard hang time is 9 PM).

- If the TPN order was submitted before the decision for transition was made, call pharmacy before 6 PM (328-5633) to request addition of insulin to TPNIndicate change with the physicians initials, date and time on original TPN order sheet.

- Order subcutaneous SSI coverage and glucose monitoring q 4 to 6 hours (see subcutaneous SSI section).

- For titration and management of insulin in the TPN see upcoming section.

- NPH or other long acting insulins should not be ordered for patients receiving TPN.

b. Titration of TPN insulin

If BG > 150 mg/dl - add ½ to 2/3 of the previous days more than once for SSI coverage to next TPN bag.the previous 24 hours If BG 100 - 150 mg/dl - maintain amount of insulin in bag.

If BG < 100 mg/dl - decrease amount of insulin in more than once for next TPN bag by 1/3 to ½.the previous 24 hours If BG < 60 mg/dl - discontinue TPN and start D10W at

the same rate for 4 to 8 hours, then change to D5W 0.45NS with 20 meq / liter KCl or other appropriate IV fluid.

- Check BG levels q4h and continue SSI. - For the next TPN order decrease amount of insulin by 1/3 to ½.

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- Continue sliding scale insulin coverage and titrate as needed.

G. Treatment of diabetic ketoacidosis (DKA) and hyperosmolar hyperglycemic state (HHS).

Successful treatment of these conditions requires not only controlled correction of the hyperglycemia, but also correction of significant electrolyte and acid-base imbalances and dehydration. The treatment of DKA and HHS should be carried out under the close supervision of a physician familiar with these conditions in a monitored patient care environment.

The following are general management guidelines:

It is important to start hydration prior to starting insulin therapy and continue these efforts until restoration of euvolemia - patients with DKA and HHS often are intra-vascularly depleted (osmotic diuresis, associated with hyperglycemic states) and insulin may cause additional fluid shifts into the intracellular space. These fluid shifts may precipitate hypotension or vascular collapse. The patient’s volume status and renal function must be closely monitored.Insulin will cause K+ shifts into the cells and may lead to profound hypokalemia and related arrhythmias; pre-existing hypokalemia (serum potassium < 3.5 mEq/L) should be corrected before initiating insulin therapy and serum electrolytes must be monitored frequently during the acute treatment phase.

Insulin therapy:

- Insulin therapy should be administered via an intravenous route- The recommended initial regular insulin infusion rate is 0.1 units/kg/hour.- Glucose levels should be monitored q 1hour - Glucose levels should decrease by 50 to 100 mg/dl/hour.- If the glucose levels do not decrease by > 50mg/dl/hour and the patient’s hydration and electrolyte status are acceptable, the insulin rate may be increased by 1 unit per hour every hour until a steady decrease in plasma glucose of between 50 to 100 mg/dl/hour is achieved. - When the plasma glucose declines to 250 mg/dl for DKA or 300 mg/dl for HHS, Dextrose 5% should be added to the patients intravenous fluids; - The rate of insulin administration and/or the concentration of IV glucose should be adjusted gradually to maintain glucose levels between 100 to 150 mg/dl until the metabolic acidosis (DKA) or obtundation (HHS) resolve. - THE FIRST DOSE OF LONG ACTING SUBCUTANEOUS INSULIN SHOULD BE GIVEN AT LEAST 2 HOURS BEFORE DISCONTINUATION OF THE INSULIN DRIP.

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V. Hyperglycemia management – abbreviated algorithm:

*attached in separate document

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VI. Human insulin – brief drug information

CONTRAINDICATIONS / PRECAUTIONS

Use with caution in patients with renal or hepatic impairment.

Insulin adsorption: Insulin adsorption into plastic IV infusion sets has reportedly removed up to 80% of a dose, but 20% to 30% is more common. Percent adsorbed is inversely proportional to insulin concentration; it takes place within 30 to 60 minutes. Because this phenomenon cannot be accurately predicted, careful patient monitoring is essential. Using glass containers does not reduce the adsorption effect because insulin appears to be adsorbed to glass as well. Make dosage adjustments (if any) with caution following a bag change to compensate for the adsorption phenomena.

PREGNANCY CATEGORY

Pregnancy Category B

ADVERSE EFFECTS

Cardiovascular: Pallor, palpitation, tachycardiaCentral nervous system: Fatigue, headache, hypothermia, loss of consciousness, mental confusionDermatologic: Redness, urticariaEndocrine & metabolic: Hypoglycemia, hypokalemia Gastrointestinal: Hunger, nausea, numbness of mouthLocal: Itching, stinging, or warmth at injection siteNeuromuscular & skeletal: Muscle weakness, paresthesia, tremorsOcular: Transient presbyopia or blurred visionMiscellaneous: Anaphylaxis, diaphoresis

DRUG INTERACTIONS

- Drugs which may DECREASE the effect of insulin:Oral contraceptives, corticosteroids, diltiazem, dobutamine, epinephrine, niacin, thiazide diuretics, thyroid hormone

- Drugs which may INCREASE the effect of insulin:Alcohol, alpha-blockers, anabolic steroids, beta-blockers*, clofibrate, guanethidine, MAO inhibitors, pentamidine, phenylbutazone, salicylates, sulfinpyrazone, tetracyclines

*Nonselective beta-blockers may delay recovery from hypoglycemic episodes and mask signs/symptoms of hypoglycemia. Cardioselective agents may be suitable alternatives.

MONITORING

Like insulin dosing, monitoring therapy should be individualized. The clinical response should be relatively rapid, but not instantaneous.

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See specific treatment regimens for blood glucose monitoring recommendations. Make adjustments to these recommendations as the clinical situation dictates.

Monitor electrolytes, especially potassium, as dictated by the clinical situation and patient’s condition.

STORAGE

The stability of parenteral admixture of regular insulin at room temperature (25°C) and at refrigeration temperature (4°C) is 24 hours.

AVAILABILITY

The standard IV insulin infusions are:- 150 units of regular insulin in 150 ml of normal saline- 250 units of regular insulin in 250 ml of normal saline

VII. The Joslin Diabetes Center is available for assistance with diabetes management or education. Fax consult form to 328-6138.

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iv insulin - final

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