1. Target Blood Glucose level in ICU: 140 - 180 mg/dL.
2. Preparation of Insulin
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Add 40 units Regular insulin (1 ml) to 39 ml of 0.9% NaCl (This gives 40 Units in 40 ml OR 1 unit/ml). |
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Infuse IV Insulin using Syringe Pump only. |
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Prime the IV tubing before infusion begins. |
3. Insulin: Bolus and Initial Infusion Rate
3.1. Start Insulin Infusion when Blood Glucose > 200mg/ dl for consecutive 2 readings done 2 hours apart.
3.2. Divide initial Blood Glucose by 100, and then round to nearest 0.5 U for bolus and initial infusion rate.
Example: Initial BG = 374mg/dL = 3.74, round to 3.5 U
Give IV bolus = 3.5 U
Start infusion @ 3.5 U/hr
4. Monitoring
4.1. Check blood glucose 1hourly until stable (3 consecutive values within target range) and then every 2 hours once stable in all patients receiving IV Insulin.
4.2. If patient is not on IV Insulin, blood glucose shall be checked every 12 hours and as needed.
4.3. If any of the following occur, check Blood glucose at least 1-hrly until stable.
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Any change in insulin infusion rate. |
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Significant changes in clinical condition. |
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Initiation or cessation of vasopressor or steroid therapy. |
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Initiation or cessation of Renal Replacement Therapy (RRT). |
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Initiation, cessation or rate change of nutritional support. |
4.4. Changing the Insulin Infusion Rate
● If Blood glucose<75 mg/dL or SYMPTOMATIC HYPOGLYCEMIA
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Stop Insulin infusion. |
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Give 50 ml 50% Dextrose IV bolus. (Two Ampoules of 25 ml 50% Dextrose) |
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Recheck blood glucose in 15 mins. If BG< 75 mg/dL, Repeat 50% Dextrose 50 ml IV Bolus. |
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Recheck blood glucose every 15 mins till BG > 100mg/dL then q 1 hourly. |
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Restart Insulin Infusion ONLY when blood glucose > 200mg/dL for consecutive 2 readings done 1 hr. apart and move one algorithm to the left than before. |
● If Blood glucose = 50 -100 mg/dL
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Stop Insulin. |
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If symptomatic – treat as per hypoglycemia. |
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If asymptomatic – reassess every 30 min. |
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When Blood glucose > 200mg/dL for consecutive 2 readings done 1 hr. apart, then Restart Insulin infusion and move one algorithm to the left than before. |
● If BG >100 mg/dL, follow the following Table 1.
Table 1: Blood glucose management using insulin infusion
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No adjustment in insulin infusion rate if blood glucose is within goal range. |
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Move one algorithm towards right in following conditions: ● If blood glucose <200 mg/ dL and when blood glucose is outside goal range and has not decreased for 2 hour. ● If blood glucose >200 mg/ dL and has not decreased by>60mg/ dL in1hour. |
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Move one algorithm towards left in following condition: ● If blood glucose < 100 for two times OR if blood glucose has decreased by>100mg/dL in one hour. |
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Consult Endocrinologist if blood glucose is not controlled by Algorithm 3. |
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Reduce the Insulin infusion rate by 50% from 12 midnight to 6 AM. |
Further readings:
1. Kelly, J. L., Hirsch, I. B., & Furnary, A. P. (2006, December). Implementing an intravenous insulin protocol in your practice: practical advice to overcome clinical, administrative, and financial barriers. In Seminars in thoracic and cardiovascular surgery (Vol. 18, No. 4, pp. 346-358). WB Saunders.
