The protocol-directed insulin infusion sliding scale is a safe and effective method. Insulin Infusion Protocol in the ICU. Consider starting a 10% dextrose infusion to maintain euglycemia ii. To achieve these goals, computer-based insulin infusion protocols have demonstrated their . - Choose the correct protocol. This has led to disagreement between "evidence-based" guidelines: The Society of Critical Care Medicine recommends targeting a glucose level of 140-180 mg/dL. The targeted blood glucose concentration range was 80-130 mg/dL. Comparison: Continuous infusion of intravenous regular insulin.. Intensive care unit (ICU) patients commonly display hyperglycemia, even without previously known diabetes. Target Blood Glucose = 140-180 mg/dL - Recommend initiating protocol when blood sugar is GREATER OR EQUAL to 180 mg/dL for two consecutive readings. Blank Order Form. BG 41-70: Give 1/3 amp D50 IV. Our protocol is about five pages long. 42. Maynard G, et al. Weight based dosing for insulin is a good starting point but dosing will likely need to be adjusted based on the Methods: Where available, the literature was evaluated using Grades of Recommendation, Assessment, Development, and Evaluation (GRADE) methodology to assess the impact of insulin infusions on outcome for general intensive . Aim to keep the BGL between 5-10 mmol/L. Once stabilized the patient can have glucose monitoring as inferequently as every 2 hours which significantly decreases the workload on the bedside . infusion over 20 to 120 minutes, followed by continuous infusion (up to 15mg/kg in up to 500ml G over 24 hours) Dilute in G only. Repeat BG q15m until BG >70 mg/dL. u Glucose <40 mg/dL: Give 1 ampule D50W (25 grams glucose) by slow IV push over 30 seconds u Decrease insulin drip rate by moving down 1 algorithm (i.e. In the intensive-treatment group, insulin infusion was started when the blood glucose level exceeded 110 mg per deciliter (6.1 mmol per liter) and was adjusted to maintain normoglycemia (80 to 110 . Implementation of a safe and effective insulin infusion protocol in a medical intensive care unit. . Insulin management: ICU/ACCC team to: Initiate Step 2 of 2: DKA/HHS/EDKA (glucose 250 mg/dL) order set with an initial insulin infusion rate of 0.1 unit/kg/hour6,7 Initiate long-acting insulin: glargine 0.125 unit/kg subcutaneous every 12 hours6,8 Titrate insulin infusion per Notify Endocrinology-Diabetes if insulin is stopped No -If blood glucose does not fall by 10% in first hour, give bolus of 0.14 units/kg while continuing insulin infusion. Implementation of a Safe and Effective Insulin Infusion Protocol in a Medical Intensive Care Unit. J. Med. Avg rating: 3.0/5.0. To evaluate the safety and effectiveness of an evidence-based insulin infusion protocol targeting moderate glycemic control in cardiac surgery patients. 41. The insulin doses in the previously published protocols are very high compared with usual . The initial glucose target was 100-140 mg/dL, based on a 2001 study demonstrating the benefits of glycemic control in that range among critically ill patients ( N. Engl. Usual dilution 300mg in 100mls G, then 900mg-1.2g in 250mls G (ICU/HDU) or 600-900mg in 46-48ml G as appropriate (run at 2ml/hr)(Cardiac . The Portland Protocol Titration Guidelines are listed below. 2004;27(2):461-7. Diabetes Care. Intensive insulin therapy: One early RCT showed a mortality benefit to tight blood glucose control (the Leuven protocol for intensive insulin therapy, goal BG 110-140). Outcome: Duration of therapy, time to resolution of DKA, time to resolution of hyperglycemia, ICU admission, ICU length of stay, hospital length of stay . Primary doc arrived and said continue with the insulin drip, then put him on sliding scale when he's below 140 for two hours. Blank Order Form. 2 Performance of the updated insulin infusion protocol (dataefits of tight glycemic control in the critical care settingpoints represent the first 72 hours of insulin infusion). The insulin infusion protocol (IIP) already being used in the ICU, the Beckett protocol, would now be used in all units. .D/C INSULIN INFUSION. The protocol. This is an active management protocol. Glucose Monitoring Orders: Perform blood glucose monitoring every hour until within . Initiate insulin infusion 1 to 2 hours after starting fluid replacement therapy. CLICK HERE FOR ONCOLOGY / INFUSION ORDERS. - IV regular insulin has a half life of 78 minutes. insulin infusion . When glucose is less than <200, add dextrose to fluids and decrease the rate to .05units/kg/hr. Insulin infusion is made up using human actrapid insulin 50 units to 50ml sodium chloride 0.9% (1 . 1 of 4- iv insulin infusion protocol for critically-ill Adult patients in the icu setting . -Dose: 0.14 unit/kg/hour IV; alternatively, a bolus of 0.1 unit/kg followed by an infusion of 0.1 unit/kg/hr has been used. Summary. Medical & Surgical Patients: Continue Portland Protocol throughout ICU stay. 4/15/2020! Evidence for Insulin Therapy. A patient must be in the ICU to use the HIGH DOSE insulin infusionColumns 7 -9. If tube feeds are stopped, hold scheduled regular insulin a. in insulin infusion rate, double the insulin infusion rate If Glucose decreases greater than 100 mg/dl in one hour, call physician Do not follow hypoglycemia protocol D/C drip if rate 2 or less for >24hours. However, this may not be generalizable to most ICU patients as it used a nutritional strategy that is not the standard of care (van den Berghe et . & administer 1/2 Amp (12.5 g) D50 IV; recheck BG q 15 minutes until 90 mg/dl. Portland Protocol for Continuous IV Insulin Infusion ICU patients Target: 70 - 110 1. Thomas JM, Kaiser C, Huey WY, Ward MR, Zack JE, Coopersmith CM: Efficacy and safety of an insulin infusion protocol in a surgical ICU. Hold if patient is NPO 3. Once BG >110 mg/dL, check BG hourly and restart infusion at 1/2 prior rate once BG >180 mg/dL. 9) treat for hypoglycemia if glucose <60 mg/dL or _____ mg/dL. 1. Question Is a subcutaneous insulin protocol implemented at a hospital level associated with use of intensive care and other outcomes among adults with diabetic ketoacidosis?. The patient's blood sugar is monitored hourly and the insulin dosage is adjusted based on the drop in the blood sugar. Less sequela of critical illness, injury, or intervention. For patients previously undiagnosed diabetes (DM) who present with Providers: If patient has active insulin / non-insulin ANTIHYPERGLYCEMIC orders, please consider . Description: What were the positive points of the past management model? Diabetes Care 2004;27(2):461-467. However, a more stringent goal of 110-140 mg/dl may be appropriate for certain patients, provided it can be achieved without causing significant hypoglycemia. Qaseem A, Chou R, Humphrey LL, Shekelle P. Clinical Guidelines Committee of the American College of Physicians. Objective: To evaluate the literature and identify important aspects of insulin therapy that facilitate safe and effective infusion therapy for a defined glycemic end point. Year: 2010. . Adherence to the former protocol was inconsistent because (1) the nurse was required to calculate the new rate of insulin infusion according to a percentage change from the previous rate (e.g., if BG level decreases by 25%, then decrease the rate of insulin infusion by 10%), (2) adjustment was not clearly specified (e.g., increase insulin by 1 . If it goes over 150, an insulin drip is started. Blood glucose control is improved when compared with the conventional practitioner-directed insulin infusion sliding scale. . It was demonstrated that hyperglycemia was associated with increased hospital mortality in various medical and surgical ICU situations. . A state of absolute or relative insulin deficiency resulting in hyperglycemia, dehydration and accumulation of ketone bodies in the blood with subsequent metabolic acidosis (pH < 7.30; serum bicarbonate < 15 mmol/L). If mild or moderate DKA initiate insulin subq and use floor DKA protocol as written below Floor Protocol: Note: 1. operating room; SICU = surgical intensive care unit; TGL = target glucose level; vs = versus. *See algorithm on insulin administration during critical care admission* . COVID-19 General Plan. This trial evaluates the efficacy and safety of this protocol (algorithm A), compared to a standard endovenous insulin infusion protocol (algorithm B) and a conventional subcutaneous insulin protocol (algorithm C). YaleNew Haven (Conn.) Hospital has used a standardized intravenous insulin infusion protocol (IIP) in its medical ICU since 2003. Most patients: start insulin at 0.1 U/kg/hr (up to a max of 15 U/hr). Background Achieving good glycemic control in intensive care units (ICU) requires a safe and efficient insulin infusion protocol (IIP). Implementation of a Safe and Effective Insulin Infusion Protocol in a Medical Intensive Care Unit. 3. Clin Ther. We have critical care trucks with critical care protocols that address insulin infusions. NOT be used in diabetic ketoacidosis (DKA ) or . Getting started: Hold insulin if K <3.3 mM. PMID: 14747229; Tamaki M, Shimizu T, Kanazawa A, et al. If subcutaneous insulin (correction scale or scheduled) is ordered, discontinue the insulin infusion 2 hr after the 1st dose of SubQ insulin. We suggest that a BG 150 mg/dL should trigger initiation of insulin therapy, titrated to keep BG < 150 mg/dL for most adult ICU patients and to maintain BG values absolutely <180 mg/dL using a protocol that achieves a low rate of hypoglycemia (BG 70 mg/dL) despite limited impact on patient mortality. . Start with 0.1 u/kg/hr of regular insulin, with out any insulin bolus. ! What sets the Beckett protocol apart from other . 4. Continue insulin infusion per protocol, until ALL the following criteria are met: If no adverse events occur the intravenous insulin infusion should be ceased 30 to 60 minutes after the meal. Efficacy and safety of modified Yale insulin infusion protocol in Japanese diabetic patients after open-heart surgery. target range . DKA INSULIN INFUSION TITRATION (BG) (mg/dL) Trend Insulin Infusion Titration 0-70 ---- 4. 1 . .D/C INSULIN INFUSION. OBJECTIVES: To measure critical care nurses' knowledge of glycemic control in cardiac surgery before and after education. Congress: 70th Scientific Sessions (2010) Category: Pharmacologic Treatment of Diabetes or its Complications. ADM Diabetic Ketoacidosis Order Set. Indications for IV insulin infusion If glucose level falls below 70, discontinue insulin drip These Inpatient glycemic control: Best practice advice . The patient's basal (long acting) subcutaneous insulin regimen should have been Continuous intravenous insulin infusion is the best method for achieving glycemic targets in the critically ill patient , and several infusion protocols for ICU patients that included computer-guided management were reported previously [12,13,14,15,16,17]. Insulin SUBACUTE 100-150 Infusion Protocol. Yale IIP patients vs historical controls Goldberg PA et al (2004). Fig. Using the Beckett protocol. ICU Insulin Drip Order Set for Target Blood Glucose 140-180 mg/dL [1267] . Two-step protocols include those by Chant, Furnary, Kanji, Van den Berghe, and Zimmerman. 2. ICU Insulin Infusion Protocol (IIP) for Adults The following IIP is intended for use in hyperglycemic adult patients in the ICU, adapted from our earlier protocols, in keeping with the latest glucose guidelines from national organizations.