Nurse Driven Intravenous Insulin Protocol among critically ill patients
Target Population:
Critically ill patients with hyperglycemia
Exclusion:
Critically ill patients with diabetic emergencies, as DKA, hyperglycemic
hyperosmolar state
Definitions:
Target blood glucose: (BG) 110-149 mg/dl
Hyperglycemia: BG ≥ 150 mg/dl
Hypoglycemia: BG ˂ 70 mg/dl
Intravenous insulin administration:
Standard insulin infusion; 50 IUs ARI in 50 ml of 0.09% Nacl via an infusion
device, units are in milliliters per hour
Initiating infusion:
All patients start in algorithm 0
Start insulin infusion when two consecutive BG level are ≥ 150 mg/dl, or
when one BG measurement is ≥ 200 mg/dl.
Ensure that patient receiving calories before insulin infusion (IV dextrose,
TPN, or EN).
Moving from algorithm to algorithm:
- Moving up: algorithm failure is defined as BG outside the target range (110-
149), BG levels increased by at least 40 mg/dl between two consecutive
measurements, or when BG remains unchanged for the last two consecutive
measurements.
- Moving down: when BG decrease by at least 40 mg/dl between two
consecutive measurements.
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- Maintenance: if BG continue to remain within the desired range (110-
149mg/dl)
Hold/discontinue intravenous insulin infusion
- If tube feeding therapy discontinued for any reason
- If BG ˂ 110 mg/dl
Monitoring of patients:
- Use a bedside glucometer or undiluted heparinized arterial blood (if SBP˂ 80
mmHg).
- Check BG level each hour in the first 8 hours of initiating the insulin protocol,
and then every two hours within target range for 8 hours.
- If patient's BG level is within the target range for 8 hours, decrease frequency of
measurement to every 4 hours.
- When the BG level falls out of the target range or if algorithm moves,
measure every hour in two hours and then measure every two hours until reach
the target range.
Treatment of hypoglycemia
- Turn off the insulin infusion
- Administer 25 ml of dextrose 25% bolus, and recheck BG after 30 min and
administer 25 ml of dextrose 25% if BG still ≤ 70 ml/dl
- If BG ˃ 70 but ≤ 110 mg/dl stop infusion and recheck each hour
- If BG ˃ 110 but ≤ 1150 mg/dl stop infusion and recheck each hour
- Recheck each every 2 hour. And restart the algorithm 0
Notify the physician:
- For any change in BG level more than 100 mg/dl between two consecutive
measurements
- If BG level ≥ 300 mg/dl
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- For unresponsive hypoglycemia that doesn't resolve after dextrose
25%intravenous
- Failure of algorithm 4 consult the endocrinologist
Intravenous insulin protocol algorithm:
BG (mg/dl) Algorithm 0 Algorithm 1 Algorithm 2 Algorithm 3 Algorithm 4
110-149 0-0.5(ml/h) 0.5 1 1.5 2
150- 179 0.5 (ml/h) 1 2 3 4
180-209 1 (ml/h) 2 3 4 5
210-239 1.5 (ml/h) 3 4 5 6
240-269 2 (ml/h) 4 5 6 7
270-299 2.5 (ml/h) 5 6 7 8
300-329 3 (ml/h) 6 7 8 9
330-359 4 (ml/h) 6 7 9 11
>360 5 (ml/h) 8 12 14 16
Reference
Khalaila R, Libersky E, Catz D, Pomerantsev E, Bayya A, Linton D, Sviri S.
Nurse-Led Implementation of a Safe and Effective Intravenous Insulin Protocol
in a Medical Intensive Care Unit. Crit Care Nurse. 2011; 31(6): 27-35.
Prepared by:
Prof. Dr. Nagwa Ahmed Reda (Professor of critical care & emergency nursing)
Dr. Saher Elshenawy (Lecturer of critical care & emergency nursing)
Dr. Sherief Abdel Fatah (Lecturer of Critical care Medicine)
Mokhtar Abdo Almoliky (Assistant Lecturer of Critical Care Nursing)
Reviewed by:
Prof. Dr. Bassem Nashaat
(Assistant Professor of Critical care Medicine - Alexandria University)
(Developed May2017) Page 3 of 3
