VINAYAKA MISSIONS INSULIN THERAPY PROTOCOL IN CRITICALLY ILL PATIENT Prepared by

KNOWN DM / HIGH BG Baseline HbA1C Stable HEMODYNAMIC STABILITY Unstable

Dr. Meyei S. Appachi

BG > 250 mg/dl?

YES NO

START IV INSULIN THERAPY & Check K+ q2h Signs of DKA/HHS?

NO YES

ORAL / RT FEEDING START S/C INSULIN THERAPY & Check K+ q24h Dose: 0.5 Unit/Kg/Day 50% Basal Insulin (BI) NPH in 2 divided doses (or) GLARGINE in Single dose 50% Recheck BG q6h Nutritional Insulin (NI) HUMAN ACTRAPID in 3 divided doses BG > 140 mg/dl BG < 140 mg/dl

Treat as DKA/HHS

BG 140-180 mg/dl IV Infusion * No IV Bolus

BG > 180 mg/dl IV Bolus * + IV Infusion *

* Dose in Units for Bolus & Infusion = Initial BG 70 (Round to nearest 0.5U)

Insulin Infusion Maintenance Therapy

BG 140-180 mg/dl BG Level Instruction on Infusion Rate (See Next Table) Continue Same Rate Infusion by BG Level or Unchanged < 140 BG > 180 mg/dl Instruction on Infusion Rate (See Next Table) Infusion by Infusion by 2 Stop Infusion Check BG q1h, Until BG > 140. Then Infusion by 2

BG TARGET Pre-meal <140 mg/dl Post-meal <180 mg/dl

Unchanged

Achieved?
< 140
YES NO

Infusion by 2 Stop Infusion Check BG q1h, Until BG > 140. Then Infusion by 2 Current Infusion Rate (U/hr) <3 3-6 6.5 - 9.5 10 - 14.5 15 - 19.5 20 - 24.5 > 25 < 100

Continue same Insulin dose

#

Supplemental Insulin (SI): Human Actrapid Insulin #

< 100

Supplemental Insulin Stat Dose Calculation

Insulin Required = [Actual BG Desired BG] [CF]

Correction Factor (CF) = 1800 Kcal Total Daily Insulin Note: Persistent requirement of SI for a meal 3 days should be averaged and added to NI for that meal thereafter

= Rate Change (U/hr) 0.5 1 1.5 2 3 4 5

- Page 2 BG Monitoring during IV Insulin Therapy Transition from IV to S/C Insulin Therapy in DM Patients
NPH in 2 divided doses (or) Glargine in Single dose (Dose: 0.2 0.3 U/Kg/Day) + Human Actrapid (Dose: 2 Infusion Rate)

Check BG q1h, Until stable (3 Consecutive values in Target range) Check BG q2h for 12 -24 hrs, if stable Check BG q3-4h Resume q1h BG checks if: Change in Infusion rate Corticosteroid therapy Vasopressor therapy Change in Clinical status Change in Nutritional Support

Stop Insulin Infusion Immediately When to change? Hemodynamically stable Able to eat orally At discharge from ICU

Hypoglycemia (< 80mg/dl) during IV Insulin Therapy

BG < 60 mg/dl BG 6079 mg/dl

Stop Infusion

Stop Infusion

Give 100ml D25% (25g) BG q10-15min

Symptomatic Give 100ml D25% (25g) BG q15min

Asymptomatic Give 50ml D25% (12.5g) or 20g Sugar/Equivalent PO/RT BG q15-30min

BG > 140 mg/dl BG in 1 hr BG still > 140 mg/dl

BG > 140 mg/dl BG in 1 hr BG still > 140 mg/dl

Resume Insulin @ rate Resume Insulin @ rate

Dr. V.P.Eswaran

Dr. Krishnachetty

Dr. V.P.Chandrasekaran

Dr. Shuba

Vinayaka Missions University, Salem