Neonatal Critical Care Hyperglycemia Management Guideline

Recommended initial action for hyperglycemia

  • Reduce glucose infusion rate (GIR) to 4-6 mg/kg/min. Recheck blood glucose (BG) hourly. If BG remains >200 x 2, proceed to insulin guideline.

Eligibility criteria for insulin

  • BG > 200 mg% x 2 (separate each sample by 1 hour)
  • Patients with neonatal diabetes mellitus should not be managed with this guideline.

Recommended initial insulin dose

  • Begin a continuous IV drip of insulin at 0.05 units/kg/hour
  • Maximum rate allowed by this guideline: 0.5 units/kg/hour
  • Insulin bolus doses are not recommended for BG titration in this guideline.

Recommended BG sampling

  • Measure BG every hour while on insulin until BG is stable.
  • Sampling frequency may be reduced by provider order if BG 101-150 mg% for at least 6-12 hours with no dosing adjustments required.
  • After insulin is stopped, sample BG every 2 hours x 2, then every 4 hours x 3.
  • Draw BG samples from an arterial line, heel stick, or central venous line. Do not draw samples from lines that infuse a dextrose-containing fluid. Clamp the dextrose-running lumen if sampling from a double lumen line.

Recommended management guide

BG (mg%) / Recommendation
<60 / Stop/Suspend insulin, administer 2 mL/kg of 10% dextrose, notify NNP or neonatologist, then re-sample BG in 30 minutes
60-100 / Stop/Suspend insulin then notify NNP or neonatologist
101-150 / Stop/Suspend insulin
151-200 / Computer titrated target range while on insulin drip
>200 / Computer adjusts insulin drip more aggressively to lower BG

Guideline finalized: August 21, 2015

Cerner rules for neonatal critical care hyperglycemia

BG Result / Insulin drip is OFF / Insulin drip is ON
BG drop
<25 mg%/hr
or increase / BG drop
26-74 mg%/hr / BG drop
>75 mg%/hr / Other Recommendations
<60 /
  • Administer 2 mL/kg 10% dextrose,
  • Notify NNP or neonatologist, then
  • Re-check BG in 30 minutes
/
  • Stop/Suspend insulin,
  • Administer 2 mL/kg 10% dextrose,
  • Notify NNP or neonatologist, then
  • Re-check BG in 30 minutes

60-100 /
  • Notify NNP or neonatologist
/
  • Stop/Suspend insulin, then
  • Notify NNP or neonatologist

101-150 / Insulin not recommended /
  • Stop/Suspend insulin

151-200 / Insulin not recommended / Continue same insulin dose / Decrease insulin dose by 25% / Decrease insulin dose by 50% / If insulin rate < 0.02 units/kg/hr, stop insulin and measure BG Q2 hours x 2, then Q4 hours x 3
201-250 /
  • If no previous BG >200 within a 45 min to 2 hour time frame, use Conditional Order to repeat glucose in 1 hour
  • If 2 successive BG >200 within a 45 min to 2 hour time frame, “Notify NNP or neonatologist that insulin is recommended in this patient per protocol.”
/ Increase insulin by 25% / Continue same insulin dose / Decrease insulin dose by 50% and notify NNP or neonatologist
>250 / Increase insulin dose by 50% and notify NNP or neonatologist / Continue same insulin dose / Decrease insulin dose by 50% and notify NNP or neonatologist / Maximum rate allowed is 0.5 units/kg/hr

Guideline finalized: August 21, 2015