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MICU Insulin Drip Protocol

TARGETRANGE FOR BLOOD GLUCOSE = 80-110 mg/dL

A Critically Ill Patient Qualifies For The MICU Insulin Drip Protocol If:

  • Confirmed blood glucose is >110mg/dLAND the anticipated MICU length of stay is >24-hrs.
  • If the patient is on TPN while in the MICU, coordinate insulin management with endocrine/metabolic support team.
  • Call endocrine/metabolic support team for all Type 1 DM patients.
  • Patients with diabetic ketoacidosis should not be placed on this protocol.

Start Continuous Insulin Drip Protocol For:

  • Type 1DM pts with initial glucose80 mg/dL
  • Type 2 DM or Stress Hyperglycemia pts with initial glucose >110mg/dL
  1. Order insulin drip mixed as 50 units of regular insulin in 500cc of NS (1:10 mixture). If the patient needs to be fluid restricted, alternatively order drip as 100 units of regular insulin in 500cc of NS (1:5 mixture).
  1. Intravenous Fluids: If not on enteral or parenteral feeding, ensure ptgets 5-10g of glucose/hr

e.g. D5W or D51/2NS at 100-200mL/hr or equivalent

  1. Monitor protocol efficacy with hourly glucometer BG measurements.
  1. Can extend BG check to q4hrs when all 3 of the following conditions are met:
  • 3 consecutive glucose values are between 80-110mg/dL
  • No change in insulin infusion rate has occurred for 3 consecutive glucose measurements
  • Nutritional/Dextrose intake has not changed during these 3 measurements
  1. If any of the following occur, consider the temporary resumption of hourly BG monitoring, until BG is again stable (2-3 consecutive BG values are within target range):
  • Any change in insulin infusion rate (i.e. BG out of target range)
  • Significant changes in clinical condition
  • Initiation or cessation of pressor or steroid therapy
  • Initiation or cessation of renal replacement therapy (HD, CVVH)
  • Initiation, cessation, or rate change of nutritional support (TPN, PPN, enteral feeding)
  1. For transport out of the MICU: D/C IV insulin, hold tube feeds, D/C D10 as indicated (continue if patient has received NPH within 24-hrs), and check glucose prior to transport. TPN should continue. For Type 1 DM pts on an insulin drip, ensure dextrose infusion, and decrease drip rate by 75%-->do not completely discontinue drip.
  1. For patients who are taking PO meals while on an insulin infusion, additional SQ insulin aspart coverage should be providedbefore each meal as per the following table.
  • Please Note:RN must assess pt’s appetite to estimate if pt will be eating > 50% or < 50% of meal prior to administering SQ insulin aspart.

Insulin Aspart Coverage Schedule
Drip rate / Eats > 50 percent of meal / Eats < 50 percent of meal
0-2 / 4 units / 2 units
2-4 / 6 units / 3 units
4-6 / 8 units / 4 units
6-8 / 10 units / 5 units
8-10 / 12 units / 6 units
>10 / 14 units / 7 units
  1. Conversion: Insulin drips should be discontinued and converted to a SQ protocol when transfer decisions are made during AM rounds. Provide adequate overlap between insulin drip and SQ insulin. DO NOT STOP THE INSULIN DRIP WITHOUT PROVIDING ENOUGH TIME FOR THE SQ INSULIN TO KICK IN.
  2. If the first dose of SQ insulin is ASPART, wait 30 minutes before turning off drip.
  3. If the first dose of SQ insulin is either GLARGINE or NPH, wait 2 hours before turning off drip.
  1. Conversion should be made as follows:
  1. Patient is eating and has Type 1 or Type 2 DM:

Step 1: Give 75% of the total daily dose as insulin glargine q24

Step 2: Provide additional meal time insulin aspart coverage as per the above table.

  1. Patient is eating and has Stress hyperglycemia (no prior diagnosis):

Stop insulin drip. Patient should be re-evaluated by primary floor team for need of further insulin therapy.

  1. Patient is receiving 24-hr tube feeds(regardless of Type 1 vs Type 2 DM):

i)If total daily dose of insulin is 20 units or less, give 75% of total daily insulin requirement as insulin glargine q24 with regular SSI q6 per TDS order set.

ii)If total daily dose of insulin is 20-40 units, then give 75% of total daily insulin as insulin glargine q12 with regular SSI q6

iii)If total daily dose of insulin is 40-80 units, then give 75% of total daily insulin as insulin NPH q6 with regular SSI q6

iv)If total daily dose of insulin is >80 units, then give 75% of total daily insulin as insulin NPH q6 with aspart SSI q3

  1. Patient is on TPN only (unable to tolerate either PO or tube feeds):Conversion to SQ insulin therapy should be done in coordition with the endocrine/metabolic support team.

Adapted from: Goldberg PA, Siegel MD, Sherwin RS, Halickman JI, Lee M, Bailey VA, Lee SL, Dziura JD, Inzucchi SE. Implementation of a safe and effective insulin infusion protocol in a medical intensive care unit. Diabetes Care 2004; 27:461-7