First name Surname

Variable Rate Intravenous Insulin Infusion

Hosp No. Sample only - not NHS No. DOB

(VRIII) for Glycaemic Control in Non-

Diabetic Adult Critical Care Patients
Consultant
for clinical use
(Use addressograph if available)
Ward Hosp

Cross reference this chart on the main inpatient drug chart. Check allergy status on main drug chart

1. Indications for VRIII:

Adult critical care patients who are NOT KNOWN to be diabetic

Do not use unless blood glucose >10mmol/L on TWO CONSECUTIVE recordings one hour apart

Once started, the VRIII can be continued even though blood glucose drops to 6.1-10mmol/L

DO NOT The patient is outside of adult critical care

Use if: The patient is a known diabetic - use Adult Variable Rate Intravenous Insulin Chart WPG845
The patient is treated for Diabetic Ketoacidosis (DKA) or Hyperosmolar Hyperglycaemic States (HHS).
Note: Separate charts are available for patients with DKA or HHS.

2. Commence intravenous fluids at the same time as VRIII

Patients must be receiving a glucose-containing infusion (or have an adequate oral intake). This may include parenteral
or enteral feed, or an intravenous glucose infusion.
If intravenous glucose is commenced with the VRIII, both infusions should be administered through either a dedicated
lumen of a vascular access device, or a cannula with a non-return valve.
See page 4 for further advice on fluids. Review insulin infusion rates as directed in the VRIII Prescription Table (see
pages 2 and 3). See page 4 for advice on adjusting rate.

3. Advice on prescribing of initial insulin infusion rates: Prescribe insulin infusion rates on pages 2
and 3

Glucose Monitor Blood

Insulin rates (units/hour) Start on standard rate unless otherwise indicated
mmol/L Glucose every
Reduced Rate - Consider in patients Increased rate - Consider in patients
Standard rate
<50kg, liver failure >90kg

< 6.0 Hour 0 0 0

6.1 - 10 2-4 Hours 0.5 1 2
10.1 - 15 1-2 Hours 1 2 4
15.1 - 20 Hour 2 4 6
20.1 - 24 Hour 3 5 7
>24 Hour 4 6 8
See page 5 for information on treating hypoglycaemia (Glucose <4mmol/L)
If patients are not achieving targets then either use reduced or increased rates or consider a
customised scale
4. The need for VRIII must be reviewed by the clinical team at least once every 24 hours
5. For advice on discontinuation of the VRIII see page 6

Pharmacist Date:
Review Sign:
 Prescribe insulin infusion rates below:
(Read advice on prescribing on page 1 before completing) Check allergy status on main drug chart

PRESCRIPTION
Human soluble insulin (Human Actrapid or Humulin S) 50 units in 50mL sodium chloride 0.9% intravenously via a syringe pump at a variable rate
Aim for blood glucose between 6.1 and 10mmol/L
Doctor: Prescribe insulin infusion rates. If the rates need to be altered, cross out the whole column and write the revised regime in a new
column.
Blood glucose Monitor Blood Insulin rate Revised Insulin rate Blood glucose Insulin rate Revised Insulin rate
mmol/L Glucose every units /hour units /hour mmol/L units /hour units /hour
<6 Hour <6
6.1-10 2-4 hours 6.1-10
10.1-15 1-2 hours 10.1-15
15.1-20 Hour 15.1-20
20.1-24 Hour 20.1-24
>24 Hour >24
Prescriber to sign & print name Prescriber to sign & print name Prescriber to sign & print name Prescriber to sign & print name

Date Date Date Date

Time Time Time Time

Blood glucose measurement record and record of IV insulin administration rate

Blood glucose should be checked as above

Date ADMINISTRATION RECORD Date ADMINISTRATION RECORD

Blood glucose Insulin Rate Blood glucose Insulin Rate
Time (mmol / L) (units / hour) Initials Comments Time (mmol / L) (units / hour) Initials Comments

09: 09:
10: 10:
11: 11:
12: 12:
13:
14:
Sample only - not 13:
14:
15:
16:
for clinical use 15:
16:
17: 17:
18: 18:
19: 19:
20: 20:
21: 21:
22: 22:
23: 23:
24: 24:
01: 01:
02: 02:
03: 03:
04: 04:
05: 05:
06: 06:
07: 07:
08: 08:

Nursing staff- call doctor if:

Doctors/Prescribers:
1. The patient has a hypoglycaemic episode (blood
glucose <4mmol/L). Must review insulin rates and the ongoing need for VRIII
within six hours and then at least every 24 hours
2. The patient has two blood glucose readings
thereafter. If the patients blood glucose is consistently
>12mmol/L, and blood glucose not falling.
not within target range seek senior advice.
3. A single blood glucose reading of 16mmol/L.
Prescribe the rates of insulin below: Check allergy status on main drug chart
(Read advice on prescribing on page 1 before completing)

PRESCRIPTION
Human soluble insulin (Human Actrapid or Humulin S) 50 units in 50mL sodium chloride 0.9% intravenously via a syringe pump at a variable rate
Aim for blood glucose between 6.1 and 10mmol/L
Doctor: Prescribe insulin infusion rates. If the rates need to be altered, cross out the whole column and write the revised regime in a new column

Blood glucose Monitor Blood Insulin rate Revised Insulin rate Blood glucose Insulin rate Revised Insulin rate
mmol/L Glucose every units /hour units /hour mmol/L units /hour units /hour
<6 Hour <6
6.1-10 2-4 Hours 6.1-10
10.1-15 1-2 Hours 10.1-15
15.1-20 Hour 15.1-20
20.1-24 Hour 20.1-24
>24 Hour >24
Prescriber to sign & print name Prescriber to sign & print name Prescriber to sign & print name Prescriber to sign & print name

Date Date Date Date

Time Time Time Time

Blood glucose measurement record and record of IV insulin administration rate

Blood glucose should be checked as above

Date ADMINISTRATION RECORD Date ADMINISTRATION RECORD

Blood glucose Insulin Rate Blood glucose Insulin Rate
Time (mmol / L) (units / hour) Initials Comments Time (mmol / L) (units / hour) Initials Comments
09: 09:
10: 10:
11: 11:
12: 12:
13: 13:
14: 14:
15:
16:
Sample only - not 15:
16:
17:
18:
for clinical use 17:
18:
19: 19:
20: 20:
21: 21:
22: 22:
23: 23:
24: 24:
01: 01:
02: 02:
03: 03:
04: 04:
05: 05:
06: 06:
07: 07:
08: 08:

Nursing staff- call doctor if:

Doctors/Prescribers:
4. The patient has a hypoglycaemic episode (blood
glucose <4mmol/L). Must review insulin rates and the ongoing need for
VRIII within six hours and then at least every 24 hours
5. The patient has two blood glucose readings
thereafter. If the patients blood glucose is consistently
>12mmol/L, and blood glucose not falling.
not within target range seek senior advice.
6. A single blood glucose reading of 16mmol/L.
 Record of Administration of
Soluble Insulin Syringes 50 units in 50mL Sodium Chloride 0.9%
Date Time Insulin 50 units/50mLs batch number Prepared by Checked by

Sample only - not

for clinical use
Summary of Fluid Recommendations with VRIII

Hyperglycaemia in Adult Hyperglycaemia has been recognised in non-diabetic patients experiencing

Critical Care patients critical illness. Also known as stress hyperglycaemia. Several trials have
shown that higher blood sugars may increase mortality in the ICU
environment.
Preventing fluid overload and peripheral oedema is paramount in critical
Sample care management.
Maintenance fluid requirements are approximately 70-100mL/hr.
only - not
This may include Parenteral Nutrition (TPN), or established enteral feed (i.e.
for clinical NG, NJ or PEG feeding).

use If no feed is established, then commence intravenous fluids at the same

Renal or Hepatic Failure
time as VRIII.
If feeding is stopped discontinue insulin or start glucose infusion and
monitor blood glucose every hour until stabilised.
Appropriate intravenous fluids include 5% Glucose or 4% Glucose / 0.18%
Sodium Chloride with potassium supplementation as necessary.
Only a Senior Intensive Care Prescriber should authorise a VRIII infusion
without concurrent glucose maintenance.
Adjust maintenance fluid rates to account for any increased insensible
losses (i.e. pyrexia)
Do not start insulin infusion unless the blood glucose is >10mmol/L on two
consecutive readings one hour apart
Once an infusion is started it can be continued even though blood glucose
drops to 6.1-10mmol/L
Use reduced rate VRIII scale as these patients may have an increased risk
of hypoglycaemia

Treatment of hypoglycaemia when on a VRIII

Hypoglycaemia is defined as blood glucose <4mmol/L

1. Ensure no problem with insulin infusion, rate and infusion of substrate.

2. STOP VRIII

3. Give 150mL of Glucose 10% (over 15 minutes, i.e. 600mL/hour) via an infusion pump. Care should be taken if
larger volume bags are used to ensure that the whole infusion is not inadvertently administered.

4. Repeat blood glucose measurement. If it is still less than 4mmol/L, repeat step 3. If still unresolved seek medical
assistance.

5. If hypoglycaemia not resolved or patient unconscious/ having seizures seek senior advice.

6. Once blood glucose >10mmol/L restart VRIII at an appropriate rate (reduced by 2 units/hour or half of the
previous rate) as soon as possible.

7. Consider reducing VRIII prescription rates to prevent further hypoglycaemic events, if no other cause found.

8. See LTHT treatment of adult hypoglycaemia guidelines on Leeds Health Pathways for further details.
Maintaining Blood Glucose Target Range
Do not start insulin infusion unless the blood glucose is >10mmol/L on two consecutive occasions one
hour apart.
Once an infusion is started it can be continued even though blood glucose drops to 6.1-10mmol/L

If blood glucose is outside of target range (6.1 - 10mmol/L):

Ensure cannula is patent and infusion equipment is working appropriately.
Ensure substrate infusion is running at correct rate.
If above criteria are correct the insulin infusion rate should be altered as follows:

Blood glucose above target and not falling, on two or more consecutive occasions:
Raise insulin dose to the increased rate scale
If patient already on the increased rate, prescribe a customised insulin infusion rate. Seek advice from the diabetes
team if there are ongoing difficulties achieving the target range.

Blood glucose consistently tight (levels between 4 and 6mmol/L on two or more consecutive occasions)
Consider reducing to a lower insulin infusion rate, or discontinuing the VRIII.

If rate of VRIII is changed, cross-off any previously used scales to avoid confusion.

Safety during use of VRIII

Monitoring
Sample only - not for clinical use
Monitor blood glucose at the frequency directed on the chart.
Review insulin infusion rate regularly (as directed in the VRIII table) to achieve target range of glucose.
The need for VRIII must be reviewed by the clinical team at least once every 24 hours.
The patients fluid status must be reviewed by the clinical team at least once every 24 hours.
A glucose source must be provided at all times.
Urea and electrolytes must be reviewed by the clinical team at least once every 24 hours.

Discontinuation of VRIII
This prescription chart is for exclusive use in the critical care environment. Patients MUST NOT be discharged with this
VRIII prescription still active.

At daily review and multi-disciplinary ward round:

The insulin infusion can be discontinued when the acute pathology is resolved (i.e. the patient is stable) AND the
dosage has not exceeded 2 units/hour in the previous 12 hours. Blood glucose should be checked 4 hours later,
and three further times within the first 24 hours.
Or:
If insulin requirements continue to be greater than 2 units/hour, then the presumption is that the patient is either a
new or previously undiagnosed diabetic
Transfer their VRIII prescription to Adult Variable Rate Intravenous Insulin Infusion (VRIII) Prescription Chart
(WPG815). Calculate the initial starting rate based on insulin requirements over the last 24 hours
Ensure that there is an appropriate glucose-containing infusion prescribed
Ask the critical care or receiving team to refer to the diabetic team for management of the patients future
glycaemic control

Special situations with VRIII

Nutrition
If NG or TPN feeding is stopped whilst patient is on this VRIII, there is a significant risk of hypoglycaemia. Either
discontinue VRIII or commence an intravenous glucose containing fluid
Aim for continuous 24 hour feeding regimens
Avoid breaks in feeding
If oral diet is well established, then discontinuing the VRIII should be strongly considered

Pregnancy
Treat hyperglycaemia in pregnancy as per obstetric/diabetic guidelines
Assume a diagnosis of Gestational Diabetes, rather than critical care hyperglycaemia

Registered by Medicines Risk Management Group Review Date Pharm Ref No. Medical Illustrations Ref No.
April 2017 April 2020 17/009 v1 20170530_008