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Title:
GUIDELINES ON ADMINISTERING INTENSIVE INSULIN THERAPY IN INTENSIVE CARE

Version Number as from December 2004 2

Document Type: Clinical Guideline Scope: Intensive Care Patients Only Author(s): Darren Illingworth Deputy Ward Manager ICU Jez Woods Consultant Anaesthetist. Groups Consulted: Consultant Anaesthetists, Louise Hilton Diabetic Nurse Specialist, Brian Smith Chief Pharmacist Validated by: Signed: Sam Westwell Title: Matron/Departmental Manager Critical Care Services (If appropriate) Replaces Description of amendments: Equality Impact Assessed: 30/05/2009 Date: 30/05/09 Classification: Formulary & Prescribing Guideline

Authorising Body: Drugs and Therapeutic Committee Master Document Controller:

Date of Authorisation:

Review Date:

Key Words: Insulin, Intensive Care, Sliding scale

GUIDELINES ON ADMINISTERING INTENSIVE INSULIN THERAPY IN INTENSIVE CARE FOR NON DIABETIC PATIENTS AIM: The aim of giving intensive insulin therapy is to achieve Blood Glucose Levels (BGL) between 4.5 8.3 mmol/l within 24 hours of admission to Intensive Care Unit (ICU). Van den Berghe G, Wouters P, Weekers F, Verwaest C, Bruyninckx
F, Schetz M, Vlasselaers D, Ferdinande P, Lauwers P, Bouillon R: (2001) Intensive insulin therapy in critically ill patients. N Engl J Med, 345:1359-1367.

RECOMMENDATION OF USE: All non-diabetic patients in the ICU whose serum blood glucose is greater than 8.3mmols during acute / critical illness. EXCLUSIONS: Known diabetic patients, use the pink variable rate IV insulin regime. Patients with suspected or proven MI or ACS, use yellow variable rate regime form. ADMINISTRATION: 1. Ensure that the correct form is used Gold colour VARIABLE RATE IV INSULIN REGIME FOR NON DIABETIC PATIENT. This form MUST be signed by a Doctor prior to commencement and be reviewed within 4 hours of initiation or modification of the regime. 2. The concentration of the infusion is ONLY to be 50 units of Human Soluble Insulin ACTRAPID or HUMULIN S diluted with 50mls of 0.9% Sodium Chloride in a 50ml syringe. NO OTHER CONCENTRATION IS PERMITTED. (Patient Safety first Preventing harm from high risk medicines, NHS National Patient Safety Agency) This infusion must be changed every 24 hours. If the BGLs are not being achieved using the standard regime then the medical staff should modify the regime to achieve the target BGL. MONITORING BLOOD GLUCOSE LEVELS 3. Check blood glucose hourly until the patient is within the target range, then hourly for a further 4 hours, then every 2 hours, using the Glucometer or the Arterial Blood Gas (ABG) analyser, if ABGs are being taken. 4. If patient blood glucose level has remained within the target range without any adjustment to the insulin rate for 24 hours, then 4 hourly blood glucose monitoring may commence. If patients clinical condition changes, or therapies introduced or discontinued which could affect the blood glucose level, eg TPN commenced or drugs administered in glucose then hourly monitoring should resume.

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If a patient is receiving Enteral or Parental nutrition and it is stopped then the insulin infusion must also be stopped (NICE guidelines CG32). A BGL MUST be taken after 1 hour, if the BGL is > 8.3mmol/l seek medical advice. Only a Doctor can request the infusion to be restarted but BGLs must be monitored closely to prevent Hypoglycaemia. In the event of a blood glucose <4.0mmols stop insulin and discuss with medical staff. In the event of a blood glucose <3.0mmols stop insulin, refer to medical staff, consider administration of 2ml per Kg 10% glucose, followed by 50ml per hour infusion 0f 10% glucose. Once the patient's blood glucose levels are maintaining at 8.3mmol or below and requiring 1 unit/hour of insulin, stop the infusion. Monitor BGLs 2 4 hourly, if the BGL rises > 8.3 mmol/l seek medical advice the infusion may need restarting. If the BGL remains < 8.3 mmol/l disconnect the infusion and monitor the patients BGLs 4 6 hourly.

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VARIABLE RATE IV INSULIN REGIME INSULIN FOR NON DIABETIC PATIENT Blood Glucose Monitoring Chart 6
This regime should be reviewed by a doctor within 4 hours of initiation or change in regime, and on a regular basis. Use Human Soluble Insulin (eg Actrapid, Humulin S) 50 units in 50ml Sodium Chloride 0.9% Blood Glucose Standard insulin regime Modification 1 Modification 2 mmol/l (units per hour) (units per hour) (units per hour)

FOR ICU ONLY

NOT TO BE USED OUTSIDE ICU

Record of insulin syringes prepared:

Date Time Started Given by Checked by Device No.

0 - 4.0 4.1 - 6.0 6.1 - 8.0 8.1 - 10.0 10.1 - 14.0 14.1 - 22.0 > 22

0 1 2 3 4 5 6
Date Time

Dr's signature - Standard insulin regime

Dr's signature - Modification 1

Date

Time

Dr's signature - Modification 2

Date

Time

Please file this sheet in the patient's notes at the end of the treatment cycle

VARIABLE RATE IV INSULIN REGIME

FOR ICU ONLY

NOT TO BE USED OUTSIDE ICU

INSULIN

FOR NON DIABETIC PATIENT

Blood Glucose Monitoring Chart 6

Please make reference to this form on the prescription chart
Affix addressograph label here

Aim: to achieve Blood Glucose levels between 4.5 - 8.3 mmol/l. within 24 hours Recommended use: All non-diabetic patients in the intensive care unit that require tight glycaemic control during acute / critical illness. Guidance: If blood glucose >8.3mmols 1. Commence an intravenous infusion of: Human Soluble Insulin (eg Actrapid or Humulin S) 50 units diluted in 50mls Sodium Chloride 0.9% in 50ml syringe (change at least every 24 hours). Administer according to the chart overleaf. This may be modified by entering the revised rate of infusion in the table overleaf. (ONLY THE INFUSION RATE CAN BE MODIFIED NOT THE
CONCENTRATION OF UNITS/ML)

Ward: Consultant:

2. In stable patients blood glucose levels should be taken 2 - 4 hourly, if the patient's blood glucose levels are unstable and/or receiving 4 units / hour or more then the blood glucose levels must be checked hourly. 3. Ensure that if NG feeding / Parental nutrition is stopped that the insulin infusion is stopped (as per NICE guidelines) and a blood glucose level is taken after 1 hour. If the this is > 8.3mmol/l seek medical

review. 4. Once the patient's blood glucose levels are maintaining at 8.3mmol or below and requiring 1 unit/hour of insulin, stop the insulin infusion and monitor blood glucose levels 2 - 4 hourly. If the blood glucose level rises > 8.3mmol/l seek medical review.
Please file this sheet in the patient's notes at the end of the treatment cycle