[TulsaTime]

Does anyone have a good insulin drip protocol that works? I just started in a new unit using the Portland Protocol but it doesn't seem to work that well and we are having issues with the fact that it has no transition off the drip to SQ. Does anyone have a protocol that works well & transitions off the drip?

[Zookeeper3]

120-150 is 1-5 units/hr
151-200 is 6-10 units/hr
201-250 is 11-15 units/hr
251-251 is 16-20 units/hr
>300 put at 25 units/hr can call MD

accuchecks q1hr.

When no adjustment between the 1-5 units is made for 3 hrs. may move to q2hr, if there is an adjustment must go back to q1 hr.

for hearts as soon as they can tolerate clears and the above, we switch to an aggressive sliding scale, but must be in the 1-5 range.

[smileyRn96]

We have very precise protocol where you compare the bs from the previous hour to the current bs and multiply the rate time a factor such as 0.9 or 1.3 depending on how quickly the glucose is moving up or down. We also use a NP for post drip management.
-Smiley

[APNgonnabe]

Tulsa,
I believe we are using the Portland protocol for insulin also. We have a very low compliance rate w/ the RNs because they feel it drops them to much once they get into the 80's range. Do you see this to?

thanks

[utahliz]

We use a chart that inputs current blood sugar, previous blood sugar and suggests whether to hold the rate, increase or decrease by a given percentage. We, too, have some nurses who are extremely concerned about bottoming out. I think it's a culture thing that needs to be overcome. When we are checking Q1 hr and adjusting, it's less likely that a pt. will bottom out. It's just that they seem to feel more comfortable with a patient above 120's than in the 80's. I must say, though, that the table is only a guideline and sometimes doesn't increase the rate fast enough or decrease it fast enough. A table is not a substitute for good judgement.

[TulsaTime]

Originally Posted by APNgonnabe

Tulsa,
I believe we are using the Portland protocol for insulin also. We have a very low compliance rate w/ the RNs because they feel it drops them to much once they get into the 80's range. Do you see this to?

thanks

Yes that has been one of the big issues. When they get down into the 80's oftentimes they end up in the 60's or lower if you follow the protocol. Then following the protocol you end up with them rebounding & getting really high again. Also there is no transition to get them off the drip so we can send them to the floor.

[Indy]

Ours is nicely confusing and I can NOT remember all of it. I usually have to read it several times just to figure out what I'm doing at the moment. It has some interesting stuff: IVF is either D5 or D51/2 NS, and you keep that insulin going even with normal or low blood sugars until ketones are negative. There are parameters in there for potassium infusions and mag piggybacks as well depending on the labs. Accuchecks are every 2 hours but if they drop fast I do them every hour or more often, depending on what's happening. Labs are every 4 hours including chem, mag, phos, and ketones. There may be one urinalysis in there somewhere.

It doesn't have set values for what the drip should run at. They usually start at some set rate in the ER, and the thing has you going up or down a certain # of units depending on the blood sugar. Oh yeah and the first time it is under 250 you have to cut the drip rate in half. But only the first time. It can have you running in circles, that's for sure. IV's don't play well when you're barraging them with K and Mag, they clog up with D5 if you don't flush quite often, acidotic dehydrated people are hard sticks and all this will happen when the lovely patient in question just dropped from 300 to 70 and it's D50 time, say bybye to that one functioning IV, hello to Q15 min. accuchecks for a little bit! It's best for me to just give up on computer charting with an insullin drip, it's all I can do to put it all on the flowsheet while doing it.

There is not a transition to SQ on it, but if my patient is going to live (read: not dead on the vent with levo and dopa going) they will be close to normal by morning and usually they go home or to medsurg and to a regular sliding scale SQ.

[utahliz]

Our protocol can be applied to everyone EXCEPT DKA and HHNK patients, if an attending invokes it. Those with DKA or HHNK have orders specifically written for each patient, because of the extreme impact of fluid and electrolyte balances, and risk of cerebral edema, that the super-high blood sugars and too-rapid correction can entail.

[joeyzstj]

Originally Posted by utahliz

We use a chart that inputs current blood sugar, previous blood sugar and suggests whether to hold the rate, increase or decrease by a given percentage. We, too, have some nurses who are extremely concerned about bottoming out. I think it's a culture thing that needs to be overcome. When we are checking Q1 hr and adjusting, it's less likely that a pt. will bottom out. It's just that they seem to feel more comfortable with a patient above 120's than in the 80's. I must say, though, that the table is only a guideline and sometimes doesn't increase the rate fast enough or decrease it fast enough. A table is not a substitute for good judgement.

We use the same type of protocol. We compare previous and current Blood Glucose and adjust accordingly. The protocol really never allows a change of more then 2 units at a time. Blood sugars greater than 250 3 consecutive times get a rebouls per the patients weight in KG's. BS less than 100 gets shut off for an hour and rechecked. It goes on and on. It works very well.

[Conrad283]

We use a protocol with two algorithm's. Low dose and high dose. It's a rate and a bolus based on the FS.