[rmaziona]

hi,
i work in an icu where paediatric population is a minority, we receive trauma and surgical cases mainly, and we need to develop a protocol for insulin infusion algorythm for non diabetic children just for the sole purpose of mainaining euglycemia.the problem is that most of the web sites i visited discuss DKA and diabetes.
i will appreciate any help i can get in relation to this, a scale that your hospital use, or a web site that can help in this regard.anything and everything.
thank u guys, you are the best!

[talaxandra]

Our policy (which is adult-only, so I don't know how helpful this will be) has the following protocol:

Actrapid 100 units in 100ml via Imed OR 50 units in 50ml via syringe driver, titrated to 1/24 BSKL (2/24 if stable); concommitant IV glucose, enteral or parenteral feed.

General guidelines (revise as required for individual patients):
A. Initial rate
BGL (mmol/L) Actrapid rate/hr
7.0 or less No infusion
7.1 - 11 1 unit/hr
11.1 - 15 2 units/hr
15.1 - 18 3 units/hr
18.1 - 21.0 4 units/hr
>21 5 units/hr

B. If BGL is the SAME or HIGHER than the last reading:
BGL (mmol/L) Actrapid rate/hr
Now <7.0 Cease infusion; check 1/24; recommence when >7
Now 7.1 - 11.0 Continue current rate
Now 11.1 - 15.0 Increase by 1 unit/hr
Now 15.1 - 21.0 Increase by 2 units/hr
Now >21 Increase by 3 units/hr

C. If BGL is LOWER than the last reading:
BGL (mmol/L) Actrapid rate/hr
Now <7.0 Check 1/24; recommence when >7
Was 7.1 - 11.0, still 7.1 - 11.0 Continue current rate
Was 11.1 - 15.0, now <11.1 Decrease by 1 unit/hr
Now 15.1 - 21.0, now <15 Decrease by 2 units/hr
Now 15.1 - 21.0, now <11 Decrease by 1 units/hr
Was >21.1, now < 15 Decrease by 3 units/hr

If amount of change does not fit in either B or C, maintain current rate and recheck in 1/24

I hope that's what you were looking for and that it's some help, if only as a starting point.

[janfrn]

Ours isn't quite that well delineated and it's not an actual protocol yet. We mix our insulin in a 20 mL syringe (pt's weight in kg X units) so that 1 mL/hr = 0.05 units/kg/hr and we use Toronto insulin. The usual order is to start at 0.025 units/kg/hr for BGL 10-13 or 0.05 units/kg/hr for BGL>13 and recheck in 1 hr. If the BGL is the same or higher we double the rate and recheck hourly. If it has dropped significantly we'll usually cut the rate in half for an hour, recheck and then usually turn it off. Our insulin infusions run peripherally if possible and always with a drive, no matter where it's running.

[kessadawn]

Our PICU doesn't have a written policy, but we will titrate the dextrose in our IVF first, if we can't control normal glucose levels with IVF, then we add an insulin gtt. Our regular insulin is always mixed 1 unit=1cc, and we start at 0.5units/kg/hr, checking Q1 hr bedside glucose. More often than not, we titrate IVF and keep the insulin at 0.5, like with our DKAs. This is a rare scenario for us, not often do I have a patient on an insulin gtt that is not a DKA, so that's probably why we have no protocol.

[janfrn]

There is compelling evidence that elevated blood glucose (greater than 10 mmoL/L or 180) greatly increases both morbidity and mortality in all critically ill patients regardless of age. We are developing a protocol as I said, so that our kids run BGLs of 5-10 (90-180). But right now we're still flying by the seat of our pants. We might have traumas, post-op cardiacs, post-op neuros, burns, even purely respiratory patients whose stress response pushes their BGLs out of range for more than a few hours, and we treat. We rarely see DKAs in our unit, not sure why though... maybe two a year.

[talaxandra]

Originally Posted by janfrn

There is compelling evidence that elevated blood glucose (greater than 10 mmoL/L or 180) greatly increases both morbidity and mortality in all critically ill patients regardless of age.

Yes - all our ICU patients have regular glucose checks and are put on an Actrapid infusion if they go over 10mmol/l for that reason.

Originally Posted by janfrn

We rarely see DKAs in our unit, not sure why though... maybe two a year.

Unless they've got a pH less than 7, DKA patients come to the ward; maybe it's the same where you work?

[janfrn]

Originally Posted by talaxandra

Unless they've got a pH less than 7, DKA patients come to the ward; maybe it's the same where you work?

That could very well be it, but I recall a gal with a pH of 7.1 and a HCO3 of 6 from a while back. Makes a nice change fromthe cardiacs with pHs of 6.8 and HCO3s of 44...

[kessadawn]

Just so you guys know, the night after I posted this I came in to a non-diabetic pt with an insulin gtt, unstable glucose results with every tiny titration, and man, do I wish we had a policy! I called that resident every 30-60 minutes all night, and she, being so brand new, had to double check every decision with a very patient but very sleepy attending. One of the longest nights I've worked in a long time!

Originally Posted by kessadawn

Our PICU doesn't have a written policy, but we will titrate the dextrose in our IVF first, if we can't control normal glucose levels with IVF, then we add an insulin gtt. Our regular insulin is always mixed 1 unit=1cc, and we start at 0.5units/kg/hr, checking Q1 hr bedside glucose. More often than not, we titrate IVF and keep the insulin at 0.5, like with our DKAs. This is a rare scenario for us, not often do I have a patient on an insulin gtt that is not a DKA, so that's probably why we have no protocol.

[janfrn]

Gotta love July...