Insulin Drip Protocol

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.

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

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

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.

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.

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.

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.

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.

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

Our protocol is about five pages long. For intubated patients that are NPO or receiving tube feedings, we give 2 units of Regular insulin IVP if the blood sugar is 110-150. If it goes over 150, an insulin drip is started. The protocol for the insulin drip itself is pretty extensive but not hard to following. If the patient is eating a liquid or solid diet than they are started on the SQ insulin protocol where we give Aspart insulin and that has five levels ranging from insulin sensitive to level 4.

Now if a patient is on tube feeds which are at goal and has an insulin gtt, as long as the TF is at goal for 24 hours and the patient has received long acting insulin for 3 days, the gtt can be discontinued and the patient blood sugars can be taken every 4 hours as opposed to every 2 hours when on the insulin gtt. We can then start the SQ insulin protocol on patients. If the blood sugar goes above 150, we increase the patient to another level on the protocol.