Page 528 - fbkCardioDiabetes_2017

504 Hyperglycemia & Glycemic Control In ICU

balance stability and responsiveness, result in mini- 1) any change in insulin infusion rate (i.e. BG out of
mal rates of hypoglycemia, and clearly communicate target range)
titration instructions and frequency of blood glucose 2) significant changes in clinical condition
monitoring.
3) initiation/cessation of pressor/steroid, renal re-
The Yale insulin Drip protocol encompasses all of placement therapy, nutritional support (TPN, PPN,
these elements.This protocol is associated with a tube feedings, etc.)
low incidence of both severe and moderate hypo-
glycemia. Calculate TDD :
Initially, blood glucose monitoring should occur hour- 1. Units of insulin given in last 6 hours -8hours
ly until blood glucose reaches the target range and 2. Use 80% of of the calculated Total dose of insulin
remains within range for 2 to 3 hours; then blood glu-
cose monitoring can occur every 2 hours.When blood 3. Use 50% Basal & 50% Bolus insulin according to
glucose is consistently within target, transition from blood sugar - model
IV to subcutaneous therapy may be considered
The Basal /Bolus insulin concept
Specific factors to be ensured include that patients
are receiving consistent nutrition, are hemodynam-
ically stable, are off vasopressors, are receiving a
stable dose of corticosteroids, have minimal periph-
eral edema, and that any infection they might have
is resolving.
A basal – bolus strategy is preferred for conversion
from IV to subcutaneous insulin.

The basal – bolus strategy should be considered for
patients with resolving acute illness who are receiving
oral nutrition. This strategy consists of administration
of basal insulin in the form of long-acting (glargine)
or intermediate – acting (isophane) with bolus insulin
in the form of rapid-acting (regular) with meals.Eighty
percent of the total insulin infusion dose from the
previous 24 hours is divided equally between basal Basal Insulin
and bolus insulin.For patients receiving enteral nutri- • Suppresses glucose production between meals
tion, basal insulin with corrective doses of short-act- and overnight
ing insulin is recommend
• Nearly constant levels
YALE INSULINE INFUSION PROTOCOL: • 50% of daily needs
Initiating the Insulin Infusion Bolus Insulin (Mealtime or Prandial)
Insulin infusion: 1 u human regular insulin per 1 cc • Limits hyperglycemia after meals
0.9% NaCl per infusion pump (increments of 1 u/h)
• Immediate rise and sharp peak at 1 hour
Priming: Flush 50 cc of Insulin/NS drip through all IV
tubing, before infusion begins (to saturate the insulin • 10% to 20% of total daily insulin requirement at
binding sites in the tubing) each meal
Threshold: Start IV insulin if BG >180 mg/dL Ideally, for insulin replacement therapy, each com-
ponent should come from a different insulin with a
Bolus & initial insulin infusion rate: specific profile
Initial BG 181-299: divide by 100, round to nearest 1
unit for initial drip rate (NO bolus) Continuous Subcutaneous Insulin Infusion
Devices
Initial BG >300: divide by 100, round to nearest 1 unit
for initial drip rate AND bolus to be given Continuous Subcutaneous Insulin Infusion Devices
: External open-loop pumps for insulin delivery. The
Consider hourly BG monitoring again (until stable) IF: devices have a user programmable pump that de-

GCDC 2017