Variable Rate Insulin Infusion

Aka: Variable Rate Insulin Infusion, Insulin Infusion, Insulin Drip

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II. Indications

  1. Diabetes Mellitus
    1. Diabetic Ketoacidosis
    2. Hospitalized patients not eating (e.g. post-operative state)
      1. Alternatively, Basal insulin may be used
  2. Other metabolic Disorders
    1. Acute Pancreatitis due to severe Hypertriglyceridemia (>1000 mg/dl)
    2. Calcium Channel Overdose (or Beta Blocker Overdose)

III. Medications

  1. Bolus Insulin (e.g. Novolog, Regular Insulin) 100 units in 100 cc NS (1 u per 1 ml)

IV. Protocol: Insulin Infusion

  1. Starting dose of Insulin Infusion
    1. Type I Diabetic: 0.5 to 1 unit per hour
    2. Type II Diabetic or poor control: 2-3 units per hour
    3. Weight-based (use true weight, not Ideal Weight)
      1. Diabetic Ketoacidosis: 0.1 Units/kg/h
      2. Non-ketotic: 0.05 Units/kg/h
        1. Consider starting with this dose in very large patients with high calculated doses
  2. Insulin bolus prior to starting Insulin Drip is controversial
    1. Not recommended in pediatric patients
    2. Use in adult Diabetic Ketoacidosis does not offer additional benefit over Insulin Infusion alone
      1. Goval (2010) J Emerg Med 38(4): 422-7 [PubMed]
    3. Insulin bolus dosing in Diabetic Ketoacidosis if used (adults only)
      1. Bolus Insulin dose: 10 units
  3. Coadminister D5W at 100 to 125 cc per hour
  4. Check Blood Glucose every 30 minutes to 1 hour
    1. Glucose <70 Then
      1. Turn off Insulin Drip for 30 minutes
      2. Blood Glucose on recheck still <70
        1. Give 25 ml of D50 IV (or 10-12 grams Glucose)
      3. Recheck Blood Glucose every 30 minutes
        1. Restart infusion when Glucose >100 mg/dl
        2. Decrease Insulin Drip rate by 1.0 u/h
    2. Glucose 71-120 Then
      1. Decrease Insulin Drip by 1.0 u/hour
    3. Glucose 121-180 Then
      1. No change
    4. Glucose 181-250 Then
      1. Increase Insulin Drip by 2 units/hour
    5. Glucose 251-300 Then
      1. Increase Insulin Drip by 3 units/hour
    6. Glucose 301-350 Then
      1. Increase Insulin Drip by 4 units/hour
    7. Glucose 351-400 Then
      1. Increase Insulin Drip by 5 units/hour
    8. Glucose >400 Then
      1. Increase Insulin Drip by 6 units/hour
  5. IF Insulin Drip drops to 0 units/hour
    1. Continue q2 hour Blood Glucose Monitoring
    2. Restart Insulin Drip when Blood Glucose >150

V. Management: Discontinuation (e.g. Postoperatively)

  1. Administer patient's usual Insulin dose pre-meal
  2. Patient eats meal
  3. Discontinue Insulin Infusion two hours after meal

VI. References

  1. Marks (2003) Am Fam Physician 67(1):93-100 [PubMed]

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