Step-Down Insulin Infusion Orders
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2Step-Down Insulin Infusion Orders
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This protocol is not to be implemented for patients who
1.
1) have diabetic emergencies, such as, Diabetic
Ketoacidosis (DKA) or Hyperglycemic Hyperosmolar Syndrome, 2) are younger than 18 years old
This protocol may be implemented for patients who are taking an oral diet; however, the ordering physician must be
contacted for prandial insulin orders.
2. Blood Glucose Monitoring
a. Check Glucose every 2 hours until stable (8 consecutive values are within the target range of 80 to 139 mg/dL).
In hypotensive patients, capillary blood glucose (fingersticks) may be inaccurate; obtaining the blood sample from
an indwelling catheter is acceptable as long as a dextrose containing infusion is not being administered through
the catheter.
b. If Glucose levels have been stable for 8 measurements, then check Glucose levels every 4 hours if:
i. No significant change in clinical status
ii. No significant change in nutritional or carbohydrate intake( e.g, change in enteral formulation).
1. If nutrition stopped, notify physician.
c. Every two hours glucose measurements should continue if:
i. Glucose out of target range of 80 to 139 mg/dL.
ii. Significant changes in clinical condition (This includes clinical improvement)
iii. Starting or stopping of steroids, such as, Solu-Medrol (methylprednisolone), Solu-Cortef (Hydrocortisone),
prednisone, or dexamethasone.
iv. Initiation or cessation of dialysis (any type).
v. Initiation, cessation, or change in nutritional support (enteral feedings, TPN, PPN, etc)
3. Initiating an Insulin Infusion
a. Discontinue:
i. Discontinue all previous insulin orders, including sliding scale insulin orders.
ii. Discontinue all oral hypoglycemic agents, such as, Actos (pioglitazone), Avandia (Rosiglitazone),
Glucophage (metformin), Glucotrol (glipizide) and others.
1. Discontinue all insulin in Parenteral Nutrition (TPNs or PPNs)
b. Exogenous Glucose. It is recommended that the patient have a parenteral or enteral source of dextrose (IV
fluids with dextrose, enteral feeding, or parenteral nutrition) while on this protocol.
c. Initiation: Two consecutive glucose levels greater than 140 mg/dL measured one hour apart.
d. Insulin Infusion: Regular Insulin Admixture (1unit per 1ml) should be administered via a pump.
e. Priming: To saturate insulin-binding sites in the tubing, flush tubing with 50 mL of Insulin Admixture.
f.
Bolus and Initial Rate:
i. Glucose levels 140 to 170: 1.5 units bolus and start insulin infusion at 1.5 units per hour.
ii. Glucose levels 171 to 250: 2 units bolus and start insulin infusion at 2 units per hour.
iii. Glucose levels 251 to 300: 3 units bolus and start insulin infusion at 3 units per hour.
iv. Glucose levels 301 to 400: 4 units bolus and start insulin infusion at 4 units per hour.
v. Glucose levels 401 to 499: 5 units bolus and start insulin infusion at 5 units per hour.
vi. Glucose levels 500 or higher: Consult physician for specific orders.
Protocol adapted from an article by Goldberg PA, et al. “Implementation of a Safe and Effective Insulin Infusion Protocol in a Medical
Intensive Care Unit”. Diabetes Care Feb 2004; 27(2): 461
(
) Verbal Order Verification
Prescriber’s Signature: ________________________________________________
Patient Identification
Date/Time: ________________________________________________
CHH-1435 Originated: 10/2007, Revised 6/2008
White: Chart
Yellow: Pharmacy
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