CARDIAC SURGERY INTRAVENOUS INSULIN PROTOCOL PHYSICIAN ORDERS INDICATIONS EXCLUSIONS. Insulin allergy

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1 Page 1 of 5 INDICATIONS EXCLUSIONS 2 consecutive blood glucose measurements greater than 110 mg per dl AND NPO with a continuous caloric source AND Diagnosis of : Cardio-thoracic Surgery NOTE: This protocol with a blood glucose target of mg/dl is recommended for cardio-thoracic surgery patients. REFERENCES: Capes SE et al. Lancet 2000;355:773-8 Furnary AP et al. Ann Thorac Surg 1999;67: German Competence Network Sepsis. N Engl J Med 2008;300: Joslin Diabetes Center NICE-SUGAR Study Investigators. N Engl J Med 2009;360: Umpierrez GE et al. J Clin Endocrinol Metab 2002;87: Van den Berghe et al. NEnglJMed 2001;345: Van den Berghe et al. NEnglJMed 2006;354: Wiener RS et al. JAMA 2008;300: Insulin allergy Diabetic Ketoacidosis (DKA) Hyperglycemic Hyperosmotic n- Ketotic Acidosis n Cardiac Surgery Critical Care Patient RELATIVE CONTRAINDICATIONS / PRECAUTIONS Patients who have taken oral hypoglycemics on the day of initiation of this protocol Patients who have had a seizure within 24 hours

2 Page 2 of 5 IMPORTANT: PLEASE WRITE LEGIBLY. Orders with a Box Require a Check Mark to Activate Initiation of IV Insulin Discontinue all diabetic medication orders, including: oral medications, insulin sliding scale, or insulin pump. Patient should have continuous source of caloric intake, approximately equal to 5 grams of glucose per hour for the duration of the insulin infusion period. (E.G.,D5W at 100 ml/hr, D10W at 50 ml/hr, tube feed at ½ of goal or greater, TPN.) Glucose source: Please indicate which glucose source is present Intravenous fluid D5W at 100 ml per hr D5 at (minimum of 100 ml per hour) D10W at 50 ml per hr D10 at (minimum of 50 ml per hour) Patient is on tube feed at ½ of goal or greater Patient is on TPN After glucose source has been initiated, test blood glucose level and start infusion rate as instructed below: (STANDARD CONCENTRATION OF HUMAN REGULAR INSULIN 1 units per ml) Blood Glucose (mg/dl) Regular Insulin (Bolus) Regular Insulin (infusion per hour) Bolus 2 units IV infusion / hour units IV 4 units IV infusion / hour Greater than 300 mg/dl 10 units IV 4 units IV infusion /hour Maintenance of IV Insulin (Goal Range 80 to 110 mg per dl) Check fingerstick blood glucose Every 1 hr if blood glucose outside goal range OR with any s in insulin infusion rate Every 2 hr if 3 consecutive blood glucose measurements between 80 to 110 mg per dl and no in insulin infusion rate during that time period Every 4hr if blood glucose 80 to 110 mg per dl for 24 consecutive hours PRN for signs or symptoms of hypoglycemia Adjust IV insulin per IV insulin chart on page 4 Check potassium every 6 hrs for 24 hours. For interruptions in enteral or parenteral caloric source: 1. Start D5W at 100 ml per hr 2. Check blood glucose in 30 minutes times 2 and continue to follow protocol 3. Call MD For transport out of unit: 1. Discontinue IV insulin 2. Hold tube feeds 3. Start D5W at 100 ml per hr 4. Check a blood glucose prior to transport 5. Check a blood glucose upon return to the unit and start insulin protocol (from initiation phase of the order set) after caloric intake (IVF/tube feeds) has been restarted. Physician Signature: Date: Time: Pager: Printed Name: Transcribed By: Date: Time: Fax Time: RN Signature: Date: Time: Fax Time:

3 Page 3 of 5 IMPORTANT: PLEASE WRITE LEGIBLY. Orders with a Box Require a Check Mark to Activate Contact physician if insulin infusion rate exceeds 20 units per hr. Conversion of IV Insulin to Subcutaneous Insulin Once patient taking adequate oral diet, begin adult subcutaneous insulin per MD. 30 minutes after administering subcutaneous insulin, discontinue IV insulin. IV insulin Dosing Chart (Blood Glucose Goal Range 80 to 110 mg per dl) See following page. Physician Signature: Date: Time: Pager: Printed Name: Transcribed By: Date: Time: Fax Time: RN Signature: Date: Time: Fax Time:

4 Form 1014, Rev 7/16/15, MAHMAH Current Blood Glucose (mg per dl) < >401 Previous Blood Glucose (mg per dl) >400 IV infusion Stop IV Insulin drip. Call MD. Give 25 gm of 50 % glucose IV. Check blood glucose every 30 min. until bld glucose is > 100 mg/dl. Then restart infusion at: Blood sugar Restart drip at 25% of last infusion rate Blood sugar Restart drip at 50% of last infusion rate Blood sugar > 301. Restart drip at 75% of last infusion rate Stop IV Insulin drip. Check blood glucose every 30 minutes until blood glucose is greater than 100 mg/dl. Then restart infusion at: Blood sugar Restart drip at 25% of last infusion rate Blood sugar Restart drip at 50% of last infusion rate Blood sugar > 301. Restart drip at 75% of last infusion rate IV infusion rate 5% IV infusion rate 5% units/ hr Recheck Blood Glucose level. If second glucose level remains between : Increase rate.5 Recheck Blood Glucose level. If second glucose level remains between : Increase rate by 3. 50% IV infusion rate 5% 50% 75% 50%.5 Recheck Blood glucose level. Call MD. If second glucose level remains above 401: Bolus with 10 units of IV insulin and Increase Rate by units/ hr by 3 Increase Rate by 3 75% by 3 Recheck blood glucose level. Call MD. If second glucose level remains above 401: Increase rate by 4 Stop infusion. Recheck every 30 min. until blood glucose is > 110. Restart drip. rate by 75% of previous rate 75% 50% by 50% of previous rate

5 Maintenance of IV Insulin (Goal Range 80 to 110 mg per dl) Check fingerstick blood glucose Every 1 hr if blood glucose outside goal range OR with any s in insulin infusion rate Every 2 hr if 3 consecutive blood glucose measurements between 80 to 110 mg per dl and no in insulin infusion rate during that time period Every 4hr if blood glucose 80 to 110 mg per dl for 24 consecutive hours PRN for signs or symptoms of hypoglycemia Adjust IV insulin per IV insulin chart on reverse side. IV infusion calculation (Round to the nearest 10th) Decrease rate 5 % : Previous Rate x 0.75 = new rate Decrease rate by 50 % : Previous Rate x 0.50 = new rate Decrease rate by 75% : Check potassium every 6 hrs for 24 hours. Previous Rate x 0.25 = new rate For interruptions in enteral or parenteral caloric source: 1. Start D5W at ml per hour 2. Check blood glucose in 30 minutes times 2 and continue to follow protocol 3. Call MD For transport out of unit: 1. Discontinue IV insulin 2. Hold tube feeds 3. Start D5W at ml per hour 4. Check a blood glucose prior to transport 5. Check a blood glucose upon return to the unit and start insulin protocol (from initiation phase of the order set) after caloric intake (IVF/tube feeds) has been restarted. Contact physician if insulin infusion rate exceeds 20 units per hour.

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