SECTION: NM NUMBER: 20. HENRY FORD HOSPITAL DETROIT, MICHIGAN TITLE: GLYCEMIC CONTROL INTENSIVE CARE PROTOCOL UNIT: All ICUs

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1 CLINICALPROTOCOL MULTIDISCIPLINARY SECTION: NM NUMBER: 2 HENRY FORD HOSPITAL DETROIT, MICHIGAN TITLE: GLYCEMIC CONTROL INTENSIVE CARE PROTOCOL UNIT: All ICUs APPROVED: 3/3 REVIEWED: REVISED: 12/3, 5/, /, /5, 3/, 11/ POLICY: The RN will administer insulin according to the Intensive Care Glycemic Control Protocol to all adult ICU patients if the responsible physician prescribes ICU Glycemic Control Protocol or per protocol and the patient is in an adult ICU. All insulin will be administered per protocol subsection entitled administration. CONTENT STATEMENTS: Goal: To attain a glucose level between and 1 mg/dl. Contraindications to the Intensive Care Glycemic Control Protocol: 1. DKA Diabetic KetoAcidosis 2. History of end stage renal disease requiring peritoneal dialysis with IcoDextrin (Extraneal ) IcoDextrin interferes with the Accu-Chek glucose meter causing a falsely elevated glucose level. For patients with end stage renal disease with a history of renal replacement therapy via peritoneal dialysis the fingerstick glucose measurement will be compared to a simultaneously measured serum glucose (measured by the hospital laboratory) before the ICU Glycemic Control Protocol is started. This accuracy check is done to assess a history of peritoneal dialysis with IcoDextrin (Extraneal ). Patients not on IcoDextrin will have a variation less than 2 percent and can proceed with the ICU Glycemic Control Protocol. If the patient has a greater than 2 percent variation, the physician will be notified and the ICU Glycemic Control Protocol will be discontinued. Glycemic control will be managed by the physician. If the variation is less than 2 percent the ICU glycemic control protocol will be initiated with variance checked daily thereafter. 3. Pancreas transplant patients Assessment: On admission to the ICU for all patients, the RN will assess and schedule blood glucose reagent strip testing ( fingerstick or IV draw ) according to the following criteria: 1. Group One Patients: Intravenous Glycemic Control: For patients who are NPO (intubated or not), receiving continuous tube feedings or total parenteral nutrition (TPN): blood glucose reagent strip testing and insulin coverage will initially occur every hours. For the first glucose measurement greater than 15 the insulin infusion per nomogram will be started (appendix A). Otherwise glucose testing shall continue every hours. If three in a row glucose values are < 1, blood glucose reagent strip testing can be discontinued by the nurse per protocol. Daily glucose checks through the AM labs will then be used to screen for glucose greater than 15. Page 1 of 1

2 CLINICALPROTOCOL MULTIDISCIPLINARY SECTION: NM NUMBER: 2 HENRY FORD HOSPITAL DETROIT, MICHIGAN TITLE: GLYCEMIC CONTROL INTENSIVE CARE PROTOCOL UNIT: All ICUs APPROVED: 3/3 REVIEWED: REVISED: 12/3, 5/, /, /5, 3/, 11/ For the first glucose value greater than 15, the nurse will initiate the insulin infusion per nomogram (Appendix A). For all initial glucose values 1 to 15, the nurse will administer 2 units of Regular per intravenous push (IVP). If at any time, when checking glucose every hours, the glucose is greater than 15, the insulin infusion per nomogram will be initiated. During the insulin infusion, fingerstick or serum glucose measurements shall be obtained every 2 hours. If the glucose measurement decreases below 1 glucose will be checked every hour until greater than mg/d, at which time every 2 hour monitoring can resume. If glucose measurements are obtained via IV draw, measurements should be drawn from the same site when possible to avoid variance in results. If the insulin drip is turned off for a glucose less than (but greater than ), check glucose every hour until greater than. When the glucose is greater than check every 2 hours. If three in row glucose checks (every 2 hour checks) are less than restart the protocol from the beginning (Change glucose checks to every hours and cover with regular insulin IV push 2 units for glucose 1 to 15 and start the insulin drip for the first glucose greater than 15 ). If all three of the qh checks are between and 1 the glucose can then be checked every 2 hours as part of daily ICU electrolytes with glucose. For patients on the insulin drip: If a patient is diagnosed as insulin sensitive (one or more glucose values less than 1 on the full dose insulin infusion nomogram) the nurse will use the Sensitive Infusion Nomogram for further dose titration. Intravenous Administration - General Considerations and Maintenance infusions will be prepared by Pharmacy as units human regular insulin in ml.9% sodium chloride (concentration: 1 unit/ml). An electronic infusion device will be used to assure proper control of flow rate The IV tubing shall be flushed with ml of the insulin drip solution (1 unit/ml) to saturate all insulin infusion binding sites on the tubing prior to attaching to the patient. will not be withdrawn from the Infusion Solution for purposes of IV push administration. The electronic infusion device controlling the Infusion will not be used to administer bolus doses of insulin. Directions for administering IV push insulin: o o o o o Using an insulin syringe withdraw the required dose of insulin from a vial of Human Regular. Determine which intravenous line will be suitable for administering an intravenous push dose of regular insulin. Use an intravenous line which does not have a continuous infusion of medication already being infused through it (to avoid a bolus of that medication). Flush the intravenous line with 3-5 ml of normal saline. Using the insulin syringe inject the insulin into the injection port. Follow the insulin injection with 3-5 ml of normal saline flush. 2. Group Two Patients: Subcutaneous Glycemic Control for the ICU: For patients who are eating (liquid or solid diet): blood glucose reagent strip testing will be assessed every four hours on this schedule ( ) The, 12, and 1 glucose check should Page 2 of 1

3 CLINICALPROTOCOL MULTIDISCIPLINARY SECTION: NM NUMBER: 2 HENRY FORD HOSPITAL DETROIT, MICHIGAN TITLE: GLYCEMIC CONTROL INTENSIVE CARE PROTOCOL UNIT: All ICUs APPROVED: 3/3 REVIEWED: REVISED: 12/3, 5/, /, /5, 3/, 11/ be before the meal. coverage will start with subcutaneous insulin aspart (Novolog) per level one (see below). When using the glycemic control subcutaneous sliding scale the insulin sensitive level will be started for any of the following: Renal Failure (creatinine greater than 2), Liver Failure, history of insulin sensitivity (one glucose less than 1mg/dl), underweight (weight less than 5kg) or the elderly (age greater than 7 yrs). For two glucose values in a row greater than 15mg/dl at any time increase up one level on the scale to level one from the insulin sensitive level. The following rules will apply to the Subcutaneous Glycemic Control: The nurse will automatically start the glycemic control scale coverage for patients in this group. No special written medications orders are needed except for the glycemic control order on admission to the ICU, unless otherwise determined by the physician. If the first three glucose values in a row are less than 1 glucose checking can be stopped. Start with level one (or insulin sensitive level if indicated). Two glucose values in a row greater than 15 at any time increase up one level on the scale One glucose value at any time less than decrease down one level The 2 (if not a full meal tray consumed), 2 and glucose will only be treated if greater than 15 per current Glycemic Control Scale with a maximum insulin dose of units. NPO: Aspart Dosing: If a patient eating meals or consuming clear liquids becomes NPO (nothing by mouth) the nurse will administer fifty percent (5%) of the dose of aspart insulin. Notify the physician if the glucose decreases below. NPO: Basal Dosing (Glargine or NPH): If a patient eating meals or consuming clear liquids becomes NPO the nurse will administer fifty percent (5%) of the long acting insulin dose (basal insulin dose). If the patient is a Type One Diabetic consult with the physician before changing the dose. Type One diabetics may require their full dose. With a single glucose value greater than 3 mgdl it is generally advised that IV insulin infusion be initiated and the patient be made NPO until 2 consecutive glucose values are less than 15. The nurse will contact the physician to select either the insulin infusion versus the intensification of the Glycemic Control Scale. The RN will document all blood glucose measurements and all insulin documentation on the Intensive Care Glycemic Control Worksheet. Assessment for long acting insulin will be done by the physician (insulin glargine [Lantus] is preferred). Long acting insulin is highly suggested for diabetics or patients on steroids (or others if appropriate). The medication order has to be written by the physician.. Glycemic Control Scales for Group Two Patients Page 3 of 1

4 CLINICALPROTOCOL MULTIDISCIPLINARY SECTION: NM NUMBER: 2 HENRY FORD HOSPITAL DETROIT, MICHIGAN TITLE: GLYCEMIC CONTROL INTENSIVE CARE PROTOCOL UNIT: All ICUs APPROVED: 3/3 REVIEWED: REVISED: 12/3, 5/, /, /5, 3/, 11/ Subcutaneous Glycemic Control Scale for patients on Solid or Liquid Diet Excluding the 2 (if not a full tray consumed), 2, and glucose check (See below table) Blood Glucose Sensitiv e One Two Three Four For Glucose greater than 3, notify the physician for use of the insulin infusion. sensitive level for renal failure (creatinine greater than 2), liver failure, history of insulin sensitivity (one glucose less than 1 ), underweight (weight less than 5 kg), or the elderly (age greater than 7 yrs) Glycemic Control Scale for the 2 (if not a full meal tray), 2, and glucose check Treat only if greater than 15mg/dl with a maximum of units Blood Glucose Sensitiv e One Two Three Four For Glucose greater than 3, notify the physician for use of the insulin infusion. sensitive level for renal failure (creatinine greater than 2), liver failure, history of insulin sensitivity (one glucose less than 1 ), underweight (weight less than 5 kg), or the elderly (age greater than 7 yrs) Page of 1

5 CLINICALPROTOCOL MULTIDISCIPLINARY SECTION: NM NUMBER: 2 HENRY FORD HOSPITAL DETROIT, MICHIGAN TITLE: GLYCEMIC CONTROL INTENSIVE CARE PROTOCOL UNIT: All ICUs APPROVED: 3/3 REVIEWED: REVISED: 12/3, 5/, /, /5, 3/, 11/ Warnings for patients receiving Intravenous or Subcutaneous Glycemic Control (both group one or group two): 1. Hypoglycemia To prevent hypoglycemia: consult physician to start tube feedings, Total Parenteral Nutrition (TPN), or infusion of Dextrose 5%. Hypoglycemia will be treated by the nurse immediately according to the following guidelines: - Glucose 1 give 25 ml of Dextrose 5% (1/2 amp) - Glucose less than 1 give 5 ml of Dextrose 5% ( 1 amp) - If mental status changes caused by hypoglycemia are not reversed, the above dextrose administration will be repeated. - After treatment of hypoglycemia the nurse will notify the physician - The serum glucose will be checked again 1 hour after Dextrose administration. The physician will be notified with the results. Glucose Checks after Hypoglycemia o o o Check Glucose every hour after Dextrose administration until the glucose is greater than mg/dl, then check the glucose every 2 hours. If the glucose continues to be less than mg/dl continue to give Dextrose as above. Restart insulin administration beginning with the SECOND 2 hour glucose check that is greater than mg/dl. If on the insulin drip resume using the insulin sensitive nomogram Previous rate 1 3 units / hr resume at.5 units/hr Previous rate greater than 3 units/hr- resume at 5% of previous rate. If using the glycemic control scales use the Sensitive Scale For patients on the insulin drip (group one patients): If a patient is diagnosed as insulin sensitive (one or more glucose values less than 1 on the full dose insulin infusion nomogram) the nurse will use the Sensitive Infusion Nomogram for further dose titration. For patients receiving aspart insulin per the glycemic control scale (group two patients): One glucose value at any time less than but greater than decrease down one level. For one glucose less than or equal to 1 mg/dl use the Sensitive Scale. 2. Sensitive Patients Group One Patients: The Sensitive Infusion Nomogram will be used for all patients with renal failure (creatinine greater than 2), liver failure, kidney transplant, liver transplant, or insulin sensitivity (one glucose less than 1 mg/dl on the standard nomogram). If a patient is diagnosed as insulin sensitive (one or more glucose values less than 1 on the full dose insulin infusion nomogram) the nurse will use the Sensitive Infusion Nomogram for further dosing. The insulin sensitive nomogram will continued to be used unless otherwise ordered by the physician. Page 5 of 1

6 CLINICALPROTOCOL MULTIDISCIPLINARY SECTION: NM NUMBER: 2 HENRY FORD HOSPITAL DETROIT, MICHIGAN TITLE: GLYCEMIC CONTROL INTENSIVE CARE PROTOCOL UNIT: All ICUs APPROVED: 3/3 REVIEWED: REVISED: 12/3, 5/, /, /5, 3/, 11/ 3. Traveling Patients Group two patients: When using the glycemic control subcutaneous sliding scale the insulin sensitive level will be started should be used for any of the following: Renal Failure (creatinine greater than 2), Liver Failure, history of insulin sensitivity (one glucose less than 1mg/dl), underweight (weight less than 5kg) or the elderly (age greater than 7 yrs). For two glucose values in a row greater than 15mg/dl at any time: increase up one level on the scale to level one from the insulin sensitive level. Group One Patients: For patients traveling off of the unit decrease the insulin infusion by one half and consult with the physician for further insulin drip rate management. Check the patient s glucose on return to the unit and resume the insulin infusion nomogram. Group One Patients: Patient on tube feedings traveling off unit: If the tube feedings are discontinued the insulin drip will be stopped.. Tube Feedings Group One Patients: When tube feedings are discontinued (or temporarily held for any reason) the insulin drip is to be stopped. The glucose will be checked every two hours. The glycemic control protocol can be restarted from the beginning at this point. For glucose values 1 to 15 give 2 units Regular IV push. When the glucose rises above 15 restart the insulin drip. If the glucose remains above 15 and is starting to increase then restart the insulin drip at 2 units/hour (if previous rate was 2 units / hour restart at 1 unit/hour) Group One or Two Patients: Patient on long acting insulin: When tube feedings are held or discontinued the long acting insulin is to be held until the tube feeding is resumed or the long acting insulin is resumed by the physician. (Long acting example: glargine or NPH). If the tube feedings are held after the long acting insulin is given check the glucose every 2 hours for at least checks (12 hours). Call the physician for supplementation with intravenous Dextrose 5% in water for any glucose less than 15. For glucose values between 15 and 2 give 2 units of IV push regular insulin and for the first glucose greater than 2 start the insulin drip per protocol. Group One Patients: Drip and on continuous Tube Feedings: If the patient is on an insulin infusion and at goal with continuous tube feedings for at least 2 hours the nurse or pharmacist should suggest long acting insulin(glargine - Lantus ). This is highly recommended for diabetics or patients on steroids. If the long acting insulin has been administered for at least 3 days and the patients tube feedings have been at goal for at least 2 hours the insulin drip can be discontinued. Every hour glucose testing can start with glycemic control level one (insulin sensitive level if indicated). Subcutaneous aspart insulin can be used unless the patient has edema then regular insulin intravenously (IV push) can be used. If two glucose values in a row are greater than 15 the glycemic control level can be advanced one level. If one glucose value is less than the glycemic control level will be decreased one level. If the patient reaches glycemic control level four and the glucose is greater than 25 the insulin infusion will be restarted. 5. For patients on total parenteral nutrition (TPN) For TPN patients, insulin can be added to the TPN, but only at moderate levels (<5 units/bag) The insulin infusion per nomogram should be used to control glucose in the intensive care unit for glucose values greater than 15. Some patients will be transferred out of the ICU on a TPN and therefore some insulin should be added to the TPN to help for the continuance of glucose control on the general practice unit. Page of 1

7 CLINICALPROTOCOL MULTIDISCIPLINARY SECTION: NM NUMBER: 2 HENRY FORD HOSPITAL DETROIT, MICHIGAN TITLE: GLYCEMIC CONTROL INTENSIVE CARE PROTOCOL UNIT: All ICUs APPROVED: 3/3 REVIEWED: REVISED: 12/3, 5/, /, /5, 3/, 11/ Conversion of Drip to Subcutaneous Glycemic Control For patients started on the insulin infusion, the insulin nomogram will be followed until: 1. the patient is extubated and ready for discharge from the ICU or 2. extubated and started on a liquid or solid diet or 3. on continuous tube feedings at goal for 2 hours and on long acting insulin for at least 3 days (see above Warnings # Tube Feedings) or. The insulin drip per protocol will be continued to control glucose for hours in all cardiothoracic surgery patients (through at least post op day two ). Even if the patient is extubated and started on clear liquids or other diet the insulin drip will be continued per protocol. If the patient is transferred out of the ICU earlier than post op day two the insulin drip can be stopped at the time of discharge. If the patient is still intubated at hours continue the insulin drip per protocol. 5. Otherwise determined by the physician. To help with the conversion off the insulin infusion and preparing for transfer out of the ICU consider starting long acting insulin (insulin glargine-lantus or NPH insulin). The initiation of long acting insulin can be started when the physician deems appropriate (e.g. hemodynamic stability). Adding long acting basal insulin several days before discharge from the ICU will aid in the transition of glycemic control on the general practice unit. This is particularly important in diabetics or patients receiving corticosteroids. This is not an automatic part of the protocol. Consult with the physician for initiating. Steps to Stop Drip: Step #1: Nurse will use aspart insulin for coverage per subcutaneous glycemic control One. Consult physician for long acting insulin (glargine or NPH) if not already prescribed. Step #2: Give long acting insulin (glargine or NPH) Step #3: One hour after giving long acting insulin stop insulin infusion, start glucose checks every 2 hours x then every hours. Cover each glucose per level one of the subcutaneous glycemic control with insulin aspart (Novolog) (for patients ready for transfer to GPU: stop every 2 hr check when ready to transfer and start every hour glucose check on GPU) If no long acting insulin indicated then discontinue drip and check chemstick every 2 hours x then every hours. Use aspart insulin for coverage per subcutaneous glycemic control One. Page 7 of 1

8 CLINICALPROTOCOL MULTIDISCIPLINARY SECTION: NM NUMBER: 2 HENRY FORD HOSPITAL DETROIT, MICHIGAN TITLE: GLYCEMIC CONTROL INTENSIVE CARE PROTOCOL UNIT: All ICUs APPROVED: 3/3 REVIEWED: REVISED: 12/3, 5/, /, /5, 3/, 11/ Extubated and ready for discharge from the ICU. - Suggested Doses for Long Acting Long Acting Dose No History of insulin use at home (and a diabetic or steroid patient) Glargine (Lantus) units Subcutaneous every 2 hours No H/O DM then no glargine needed unless indicated by physician History of use at Home 5% of Home insulin dose as glargine(lantus) subcutaneous every 2 hours or NPH insulin every 12 hours Documentation: Long acting insulin Time (glargine or NPH) Give glargine(lantus) insulin and stop insulin infusion in one hour Give glargine or NPH insulin and stop insulin infusion in one hour Sliding Scale Coverage Start coverage with subcutaneous aspart insulin per One when insulin drip stopped (1 hr after Long acting insulin given): Check Glucose every 2 hours x then every fours until discharge. Start coverage with subcutaneous aspart insulin per One when insulin drip stopped (1 hr after Long acting insulin given): Check Glucose every 2 hours x then every fours until discharge. For all patients admitted to the intensive care unit, the physician shall write in the medication orders ICU Glycemic Control Protocol Document all glucose values and insulin doses on the ICU Glycemic Control Worksheet (Appendix-B). infusion rate adjustments shall also be documented on the ICU flowsheet. References: Zimmerman CR, Mlynarek ME, Jordan JA, Rajda CR, Horst MH. An insulin infusion protocol in critically ill cardiothoracic surgery patients. Ann Pharmacother 2 ;3: july/aug Van Den Berghe G, Wouters P, Weekers F et al. Intensive insulin therapy in critically ill patients. N EnglJ Med. 21; 35: Van Den Berghe G, Wilmer A, Hermans G, et al. Intensive insulin therapy in the medical ICU. N Engl J Med 2;35:5:9-1 AUTHOR, 2, 2: Mark Mlynarek, R.Ph., BCPS CONSULTANTS, 2, 2: Gail Boleski, RN, CCRN Lisa Cohen, RN Page of 1

9 CLINICALPROTOCOL MULTIDISCIPLINARY SECTION: NM NUMBER: 2 HENRY FORD HOSPITAL DETROIT, MICHIGAN TITLE: GLYCEMIC CONTROL INTENSIVE CARE PROTOCOL UNIT: All ICUs APPROVED: 3/3 REVIEWED: REVISED: 12/3, 5/, /, /5, 3/, 11/ APPROVALS: Yosely Cruz, RN Bruno DiGiovine, M.D. Mattie Horst, M.D. Michael Hudson, M.D. Beth McLellan, RN Princetta Morales, RN Mike Peters, R.Ph., BCPS Dawn Smith, RN Fred Whitehouse, M.D. SICU Committee: 3/25 Executive ICU Committee: 3/2 Critical Care Operations: 3/2, 11/27 Pharmacy & Therapeutic Committee: /2 ICU Clinical Practice: 11//2 Nursing Practice Council: 11//2 Page 9 of 1

10 Appendix A GLYCEMIC CONTROL INSULIN NOMOGRAM <1 INTENSIVE CARE UNIT PATIENTS ONLY Appendix A Group One- Intravenous Infusion- GLYCEMIC CONTROL INSULIN NOMOGRAM <1 INTENSIVE CARE UNIT PATIENTS ONLY GOAL: Glucose levels between -1. Start insulin infusion for 1st value greater than 15 MONITORING: Check glucose Q2h,(either capillary or blood) If Glucose less than check every hour. Restart Q 2 hr blood glucose checks when glucose is greater than. Document all glucose values and dosing on ICU Glycemic Control Worksheet. Guidelines: All Doses are Regular IV 1. Intubated Patients, Not Intubated and NPO, any patient on tube feedings or receiving TPN-Start insulin infusion for 1st value >15 mg/dl. 2. If insulin drip held for glucose less than, restart insulin drip when glucose greater than according to protocol 3. Continue Infusion Protocol until preparing for discharge or otherwise directed by physician.. Consult physician for starting long acting insulin (basal) - glargine ( Lantus) Collaborate with physician or pharmacist about dose. 5. Consult physician to start tube feeding, TPN, or D5W for caloric source and to prevent hypoglycemia. Continue insulin drip protocol. All peritoneal dialysis patients check blood glucose in lab before starting protocol. Make sure blood glucose matches chemstick glucose. 7. If tube feedings are discontinued or held stop the insulin drip- check glucose q2hr restart glycemic control protocol from beginning. Any patient traveling off of the unit, decrease the insulin drip by 5%. Check the glucose on return to the ICU and restart nomogram. STARTING INSULIN INFUSION Glucose >22 Starting Dose Give 2 units Regular insulin IVP and start 2 units/hr If Renal Failure (creatinine >2), Liver Failure, Liver Transplant or Kidney Transplant start at 1 unit/hour Maintenance Drip Glucose Rate 1-3 units/hr < 1 D/C infusion. Give 1 amp Dextrose 5% IVP-Notify Physician. Check glucose hourly until glucose greater than, then every 2 hours. When 2 in a row every 2 hour glucose checks are greater than restart drip at.5 unit/hour and use the insulin sensitive nomogram. Notify physician when glucose greater than 1- D/C infusion. Give 1/2 amp Dextrose 5% IVP-Notify Physician. Check glucose hourly until glucose greater than, then every 2 hours. When 2 in a row every 2 hour glucose checks are greater than restart drip at.5 unit/hour and use the insulin sensitive nomogram. Notify physician when glucose greater than Give units Regular insulin IVP and start units/hr If Renal Failure (creatinine >2), Liver Failure, Liver Transplant, or Kidney Transplant start at 2 units/hour Rate > 3 units/hr D/C infusion. Give 1 amp Dextrose 5% IVP-Notify Physician. Check glucose hourly until glucose greater than, then every 2 hours. When 2 in a row every 2 hour glucose checks are greater than restart drip but reduce rate by 5% and use insulin sensitive nomogram Notify Physician when glucose greater than D/C infusion. Give 1/2 amp Dextrose 5% IVP-Notify Physician. Check glucose hourly until glucose greater than, then every 2 hours. When 2 in a row every 2 hour glucose checks are greater than restart drip but reduce rate by 5% and use insulin sensitive nomogram Notify Physician when glucose greater than 1- Rate 1-3 units/hr D/C Infusion: Recheck glucose EVERY HOUR When glucose greater than restart drip at 1 unit/hr Rate > 3 units/hr D/C Infusion: Re-Check glucose EVERY HOUR. When glucose greater than restart insulin infusion, but decrease dose rate 5% If insulin drip turned off for glucose less than (but greater than ) check every hour until greater than then every 2 hours. If 3 in a row every 2 hour checks are less than restart protocol from beginning. Change glucose check to qh and cover with regular insulin IV push 2 units for glucose 1 to 15 and start insulin drip for first glucose greater than 15. Rate 1-3 units/hr Rate > 3 units/hr 1-1 No Change unless: If previous glucoses higher Reduce drip by 1 unit/hr (If current dose 1 unit / hour do not change) No Change unless: If previous glucose higher then reduce per below: Infusion Rate Decrease Dose by: 7 units/hr 1 unit/hr 12 units/hr 2 units/hr units/hr 3 units/hr 1 22 units/hr units/hr >22 units/hr 5 units/hr Page of 1

11 STANDARD INSULIN NOMOGRAM INSULIN SENSITIVE INFUSION NOMOGRAM Glucose > Dosage All Others Increase Drip Rate by.5 unit/h (no bolus) Continue same rate if Last glucose was higher value Give 2 units Regular insulin IVP and Increase drip rate by 1 u/h Give units Regular insulin IVP and Increase drip rate by 1 u/h Give units Regular insulin IVP and Increase drip rate by 1 u/h Give units Regular insulin IVP and Increase drip rate by 1 u/h Glucose Dosage for: Renal failure-(creatinine > 2), Liver Failure Liver or Kidney Transplant, or one glucose less than 1 mg/dl No Change Give 2 units Regular insulin IVP and Increase drip rate by.5 u/h Give units Regular insulin IVP and Increase drip rate by.5 u/h Give units Regular insulin IVP and Increase drip rate by.5 u/h 31- Give units Regular insulin IVP and Increase drip rate by.5 u/h Call MD for New Order > Call MD for New Order Page 11 of 1

12 Appendix B Group Two Patients- Subcutaneous Glycemic Control Glycemic Control Scales for Group Two Patients Subcutaneous Glycemic Control Scale for patients on Solid or Liquid Diet Excluding the 2 (if not a full tray consumed), 2, and glucose check (see below table) Blood Glucose Sensitive One Two Three Four For Glucose greater than 3 notify the physician for use of the insulin infusion. sensitive level for renal failure (creatinine greater than 2), liver failure, history of insulin sensitivity (one glucose less than 1 ), underweight (weight less than 5 kg), or the elderly (age greater than 7 yrs) 22 Glycemic Control Scale for the 2 (if not a full meal tray), 2, and glucose check Treat only if greater than 15mg/dl with a maximum of units Blood Glucose Sensitive One Two Three Four For Glucose greater than 3 notify the physician for use of the insulin infusion. sensitive level for renal failure (creatinine greater than 2), liver failure, history of insulin sensitivity (one glucose less than 1 ), underweight (weight less than 5 kg), or the elderly (age greater than 7 yrs) Page 12 of 1

13 Hypoglycemia: For Glucose 1- give ½ ampule (25ml) of Dextrose 5% For Glucose < 1 give 1 ampule (5ml) of Dextrose 5% o Check Glucose every hour after Dextrose administration until the glucose is greater than mg/dl, then check the glucose every 2 hours. o Restart insulin administration beginning with the SECOND 2 hour glucose check that is greater than mg/dl. If on the insulin drip resume using the insulin sensitive nomogram Previous rate 1 3 units / hr resume at.5 units/hr Previous rate greater than 3 units/hr- resume at 5% of previous rate. If using the glycemic control scales use the Sensitive Scale Sensitive : For renal failure(creatinine greater than 2), liver failure, history of insulin sensitivity(one previous glucose less than 1 ), underweight (weight less than 5 kg), or elderly (age greater than 7) If on the Sensitive there are two glucose values in a row greater than 15mg/dl at any time: increase up one level on the scale. Approved Uses of Glycemic Scale: 1. Conversion of Drip to Subcutaneous Glycemic Control-continue insulin drip until: a. The patient is extubated and ready for discharge from the ICU or b. Extubated and started on a liquid or solid diet or c. On continuous tube feedings at goal for 2 hours and on long acting insulin for at least three d. All cardiothoracic surgery patients- continue the IV insulin infusion for at least hours- see protocol. 2. Patients who are eating (liquid or solid diet): Blood glucose reagent strip testing will be assessed every four hours on this schedule ( ) The, 12, and 1 glucose check should be before the meal. coverage will start with subcutaneous insulin aspart (Novolog) per level one. The following rules will apply to the Subcutaneous Glycemic Control Scale: The nurse will automatically start the glycemic control scale coverage for patients in this group. No special written medications orders are needed except for the glycemic control order on admission to the ICU. If the first three glucose values in a row are less than 1, glucose checking can be stopped. Start with level one (or insulin sensitive level if indicated). Two glucose values in a row greater than 15 at any time increase up one level on the scale. One glucose value at any time less than decrease down one level. The 2 (if not a full meal tray consumed), 2 and glucose will only be treated if greater than 15 per current Glycemic Control Scale with a maximum insulin dose of units. NPO: Aspart Dosing: If a patient eating meals or consuming clear liquids becomes NPO (nothing by mouth) the nurse will administer fifty percent (5%) of the dose of aspart insulin. Notify the physician if the glucose decreases below. NPO: Basal Dosing (Glargine or NPH): If a patient eating meals or consuming clear liquids becomes NPO the nurse will administer fifty percent (5%) of the long acting insulin dose (basal insulin dose). If the patient is a Type One Diabetic consult with the physician before changing the dose. Type One diabetics may require their full dose. With a single glucose value greater than 3, it is generally advised that IV insulin infusion be initiated and the patient be made NPO until 2 consecutive glucose values are less than 15. The nurse will contact the physician to select either the insulin infusion versus the intensification of the Glycemic Control Scale. Page 13 of 1

14 Assessment for long acting insulin will be done by the physician (insulin glargine [Lantus] is preferred). Long acting insulin is highly suggested for diabetics or patients on steroids (or others if appropriate). The medication order has to be written by the physician. The RN will document all blood glucose measurements and all insulin documentation on the Intensive Care Glycemic Control Worksheet. Page 1 of 1

15 INTENSIVE CARE UNIT GLYCEMIC CONTROL WORKSHEET Appendix C Date: MRN: Name: Guidelines: A. NPO (intubated or not), TPN, continuous Tube Feedings 1. Check glucose every hours x3 on admission to ICU 2. All three glucose values < 1, discontinue checks 3. Any glucose 1 to 15 give 2 units of Regular insulin IV Push. First Glucose greater than 15 start insulin infusion.. Continue Infusion Protocol until preparing for discharge from ICU or otherwise directed by physician. 5. Consult physician for starting long acting insulin (basal) - glargine ( Lantus) or NPH. Collaborate with physician or pharmacist about dose.. If on long acting insulin for 3 days and at goal with continuous tube feedings for 2 hours consider glycemic scale coverage qh 7. Consult physician to start tube feeding, TPN, or D5W for caloric source and to prevent hypoglycemia. B. All Patients on Solid or Liquid Diet (Fork and Knife or drinking from cup) 1. Check glucose every hours on 12-- schedule 2. Use subcutaneous aspart insulin (Novolog) coverage per glycemic control scale. Start with level one or insulin sensitive level if indicated 3. Two glucose values in a row greater than 15, increase up one level (if 1 st 3 in a row<1-stop checks). One glucose value less than decrease one level 5. For pm(if no meal), 12mn and am glucose checks-treat only if glucose greater than 15 dose is per current Glycemic Control Scale with a maximum insulin dose of units. C. Other Guidelines For Glucose 1- give ½ ampule (25ml) of Dextrose 5% For Glucose < 1 give 1 ampule (5ml) of Dextrose 5% Sensitive for renal failure, liver failure, history of insulin sensitivity, or underweight elderly Blood Glucose Regular IV bolus and Drip doses Glycemic Scale For subcutaneous glycemic control Long Acting (BASAL) Date Time Initial Result Regular IV push dose Drip Dose (Units/hr) Date Time Aspart Subcutaneous Dose Time/dose/ Initials of NPH or glargine Initials Name/Professional Designation Initials Name/Professional Designation 11/7 CONTINUE ON OTHER SIDE Page 15 of 1

16 INTENSIVE CARE UNIT GLYCEMIC CONTROL WORKSHEET Date: MRN: Name: Blood Glucose Regular IV bolus and Drip doses Glycemic Scale For subcutaneous glycemic control Long Acting (BASAL) Date Time Initial Result Regular IV push dose Drip Dose (Units/hr) Date Time Aspart Subcutaneous Dose Time/dose/ Initials of NPH or glargine Initials Name/Professional Designation Initials Name/Professional Designation Page 1 of 1

17 INTENSIVE CARE UNIT GLYCEMIC CONTROL WORKSHEET Date: MRN: Name: Guidelines: A. NPO (intubated or not), TPN, continuous Tube Feedings 1. Check glucose every hours x3 on admission to ICU 2. All three glucose values < 1, discontinue checks 3. Any glucose 1 to 15 give 2 units of Regular insulin IV Push. First Glucose greater than 15 start insulin infusion.. Continue Infusion Protocol until preparing for discharge from ICU or otherwise directed by physician. 5. Consult physician for starting long acting insulin (basal) - glargine ( Lantus) or NPH. Collaborate with physician or pharmacist about dose.. If on long acting insulin for 3 days and at goal with continuous tube feedings for 2 hours consider glycemic scale coverage qh 7. Consult physician to start tube feeding, TPN, or D5W for caloric source and to prevent hypoglycemia. B. All Patients on Solid or Liquid Diet (Fork and Knife or drinking from cup) 1. Check glucose every hours on 12-- schedule 2. Use subcutaneous aspart insulin (Novolog) coverage per glycemic control scale. Start with level one or insulin sensitive level if indicated 3. Two glucose values in a row greater than 15, increase up one level (if 1 st 3 in a row<1-stop checks). One glucose value less than decrease one level 5. For pm(if no meal), 12mn and am glucose checks cover with units only if glucose greater than 2 C. Other Guidelines For Glucose 1- give ½ ampule (25ml) of Dextrose 5% For Glucose < 1 give 1 ampule (5ml) of Dextrose 5% Sensitive for renal failure, liver failure, history of insulin sensitivity, or underweight elderly Date Time Blood Glucose Initial Result Regular IV bolus and Drip doses Regular IV push dose Drip Dose (Units/hr) Glycemic Scale For subcutaneous glycemic control Date Time Aspart Subcutaneous Dose Long Acting (BASAL) Time/dose/ Initials of NPH or glargine Initials Name/Professional Designation Initials Name/Professional Designation CONTINUE ON OTHER SIDE Page 17 of 1

18 INTENSIVE CARE UNIT GLYCEMIC CONTROL WORKSHEET Date: MRN: Name: Blood Glucose Date Initial Result Time Regular IV bolus and Drip doses Regular IV push dose Drip Dose (Units/hr) Date Glycemic Scale For subcutaneous glycemic control Time Aspart Subcutaneous Dose Long Acting (BASAL) Time/dose/ Initials of NPH or glargine Initials Name/Professional Designation Initials Name/Professional Designation Page 1 of 1