V TTG T F G UM - G & UG U FU T Goal Blood Glucose (BG) ange = 80-150 mg/d GTU T M G U/ T TM T. M B lgorithm 1 ecommend start here for type 1 diabetes lgorithm 2 ecommend start here for type 2 diabetes lgorithm 3 ecommend patients start here U Medicine arborview Medical enter U Medical enter University of ashington hysicians UM UG U FU *FT* *U2627* U2627 V UG 08 lgorithm 4 ecommend patients start here BG Units/hr BG Units/hr BG Units/hr BG Units/hr <60 = ypoglycemia (ee below for treatment) <70 ff <70 ff <70 ff <70 ff 70-109 0.2 70-109 0.5 70-109 1 70-109 1.5 110-119 0.5 110-119 1 110-119 2 110-119 3 120-149 1 120-149 1.5 120-149 3 120-149 5 150-179 1.5 150-179 2 150-179 4 150-179 7 180-209 2 180-209 3 180-209 5 180-209 9 210-239 2 210-239 4 210-239 6 210-239 12 240-269 3 240-269 5 240-269 8 240-269 16 270-299 3 270-299 6 270-299 10 270-299 20 300-329 4 300-329 7 300-329 12 300-329 24 330-359 4 330-359 8 330-359 14 >330 28 >360 6 >360 12 >360 16 General Guidelines: tandard insulin infusion: 100 units/100 m 0.9% odium chloride via an infusion device tart insulin infusion when: o BG > 150 X 2 readings for patients not previously on insulin o BG 70 for patients with Type 1 diabetes or already on insulin infusion therapy heck blood glucose V hour ypoglycemia protocol for BG < 60 mg/d o Turn off infusion give 50% dextrose V BG 50-60 mg/d 25 m (1/2 amp) BG <50 mg/d 50 m (1 amp) o echeck blood glucose (BG) every 20 minutes and repeat 25 m of 50% dextrose V if BG < 60 mg/d. estart infusion at a lower algorithm once blood glucose is >70 mg/d X 2 checks hanging lgorithms according to blood glucose: Moving Up: blood glucose (BG) is out of goal range and has not decreased by at least 60 mg/d Moving own: BG < 70 mg/d BG decreases >100 mg/d in an hour pt has hypoglycemic episode. T/Tube Feeds ecrease insulin infusion rate by 50% if nutritional therapy is discontinued or significantly reduced and check BG every hour. T - M - M K - UG
V TTG T F G UM nsulin nfusion rotocol Goal BG ange = 80-180 mg/d U Goal BG ange = iscontinue ll revious nsulin rders lgorithm 1 lgorithm 2 lgorithm 3 lgorithm 4 BG Units/hr BG Units/hr BG Units/hr BG Units/hr <60 = ypoglycemia (ee below for treatment) <70 ff <70 ff <70 ff <70 ff 70-109 0.2 70-109 0.5 70-109 1 70-109 1.5 110-119 0.5 110-119 1 110-119 2 110-119 3 120-149 1 120-149 1.5 120-149 3 120-149 5 150-179 1.5 150-179 2 150-179 4 150-179 7 180-209 2 180-209 3 180-209 5 180-209 9 210-239 2 210-239 4 210-239 6 210-239 12 240-269 3 240-269 5 240-269 8 240-269 16 270-299 3 270-299 6 270-299 10 270-299 20 300-329 4 300-329 7 300-329 12 300-329 24 330-359 4 330-359 8 330-359 14 >330 28 >360 6 >360 12 >360 16 General Guidelines: tandard drip: 100 units/100 m 0.9% al via an infusion device tart when: o BG > 120 for patients who have received oral diabetes medication within 24 hrs o BG 70 for patients treated with insulin prior to hospital admission iscontinue insulin infusion when patient is eating has received first dose of subcutaneous insulin. ypoglycemia protocol for BG<60 mg/d (see back for specifics) ntravenous Fluids: ecommendations for patients that are not eating: M Type 1 (10 grams glucose/hour) M Type 2 (5 grams glucose/hr) GTU T M G U T TM T. M B 51/2 normal saline with 20 mq/ otassium chloride V at m/hr 5 with 20 mq/ otassium chloride V at U Medicine arborview Medical enter U Medical enter University of ashington hysicians UM U FU T *U1957* *U1957 U1957 V 06 m/hr T or nteral Feeds (see separate orders) at m/hr T - M - M K - UG
nitiating The nfusion lgorithm 1: tart here for most patients. lgorithm 2: tart here if s/p BG, solid organ transplant, receiving glucocorticoids, or patient receiving >80 units/day of insulin as an outpatient. lgorithm 3 TT TT. lgorithm 4 TT TT Moving lgorithms: (Move up or down only one algorithm per BG check) Moving Up: f BG is out of goal range and has not decreased by at least 60 mg/d Moving own: hen blood glucose <70 mg/d or if BG decreases >100 mg/d in an hour if pt has hypoglycemic episode. Maintain atient ithin urrent lgorithm-nce BG is in Goal ange djust T within current algorithm until patient is in goal range for 4 hours nce patient is within goal range for 4 hours, there is no need to adjust T unless BG falls out of goal range atient Monitoring: heck BG every hour until it is within goal range for 4 hours. Then check every 2 hours X2, then every 4 hours. esume hourly checks if BG falls out of goal range. ourly monitoring may be indicated for critically ill patients even if they have stable blood glucose. f patient is eating, check BG every hour X 3 after meals. T/Tube Feeds o ecrease insulin infusion rate by 50% if nutritional therapy is discontinued or significantly reduced and check BG every hour X 4 hrs. Treatment of ypoglycemia (BG<60 mg/d) igns and symptoms include, palpitations, diaphoresis, weakness, altered mental status. Turn off drip Give 50 V o BG 50-60 mg/d 25 m (1/2 amp) o BG <50 mg/d 50m (1 amp) echeck BG every 20 minutes and repeat 25m of 50 V if BG<60mg/d. estart drip once blood glucose is >70 mg/d X2 checks. estart infusion at a lower algorithm (see moving down). otify the hysician: For any blood glucose change >100 mg/d in one hour. For blood glucose > 360 mg/d For any hypoglycemia which results in loss of consciousness For hypoglycemia which has not resolved within 20 min of administering 50m of 50 V and discontinuing the insulin infusion. Failure of algorithm 4 (onsider ndocrine consult) U1957 V 06 BK
TG TV istorical Medical ecord at bedside V: tart upon pre-op arrival actated ingers at m/hr 0.9% odium chloride at m/hr 5 at m/hr Meds: KG X Urine G abs ther GU T heck capillary blood glucose (BG) on arrival and every hour heck ne of the Following: atient uses subcutaneous insulin pump at home 1. Turn pump off and disconnect tubing when patient arrives 2. iggyback nsulin nfusion per UM perating oom nsulin nfusion rotocol 3. f V fluid does T contain dextrose - piggyback dextrose 5% to deliver 50-100 m/hour atient is an inpatient already on the insulin infusion protocol. 1. ontinue insulin infusion at current rate U T/enteral feeds will be interrupted. educe rate by 50% for these cases per the insulin infusion protocol a) f V fluid does T contain dextrose - piggyback dextrose 5% to deliver 50-100 m/hour b) ontinue hourly BG monitoring and titration per protocol atient is not currently receiving an insulin infusion 1. heck blood glucose hourly and if >150 mg/d confirm with another point of care test or lab draw within 20 minutes. 2. f confirmed BG>150 (see step 1) any single BG>250 mg/d nitiate UM perating oom nsulin nfusion rotocol with BG monitoring per protocol. f V fluid does T contain dextrose - piggyback dextrose 5% to deliver 50-100 m/hour f BG<60 mg/d: 1. Give 25 m of 50% dextrose and turn off insulin infusion if on (see insulin infusion protocol orders) 2. f V fluid does T contain dextrose - piggyback dextrose 5% to deliver 50-100 m/hour 3. echeck BG in 20 minutes. f blood glucose is still <60 mg/d, retreat with 50% dextrose and call anesthesiologist. TGT GTU T M G T TM T. M B U Medicine arborview Medical enter U Medical enter University of ashington hysicians TG *U2397* *U2397* U2397 V JU 08 T M M K UG
G U BT atient is to be admitted to the hospital or stay overnight on 4 outh ontinue urgery insulin infusion protocol with hourly blood glucose monitoring all surgical team for post p insulin orders atient will be discharged to home from the U iscontinue insulin infusion upon arrival to U heck blood glucose (BG) on arrival and hourly until discharge f BG<60 mg/d Give 25 m of 50% dextrose V and recheck BG in 20 minutes f BG>250 mg/d all anesthesiologist for additional orders atient receives insulin as a routine medication at home f BG>150 mg/d administer ispro (umalog ) insulin every 3 hours using the algorithm below. (Blood glucose is checked hourly but correction ispro is given only every 3 hours) T TM V GTU T M G U/ T. M B Blood Glucose (mg/d) ubq orrection ose of ispro (umalog ) atient 50 kg atient 51-70 kg U Medicine arborview Medical enter U Medical enter University of ashington hysicians U BT *U2628* *U2628* U2628 V UG 08 atient 71-90 kg atient >90 kg 150-199 1 unit 2 units 3 units 4 units 200-249 2 units 4 units 5 units 6 units 250-299 4 units 6 units 7 units 9 units 300-349 6 units 8 units 10 units 12 units >349 7 units 9 units 12 units 14 units estart routine prandial subq insulin once patient is able to resume usual oral diet and/or esume basal subq insulin at next scheduled dose or esume subq insulin pump once patient awake and able to self manage his/her diabetes (To have administer insulin at UM, you must complete ub-q insulin order form U1807) on-insulin Treated atient nstruct patient at discharge to restart oral anti-diabetic agents XT MTFM once able to resume oral diet (provide patient with ow to Manage our iabetes Before and fter urgery handout) For atients Taking Meformin (check one below): rocedure unlikely to alter renal function: (e.g. ataract or minor orthopedic procedures) estart Metformin once patient is able to resume his/her usual oral diet rocedure likely to alter renal function: (e.g. upper G procedure, procedure involved significant blood loss and/or V contrast/aminoglycoside administration): nstruct patient to call primary care physician in 2 days before restarting Metformin T - M - M K - UG