Neonatal Critical Care Hyperglycemia Management Guideline Recommended initial action for hyperglycemia Reduce glucose infusion rate (GIR) to 4-6 mg/kg/min. Recheck blood glucose (BG) hourly. If BG remains >200 x 2, proceed to insulin guideline. Eligibility criteria for insulin BG > 200 mg% x 2 (separate each sample by 1 hour) Patients with neonatal diabetes mellitus should not be managed with this guideline. Recommended initial insulin dose Begin a continuous IV drip of insulin at 0.05 units/kg/hour Maximum rate allowed by this guideline: 0.5 units/kg/hour Insulin bolus doses are not recommended for BG titration in this guideline. Recommended BG sampling Measure BG every hour while on insulin until BG is stable. Sampling frequency may be reduced by provider order if BG 101-150 mg% for at least 6-12 hours with no dosing adjustments required. After insulin is stopped, sample BG every 2 hours x 2, then every 4 hours x 3. Draw BG samples from an arterial line, heel stick, or central venous line. Do not draw samples from lines that infuse a dextrose-containing fluid. Clamp the dextrose-running lumen if sampling from a double lumen line. Recommended management guide BG (mg%) <60 60-100 101-150 151-200 >200 Recommendation Stop/Suspend insulin, administer 2 mL/kg of 10% dextrose, notify NNP or neonatologist, then re-sample BG in 30 minutes Stop/Suspend insulin then notify NNP or neonatologist Stop/Suspend insulin Computer titrated target range while on insulin drip Computer adjusts insulin drip more aggressively to lower BG Guideline finalized: August 21, 2015 Cerner rules for neonatal critical care hyperglycemia Insulin drip is ON BG Result Insulin drip is OFF <60 Administer 2 mL/kg 10% dextrose, Notify NNP or neonatologist, then Re-check BG in 30 minutes Stop/Suspend insulin, Administer 2 mL/kg 10% dextrose, Notify NNP or neonatologist, then Re-check BG in 30 minutes Notify Stop/Suspend insulin, then Notify NNP or neonatologist Stop/Suspend insulin 60-100 101-150 151-200 NNP or neonatologist Insulin not recommended Insulin not recommended BG drop <25 mg%/hr or increase Continue same insulin dose BG drop 26-74 mg%/hr Decrease insulin dose by 25% Other BG drop >75 mg%/hr Recommendations If insulin rate < 0.02 Decrease units/kg/hr, stop insulin insulin dose by and measure BG Q2 hours x 2, then Q4 50% hours x 3 201-250 If no previous BG >200 within a 45 min to 2 hour time frame, use Conditional Order to repeat glucose in 1 hour If 2 successive BG >200 within a 45 >250 Increase insulin by 25% Continue same insulin dose Decrease insulin dose by 50% and notify NNP or neonatologist Continue same insulin dose Decrease insulin dose by 50% and notify NNP or neonatologist Increase min to 2 hour time frame, “Notify NNP insulin dose by or neonatologist that insulin is 50% and notify recommended in this patient per NNP or protocol.” neonatologist Maximum rate allowed is 0.5 units/kg/hr Guideline finalized: August 21, 2015