Intensive Care Insulin Protocol
ICMS / ICCS / CCU
WRHA CARDIAC SCIENCES
GUIDELINES
Approved By:
Cardiac Sciences Standards Committee
Cardiac Sciences Quality and Standards Committee
Effective Date/ Last
Revised:
April 29, 2013
Originated from:
Page:
 CI
 LEAN ■ QI  Other
Lead: Dr Ariano and Glycemic Control Review
Committee
Number: 105
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Introduction and Statement of Guidelines:
The maintenance of blood glucose levels in the range 5-10 mmol/L in ICU/CCU patients has
been shown to reduce morbidity among critically ill patients regardless of whether they have a
history of diabetes. Other data suggests sternal wound infections may be reduced in cardiac
surgery patients by control of perioperative blood glucose levels.
Purpose of Protocol:
The protocol is designed to allow nursing staff and physicians to safely manage patients with
insulin infusions. The protocol will provide guidance for insulin administration. Orders for
frequency of monitoring and for glucose administration in the event of hypoglycemia are part of
the protocol.
Patient Population:
All patients admitted to ICU/CCU should be considered for management of blood glucose
according to this protocol. The ICU/CCU attending physicians will ultimately decide who is
managed by this protocol.
Activation of the Protocol:
The ICU/CCU Insulin Protocol must be ordered by a physician. Blood glucose management is
included in the Cardiac Surgery Postoperative orders according to the principles in this protocol.
Patient and Family Education:
ICU nursing and medical staff will be responsible for explaining the protocol and the use of
insulin to the patients and their families. It is anticipated that there will be some issues as
patients who are not normally on insulin will be receiving this medication while in ICU/CCU.
Nursing and Physician Education:
The protocol will have to be introduced to physicians, nurses, and pharmacists. This protocol will
also need to be introduced to the WCCNEP Winnipeg Critical Care Nursing Education Program
and taught as part of that educational package. Educational initiatives that may be used include:
information packages for nursing and medical staff; bedside charts with the protocol available for
easy reference; formal lectures at in-service time for unit staff; safety huddles and case based
teaching sessions.
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WRHA Cardiac Sciences Program: Intensive Care Insulin Protocol ICMS / ICCS / CCU
Number: 105
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Medication Caution:
Insulin is a dangerous medication which can produce severe patient morbidity and potential
mortality. Severe hypoglycemia may result when insulin is infused especially in critically ill
patients. The protocol has been designed to avoid dangerous hypoglycemia. Insulin must only be
administered by direct continuous infusion pump using the safety software. Insulin must be
administered utilizing a basic solution set and is never to be piggybacked (run as a secondary
medication line above the pump (as a mini infusion is)). Nursing staff must be vigilant to ensure that
insulin infusions are not continued at the same dose if intravenous glucose infusions or enteral
feeding are interrupted. Caution with patients who are eating during the day and not maintaining
caloric intake at night.
Anesthesia Caution:
Despite the lack of evidence for any benefit (and possibly some risk) ascribed to aggressive insulin
therapy to target normoglycemia, excessive hyperglycemia (i.e. blood glucose > 9.9 mmol/L)
remains undesirable in the cardiac surgery patient. As a result, the initiation of an insulin infusion
will be considered in the operating room in cardiac surgery patients whose blood glucose exceeds
9.9 mmol/L.
ICU/CCU Insulin Protocol
Coverage:
All Registered Nurses may administer insulin according to this protocol in the following locations:
 Intensive Care Cardiac Sciences (ICCS)
 Intensive Care Medical Surgical (ICMS)
 Cardiac Care Unit (CCU)
Initiation:
This protocol will be initiated upon a physicians order after admission to ICU/CCU.
Protocol:
1. For all patients on the insulin infusion protocol start either Ringers lactate solution or D5 ½ NS
at 75mL to 100 mL/hr as a maintenance ‘dextrose-containing’ intravenous solution; or as
directed by physician. Suggest 500 mL of Ringers lactate boluses as resuscitation fluid as
necessary. Reassess IV fluids on post-operative day #1 in the cardiac surgical population.
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WRHA Cardiac Sciences Program: Intensive Care Insulin Protocol ICMS / ICCS / CCU
Number: 105
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2. Start insulin infusion as follows depending on what the starting blood glucose is.
Remember that a dedicated pump must be used to administer insulin:
Initial Blood Glucose
Begin Insulin at:
< 10 mmol/L
no insulin
10 -11.9mmol/L
2 units/hr
>12.0mmol/L
4 units/hr
3. Insulin titration and glucose monitoring AFTER initiation of infusion:
a. When blood glucose is outside of the 5-10mmol/L range insulin may be adjusted up or down. If
there is a 50% or greater drop in blood glucose after adjustment of insulin dose the insulin
infusion should be decreased by 50% and a blood glucose must be rechecked within 60 minutes.
b. Check blood glucose every hour until glucose level is 5-10mmol/L AND insulin infusion rate
remains unchanged for 2 hours. After that, check blood glucose q2h, and if glucose level is
stable after two measurements, may monitor glucose q4h.
c. Maximum dose of insulin by this protocol is 20 units/hr. Insulin infusion rates over 20 units/hr
must be ordered by a physician.
d. The following orders are for treatment of hypoglycemia:
If glucose level < 2.2 mmol/L →
 STOP INSULIN INFUSION
 Draw serum glucose
 Administer dextrose 50% injection 25g IV push (50mL)
 Re-check blood glucose level in 30-60 minutes
 Notify physician
If glucose level 2.3-3.5 mmol/L →
 STOP INSULIN INFUSION OR administer insulin at half the previous rate
 Administer dextrose 50% injection 12.5g IV push (25mL)
 Re-check blood glucose level in 30-60 minutes
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WRHA Cardiac Sciences Program: Intensive Care Insulin Protocol ICMS / ICCS / CCU
Number: 105
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4. Factors to consider when using Intensive Care Insulin Protocol:
a. Nursing staff should use good clinical judgment when titrating insulin infusions. Previous
glucose readings and the trend in insulin adjustments should be considered. Prolonged episodes
of hypoglycemia (glucose <3.6 mmol/L) must be avoided! Short episodes of glucose levels
above the range are not a major problem. Continue to check blood glucose hourly and adjust
insulin hourly until you get to goal range.
b. Sensitivity to insulin improves as patient condition stabilizes. Therefore, the need for insulin
usually decreases as the ICU/CCU stay progresses. If glucose starts to fall, even though the
glucose remains in “normal” range, insulin doses may need to be reduced by approximately 20%
(example: if Insulin was running 2 units/hr and the glucose is falling, reduce the infusion by 0.5
units/hr to a final rate of 1.5 units/hr).
c. Increased body temperature causes an increase in insulin requirements, particularly if caused by
infection. Insulin needs decrease as the infection improves and temperature returns to normal.
The intervention with therapeutic hypothermia in some patients may also significantly alter
insulin requirements. Closer monitoring of blood glucoses are required.
d. If tube feeds or TPN (TNA) are discontinued, stop the insulin infusion and check blood sugar
within 60 minutes before administering more insulin. The only exception to this practice is in
patients who are known insulin dependent diabetics. In these patients the insulin dose should be
reduced by at least 50% and the sugar checked again within 60 minutes. The physician should
be contacted to order provide an alternate source of glucose (e.g. IV dextrose infusion or enteral
nutrition), if tube feeds are unexpectedly interrupted (tube pulled out etc).
e. For ‘Volume based feeding schedules’ in tube fed patients some consideration should be given
to the increased volume of tube feed being administered over a shorter period of time. Check
the blood glucose level in 60 minutes and then re-adjust the insulin infusion rate upward as
necessary for the same glucose target level of 5 – 10 mmol/L. Once the normal tube feed rate is
returned; immediately drop the insulin rate back down to its initial value and then repeat blood
glucose level in 60 minutes and reassess.
5. Insulin and drug reactions:
a. Glucocorticoids (steroids) increase insulin resistance in ICU/CCU patients. The dose of insulin
may need to be titrated upward, whenever such treatments are initiated.
b. Some drugs (epinephrine, norepinephrine) will increase blood glucose levels. More insulin will
be needed when these drugs are infusing. Less insulin will be needed as the catecholamines are
titrated off. Glucose levels must be checked frequently every 30 minutes to 1 hour, and insulin
doses reduced as epinephrine and norepinephrine infusions are being discontinued.
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WRHA Cardiac Sciences Program: Intensive Care Insulin Protocol ICMS / ICCS / CCU
c.
Number: 105
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High doses of insulin (i.e. > 6 units per hour) may lead to hypokalemia, so potassium levels
must be checked more frequently until stable. If the insulin is stopped, potassium levels can
increase. Caution must be exercised if potassium has recently or is still being administered when
the insulin infusion is stopped or the infusion rate has been significantly reduced. Potassium
infusions should NOT be administered during the first four hours after discontinuation of insulin
infusions unless potassium levels are being closely monitored and the serum potassium is less
than 4.0 mmol/L. Caution with the administration of red packed cells which can increase
potassium levels and the potential for hemolysis (i.e. CRRT, valve case and IABP).
Suggested monitoring of potassium levels while on insulin infusions:
 Insulin running 6 units per hour or greater - Monitor potassium q4-6h
 Insulin running 4-6 units per hour - Monitor potassium q12h
 Insulin stopped, but the patient has received potassium infusion within the
last 2 hours - Monitor potassium q4h for the next 8 hours.
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