INSULIN Infusions
Case Study: NEW Standardized
Concentration
Medication Management Safety
Team
Learning Objectives
•Review new insulin protocols and highlight
important changes
•Case studies for NPO adult diabetic
patients
•Resources
•Implementation Date
•Reminders
NEW revised insulin protocols
2 protocols: one for adult NPO diabetic patients and one for
adult NPO diabetic patients requiring low fluid volumes
Changed the concentration from 0.1 unit/mL to 1 unit/mL (to
align with AHS Standardized Concentrations Policy)
Updated the monitoring parameters and action items when
glucose is less than 5 mmol/L or greater than 20 mmol/L
Maintenance IV solution is D10W (minimum 10 mL/hour for
line patency in protocol for patients requiring low fluid volumes)
QUIZ
1. What patient population do these new protocols address?
a)NPO diabetic patients
b)All diabetic patients
c)Diabetic ketoacidosis patients
d)NPO adult diabetic patients
ANSWER is:
d) NPO adult diabetic patients
Case Study #1
CC, a 68 year old woman was admitted to your unit
awaiting hip replacement surgery.
Medical History:
• insulin dependent diabetic
• Hypertension
Doctor’s orders:
• NPO
• “Intravenous insulin infusion for NPO adult diabetic
patients”
Preparing the IV solution
Mix 100 units of regular insulin with 100 mL of Normal
Saline (NS)
Label bag appropriately
Connect bag to infusion set and prime with 25 to 50mL
of insulin solution ( See Parenteral Monograph)
Label tubing “insulin” at lower port
Y connect 1 litre of D10W and run at 80 mL/hour
Preparing the IV solutions Quiz
When setting up the insulin infusion set…
a)Insulin tubing should always be labelled
b)Insulin is Y-sited in to the main IV solution at the lowest injection port
c)Prime with half the volume of the tubing
d)Run D10W at 25 mL/hour regardless of capillary blood glucose readings
ANSWER is:
a) Insulin tubing should always be labelled
Initiating IV insulin infusion
You check CC’s capillary
blood glucose. It is “8.4”.
What would you do?
Start insulin at 1 unit/hour and
keep D10W at 80 mL/hour
When would you take the
next C/S(Chem Strip)?
In 2 hours.
Adjusting the Insulin infusion
Two hours later you check
CC’s C/S. It reads “12.2”.
What should you do?
Use Table 2 and increase rate
by 0.5 units/hour, =total 1.5
units/hour
When would you check C/S
again?
In 4 hours
Adjusting the insulin cont’d..
After 4 hours, you check CC’s
C/S. It reads “9.0”.
What should you do?
Use Table 3 and infuse insulin at 1
unit/hour
When should you recheck
C/S?
In 1 hour.
Case Study #2
Mr. FR is an 80 year old man admitted to your unit
while awaiting elective surgery.
Past medical history
• Insulin dependent diabetes
• Congestive heart failure
• Hypertension
Doctor’s orders:
• NPO
• “Intravenous Insulin Infusion for NPO adult
diabetic patients requiring low fluid volumes”
Preparing the IV solution
Mix 100 units of regular insulin with 100 mL of Normal
Saline (NS)
Label bag appropriately
Connect bag to infusion set and prime with 25 to 50mL
of insulin solution
Label tubing “insulin” at lower port
Y connect 1 litre of D10W and run at a minimum of
10mL/hour to maintain line patency
Initiating IV insulin infusion
You check FR’s capillary blood
glucose. It reads “12.8”.
What should you do?
Start insulin at 1.2 units/ hour.
Run D10W at 10 mL/hour to
keep line patent.
When should you repeat C/S?
In 2 hours.
Adjusting insulin rate
After 2 hours, FR’s C/S
reads “9.3”.
What should you do?
Use Table 3 (not Table 2) and run
insulin at 1unit/hour. Leave D10W
at 10mL/hour.
When should you repeat
C/S?
In 1 hour.
What does “Use Table 2 or 3 as
appropriate mean?”
(Depending on if the glucose drops 3mmol/L
or more)
Adjusting the infusion rate
After 1 hour, FR’s next C/S
reads “8.0”.
What should you do?
Use Table 2 and decrease
insulin rate by 0.3units/hour,
total rate = 0.7 units/hour.
Increase D10W to 50 mL/hour.
When should you repeat C/S?
In 2 hours.
Adjusting the infusion rate
After 2 hours, FR’s C/S reads
“10.2”
What should you do?
Use Table 2 and leave rate the
same (i.e. 0.7 mL/hour).
Decrease D10W to
10mL/hour.
When should you check
C/S?
In 2 hours.
Protocol comparison
Which of the following are true about the two protocols?
a)Always use Table 2 unless glucose increases by 3mmol/L or more
b)Notify the prescriber whenever the glucose is less than 4 or greater
than 22 mmol/L
c)Tighter glucose monitoring is required in patients who require low
fluid volumes
d)They both Y-connect D10W to the insulin bag to keep the line patent.
ANSWER is:
b)
Case Study #3
Mrs. DM is admitted to your unit awaiting elective
colonoscopy
Past medical history:
• Type 2 diabetes
• Arthritis
Doctor’s orders:
• NPO
• “Intravenous insulin infusion for NPO adult
diabetic patients”
Setting up the insulin infusion
How should the insulin be prepared?
•
•
•
100 units of regular insulin in 100 mL NS
Prime the line with 25 to 50 mL of insulin
Label the tubing “insulin” at the lower port
What IV solution needs to be Y-connected with the insulin?
•
D10W to run at 80 mL/hour regardless of capillary glucose.
Do you need an independent double check prior to administration
to the patient?
•
YES
Initiating IV insulin infusion
You check DM’s capillary
blood glucose. It is “7.8”.
What would you do?
Start insulin at 0.7 unit/hour
and run D10W at 80 mL/hour
When would you take the
next C/S?
In 2 hours.
Adjusting the insulin rate
After 2 hours, DM’s C/S is 9.4
(keep same rate 0.7 unit/hour,
check in 4h)
C/S = 13
(increase to 1.2 unit/h, check in
4h)
C/S = 18.6
(increase to 2.7units/hr, check in 2
hours)
Adjusting the insulin rate
DM’s C/S is 15.4
(Use Table 3, decrease rate to
1.5 unit/hour, check in 1h)
C/S = 11.7
(decrease rate to 1 unit/hour,
check in 1h)
Adjusting the Insulin Rate
DM’s C/S = 10.2
(continue rate at 1 unit/hour,
check in 4 hours)
C/S = 9.3
(continue rate at 1 unit/hour,
check in 4 hours)
Quiz
Which of the following is true?
a)Table 3 indicates rates to increase or decrease by
b)If the patient’s glucose readings haven’t changed in the past 2
readings, monitoring frequency may be increased to every 6
hours
c)Prescribers are not allowed to change the IV solution (D10W).
d)1 litre of D10W is to run at 80 mL/hour even if capillary
glucose reading is high.
ANSWER is:
d)
Case Study #4
Mr. HP is a 73 year old man waiting for a colonoscopy.
Past medical history:
•
•
•
•
Type 2 Diabetes
Ulcerative colitis
Atrial fibrillation
Chronic renal failure
Doctor’s orders:
• NPO
• “Intravenous Insulin Infusion for NPO adult diabetic
patients requiring low fluid volumes”
Setting up the insulin infusion
What is the concentration of insulin being prepared?
•
1 unit/mL
How many channels do we need on the pump to run this protocol?
•
Two
What IV solution do we need to run along with the insulin?
•
D10W, minimum of 10 mL/hour to keep line patency
When can I piggyback the D10W to the insulin tubing?
•
Never, always use a Y-connector to ensure the insulin doesn’t get accidentally
pushed out when the D10W rate is increased.
Initiating IV insulin infusion
You check HP’s capillary
blood glucose. It reads “8.0”.
What should you do?
Start insulin at 0.7unit/ hour.
Run D10W at 50 mL/hour.
When should you repeat
C/S?
In 2 hours.
Adjusting the infusion rate
After 2 hours, HP’s next C/S
reads “6.1”.
What should you do?
Use Table 2 and decrease
insulin rate by 0.3units/hour,
total rate = 0.4 units/hour.
Continue D10W at 50 mL/hour.
When should you repeat C/S?
In 2 hours.
Adjusting infusion rate…
HP’s next capillary glucose is
“5.0”.
What should you do?
Decrease insulin rate by 0.5
(0.4 – 0.5 = -0.1), therefore,
stop the insulin. Notify
prescriber and continue D10W
at 50 mL/hour.
Prescriber says to follow tables
in protocol.
Stopping and re-starting infusion
How often should you repeat capillary glucose?
• Every 2 hours
When can you restart insulin? And at what rate?
• When capillary glucose is greater than 12 mmol/L
• Re-start insulin at 0.5 units/hour (= 0.5 mL/hour)
What table should you use when restarting insulin?
• Table 2
Cancelled procedure
Mr. HP’s colonscopy was cancelled and needs to be rescheduled for a
later time this week.
What should you do?
a)Continue his insulin infusion and adjust using protocol.
b)Notify the prescriber to reassess diet and diabetes management
since procedure has been cancelled.
c)Stop insulin infusion and use previous insulin sliding scale orders.
d)Notify prescriber that the colonoscopy will be done two days from
now.
Answer: b)
Quiz
When adjusting insulin and D10W solution rates…
a)Always use Table 1 when re-starting insulin after it’s been stopped.
b)Increase D10W by 50mL/hour whenever the glucose is less than 5
mmol/L.
c)Table 3 should be used whenever glucose readings increase by 3
mmol/L or more from previous reading.
d)If the calculated rate is less than zero, the insulin infusion should be
stopped.
ANSWER is:
d)
Resources
• New revised protocols (ordering information from
Datagroup pending)
• Nursing Poster, Physician Poster
• Education Package
 Powerpoint (hands on case studies + quizzes)
 Checklist
 Diagram
 FAQ
Implementation Date
June 9, 2015
Reminders
Familiarize yourself with the new insulin IV infusion protocols, paying
particular attention to the new rates.
Do not use the previous insulin protocols containing the old
concentrations.
Refer to the Regional Parenteral Monographs for mixing instructions.
Select the correct concentration in the Alaris Smart pumps.
Get an independent double check prior to administering any insulin
infusions.
Request prescribers to give verbal orders for rate changes in unit/hour,
not mL/hour.
Ensure proper “Y-site” connections
References:
AHS Insulin Standardized Concentration
Working Group