What is intravenous insulin therapy?
Intravenous insulin therapy is a treatment procedure to control high blood sugar (hyperglycemia) in ICU patients. Rapid and efficient control of hyperglycemia improves recovery rates and reduces mortality in critically ill patients.
Intravenous insulin therapy is performed only under medical supervision along with continuous monitoring of blood sugar levels and other vital parameters.
Self-administration of insulin by people with diabetes is always an injection in the fatty tissue under the skin (subcutaneous), and never intravenous.
How do you give intravenous insulin therapy?
Intravenous insulin therapy for managing hyperglycemia requires a well-coordinated protocol in place and combined effort from the various health professionals in the hospital.
- The treating physician determines when IV insulin therapy should be started in consultation with the endocrinologist.
- The nurse administers the IV insulin and monitors the patient’s sugar levels with measurements at set intervals.
- The dosage is continually adjusted (titrated) based on the patient’s sugar levels.
- The patient is weaned from intravenous insulin at the appropriate time.
Most hospitals follow an established protocol for hyperglycemia management in ICU patients, though there may be minor variations in protocols.
What are the factors in the selection of an IV insulin protocol?
An ideal insulin protocol aims at achieving the target glucose levels within a short period and maintaining them within that range. Glucose levels of below 70 mg/dl is considered hypoglycemia, and persistent levels of 200 mg/dl is hyperglycemia.
A safe and effective IV insulin protocol incorporates the following:
- Determines the appropriate glucose level target
- Defines the hyperglycemic threshold to start treatment
- Provides clear directions for monitoring the glucose levels and titrating the dosage based on changes in the levels
- Plans for transition to subcutaneous insulin
What are the intravenous insulin protocols in use?
Many institutions have developed and implemented intravenous insulin protocols based on clinical experience. Most IV insulin protocols are significantly similar, though differences exist in factors such as:
- Treatment in the presence and absence of pre-existing diabetes
- Initial hyperglycemic threshold to start treatment
- Calculation of initial bolus (rapid-acting) insulin dose
- Calculation of subsequent doses and changes based on
- sugar levels
- insulin resistance
- Target glucose level
Over 20 protocols are in use, and the following sections outline two archetypal intravenous insulin protocols.
Georgia Hospital Association Intravenous Insulin Protocol
Also known as Davidson or Glucommander Protocol, the Georgia Hospital Protocol’s glucose control target is 140-180 mg/dl. The Glucommander Protocol is a computer-directed system that dynamically determines the dosage, timing and titration of insulin based on blood glucose levels and rate of change in the levels.
The steps followed in the protocol include the following:
- Insulin infusion
- Discontinuation of previous diabetes medications
- Obtaining the patient’s metabolic profile
- Checking initial blood glucose level
- Regular human insulin is mixed with normal saline before administration
- After initiation of IV infusion, glucose levels are checked every hour
- Glucose level testing is reduced to every 2 hours if target range is stable for 4 consecutive readings
- Administration of dextrose in case of hypoglycemia and glucose level test is done every 15 minutes until the glucose level stabilizes
Glucose Readings that Prompt a Physician Alert
Glucommander Protocol is a simple system that can be administered by a trained nurse. Glucose levels and potassium levels are regularly monitored. The nurse notifies the physician if:
- Glucose level is less than 60 mg/dl for two consecutive readings
- Glucose level is more than 200 mg/dl for two consecutive readings
- Insulin requirement exceeds 24 units/hour
- Patient’s potassium level drops below 4 mmol/L
- Continuous enteral feeding (through nasal tube), parenteral nutrition (through the vein) or insulin infusion is stopped or interrupted
Transition to Subcutaneous Insulin
- Glucose levels should be within target range for at least four hours before discontinuing IV insulin
- Subcutaneous insulin dosage is calculated and initiated
- IV infusion of insulin continues for two hours after starting subcutaneous insulin therapy
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Portland Protocol for Intravenous Insulin
The Portland Protocol targets a glucose level of 125-175 mg/dl and is started for all ICU patients if glucose level is more than 150 mg/dl, even if “nondiabetic.” Dosage of insulin is based on blood glucose levels, and is changed in proportion with change in levels. A chart specifies the dosage and their adjustments in relation to changes in glucose levels.
The Portland Protocol involves the following steps:
- Blood glucose level check upon admission
- Hemoglobin A1c (HbA1c) measurement is taken
- Regular human insulin is mixed with normal saline before administration
- Intravenous insulin is initiated and blood glucose level checked every two hours
- Dextrose is administered in case of hypoglycemia
- If bedside measurement of glucose shows a level below 40 mg/dl or above 450 mg/dl, a confirmatory laboratory glucose test is done
- All patients who remain hyperglycemic should continue the protocol throughout the ICU stay.
- Nondiabetic, euglycemic (normal sugar level) patients can stop the protocol if target level is maintained with less than half a unit of insulin. The glucose level will be monitored for 24 hours and if the level goes above 150 mg/dl, the insulin protocol will be resumed.
- If diabetic patients continue to need insulin after three days post-surgery, and if their HbA1C is higher than 6% at admission time, further treatment will be designed in consultation with the endocrinologist.
Intravenous insulin therapy is a treatment procedure to control high blood sugar (hyperglycemia) in ICU patients. Rapid and efficient control of hyperglycemia improves recovery rates and reduces mortality in critically ill patients. People with diabetes self-administer their daily doses into the skin, not into a blood vessel.
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Diabetes is a chronic condition characterized by high levels of sugar (glucose) in the blood. The two types of diabetes are referred to as type 1 (insulin dependent) and type 2 (non-insulin dependent). Symptoms of diabetes include increased urine output, thirst, hunger, and fatigue. Treatment of diabetes depends on the type.
Diabetes Symptoms in Men
Diabetes mellitus is a disease in which a person's blood sugar (blood glucose) is either too high (hyperglycemia) or too low (hypoglycemia) due to problems with insulin regulation in the body. There are two main types of diabetes mellitus, type 1 and type 2. Type 1 diabetes usually occurs during childhood, while type 2 diabetes usually occurs during adulthood, however, rates of both types of diabetes in children, adolescents, and teens is increasing. More men than women have diabetes in the US, and the disease can affect men differently than women.Warning symptoms of diabetes that men have and women do not include low testosterone (low-t), sexual problems, impotence (erectile dysfunction), decreased interest in sex, and retrograde ejaculation. Type 1 and type 2 diabetes symptoms and signs that are the same in men and women include skin infections, numbness or tingling in the feet or hands, nausea, excessive thirst or hunger, fatigue, irritability, blurred vision, weight gain, weight loss, urinary tract infections (URIs), and kidney problems. Treatment for type 1 diabetes is insulin, and treatment for type 2 diabetes are lifestyle changes like eating a healthy diet, getting exercise daily, and if necessary, diabetes medications.
Diabetes Treatment: Medication, Diet, and Insulin
The major goal in treating diabetes is controlling elevated blood sugar without causing abnormally low levels of blood sugar. Type 1 diabetes is treated with: insulin, exercise, and a diabetic diet. Type 2 diabetes is first treated with: weight reduction, a diabetic diet, and exercise. When these measures fail to control the elevated blood sugar, oral medications are used. If oral medications are still insufficient, insulin medications are considered.
Diabetes Symptoms in Women (Early and Late)
Diabetes symptoms in women include vaginal itching, pain, or discharge, loss if interest or pain after having sex, polycystic ovarian syndrome (POS), and urinary tract infections or UTIs (which are more common in women. Symptoms of diabetes that are the same in women and men are excessive thirst and hunger, bad breath, and skin infections, darkening of skin in areas of body creases (acanthosis nigricans), breath odor that is fruity, sweet, or acetone, and tingling or numbness in the hands or feet, blurred vision, fatigue, tingling or numbness in the hands or feet, wounds that heal slowly, irritability, and weight loss or gain. Complications of type 1 and type 2 diabetes are the same, for example, skin, eye, and circulation problems, low blood sugar (hypoglycemia), high blood sugar (hyperglycemia), ketoacidosis, and amputation. If diabetes is not managed a person may not survive.
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Diabetes insipidus is a condition in which the patient has frequent urination. Symptoms of diabetes insipidus include irritable, listless, fever, vomiting, or diarrhea due to the loss of large volumes of urine. There are three types of diabetes insipidus, central, nephrogenic, dipsogenic, and gestational. Treatment depends upon the type of diabetes insipidus.
Can Type 2 Diabetes be Cured?
Type 2 diabetes is a long-term medical condition in which the body is not able to regulate blood sugar (glucose) level because of the inability of the body to properly use insulin. An individual can get type 2 diabetes because of a number of factors that reduce insulin action or quantity in the body. The goals of diabetes management are to eliminate symptoms and prevent the development of complications. Many drugs, both oral and injectable, are available for diabetes management.
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