Yale Insulin Infusion Protocol

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Presented at the Philippine General Hospital 1st Intravenous Therapy Nursing Update 2011

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Yale Insulin Infusion Protocol

  1. 1. http://www.flickr.com/photos/ jill_a_brown/2628388839/ IV Insulin Therapy: The Yale Insulin Infusion Protocol Iris Thiele Isip Tan MD, FPCP, FPSEM Clinical Associate Professor, UP College of Medicine Section of Endocrinology, Diabetes & Metabolism Department of Medicine, Philippine General Hospital
  2. 2. Outline•AACE/ADA Consensus on Inpatient Glycemic Control•Characteristics of an ideal insulin infusion protocol•PGH-Modified Yale Insulin Infusion Protocol
  3. 3. 140-180 mg/dL(7.8-10 mmol/L) Critically illht 2009 AACE/ADA tp ://w ww .sx c.h u/ ph ot Consensus Statement o/ 11 76 209 Moghissi E et al. Endocrine Practice 2009;15(4):1-17
  4. 4. http://www.sxc.hu/photo/253396 IV insulin infusion preferred Validated insulin infusion protocol: effective with low rates of hypoglycemia Moghissi E et al. Endocrine Practice 2009;15(4):1-17
  5. 5. IV insulin infusion protocol More consistent glucose controlReduction in trial & error patterns 6 44 ho 11 to/ 31 Maintain blood glucose within desired range u/p c.h .sx ww Earlier treatment of /w p:/ htt hypoglycemic events Anger et al Pharmacotherapy 2006;26(2)214-28
  6. 6. An ideal insulin infusion protocol ... http://www.sxc.hu/photo/1142176 ... adapts to individual patient responses to insulin Anger et al Pharmacotherapy 2006;26(2)214-28
  7. 7. An ideal insulin infusion protocol ... http://www.sxc.hu/photo/1142177 ... balances stability and responsiveness to maintain target blood glucose Anger et al Pharmacotherapy 2006;26(2)214-28
  8. 8. An ideal insulin infusion protocol ... http://www.sxc.hu/photo/1142175 ... varies the frequency of glucose monitoring based on trends Anger et al Pharmacotherapy 2006;26(2)214-28
  9. 9. An ideal insulin infusion protocol ... 0 oto/80538 .sxc.hu/ph http://www ... addresses potassium supplementation Anger et al Pharmacotherapy 2006;26(2)214-28
  10. 10. An ideal insulin infusion protocol ... http://www.sxc.hu/photo/1148437 ... clearly communicates instructions to the nurses responsible for titrating infusion Anger et al Pharmacotherapy 2006;26(2)214-28
  11. 11. A ideal insulin infusion protocol ... http://www.sxc.hu/photo/1148436 ... streamlines decision making & eliminates need for complex calculations Anger et al Pharmacotherapy 2006;26(2)214-28
  12. 12. modifiedYale protocol
  13. 13. Yale Target blood glucoseProtocol 90-119 mg/dL “Modified” 100-139 mg/dL PGH-modified Yale 140-180 mg/dLGoldberg PA et al (2004).Implementation of a Safe and Effective Insulin Infusion Protocolin a Medical Intensive Care Unit. Diabetes Care 27(2):461-7.
  14. 14. Yale ProtocolNot to be used for DKA or HHS! Call MD if BG >500 mg/dL http://www.sxc.hu/photo/1156296
  15. 15. Initiating the Insulin Infusion Insulin infusion: 1 u human regular insulin per 1 cc 0.9% NaCl per infusion pump (increments of 1 u/h) Priming: Flush 50 cc through all IV tubing before infusion begins Yale Protocol Threshold: Start IV insulin if BG >180 mg/dL
  16. 16. Initiating the Insulin Infusion Target blood glucose: 140-180 mg/dL Bolus & initial insulin infusion rate: Initial BG 181-299: divide by 100, round to nearest 1 unit for initial drip rate (NO bolus) Yale Protocol Initial BG >300: divide by 100, round to nearest 1 unit for initial drip rate AND bolus to be given http://www.sxc.hu/photo/689723
  17. 17. http:/ /wwwBlood glucose .sxc.h u/pho to/48 5480monitoring Check BG hourly until stable (3 consecutive values within target range) Use blood from indwelling catheter for hypotensive patients
  18. 18. Blood glucosemonitoringOnce stable for 12-24 h, checkBG q 2 hMay check BG q 4 h IF:no significant change in clinicalcondition AND no significantchange in nutritional intake http://www.sxc.hu/photo/1215187
  19. 19. Blood glucose monitoringConsider hourly BG monitoringagain (until stable) IF:any change in insulin infusion rate (i.e.BG out of target range)significant changes in clinical conditioninitiation/cessation of pressor/steroid,renal replacement therapy, nutritionalsupport (TPN, PPN, tube feedings,etc.) http://www.sxc.hu/photo/1215187
  20. 20. Blood <50 mg/dL 50-69 mg/dL 70-99 mg/dL glucose Insulin D/C D/C D/C infusion for 30 min 1 amp if symptomatic; D50 IV 1 amp None 1/2 amp if asymptomatic q 15 min if Recheck symptomatic; q 15 min q 30 min BG q 30 min if asymptomatic If BG >100 mg/dL, wait 1 h. If repeat BG still If BG >100 mg/ >100 mg/dL, resume insulin drip at dL, resumeInsulin drip insulin drip at 50% of previous 75% of previous 75% of previous rate
  21. 21. Determine the current BG level BG 100-130 BG 140-179 BG 180-249 BG >250 mg/dL mg/dL mg/dL mg/dL identifies a COLUMN in the table
  22. 22. Determine the rate of change from prior BG BG 100-130 BG 140-179 BG 180-249 BG >250 Instructions BG ↑ by >40 mg/ BG ↑ ↑ DRIP by “2Δ” dL/h BG BG ↑ by 1-40 UNCHANGED BG ↑ by >20 mg/ mg/dL/h OR OR ↑ DRIP by “Δ” dL/h BG BG ↓ by 1-40 UNCHANGED mg/dL/h BG ↑ by >20 mg/ dL/h, BG BG ↓ by 1-40 BG ↓ by 41-80 NO DRIP BG ↑ UNCHANGED, OR mg/dL/h mg/dL/h CHANGE BG ↓ by 1-20 mg/ dL/hBG unchanged BG ↓ by 21-40 BG ↓ by 41-80 BG ↓ by 81-120 OR BG ↓ by ↓ DRIP by “Δ” mg/dL/h mg/dL/h mg/dL/h1-20 mg/dL/h HOLD DRIP x 30 BG ↓ by BG ↓ by >40 mg/ BG ↓ by >80 mg/ BG ↓ by >120 min then ↓ DRIP >20 mg/dL/h* dL/h dL/h mg/dL/h by “2Δ”* D/C insulin drip, check CBG q 30 min, when BG >100 mg/dL, resume drip at 75% of previous rate.
  23. 23. Changes in infusion rate (“Δ”)determined by current rateCurrent Rate Δ = rate 2Δ= 2x rate (units/hr) change change (units/hr) (units/hr) <3 0.5 1 3-6 1 2 6.5 – 9.5 1.5 3 10-14.5 2 4 15-19.5 3 6 20-24.5 4 8 ≥25 ≥5 10 (consult MD)
  24. 24. Let’s practice ...
  25. 25. Let’s practice ...•64/F admitted for pneumonia; not a known diabetic
  26. 26. Let’s practice ...•64/F admitted for pneumonia; not a known diabetic•Initial CBG 321 mg/dL
  27. 27. Let’s practice ...•64/F admitted for pneumonia; not a known diabetic•Initial CBG 321 mg/dL•321/100 = 3.21 so give HR 3 units bolus and start insulin drip at 3 units/h
  28. 28. Let’s practice ...•64/F admitted for pneumonia; not a known diabetic•Initial CBG 321 mg/dL•321/100 = 3.21 so give HR 3 units bolus and start insulin drip at 3 units/h•CBG after 1 h is 285 mg/dL
  29. 29. Let’s practice ...•64/F admitted for pneumonia; not a known diabetic•Initial CBG 321 mg/dL•321/100 = 3.21 so give HR 3 units bolus and start insulin drip at 3 units/h•CBG after 1 h is 285 mg/dL•321-285 = 36 mg/dL
  30. 30. Determine the rate of change from prior BG BG 100-130 BG 140-179 BG 180-249 BG >250 Instructions BG ↑ by >40 mg/ BG ↑ ↑ DRIP by “2Δ” dL/h BG BG ↑ by 1-40 UNCHANGED BG ↑ by >20 mg/ mg/dL/h OR OR ↑ DRIP by “Δ” dL/h BG BG ↓ by 1-40 UNCHANGED mg/dL/h BG ↑ by >20 mg/ dL/h, BG BG ↓ by 1-40 BG ↓ by 41-80 NO DRIP BG ↑ UNCHANGED, OR mg/dL/h mg/dL/h CHANGE BG ↓ by 1-20 mg/ dL/hBG unchanged BG ↓ by 21-40 BG ↓ by 41-80 BG ↓ by 81-120 OR BG ↓ by ↓ DRIP by “Δ” mg/dL/h mg/dL/h mg/dL/h1-20 mg/dL/h HOLD DRIP x 30 BG ↓ by BG ↓ by >40 mg/ BG ↓ by >80 mg/ BG ↓ by >120 min then ↓ DRIP >20 mg/dL/h* dL/h dL/h mg/dL/h by “2Δ”* D/C insulin drip, check CBG q 30 min, when BG >100 mg/dL, resume drip at 75% of previous rate.
  31. 31. Changes in infusion rate (“Δ”)determined by current rateCurrent Rate Δ = rate 2Δ= 2x rate (units/hr) change change (units/hr) (units/hr) <3 0.5 1 3-6 1 2 6.5 – 9.5 1.5 3 10-14.5 2 4 15-19.5 3 6 20-24.5 4 8 ≥25 ≥5 10 (consult MD)
  32. 32. One more time ...
  33. 33. One more time ...•54/M type 2 diabetic with pancreatitis; on NPO
  34. 34. One more time ...•54/M type 2 diabetic with pancreatitis; on NPO•Initial CBG 240 mg/dL
  35. 35. One more time ...•54/M type 2 diabetic with pancreatitis; on NPO•Initial CBG 240 mg/dL•240/100 = 2.4 so start insulin drip at 2 units/h
  36. 36. One more time ...•54/M type 2 diabetic with pancreatitis; on NPO•Initial CBG 240 mg/dL•240/100 = 2.4 so start insulin drip at 2 units/h•CBG after 1 h is 170 mg/dL
  37. 37. One more time ...•54/M type 2 diabetic with pancreatitis; on NPO•Initial CBG 240 mg/dL•240/100 = 2.4 so start insulin drip at 2 units/h•CBG after 1 h is 170 mg/dL•240-170 = 70 mg/dL
  38. 38. Determine the rate of change from prior BG BG 100-130 BG 140-179 BG 180-249 BG >250 Instructions BG ↑ by >40 mg/ BG ↑ ↑ DRIP by “2Δ” dL/h BG BG ↑ by 1-40 UNCHANGED BG ↑ by >20 mg/ mg/dL/h OR OR ↑ DRIP by “Δ” dL/h BG BG ↓ by 1-40 UNCHANGED mg/dL/h BG ↑ by >20 mg/ dL/h, BG BG ↓ by 1-40 BG ↓ by 41-80 NO DRIP BG ↑ UNCHANGED, OR mg/dL/h mg/dL/h CHANGE BG ↓ by 1-20 mg/ dL/hBG unchanged BG ↓ by 21-40 BG ↓ by 41-80 BG ↓ by 81-120 OR BG ↓ by ↓ DRIP by “Δ” mg/dL/h mg/dL/h mg/dL/h1-20 mg/dL/h HOLD DRIP x 30 BG ↓ by BG ↓ by >40 mg/ BG ↓ by >80 mg/ BG ↓ by >120 min then ↓ DRIP >20 mg/dL/h* dL/h dL/h mg/dL/h by “2Δ”* D/C insulin drip, check CBG q 30 min, when BG >100 mg/dL, resume drip at 75% of previous rate.
  39. 39. Changes in infusion rate (“Δ”)determined by current rateCurrent Rate Δ = rate 2Δ= 2x rate (units/hr) change change (units/hr) (units/hr) <3 0.5 1 3-6 1 2 6.5 – 9.5 1.5 3 10-14.5 2 4 15-19.5 3 6 20-24.5 4 8 ≥25 ≥5 10 (consult MD)
  40. 40. Histogram of 2242 hourly BG recordingsafter achievement of target BG levels Goldberg PA et al (2004). Implementation of a Safe and Effective Insulin Infusion Protocol in a Medical Intensive Care Unit. Diabetes Care 27(2):461-7.
  41. 41. Yale IIP patients vs historical controls Goldberg PA et al (2004). Implementation of a Safe and Effective Insulin Infusion Protocol in a Medical Intensive Care Unit. Diabetes Care 27(2):461-7.
  42. 42. !ank Y"http://www.endocrine-witch.net

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