Yale Insulin Infusion Protocol

IV Insulin Therapy:

The Yale Insulin Infusion Protocol

Iris Thiele Isip Tan MD, FPCP, FPSEMClinical Associate Professor, UP College of MedicineSection of Endocrinology, Diabetes & MetabolismDepartment of Medicine, Philippine General Hospital

http://www.flickr.com/photos/jill_a_brown/2628388839/





Outline

•AACE/ADA Consensus on Inpatient Glycemic Control

•Characteristics of an ideal insulin infusion protocol

•PGH-Modified Yale Insulin Infusion Protocol

Critically ill

140-180 mg/dL(7.8-10 mmol/L)

2009 AACE/ADA Consensus Statement

Moghissi E et al. Endocrine Practice 2009;15(4):1-17

http://www.sxc.hu/photo/1176209































Moghissi E et al. Endocrine Practice 2009;15(4):1-17

IV insulin infusion preferred

Validated insulin infusion protocol: effective with low rates of hypoglycemia




IV insulin infusion protocol

More consistent glucose control

Reduction in trial & error patterns

Maintain blood glucose within desired range

Earlier treatment of hypoglycemic events

Anger et al Pharmacotherapy 2006;26(2)214-28

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An ideal insulin infusion protocol ...

... adapts to individual patient responses to insulin






... balances stability and responsiveness

to maintain target blood glucose






... varies the frequency of glucose monitoring

based on trends






... addresses potassium supplementation













... clearly communicates instructions to the nurses responsible for titrating infusion





A ideal insulin infusion protocol ...

... streamlines decision making& eliminates need for complex calculations





modified

Yale protocol

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.

Target blood glucose 90-119 mg/dL

Yale Protocol

“Modified” 100-139 mg/dL

PGH-modified Yale 140-180 mg/dL

Not to be used for DKA or HHS!

Call MD if BG >500 mg/dL

Yale Protocol




Yale Protocol

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

Threshold: Start IV insulin if BG >180 mg/dL

Yale Protocol

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)

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/485480Blood glucose monitoring

Check BG hourly until stable (3 consecutive values within target range)

Use blood from indwelling catheter for hypotensive patients
















Once stable for 12-24 h, check BG q 2 h

May check BG q 4 h IF: no significant change in clinical condition AND no significant change in nutritional intake

Blood glucose monitoring




Consider hourly BG monitoring again (until stable) IF:

any change in insulin infusion rate (i.e. BG out of target range)

significant changes in clinical condition

initiation/cessation of pressor/steroid, renal replacement therapy, nutritional support (TPN, PPN, tube feedings, etc.)

Blood glucose monitoring



Blood glucose <50 mg/dL 50-69 mg/dL 70-99 mg/dL

Insulin infusion

D/C D/CD/C

for 30 min

D50 IV 1 amp

1 amp if symptomatic;

1/2 amp if asymptomatic

None

Recheck BG

q 15 min

q 15 min if symptomatic;

q 30 min if asymptomatic

q 30 min

If BG >100 mg/dL, wait 1 h. If repeat BG still >100 mg/dL, resume insulin drip at

If BG >100 mg/dL, resume

insulin drip at 75% of previous

Insulin drip rate

50% of previous 75% of previous

Determine the current BG level

BG 100-130 mg/dL

BG 140-179 mg/dL

BG 180-249 mg/dL

BG >250 mg/dL

identifies a COLUMN in the table

BG 100-130 BG 140-179 BG 180-249 BG >250 InstructionsBG ↑ by >40 mg/

dL/hBG ↑ ↑ DRIP by “2Δ”

BG ↑ by >20 mg/dL/h

BG ↑ by 1-40 mg/dL/h OR

BG UNCHANGED

BG UNCHANGED

OR BG ↓ by 1-40

mg/dL/h

↑ DRIP by “Δ”

BG ↑

BG ↑ by >20 mg/dL/h, BG

UNCHANGED, OR BG ↓ by 1-20 mg/

dL/h

BG ↓ by 1-40 mg/dL/h


NO DRIP CHANGE

BG unchanged OR BG ↓ by

1-20 mg/dL/h




↓ DRIP by “Δ”

BG ↓ by>20 mg/dL/h*

BG ↓ by >40 mg/dL/h



HOLD DRIP x 30 min then ↓ DRIP

by “2Δ”

Determine the rate of change from prior BG

* D/C insulin drip, check CBG q 30 min, when BG >100 mg/dL, resume drip at 75% of previous rate.

Changes in infusion rate (“Δ”) determined by current rate

Current Rate(units/hr)

Δ = rate change

(units/hr)

2Δ= 2x rate change

(units/hr)

<3 0.5 13-6 1 2

6.5 – 9.5 1.5 310-14.5 2 415-19.5 3 620-24.5 4 8≥25 ≥5 10 (consult MD)

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





BG UNCHANGED

BG UNCHANGED

OR BG ↓ by 1-40

mg/dL/h


BG ↑



dL/h



NO DRIP CHANGE


1-20 mg/dL/h










by “2Δ”





Δ = rate change

(units/hr)

2Δ= 2x rate change

(units/hr)

<3 0.5 13-6 1 2

6.5 – 9.5 1.5 310-14.5 2 415-19.5 3 620-24.5 4 8≥25 ≥5 10 (consult MD)

One more time ...

One more time ...

•54/M type 2 diabetic with pancreatitis; on NPO

One more time ...



One more time ...



•240/100 = 2.4 so start insulin drip at 2 units/h

One more time ...





One more time ...





•240-170 = 70 mg/dL





BG UNCHANGED

BG UNCHANGED

OR BG ↓ by 1-40

mg/dL/h


BG ↑



dL/h



NO DRIP CHANGE


1-20 mg/dL/h










by “2Δ”





Δ = rate change

(units/hr)

2Δ= 2x rate change

(units/hr)

<3 0.5 13-6 1 2

6.5 – 9.5 1.5 310-14.5 2 415-19.5 3 620-24.5 4 8≥25 ≥5 10 (consult MD)


Histogram of 2242 hourly BG recordings after achievement of target BG levels


Yale IIP patients vs historical controls

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Yale Insulin Infusion Protocol