Pdf yale insulin protocol infusion in sepsis patients. Intravenous insulin protocols and order sets critically ill patients require an intravenous insulin protocol that has demonstrated efficacy and safety in achieving the desired goal glucose range without increasing risk for severe hypoglycemia. A comparison of two insulin infusion protocols in the medical. Objective in a recent randomized controlled trial, lowering blood glucose levels to 80110 mgdl improved clinical outcomes in critically ill patients. The yale insulin infusion yii aims to control blood glucose levels in hyperglycemic patients in critical care the yale insulin infusion yii is a protocol that aims to control blood glucose levels in hyperglycemic patients in critical care. Infuse dextrose containing ivfluids check bg every 1 hour 5. Subsequent insulin adjustment is not included in this. In any patient with bg 500 mgdl, the initial orders should also be. Blood glucose monitoring before starting insulin infusion 6. Flush 50 cc through all iv tubing before infusion begins yale protocol threshold. Perform blood glucose monitoring every hour until within.
University of toledo insulin infusionstandard dose adult practice protocol. Any documents appearing in paper form are not controlled and should be checked against the electronic file version prior to use. Triggers to consider for initiating insulin infusion protocol patient is diabetic glucose level 140 mgdl for all inpatients, perform an intraoperative glucose measurement within 45 min past start of procedure and if glucose level 140 mgdl then initiate insulin infusion protocol insulin infusion protocol. At time of conversion to subcutaneous insulin or oral agent obtain md order for glycemic control medications. The medical intensive care unit micu at yale new haven hospital ynhh is regarded as one of the regions elite icus and has developed into a major regional referral center. Achieving good glycemic control in intensive care units icu requires a safe and efficient insulin infusion protocol iip. Intravenous insulin infusion protocols are used in the intensive care unit, and occasionally on the labour floor and the renal unit.
Insulin infusion pumps should only be prescribed and used by practitioners familiar with this operation. The yale protocol provided better average glycemia, more time spent in. Start insulin infusion via pump piggybacked to normal saline iv as follows. A hypoglycemia protocol, taken from the canadian diabetes association guidelines,3 is an integral part of our insulin protocols. Insulin protocols for hospital management of diabetes. A guideline for the use of variable rate intravenous. From 1991 to 1998, a continuous intravenous iv insulin infusion was used to keep serum glucose between 150 and 200 mgdl. Iv infusion iv infusion iv infusion ob only regular insulin may be administered by the iv route. Yale insulin infusion protocol insulin intravenous therapy. Transitioning off insulin drip overlap basal insulin and iv insulin infusion by 2 hours. The management of hyperglycemia in the intensive care unit has been a controversial topic for.
Page 1 of 7 hyperglycemic emergency management dkahhs1 adult. The yale protocol directs users to automatically restart the insulin after cessation of the infusion for rapidly decreasing bg or low bg level. Objectives discuss the adaaace recommendations for inpatient glycemic control. Diabetes facts 2012 and guidelines 2011 yale school of medicine. Implementation of a safe and effective insulin infusion protocol in a medical intensive care unit philip a. To report our preliminary experience with the revised, more conservative yale insulin infusion protocol iip that targets blood glucose concentrations of 120 to 160 mgdl. University of toledo insulin infusion standard dose adult practice protocol. In those patients managed with insulin infusion, adjust hourly. Continuous glucose monitoring cgm using a nonimplanted device by a healthcare provider is proven and considered medically necessary in the. Minimization of hypoglycemia as an adverse event during. Numerous insulin infusion protocols have been published.
Implementing an intravenous insulin infusion protocol in the. This implementation serves to enable yii as a rest api deployed on algorithmia. We prospectively tracked clinical responses to the new iip in our medical intensive care unit icu by recording data on the first 115 consecutive insulin infusions that were initiated. Analyze the evidence and role of iv insulin infusion protocols in the hospital. Implementation of a safe and effective insulin infusion. Diabetes resource center aace disease state resources. Pdf yale insulin protocol infusion in sepsis patients researchgate. Describe insulin concepts basal, prandial and correction. E indication for intravenous insulin infusion among nonpregnant adults with hyperglycemia include.
In our hands, however, ongoing expert supervision was required to effectively manage the. Insulin recommended safe practice guidelines monitoring blood glucose monitoring while on non. The development of an insulin infusion protocol was initiated by key contributors from a team of nurses, dietitians, pharmacists, and physicians. Mean blood glucose bg levels, time to target range and incidence of sh yale insulin infusion yii aims to control blood glucose levels in hyperglycemic patients in critical care the yale insulin infusion yii is a protocol that aims to control blood glucose levels in hyperglycemic patients in critical care. All patients reached the target in 72 hours of insulin infusion in the pg while only 29 patients in the cg reached this target.
Finally, as over dosage of insulin can cause hypoglycemia lower than normal blood glucose levels, the ideal protocol should minimize hypoglycemia and provide specific instructions for prompt treatment of hypoglycemia should it occur. Thirtyfive subjects were treated with iv insulin insulin aspart, novo nordisk, bagsvaerd, denmark according to a modified yale protocol, targeting a blood glucose level between 80 and 120 mgdl. A guideline for the use of variable rate intravenous insulin. This is a pooled data analysis of two published prospective randomized controlled trials. Initial insulin rate unitshour circle one blood glucose mgdl. A comparison of two insulin infusion protocols in the.
Apr, 2011 initiating the insulin infusion insulin infusion. University of toledo insulin infusionstandard dose adult. Iv insulin infusion rate units of insulin hour blood glucose 60 multiplier 1. Yale insulin infusion protocol free download as pdf file. Implementation of a safe and effective insulin infusion protocol in a medical intensive care unit. Computerization of the yale insulin infusion protocol and potential insights into causes of hypoglycemia with intravenous insulin. Efficiency and safety of new insulin infusion protocol for japanese. Clinical results of an updated insulin infusion protocol.
Insulin infusion pump management inpatient guidelines. Tight glycemic control is a major concern in critical care. A retrospective analysis of all patients admitted to an icu who were treated with an insulin infusion directed by the glucocare igc system, an fdacleared insulindosing calculator yale 100140 mgdl protocol. The yale insulin infusion protocol iip is one of the best available iips, considered safe and effective for treatment of critically ill patients. Prior to initiation of continuous infusion insulin 6. Safe management of patients with continuous subcutaneous insulin infusion csii. Strict glycemic control has recently been shown to improve clinical outcomes in critically ill patients. Medical intensive care unit yale school of medicine. Implementation of a safe and effective insulin infusion protocol in a. Hourly monitoring must be resumed if blood glucose deviates from. Goldberg and associates diabetes care, volume 27, number 2, february 2004 463. To offer practical suggestions for overcoming these barriers, drawing from our experiences selling root canals during the successful implementation of our hospitalwide iips. Process action rationale inclusion criteria all adult patients admitted to intensive care requiring variable rate intravenous insulin infusion the protocol used in this guideline is based on the nicesugar study which included type 1, type 2. Pdf effectiveness of the computerization of a yale insulin.
The objective of this study in the icu was to evaluate the effectiveness and safety of the yale insulin infusion protocol in sepsis. Unlike the yale infusion protocol, the glucommanders protocol is based on an algorithm involving the exact blood glucose level, and not on the range in which the measured blood glucose belongs to. Minimization of hypoglycemia as an adverse event during insulin infusion. In that study, the insulin infusion protocol iip used to normalize blood glucose levels.
Consult endocrinologist on pod 2 for dm workup and followup orders. Clinical policyprotocolclinical practice guideline this is a controlled document for internal use only. Make the change at the time of a meal and discontinue the iv insulin infusion 1 hour after regular insulin sc or 30 minutes after. If blood glucose is 250 mgdl and is decreasing by insulin, call md for adjustment of insulin infusion. We aimed to compare the clinical performance of two iips leuven versus modified yale protocol in patients admitted to medical icu, by using continuous glucose monitoring cgm. The micu employs a variety of protocols to drive a high level of routine practice including low and high peep ardsnet protocols, a spontaneous breathing protocol for ventilator weaning, an insulin infusion protocol for management of hyperglycemia and a novel protocol for management of severe alcohol withdrawal minds. In the february 2004 issue of diabetes care, we reported our early experience implementing an insulin infusion protocol iip in a medical intensive care unit micu. University of pittsburgh medical center insulin protocol. Diabetes facts 2012 and guidelines 2011 yale school of. Aaces diabetes resource center provides its members access to clinical practice guidelines, treatment algorithms, and other resources related to the broad spectrum of diabetes care including type 2 diabetes and gestational diabetes.
If subcutaneous insulin correction scale or scheduled is ordered, discontinue the insulin infusion 2 hr after the 1st dose of subcutaneous insulin discontinue this protocol when the patient is able to tolerate po carbohydrate intake and is being transitioned to subcutaneous insulin or no longer requires insulin therapy. Therefore, multiple insulin infusion protocols iips were created, all meant to. Computerization of the yale insulin infusion protocol and. Adapting to the new consensus guidelines for managing. In that study, the insulin infusion protocol iip used to normalize blood glucose levels provided valuable guidelines for adjusting insulin therapy. Insulin infusion calculator webbased, lives outside of epic rns utilize the. The yale insulin infusion protocol iip is one of the best available. We prospectively tracked clinical responses to the new iip in our medical intensive care unit icu by recording data on the first 115 consecutive. If insulin drip is stopped for one 1 hour or more, check bs and restart using initial insulin infusion as above for insulin infusion rates 8 unitsh, do not exceed, where indicated, the maximum infusion rates in table 3. Background an insulin pump is a complex electronicallycontrolled device for the continuous subcutaneous infusion of insulin to patients with type 1 diabetes mellitus. The most prevalent intravenous iv insulin infusion protocol is the yale insulin infusion protocol. Bicarbonate replacement indicated for lifethreatening hyperkalemia. Yalenew haven hospital icu insulin infusion protocol. However, headtohead comparisons are rare, and efficacy and safety are difficult to determine because of differing patient populations, glycemic targets, metrics for evaluation, and definitions of hypoglycemia used in the various protocols.
Example, give 3 units if patient eats 50% cho for meal. University of toledo insulin infusionstandard dose. To summarize key metabolic results from use of the yale insulin infusion protocols iips, as well as the primary barriers to their implementation. Efficiency and safety of new insulin infusion protocol for. If the glucose measurement is above a predefined level, initiate the insulin protocol as ordered. The objective of this study in the icu was to evaluate the effectiveness and safety of the yale insulin infusion protocol in sepsis patients. Micu patients are cared for by the internal medicine house staff of the yale new haven hospital, under. If bg greater than 200 mgdl, resume infusion at 50% of previous infusion rate i. Guardrail drug requires documentation of two 2 rns for doublechecking.
Yale insulin infusion protocol linkedin slideshare. Practice reports intravenous insulin infusion protocol am j healthsyst pharmvol 64 feb 15, 2007 387 figure 1. Conclusion the yale insulin infusion protocol was effective and safe in sepsis patients admitted to the icu. Our specific goal was to create a protocol that could be safely and effectively implemented by an icu nursing staff with minimal need for ongoing physician supervision. Inzucchi, md 1 objective in a recent randomized controlled trial, lowering blood. Effectiveness of the computerization of a yale insulin infusion modified protocol in reducing the nursing workload in an internal medicine. Iv insulin infusion rate units of insulinhour blood glucose 60 multiplier 1. In march of 2010 the micu moved into its new state of the art facilities on the 9 th and 10 th floors of the smilow cancer hospital north pavilion which contains 36. Effectiveness of the computerization of a yale insulin infusion modified protocol insulin dosing it considers not only the absolute value of glycemia but also the glycemic trend, i. Diabetes treatment algorithms iv insulin infusion protocol. We modified the original yale iip and built a simple computerprogrambased iip to fit japanese patients, who were normally known to be less obese and less insulin resistant. Computerization of the yale insulin infusion protocol and potential. Options here are to decrease the insulin infusion rate table 1 suggested scales for insulin infusion rates during a variable rate intravenous insulin infusion vriii glucose mmoll insulin rates mlh start on standard rate unless otherwise indicated 24. Decrease insulin infusion rate by half notify icuec team to.
Intravenous insulin for glucose control on critical care v1. See dka guidelines in ynhh clinical practice manual cpm for further instructions. Implementing an intravenous insulin infusion protocol in. Iv insulin infusion protocol more consistent glucose controlreduction in trial. Clinical results of an updated insulin infusion protocol in.
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