regulasi insulin

Table 59-6. Intravenous Insulin Therapy Protocol
General Guidelines: Goal Blood Glucose (BC) = ___ (Usually 80-180 mg/dL)
• Standard drip: 100 Unts/100 mL 0,9% NaCl via an infusion device
• Surgical patients who have received an oral diabetes medication within 24 hr should start when BG > 120 mg/dL. All other patients can start when BG ≥ 70.
• Insulin infusions should be discontinued when a patient is eating AND has recelved first dose of subcutaneous insulin
Intravenous fluids:
• Most patients will need 5-10 g of glucose/hr
- D5W or D5W1 \ 2NS at 100-200 mL/hr or equivalent (e.g. TPN, enteral feeds)
Intiating the infusion:
• Algorithm 1: start here for most patients
• Algorithm 2: For patients not controlled with Algorithm 1, or start here if s/p CABG, s/p solid organ transplant or islet cell transplant, receiving glucocorticoids, or patient with diabetes receiving > 80 units/day of insulin as an outpatient.
• Algorithm 3: For patients not controlled on Algorithm 2, NO PATIENTS START HERE without authorization from the endocrine service.
• Algorithm 4: For patients not controlled on Algorithm 3. NO PATIENTS START HERE.
• Patients not controlled with the above algorithms need and endocrine consult
Algorithm 1 Algorithm 2 Algorithm 3 Algorithm 4
BG Units/hr BG Units/hr BG Units/hr BG Units/hr
<60 = Hypoglycemia (See below for treatment)
<70 off <70 off <70 off <70 off
70-109 0.2 70-109 0.5 70-109 1 70-109 1.5
110-119 0.5 110-119 1 110-119 2 110-119 3
120-149 1 120-149 1.5 120-149 3 120-149 5
150-179 1.5 150-179 2 150-179 4 150-179 7
180-209 2 180-209 3 180-209 5 180-209 9
210-239 2 210-239 4 210-239 6 210-239 12
240-269 3 240-269 5 240-269 7 240-269 16
270-299 3 270-299 6 270-299 10 270-299 20
300-329 4 300-329 7 300-329 12 300-329 24
330-359 4 330-359 8 330-359 14 >330 28
>360 6 >360 12 >360 16
Moving from Algorithm to Algorithm:
• Moving Up: An algorithm failure is defined as BG outside the goal range (see above goal), and the GB does not change by at least 60 mg/dL within 1 hr
• Moving Down: when BG is <70 mg/dL x 2
Patient Monitoring
• Check capillary BG every hour until it is within goal range for 4 hr, then decrease to every 2 hr for 4 hr, and if remains stable may decrease to every 4 hr.
• Hourly monitoring may be indicated for critically ill patients even if they have stable BG
Treatment of Hypoglycemia (BG < 60 mg/dL
• Discontinue insulin drip AND
• Give D50W IV
- Patient awake: 25 mL (1/2 amp)
- Patient not awake: 50 mL )1 amp)
• Recheck BG every 20 min and repeat 25 mL of D50W IV if < 60 mg/dL. Restart drip once BG is > 70 mg/dL x 2 checks. Restart drip with lower algorithm (see Moving Down)
Notify the physicion:
• For any BG change > 100 mg/dL in 1 hr
• For BG > 360 mg/dL
• For hypoglycemia that has not resolved within 20 min of administering 50 ml of D50W IV and discontinuing the insulin drip.
BG, blood glucose: CABG, coronary artery bypass grafting; NS, normal saline: TPN, total parenteral nutrion.
Adapted with permission from Trence D, Kelly J, Hirsh I: The rationale and management of hyperglycemia for in-patients with cardiovascular disease.
Time for a change. J. Clin Endocrinol Metab 2003, 88:2430-2437. Copyright 2003, The Endocrine Society