Regional Local Health Networks

Clinical Support Guide |

Intravenous Insulin Infusion
(MR-INF-A)
(MR-INF-B)
Protocol author: Diabetes Service, Rural Support Service
Protocol sponsor: Drug & Therapeutics Advisor Committee
Approved by: Drug & Therapeutics Advisory Committee on: 13/12/2019

Next review due: 13/06/2021

Summary This protocol outlines responsibilities and actions required

by medical staff, nurses and midwives to ensure the safety
and quality of patient care.

Policy/Procedure This protocol supports the SA Health Recognising and

reference Responding to Clinical Deterioration Policy Directive and
Guideline, Diabetes Service Plan and Diabetes Inpatient
Model of Care.
Keywords Clinical, Protocol, medical, nursing, midwifery, emergency,
safety, quality, standards.
Document history Is this a new LHN Protocol? N
Does this protocol amend or update an existing protocol? Y
Diabetic Ketoacidosis Management in Adults with Type 1
Diabetes, 2019
Does this protocol replace an existing protocol? N

Applies to This protocol applies to all hospital medical, nursing and

midwifery staff.
Objective File No. 2019 - to be updated

Version control and change history

Version Date Amendment Amended by:
1.0 4/12/2015 Original version Jane Giles
2.0 17/01/2019 Reviewed with no changes Jane Giles
3.0 13/12/2019 Reviewed with no changes Jane Giles

© Department of Health, Government of South Australia. All rights reserved.

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Table of Contents

page
Background 3
Purpose 3
Indications for IV insulin infusion 3
Medication management 3
Nursing considerations 4
Targets for blood glucose levels 4
Frequency of blood glucose monitoring 4
Identifying the protocol type 4
Preparation of insulin infusion - Equipment 4
Preparation of insulin infusion 5
IV Chart examples 7
Important points of difference between charts 9
Documenting on the blood glucose monitoring
9
section
Intravenous insulin protocol 10
Nursing medication administration record 10
Medication management 10
What can go wrong 11
When to Stop/Suspend infusion 11
Transition off IV insulin infusion 11
Switching from IV to the Basal Bolus Insulin
11
protocol
Switching from IV to pre-mixed insulin 12
Switching from IV to continuous subcutaneous
12
insulin infusion (CSII) or insulin pump
Documentation 12
Appendix 1 – Hypoglycaemia protocol 13

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Clinical Support Guide |

Intravenous insulin infusion
This clinical support guide is only for the management and titration of intravenous (IV)
insulin infusion. It does not explain dose titration for any other type of insulin or method of
administration.

1. Background
Hyperglycaemia on general medical and surgical units is associated with an 18 fold increase in
in-hospital mortality, longer length of stay and greater risk of infection. 1 The use of IV insulin to
treat hyperglycaemia has been shown to reduce mortality, sepsis and acute renal failure by up to
45%.2

2. Purpose
The aim of this document is to support best practice in the titration and stabilisation of the person
with diabetes requiring an IV infusion of insulin. The clinical guide is to be used in conjunction with
the CHSA Intravenous Actrapid Infusion Protocols (MR-INF-A Adult - DKA/Type 1 and MR-INF-B
Adult – HHS/Type 2 protocols). Actrapid is the insulin of choice for IV insulin infusion.3

3. Indications for IV insulin infusion

For the purposes of this clinical guide, indications for use in South Australian Regional hospitals
are:
 Diabetic ketoacidosis (DKA), including euglycaemic DKA
 Hyperosmolar hyperglycaemic state (HHS).
 Surgical management of type 1 and 2 diabetes.
 Type 1 diabetes - patient not eating/fasting.
Careful consideration for use with:
 Hyperglycaemia on admission or persistent hyperglycaemia during hospitalisation.
Situations where these protocols are not in scope thus not approved are:
 Peri-partum management of diabetes (refer to SA Health Perinatal Guidelines for IV insulin
protocol). Insulin and blood glucose are documented on the Partogram.
 Paediatric patients. Consultation with a paediatrician or paediatric service is recommended. A
written medication authority from a medical practitioner is required.
4. Medication management
 Maintain basal insulin doses and cease rapid acting insulin.
 Review any oral medications and withhold if potential to worsen clinical state. Immediately
cease sodium-glucose co-transporter-2.
 Review medications as part of discharge planning, and consider discontinuing the sodium-
glucose co-transporter-2 in at risk patients.

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5. Nursing considerations
Number of nursing staff and frequency of observations will be determined by patient stability
and treatment intensity. There is a need for a 1:1 or 1:2 nurse:patient ratio if an IV insulin
infusion is used as hourly observations are required.
Observations include:
 2 intravenous lines setup plus syringe pump for IV insulin infusion
 capillary blood glucose and blood ketone monitoring
 fluid balance record (catheterisation and hourly measures) calculate and report deficit or
positive fluid balance hourly
 pulse oximetry, temperature, pulse, respirations and blood pressure
 cardiac monitoring if hyperkalaemia or hypokalaemia
 level of consciousness - Glasgow coma scale (GCS).

5. Targets for blood glucose

The blood glucose (BG) target range during an intravenous insulin infusion is 7.0 – 10.0mmol/L
for adult inpatients:
Figure 1: Target BG range

6. Frequency of blood glucose monitoring

All patients require hourly BG monitoring for the duration of the infusion unless BG has been
within target range for at least six hours. In this situation, 2 hourly BG monitoring may be ordered
by the medical practitioner. If there are any changes to the infusion rate, IV fluids or TPN, revert
back to hourly monitoring.

7. Identifying the protocol type

There are two IV insulin infusion protocols. The required protocol should be specified by the
medical practitioner.
 MR-INF-A (DKA/Type 1) is an adult protocol to be used for patients with type 1 diabetes and in
conjunction with the CHSA Diabetic Ketoacidosis (DKA) protocol.
 MR-INF-B (HHS/Type 2) is also an adult protocol to be used for patients with type 2 diabetes
and in conjunction with the CHSA Hyperglycaemia Hyperosmolar State (HHS) protocol.

8. Preparation of insulin infusion - Equipment

 Actrapid insulin cartridge
 Syringe driver pump
 50 unit (0.5mls) insulin syringe
 50ml leur lock syringe
 Blunt tip cannula
 ‘Medication added’ label
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 Extension tubing
 IV fluids (usually normal saline at commencement)
 Giving set with anti-reflex valve

9. Preparation of insulin infusion

Equipment and supplies as per local instructions.
1. Draw up 50 units of Actrapid insulin in a subcutaneous insulin syringe.

2. Draw up 49.5mls of 0.9% sodium chloride (normal saline) in a 50ml leur lock syringe.

3. Leave enough space in the normal saline syringe and inject the insulin into the syringe. This
will make the solution up to 50mls in total.
4. Apply a blunt tip cannula and mix gently.

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5. Attach a ‘medication added’ label to the syringe stating the quantities added of each
medication as above. Concentration = 1 unit insulin per 1 ml of normal saline, ie 50 units in
50mls.

6. Attach extension tubing to the syringe and manually prime the line with the insulin/saline
solution.
7. Position the syringe on a syringe driver pump ensuring the flange of the barrel and base of
plunger are firmly engaged.

8. Assemble IV fluids as ordered (usually normal saline) using a giving set with an anti-reflux
valve. Prime the line and attach to the patients IV cannula. The insulin infusion line MUST be
attached via a side-line port below the anti-reflux valve on the giving set.
9. Commence infusions as ordered.

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DKA/Type 1/ Protocol - Adult

Figure 2: Intravenous actrapid infusion – DKA/Type 1 protocol (Adult)

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HHS/Type 2 Protocol - Adult

Figure 3: Intravenous actrapid infusion – HHS/Type 2 protocol (Adult)

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10. Important points of difference between charts
 Check title of chart to ensure you have the correct one.

 Column values for BG and infusion rate are different.

 Recording methods for all information are identical.

11. Documenting on the BG monitoring section

 Document the date and time in the appropriate column
 The BG is graphed with a dot (·) in the centre of the square which coincides with the BG level.
Eg 16.1 or 16.8mmol/L is a dot in the box that corresponds to 16. Connect to the previous dot
with a straight line.
 Document the numerical value of the BG in the designated row below the graph.
 Record IV insulin infusion rate as it relates to BGL. New patients always begin in the green
column (column 1).
 Record the column being used to titrate the infusion at that point in time eg column 1, 2 or 3.
 Nurse taking and recording BGL to initial in allocated box.
 If the Hypoglycaemia Protocol (see appendix 1) is initiated or a medical practitioner is
contacted, tick the corresponding box on the chart.
 Medical practitioner to be contacted if the patient remains in column 3 for four (4)
measurements and has still not achieved target BGL.
Figure 4: example of how to chart the information

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12. Intravenous insulin protocol
 New patients always begin in the green column – Column 1.
 Moving up – At each BG measurement ask the following two questions.
 Is the patient’s BG 10.0mmol/L or less?
 Has the BG dropped by at least 2.5mmol/L in the last hour?
 If the answer to either question is YES - patient remains in the current column.
 If the answer to both questions is NO - patient moves up one column.
 Moving down
 If BG <4.0mmol/L for two consecutive measurements or insulin has been switched
off – patient moves down one column.

13. Nursing medication administration record

At commencement of IV insulin infusion and with EACH syringe change, two nurses to check and
sign the nursing administration record as per example below:
Figure 5: Example of how to complete the nursing administration record

IV insulin infusion hourly rate is to be checked by two nurses and both initials are to be
documented as per the example below:
Figure 6: Example of how to complete the nursing administration hourly rate record

14. Pump and line management

 Senior nurse to check the order and settings on the syringe driver at the commencement of
their shift AND with each syringe change.
 Check the IV insertion site and connections at commencement of each shift AND at each
syringe/line change.
 Always check the rate changes with a second nurse.
 Change the Leur Lock Syringe every 24 hours. Lines replaced every 4 days.4

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15. What can go wrong?
 If the patient remains in column 3 for four (4) BG measurements, and still has not achieved
target, call the supervising medical practitioner immediately.
 Remember that this protocol has adjustments built in so that moving up and down will adjust for
each person’s individual insulin sensitivity. Hypoglycaemia, although always a possibility, will
occur less frequently than with subcutaneous sliding scales.
 At any time, a registered nurse should contact the prescribing medical practitioner if they have
any concerns related to the IV insulin infusion or blood glucose results.

16. When to Stop/Suspend infusion

 If hypoglycaemia occurs:
 suspend infusion and follow hypoglycaemia protocol
 notify the medical practitioner if infusion is suspended for >45 minutes.
17. Discharge planning
 Once the patient has remained in the same column for 10-12 hours with target BG achieved,
the medical practitioner can review for transition to alternate and appropriate therapy in
preparation for discharge.

18. Transition off IV insulin infusion

IV insulin can only be discontinued once subcutaneous basal insulin has been on board
for 4 hours.
 Patients must not have their IV insulin infusion discontinued until 4 hours after commencement
of basal (e.g. glargine) subcutaneous insulin.
 IV insulin (actrapid) has a half-life of only 7 minutes with duration of only 1 hour.
 IV insulin can only be discontinued once basal insulin has been on-board for 4 hours.
 IV insulin adjustments can continue based on blood glucose levels as this ensures adequate
insulin coverage during transition.
At discontinuation of IV insulin infusion, two nurses to sign the nursing administration record as
per example below:
Figure 7: Example of the nursing administration record when ceasing the IV insulin infusion

19. Switching from IV to the Basal Bolus Insulin protocol

 Ensure long-acting insulin has been on board for a minimum of 4 hours before IV infusion is
discontinued.
 Calculate total insulin required over the last 6 hours and multiply this amount by 4 (=TDD)
 50% of TDD is given as basal insulin
 50% of TDD is given in three divided doses with meal.

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 Continue to follow the protocol as outlined in the Regional Hyperglycaemia Management
Protocol and Basal Bolus Insulin Chart MR62A.

20. Switching from IV to pre-mixed insulin

 If pre-mixed insulin (twice/day) is chosen, 2/3 TDD is given at breakfast and 1/3 is given with
the evening meal. Continue supplemental insulin.

21. Switching from IV to continuous subcutaneous insulin infusion (CSII) or insulin

pump
 A patient’s endocrinologist should be consulted if transitioning to insulin pump therapy.
 Insulin pump therapy is to be recommenced at the previous basal rate settings with the IV
Infusion running concurrently.
 IV Insulin Infusion rate will be titrated down based on blood glucose levels.
 If a meal is due during the 4 hours of transition, the insulin pump’s advanced settings are to be
used to calculate the meal-related bolus.
The insulin pumps’ advanced settings consider the pre meal blood glucose test result, blood
glucose target, insulin sensitivity factor, insulin:carbohydrate ratio and insulin action time (also
known as ‘insulin on board’) to suggest a meal-related bolus dose to be delivered.
The patient can self-administered this suggested meal-related bolus dose or administer a
reduction in the suggested dose if concerned about post prandial hypoglycaemia.
The CSII Inpatient Rate Record (MR-CIR) is to be used by the patient to document the meal-
related bolus administered.
 After at least 4 hours of basal insulin via the insulin pump AND if the patient has tolerated food
and fluid AND if the blood ketone remains less than 0.3mmol/L, the IV infusion can be
discontinued.
 After the IV Infusion is discontinued, maintain insulin pump therapy (using both basal and
advanced settings at main meal times). Continue hourly blood glucose for 2-4 hours then if
stable, reduce blood glucose monitoring frequency to QID. The blood ketone should be
rechecked in 1 hour and then as instructed by the medical officer.
22. Transitioning to oral medications
 Identify medications options that are safe for the patient. If reason for DKA was sodium-glucose
co-transporter-2 use, then this medication should not be re-commenced.
 Assess pre admission HbA1c to inform discharge medication adjustment
 On target - Recommence on usual diabetes treatment.
 Above target - Will need assessment for increase in usual therapy; arrange follow
up GP appointment and diabetes education follow up.
23. Documentation
 Capillary BG levels
 Insulin doses/infusion rate and any IV fluid therapy
 Capillary blood ketone levels
 Hypo treatments
 Rate changes
 Medical practitioner notifications

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Appendix 1
Hypoglycaemia management
The hypoglycaemia protocol below has been developed to standardise the management of
hypoglycaemia in hospitals and aged care facilities. Two pathways are included on the flowchart
(safe to swallow/unconscious or unsafe to swallow). This protocol still applies for patients on an
insulin infusion.
Figure 8: Hypoglycaemia protocol

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1. Attached Documents
Document Name

Treatment of hypoglycaemia in patients with diabetes protocol (2019)

2. References

Document Name
1. Australian Diabetes Society, Guidelines for routine glucose control in hospital. 2012,
Australian Diabetes Society: Sydney.
2. American Diabetes Association, 2015 Standards of medical care in diabetes. Diabetes
Care. 38 (Supp 1).

3. Northern Adelaide Local Health Network, The management of intravenous insulin

infusions. 2019, Lyell McEwin Hosptial: Adelaide.

4. National Health & Medical Research Council, Australian guidelines for the prevention
and control of infection in healthcare 2010, Commonwealth of Australia: Canberra.

3. Accreditation Standards
National Safety and Quality Health Service Standards (NSQHSS)

1 2 3 4 5 6 7 8 9 10
☒ ☐ ☐ ☒ ☐ ☒ ☐ ☒ ☒ ☐
Governance Partnering Preventing & Medication Patient Clinical Blood & Blood Preventing & Recognising & Preventing
for Safety and with Controlling Safety Identification & Handover Products Managing Responding to Falls & Harm
Quality in Consumers Healthcare Procedure Pressure Clinical from Falls
Healthcare Associated Matchng Injuries Deterioration
Infections

Evaluation and Quality Improvement Program (EQuIP)

11 12 13 14 15
☒ ☒ ☐ ☐ ☐
Service Provision of Workforce Information Corporate
Delivery Care Planning and Management Systems and
Management Safety

4. Consultation

Version Consultation

CHSA Diabetes Specialist Nurse Network, CHSA Clinical Nurse

1.0
Consultants and emergency department staff.
CHSA Diabetes Specialist Nurse Network, CHSA Clinical Nurse
2.0
Consultants and emergency department staff.
Regional Diabetes Specialist Nurse Network, Regional Nurse Unit
3.0
Managers and emergency department staff.

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