The following insulin infusion protocol is intended for use in hyperglycemic adult patients in an ICU seing, but

is notspecically tailored for those individuals with diabetic emergencies, such as diabetic ketoacidosis (DKA) or
hyperglycemichyperosmolar syndrome (HHS). When these diagnoses are being considered, or if BG > 500 mg/dL,
an MD should be con-sulted for specic orders. Also, notify the responsible physician immediately if the response
to the insulin infusion isunusual or unexpected, or if any situation arises that is not adequately addressed by
these guidelines. Any patient on aninsulin infusion should have frequent measurement of serum electrolyte
concentrations, especially potassium.
YALE INSULIN INFUSION PROTOCOL
Adapted from Goldberg PA, et al.
29
(Endocrine Practice. July/August 2006.)
Initiating the Insulin Infusion
1.) INSULIN INFUSION: Mix 1 unit Regular Human Insulin per 1 mL 0.9% NaCl. Administer via infusion pump
(in increments of 0.5 unit/hr.)
2.) PRIMING: Flush 20 mL of infusion through all IV tubing before infusion begins (to saturate insulin binding
sites in tubing.)
3.) THRESHOLD: IV insulin is indicated in any critically ill patient with persistent BG > 140 mg/dl; consider use
if BG > 120 mg/dl.
4.) TARGET BLOOD GLUCOSE (BG) LEVEL: 90-120 mg/dL
5.) BOLUS & INITIAL INSULIN INFUSION RATE: If initial BG > 150, divide initial BG level ( mg/dL) by 70, then
round to nearest 0.5 unit for bolus AND initial infusion rate. If initial BG < 150 mg/dl, divide by 70 for initial
infusion rate only ( i.e., NO bolus.)
Examples: 1) Initial BG = 335 mg/dL: 335 70 = 4.78, rounded up to 5: Give 5 units IV bolus + start infusion @ 5 units/hr.
2) Initial BG = 148 mg/dL: 148 70 = 2.11, rounded down to 2: Start infusion @ 2 units/hr ( NO bolus.)
Blood Glucose (BG) Monitoring
1.) Check BG hourly until stable (dened as 3 consecutive values in target range.) In hypotensive patients, capillary
blood glucose ( i.e., ngersticks) may be inaccurate and obtaining a blood sample from an indwelling vascular
catheter is preferable.
2.) Then check BG Q 2 hours; once stable x 12-24 hours, BG checks can be spaced to Q 3-4 hours IF:
a) no signicant change in clinical condition AND b) no signicant change in nutritional intake.
3.) If any of the following occur, consider the temporary resumption of hourly BG monitoring, until BG is again stable:
a) any change in insulin infusion rate (i.e. BG out of range)
b) signicant changes in clinical condition
c) initiation or cessation of steroid or pressor therapy d) initiation or cessation of dialysis or CVVH
e) initiation, cessation, or rate change of nutritional support (TPN, PPN, tube feedings, etc.)
Changing the Insulin Infusion Rate
If BG < 50 mg/dL:
HOLD INSULIN INFUSION. Give 1 Amp (25 g) D50 IV; recheck BG Q 10-15 minutes
When BG > 90 mg/dL, wait 1 hour, recheck BG. If still > 90 mg/dL, restart infusion
at 50% of most recent rate.
If BG 50-69 mg/dL:
HOLD INSULIN INFUSION. If symptomatic (or unable to assess), give 1 amp (25 g) D50 IV;
If asymptomatic, consider 1/2 Amp (12.5 g) D50 IV or 8 ounces juice PO; recheck
BG Q 15-30 minutes.
When BG > 90 mg/dL, wait 1 hour, recheck BG. If still > 90 mg/dL, restart infusion
at 75% of most recent rate.
1
recheck BG Q 15 minutes.
e t a R n o i s u f n I n i l u s n I e h t g n i g n a h C ) . d t n o c (
G B f I / g m 0 7 : L d
: 1 P E T S L E V E L G B T N E R R U C e h t e n i m r e t e D N M U L O C a s e i f i t n e d i - : e l b a t e h t n i
L d / g m 9 8 - 0 7 G B L d / g m 9 1 1 - 0 9 G B L d / g m 9 7 1 - 0 2 1 G B G B L d / g m 0 8 1
L d / g m 9 8 - 0 7 G B L d / g m 9 1 1 - 0 9 G B L d / g m 9 7 1 - 0 2 1 G B G B L d / g m 0 8 1
S N O I T C U R T S N I *
G B r h / L d / g m 0 4 > y b G B y b N O I S U F N I E S A E R C N I
2
G B r h / L d / g m 0 2 > y b
G B r h / L d / g m 0 4 - 1 y b
R O
D E G N A H C N U G B
D E G N A H C N U G B
R O
G B r h / L d / g m 0 4 - 1 y b
y b N O I S U F N I E S A E R C N I

G B
G B , r h / L d / g m 0 2 - 1 y b
D E G N A H C N U G B , R O
G B r h / L d / g m 0 2 - 1 y b
G B r h / L d / g m 0 4 - 1 y b G B r h / L d / g m 0 8 - 1 4 y b E G N A H C N O I S U F N I O N
D E G N A H C N U G B
R O
G B r h / L d / g m 0 2 - 1 y b
G B r h / L d / g m 0 4 - 1 2 y b G B r h / L d / g m 0 8 - 1 4 y b G B r h / L d / g m 0 2 1 - 1 8 y b y b N O I S U F N I E S A E R C E D

G B r h / L d / g m 0 2 > y b
w o l e b e e s

G B r h / L d / g m 0 4 > y b G B r h / L d / g m 0 8 > y b G B r h / L d / g m 0 2 1 > y b n i m 0 3 X N O I S U F N I D L O H

n e h t 2 y b E S A E R C E D

; N O I S U F N I N I L U S N I D L O H
n e h w ; n i m 0 3 - 5 1 Q G B k c e h c
t a n o i s u f n i t r a t s e r , l d / g m 0 9
>> . e t a r t n e c e r t s o m f o % 5 7
N e t o r o f s e u l a v t r e v n o c o T :
o t L d / g m m o r f e s o c u l g
. 1 5 5 5 0 . 0 y b y l p i t l u m , L / l o m m
* D n e p e i d t n o g n h c e i l ni a c l ci , s e c n a t s m u c r inf s u i p y t s e t a r n o i a c l l e g n a r y b n e e w t e 2- 0 1 n u i s t h / . r D s e s o
e r o l p x e o t d e i f i t o n e b d l u o h s D M e l b i s n o p s e r e h t , d e r i u q e r f i , d n a , l a u s u n u e r a r h / s t i n u 0 2 f o s s e c x e n i
) . c t e , s r o r r e n o i t u l i d s a h c u s , s m e l b o r p l a c i n h c e t g n i d u l c n i ( s r o t c a f g n i t u b i r t n o c l a i t n e t o p r e h t o
*
E T A R N O I S U F N I N I S E G N A H C r o a t l e d ( : e t a r n o i s u f n i t n e r r u c y b d e n i m r e t e d e r a )
e t a R n o i s u f n I t n e r r u C
) r h / s t i n u (
e g n a h C e t a R =
) r h / s t i n u (
2 e g n a h C e t a R X 2 =
) r h / s t i n u (
1 5 . 0 3 <
2 1 6 - 3
3 5 . 1 5 . 9 - 5 . 6
4 2 5 . 4 1 - 0 1
* 6 * 3 5 . 9 1 - 5 1
* 8 * 4 * 5 . 4 2 - 0 2
* 5 2 * 5 0 1 *

STEP 2: Determine the RATE OF CHANGE from the prior BG level - identifies a CELL in the table - Then move right
for INSTRUCTIONS:
[Note: If the last BG was measured 2-4 hrs before the current BG, calculate the hourly rate of change. Example: If the BG at 2PM was
150 mg/dL and the BG at 4 PM is now 120 mg/dL, the total change over 2 hours is -30 mg/dL; however, the hourly change is
-30 mg/dL 2 hours = -15 mg/dL/hr.]
2