1. Glycemic Control in
the Intensive Care
Unit
Hanna Yudchyts, Pharm.D.
PGY-1 Pharmacy Resident
NSLIJ Lenox Hill Hospital

2.  Introduce patient case
 Describe YALE Insulin Drip Protocol
 Discuss benefits of insulin drip in the ICU
 Review Basal- Bolus Insulin Model
 Apply learned material to patient case and
evaluate therapy chosen by medical team

3. Patient Case

4. History of Present Illness
 GS is a 52 year old male
 Patient experienced episode of midsternal chest
pain while at work
 He presented at Jersey City Medical Center ED
 Angiogram revealed a three-vessel disease
 Patient was instructed to follow up with CT
surgery for further management and evaluation
 He presented to Lenox Hill Hospital for surgical
consultation

5. Past Medical History
Diabetes Mellitus Type 1
HbA1c 10.2
Hypertension
Hyperlipidemia
Coronary Artery Disease
Angina

6. Medications Prior to Admission
Insulin Glargine 14 units at bedtime
Lisinopril 40 mg daily
Rosuvastatin 20 mg daily
Metoprolol ER 25 mg daily
Aspirin 81 mg daily
Ranolazine 1000 mg daily
Ticagrelor 90 mg daily
Amiodarone 300 mg twice daily

7. Treatment Course
 On 09/11/2013 patient underwent Off-Pump
Coronary Artery Bypass Grafting (OPCABG)
 After surgery was started on insulin infusion
as per YALE insulin drip protocol
– Insulin Regular Sliding Scale IV
– 250 units in 250 mg NS IV Continuous Infusion
– Titrate per protocol

8. Give Your Patient FAST HUG Once a Day
Feeding
Analgesia
Sedation
Thromboembolic prophylaxis
Head-of-bed elevation
Ulcer prevention
Glucose control

9. 140-180 mg/dL
2009 ACE/ADA Guidelines
Target Blood Glucose
90-119 mg/dL
YALE Insulin Drip Protocol

10. In critical care settings continuous IV insulin
infusion is the most effective method to
achieving specific glycemic targets
YALE Insulin Drip Protocol

11. YALE Protocol Benefits
Eliminates the need for multiple injections
Allows for more accurate dose administration
Has more predictable kinetics
Provides a quick response to rapidly changing
glucose levels
Accomplish adequate control with smaller insulin
doses
Incorporate current and previous blood glucose
levels, current infusion rate and rate of change

12. YALE Protocol Not to be Used
•Diabetic Ketoacidosis (DKA)
•Hyperglycemic Hyperosmolar
Syndrome (HHS)
•BG≥ 500 mg/dL

13. Initiating an Insulin Drip
Insulin infusion
Mix 1 unit Regular Human Insulin per 1 ml 0.9% NaCl
Administration
Via infusion pump in increments of 0.5 units/hr
Priming
Flush 50 ml of Insulin/NS drip through all IV tubing

14. Calculating Initial Insulin Rate
Blood Glucose divide by 100, then round to
nearest 0.5 units for bolus and initial drip rate
Example
– Initial BG 325 mg/dL
325: 100=3.25
rounded up to 3.5
3.5 units IV bolus + 3.5 units/h start drip

15. Blood Glucose
Monitoring
Check FS hourly until stable
(3 consecutive values in target range)

16. Blood Glucose Monitoring
Once stable check FS every 2 hours
Stable for 12-24 hours
No significant change in clinical condition
No significant change in nutritional intake
Every 4 hours

17. Blood Glucose Monitoring
Consider resumption of hourly FS monitoring:
•Any change in insulin drip rate
• Significant changes in clinical
condition
• Initiation/cessation of pressor/
steroid therapy, dialysis,
nutritional support

18. BG<50 mg/dL BG 50-69 mg/dL
Discontinue Drip
Dextrose 1 amp (25g) Symptomatic: 1 amp (25 g)
Asymptomatic: ½ amp (12.5 g) or
8 oz juice PO
Check BG q 15 min Symptomatic: q 15 min
Asymptomatic: q 15-30 min
Restarting Drip
When BG ≥ 90 mg/dL wait 1 hour
Recheck BG if still ≥ 90 mg/dL restart drip
New Rate 50% of recent rate 75% of recent rate
Changing the Insulin Drip Rate

19. Changing the Insulin Drip Rate
IF BG≥ 70 mg/dL
Determine the Current BG LEVEL
70-89 mg/dL 90-119 mg/dL 120-179 mg/dL ≥ 180 mg/dL
Identify a COLUMN in the tablet

20. Determine RATE OF CHANGE from prior BG level

21. Conversion from IV to SQ Insulin
 To calculate TDD:
1. Units of insulin given in last 6 hours x 4
2. Use 80% of that value ( x 0.8)
OR
1. Use last 7 insulin drip rates and omit the 2 highest
2. Sum of the lowest 5 drip rates x 4
 Apply Basal- Bolus Insulin Model

22. Basal-Bolus Insulin Model
Total Daily Dose
Basal (50%) Bolus (50%)
Breakfast
Lunch
Dinner
Correctional
Insulin

23. Insulin Options
Basal
Glargine
Detemir
NPH
Bolus
Lispro
Aspart
Glulisine
Regular
Correctional
Lispro
Regular

24. Duration of action of different insulin formulations

25. Back to Patient Case

26. Insulin Infusion Administration Record
2-8 AM Before Discontinuation
Time BG RESULT
(mg/dL)
CHANGE in BG
(mg/dL)
NEW HOURLY
RATE (units/h)
2 AM 108 0 1
3 AM 116 8 1
4 AM 109 7 1
5 AM 121 11 1.5
6 AM 141 20 2
7 AM 118 23 1.5
8 AM 138 20 2
Insulin administered in last 6 hours: 9 units

27. Transition from IV to SQ
Calculating TDD
 9 units x 4= 36 units
 36 units x 0.8= 28.8 units
Implementing Basal- Bolus regimen
 28.8 x 0.5= 14.25≈ 14 units of basal insulin
 14.25 : 3= 4.75 ≈ 5 units of bolus insulin before
each meal
 Insulin Correctional Scale

28. Transition from IV to SQ
Patient was started on
 Insulin Glargine 17 units once daily
 Insulin Lispro 6 units three times a day with each
meal
 Insulin Correctional Scale (Lispro)
Monitoring
 BG monitoring before meals and at bedtime

29. Conclusion
 Glucose concentrations should be closely
monitored in critically ill patients
 IV insulin infusion is preferred for optimum
blood glucose control
 Maintains blood glucose within desired range
 Basal- Bolus insulin model once patient is
stabilized

31. References
• American Association of Clinical Endocrinologists and American
Diabetes Association Consensus Statement on Inpatient Glycemic
Control. Diabetes Care. 2009 June; 32(6): 1119–1131.
• http://www.istockphoto.com
• 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.
• Improving Care of the Hospitalized Patient with Hyperglycemia and
Diabetes from the SHM Glycemic Control Task Force.
Supplement to Journal of Hospital Medicine Volume 3 Issue S5 ,
Pages 1 - 83 (September/October 2008).
• Armahizer M., PharmD, Benedict N., PharmD. FAST HUG: ICU
Prophylaxis. Last updated: June 1, 2011.
• Egi M. MD, Finfer S. MD, Bellomo R. MD. Glycemic Control in the
ICU. CHEST; June 2010.