Intravenous Insulin Prescription and Fluid Protocol

FOR DIABETIC KETO-ACIDOSIS (DKA)

For use for ALL ADULT (over 18 years) patients with a diagnosis of Ward Consultant Admission Date:
DKA
Discharge Date:
NOT FOR USE IN CHILDREN
NEVER use an IV syringe to draw up insulin Surname First Name
ALWAYS draw up insulin using an insulin syringe
ALWAYS continue subcutaneous intermediate* or basal insulin** Hospital Number Date of Birth / Age
® ® ®
*Intermediate: Insulatard , Humulin I , Insuman Basal NHS Number
® ® ®
**Basal: Lantus (glargine), Levemir (detemir), Tresiba (degludec),
®
Toujeo (long acting glargine) Address
Doctor: All prescriptions for insulin and fluids must be signed
Nurse: All entries must be signed
ENTRY (diagnostic) CRITERIA (ALL must be ticked to establish diagnosis)
Established or new diagnosis of diabetes mellitus ☐
Capillary blood ketonaemia on Trust approved ketone meter of ≥ 3 mmol/L or
ketonuria ++ or more on standard urine sticks ☐
Venous bicarbonate <15 mmol/L and/or venous pH <7.3 ☐
If patient satisfies all ENTRY CRITERIA, commence insulin therapy (see BOX 1); intravenous fluid management (see BOX 2,
BOX 3 and BOX 4); and intravenous fluid prescription (see BOX 5)
If patient has ketonaemia WITHOUT acidosis (pH>7.3 or HCO3>15 mmol/L, intravenous insulin therapy may not be required
BUT intravenous fluid hydration and subcutaneous insulin dose correction may be necessary
BOX 1: INTRAVENOUS INSULIN THERAPY AND PRESCRIPTION Weight/insulin dose reference Guide
A Fixed Rate Intravenous Insulin Infusion (FRIII) calculated on 0.1 units/kg Weight Insulin Weight (in Insulin
body weight is recommended (see Weight/insulin dose Reference Guide) (in kg) dose/hr kg) dose/hr
It may be necessary to estimate the weight of the patient (Units) (Units)
Patient’s Weight: ___________ kg (Actual/Estimated) *50-59 5 100-109 10
Insulin dose per hour: ___________ units Date: _________________ 60-69 6 110-119 11
Print Name: ____________________ Signature: _____________ 70-79 7 120-129 12
If blood ketones not falling by at least 0.5 mmol/L/hr OR venous 80-89 8 130-139 13
bicarbonate not rising by at least 3 mmol/L/hr OR CBG not falling by at 90-99 9 >140 *
least 3 mmol/L/hr- increase insulin infusion rate by 1.0 unit/hr until falling
at target rates
Date Time Adjusted dose Prescriber Name Prescriber Bleep *<50kg or >140kg: seek advice from the
(units/hr) Signature Diabetes Specialist Team

Drug (approved name) Dose Volume Route Prescriber’s Prescriber Date

Signature Print name
Actrapid® 50 Made up to 50ml with
UNITS NaCl 0.9% (1 UNIT per mL) IV
BOX 2: INTRAVENOUS FLUID MANAGEMENT (Saline regime) BOX 3: INTRAVENOUS FLUID MANAGEMENT (Dextrose regime)
CAUTION: Slower in young people aged 18-25 years, elderly, Once CBG<14 mmol/L, or in the event of non-hyperglycaemic
pregnant, heart or renal failure DKA presenting with CBG <14 mmol/L:
st
0.9% sodium chloride 1 litre (no KCl) Over 1 hour Give 10% Dextrose to run at 125 mls/hr AND
0.9% sodium chloride 1 litre (check K+) Over next 2 hours Continue saline as per Saline regime (see BOX 2)
0.9% sodium chloride 1 litre (check K+) Over next 2 hours Run through Saline and Dextrose regime in 2 separate lines at
0.9% sodium chloride 1 litre (check K+) Over next 4 hours the SAME time
0.9% sodium chloride 1 litre (check K+) Over next 4 hours Run Dextrose regime and insulin therapy in the same line via a
Anticipate a fall in potassium and replace (see BOX 4) three way non-return valve
Re-assessment of cardio-vascular status at 12 hours is mandatory, further fluid may be required
SYRINGE PREPARATION BOX 4: POTASSIUM REPLACEMENT
Prepared and Date Time Time Add potassium as per guidance below
administered by started stopped EXCEPT for the first Saline (1 hour) bag
ONLY use pre-prepared bags
>5.5 mmol/L None
3.5 – 5.5 mmol/L 40 mmol KCl per litre (see rate in Box 2)
<3.5 mmol/L 40 mmol KCl per litre (senior review if additional
potassium needs to be given- See rate in Box 2)
UKD/EC_V1 04/2018
 Intravenous Insulin Prescription and Fluid Protocol
FOR HYPEROSMOLAR HYPERGLYCAEMIC STATE (HHS)
For use for ALL ADULT (over 18 years) patients with a diagnosis of Ward Consultant Admission Date:
HHS
Discharge Date:
NOT FOR USE IN CHILDREN
NEVER use an IV syringe to draw up insulin Surname First Name
ALWAYS draw up insulin using an insulin syringe
ALWAYS continue subcutaneous intermediate* or basal insulin** Hospital Number Date of Birth / Age
® ® ®
*Intermediate: Insulatard , Humulin I , Insuman Basal NHS Number
® ® ®
**Basal: Lantus (glargine), Levemir (detemir), Tresiba (degludec),
®
Toujeo (long acting glargine) Address
Doctor: All prescriptions for insulin and fluids must be signed
Nurse: All entries must be signed
ENTRY (diagnostic) CRITERIA (ALL must be ticked to establish diagnosis)
Hypovolaemia ☐
Marked hyperglycaemia (>30 mmol/L) without significant hyperketonaemia (<3.0 mmol/L) or acidosis (pH >7.3, bicarbonate
>15 ☐
Osmolality >320 mosmol/kg Venous bicarbonate <15 mmol/L and/or venous pH <7.3 ☐
If patient satisfies all ENTRY CRITERIA, commence intravenous fluid management (see BOX 2)
ONLY commence intravenous insulin therapy IF patient has significant ketonaemia (blood ketones >1.0 mmol/L or
ketonuria (urine ketones >++) (see BOX 1)
BOX 1: INTRAVENOUS INSULIN THERAPY AND PRESCRIPTION Weight/insulin dose reference Guide
A Fixed Rate Intravenous Insulin Infusion (FRIII) calculated on 0.05 units/kg Weight Insulin Weight (in Insulin
body weight is recommended (see Weight/insulin dose Reference Guide) (in kg) dose/hr kg) dose/hr
It may be necessary to estimate the weight of the patient (Units) (Units)
Patient’s Weight: ___________ kg (Actual/Estimated) 50-59* 2.5 100-109 5
60-69 3 110-119 5.5
Insulin dose per hour: ___________ units Date: _________________ 70-79 3.5 120-129 6
80-89 4 130-139 6.5
Print Name: ____________________ Signature: _____________ 90-99 4.5 >140 *
Date Time Adjusted dose Prescriber Name Prescriber Bleep *<50kg or >140kg: seek advice from the
(units/hr) Signature Diabetes Specialist Team

Drug (approved name) Dose Volume Route Prescriber’s Prescriber Date

Signature Print name
®
Actrapid 50 Made up to 50ml with
UNITS NaCl 0.9% (1 UNIT per mL) IV
BOX 2: INTRAVENOUS FLUID MANAGEMENT (Saline regime) BOX 3: INTRAVENOUS FLUID MANAGEMENT (Dextrose regime)
CAUTION: Slower in young people aged 18-25 years, elderly, Once CBG<14 mmol/L
pregnant, heart or renal failure
st
0.9% sodium chloride 1 litre (no KCl) Over 1 hour Give 10% Dextrose to run at 125 mls/hr AND
0.9% sodium chloride 1 litre (check K+) Over next 2 hours Continue Saline as per Saline regime (see BOX 2)
0.9% sodium chloride 1 litre (check K+) Over next 2 hours Run through Saline and Dextrose regime in 2 separate lines at
0.9% sodium chloride 1 litre (check K+) Over next 4 hours the SAME time
0.9% sodium chloride 1 litre (check K+) Over next 4 hours Run Dextrose regime and insulin therapy in the same line via a
Anticipate a fall in potassium and replace (see BOX 4) three way non-return valve
Re-assessment of cardio-vascular status at 12 hours is mandatory, further fluid may be required
SYRINGE PREPARATION BOX 4: POTASSIUM REPLACEMENT
Prepared and Date Time Time Add potassium as per guidance below
administered by started stopped EXCEPT for the first Saline (1 hour) bag
ONLY use pre-prepared bags
>5.5 mmol/L None
3.5 – 5.5 mmol/L 40 mmol KCl per litre
<3.5 mmol/L 40 mmol KCl per litre (senior review as additional
potassium needs to be given)

UKD/EC_V1 04/2018
BOX 5: INTRAVENOUS FLUID PRESCRIPTION
For information on dilutions, infusion rates, compatibilities and monitoring parameters, consult the:
Injectable Medicines Guide or contact Medicines Information
CAUTION: Slower in young people aged 18-25 years, elderly, pregnant, heart or renal failure
Date Solution Volume Additives and dose Rate Duration Route Prescriber Batch Given by Time Time Pharm and
Check potassium Signature & Bleep No. started stopped supply notes
nd
Refer to BOX 4 2
check
0.9% NaCl 1 litre KCl None 1000 mls/hr 1 hr IV
0.9% NaCl 1 litre KCl 500 mls/hr 2 hrs IV
0.9% NaCl 1 litre KCl 500 mls/hr 2 hrs IV
0.9% NaCl 1 litre KCl 250 mls/hr 4 hrs IV
0.9% NaCl 1 litre KCl 250 mls/hr 4 hrs IV
0.9% NaCl 1 litre KCl 166 mls/hr 6 hrs IV
10% Dextrose 1 litre 125 mls/hr 8 hours IV
10% Dextrose 500 mls KCL 0.15% 50 mls/hr 10 hours IV

SWITCH FROM FIXED RATE INTRAVENOUS INSULIN Bedside and laboratory results EXIT CRITERIA (ALL must be ticked)
INFUSION TO VARIABLE RATE INTRAVENOUS INSULIN Check creatinine, electrolyte and venous bicarbonate and pH at 2 hours then 2 DKA:
INFUSION (VRIII) with 10% Dextrose with 0.15% KCl at 50
to 4 hourly until venous bicarbonate >15 mmol/L Blood ketones <0.6 mmol/L and ☐
mls/hr IF:
DKA: CAPILLARY BLOOD KETONES < 0.6 mmol/L and Date Time Ketones Na+ K+ Creatinine HCO3 pH Osmolality Signature Venous bicarbonate >15 mmol/L and ☐
HCO3 > 15 mmol/L and STILL not eating and drinking Eating and drinking ☐
HHS: Biochemical markers have normalised and STILL HHS:
not eating and drinking Osmolality normalised and ☐
PRESCRIPTION Eating and drinking ☐
CBG Insulin Insulin Insulin Transfer to subcutaneous insulin regime
mmol/L units/hr units/hr units/hr
> 14 6 Notes:
12.1 – 14 4 Maintain IV insulin infusion for 30 minutes
10.1 - 12 3 after re-starting original insulin regime- IV
insulin has a 5 minute half-life
7.1 – 10 2 ALWAYS continue subcutaneous basal
4-7 1 insulin
<4 0.5 Refer to the Diabetes Specialist Team
Signature Seek and treat precipitating factors
Bleep No. Consider prophylactic or full anticoagulation
Date Other issues:
Time

UKD/EC_V1 04/2018
 INTRAVENOUS INSULIN, CBG AND KETONES MONITORING RECORD SHEET
Guide:
ADDRESSOGRAPH
Only use for patients on intravenous insulin regimen (use different chart for patients on subcutaneous insulin)
Make sure the patient’s hands are clean LABEL
Check CBG hourly
Check capillary blood ketone hourly until DKA resolved
DATE Time Blood glucose Blood Hourly infusion Volume left in Volume infused Total volume infused Signatures KEY EVENTS /
ketones rate (units/hr) syringe (ml) in one hour (ml) (ml) NOTES

UKD/EC_V1 04/2018