Download 5. Insulin titration and glucose monitoring

Cardiac Surgery Inpatient Unit
Glycemic Protocol
WRHA CARDIAC SCIENCES
GUIDELINES
Approved By:
Cardiac Sciences Standards Committee
Cardiac Sciences Quality and Standards Committee
Effective Date/ Last
Revised:
April 29, 2013
Originated from:
Page:
 CI
 LEAN ■ QI  Other
Lead: Dr Ariano and Glycemic Control Review
Committee
Number: 205
1 of 4
Introduction and Statement of Guidelines:
The maintenance of blood glucose levels in the range 5-10 mmol/L has been shown to reduce the
incidence of post op infections in patient undergoing cardiac surgery regardless of whether they
have a history of diabetes. This protocol was developed by the Cardiac Sciences Surgical Site
Infection Control Committee with direction from Dr. Sora Ludwig, Endocrinology Department.
Purpose of Protocol:
The protocol is designed to allow nursing staff and physicians to safely manage patients with
insulin infusions. The protocol will provide guidance for insulin administration. Orders for
frequency of monitoring and for glucose administration in the event of hypoglycemia are part of
the protocol.
Patient Population:
All post operative cardiac surgery patients transferred /admitted to the Cardiac Surgery Inpatient
Unit (CSIU) should be considered for management of blood glucose according to this protocol.
The Physician/ Clinical Assistants (CA) will ultimately decide who is managed by this protocol.
Activation of the Protocol:
The Cardiac Surgery Inpatient Unit Glycemic Protocol must be ordered by a physician/CA.
Blood glucose management is included in the Cardiac Surgery Postoperative order sets according
to the principles in this protocol.
Patient and Family Education:
The cardiac surgery nursing and medical staff will be responsible for explaining the protocol and
the use of insulin to the patients and their families. It is anticipated that there may be some issues
as patients who are not normally on insulin will be receiving this medication while on the
Cardiac Surgery Inpatient Unit.
Nursing and Physician Education:
The protocol will have to be introduced to physicians, Clinical Assistants, nurses, and
pharmacists. This protocol will also need to be included in the orientation of new nursing staff
and taught as part of that educational package prior to clinical practice on the unit. Educational
initiatives that may be used include: information packages for nursing and medical staff; bedside
charts with the protocol available for easy reference; formal lectures at in-service time for unit
staff; safety huddles and case based teaching sessions.
1
WRHA Cardiac Sciences Program: Cardiac Surgery Inpatient Unit Glycemic Protocol
Number: 205
Page: 2 of 4
Medication Caution:
Insulin is a dangerous medication which can produce severe patient morbidity and potential
mortality. Severe hypoglycemia may result when insulin is infused. The protocol has been
designed to avoid dangerous hypoglycemia. Insulin must only be administered by direct
continuous infusion pump using the safety software. Insulin must be administered utilizing a
basic solution set and is never to be piggybacked (run as a secondary medication line above the
pump (as a mini infusion is)). IV dextrose must always be administrated along side with the
insulin infusion. Nursing staff must be vigilant to ensure that insulin infusions are not continued
at the same dose if intravenous dextrose infusions or enteral feeding are interrupted.
Glycemic Protocol
Coverage:
All Registered Nurses may administer insulin according to this protocol on the Cardiac Surgery
Inpatient Unit.
Initiation:
This protocol will be initiated upon a Physician/CA order after transfer/admission to the Cardiac
Surgery Inpatient Unit.
Protocol:
1. Recommend running D5 ½ NS at 25 to 75 ml/hr while running insulin infusion (i.e.
background solution must contain some form of Dextrose 5%). With each gram of i.v.
dextrose providing 3.4 Kcal/g; 25 to 75 mL/h of D5 ½ NS provides 102 to 306 Kcal per day,
respectively.
2. A dedicated infusion pump and solution set must be used for the infusion.
3. Human regular insulin is used in the infusion.
4. Start insulin infusion at 1 unit/hour.
2
WRHA Cardiac Sciences Program: Cardiac Surgery Inpatient Unit Glycemic Protocol
Number: 205
Page: 3 of 4
5. Insulin titration and glucose monitoring AFTER initiation of infusion or change in infusion
rate:
a. Based on hourly blood glucose levels titrate (increase or decrease) the infusion by 0.5 - 1
units/hour to achieve the target glucose range of 5 – 10 mmol/L.
b. Once the blood glucose level is 5-10mmol/L AND newly initiated insulin infusion rate
remains unchanged for 2 hours continue with blood glucose monitoring q2hours for 36
hours. After 36 hours continue with q4 hourly and prn blood glucose checks.
c. Maximum dose of insulin by this protocol is 10 units/hr. Insulin doses over 10 units/hr
must be ordered by a physician.7
d. ICU that has an infusion running at 10 units/hour or more cannot be transferred to CSIU.
e. Based on hourly blood glucose levels, adjust the insulin infusion by 0.5 – 1 units/hour
(increase or decrease) if the blood glucose falls out of the target range of 5 – 10 mmol/L.
f. Follow the Hypoglycemia Treatment protocol (Appendix A).
g. Continue the insulin infusion until eating is well established.
h. Once oral hypoglycemic agents are administered stop the insulin infusion. This transition
is best done in the morning coinciding with breakfast and requires a Physician/CA order.
6. Factors to consider when using Cardiac Surgery Inpatient Glycemic Protocol:
a. Factors that can affect the insulin infusion rate include (but not limited to)
Glucocorticoids (steroids) and post-operative infections. Sensitivity to insulin
improves as patient condition stabilizes. Therefore, the need for insulin usually
decreases as the length of stay progresses.
b. For patients requiring enteral or parenteral nutrition if there are either interrupted or
discontinued, it is necessary to stop the insulin infusion and check blood glucose
within 60 minutes. Follow titration guidelines. For patients with known diabetes
specific orders are required.
c. Daily lab values required are: electrolytes, urea, and creatinine. High doses of
intravenous insulin may lead to hypokalemia.
3
WRHA Cardiac Sciences Program: Cardiac Surgery Inpatient Unit Glycemic Protocol
7.
Number: 205
Page: 4 of 4
WRHA community follow-up for newly diagnosed diabetics
a. Follow-up should be provided to those with operating room pre bypass Hemoglobin
A1c > 6.5%; ICMS patients with any Hemoglobin A1c > 6.5%; or any newly
diagnosed diabetic based on the following criteria:
 Fasting blood glucose > 7 mmol
 Oral glucose tolerance of 75 grams result in blood glucose > 11.1 mmol (2 hour
test result)
 Casual blood glucose > 11.1 mmol
b. The bedside nurse will give the WRHA Diabetes Teaching Package to the patient.
c. Physician/CA will refer these patients to the post-operative Nurse Practioner clinic
for further teaching/monitoring until diabetes is stable and patient can then be
referred to family doctor for ongoing management.
d. Consultation with the Endocrine service is not necessary for all newly diagnosed
diabetics.
8.
In-patient Pharmacist intervention
a. Review their most recent Hemoglobin A1c and its implications for discharge
counseling.
b. Review the changes to their diabetic medications and counsel the patient on their
newer agents.
c. Encourage the patient to seek a community diabetic educator.
4
Appendix A - Hypoglycemic Protocol
5