Management of DM

Management of DM
in critically ill pts
 Introduction
• This section provides guidance to appropriate
guidelines on the use of variable rate
intravenous insulin infusion.
• The guidance provided in this section is in
keeping with the recent JBDS guidelines.
Indications for VRIII (sliding scale)
• Hyperglycemia in patients with known diabetes or with
hospital related hyperglycemia who are unable to take
oral fluid/food and for whom adjustment of their own
insulin regimen is not possible.
• Patients with insulin-controlled diabetes who are nil by
mouth ( NPO) for more than one meal
• Patients with type 1 diabetes with recurrent vomiting
(exclude DKA)
• Patients with type 1 or 2 diabetes and severe illness
with need to achieve good glycaemia control e.g. sepsis
 Practical aspects of prescribing VRIII
• Withhold usual diabetes treatment during the
VRIII but if the patient is on sub-cutaneous
basal insulin (Levemir, Lantus, Tresiba
(degludec), Insulatard, Insuman basal or
humulin I) prior to VRIII, continue this whilst
on insulin insfusion.
• Actrapid is the most commonly used insulin for
VRIII (Actrapid 50 units is added to 49.5 ml of
0.9% sodium chloride)
 Choice of fluids
• Aim to maintain steady rate of glucose
infusion and alter rate of insulin to achieve
target blood glucose control unless there is
risk of fluid overload.
• Altering fluid rate or type of substrate
frequently will lead to high variability in
glucose levels.
• First choice:
0.45% NaCl and 5% glucose(D5% ½ NSS)
with 0.3% KCl (40 mmol/L).

• Second choice:
5% glucose (D5%water ) with 40 mmol/L KCl at
rate of 100-125 ml/hr.
• Use of IV fluids with VRIII is to avoid
hypoglycemia by providing substrate
(dextrose) at a steady rate for the insulin
infusion and to maintain fluid and electrolyte
balance.
• Note: Patients needing VRIII for more than 24
hours will need fluid containing sodium
chloride along with dextrose to avoid
hyponatremia
• Special circumstances: The guidelines for rate
of fluid administration, choice of substrate and
glycemic targets may differ for ACS, stroke,
TPN/enteral feeding, steroid use and
pregnancy.
 Rate of IVF infusion
• Rate of infusion depends on the fluid status of
the patient.
• If there is no risk of fluid overload substrate rate
of 100-125mls/ hr is acceptable.
• In patients with risk of fluid overload, frail and
elderly, use 83ml/hour.
• Consider higher strength substrate (10% glucose)
at 42mls/hour if further fluid reduction is needed
 Monitoring CBGs while on VRIII
• Monitor CBGs( capillary blood glucose) on an
hourly basis.
• Aim for CBGs are in the range 6.0‐10.0 mmol/L
(4.0‐12.0 mmol/L acceptable)
• If the CBGs are above the target range, ensure
that the lines are patent. You may need to
adjust the insulin infusion rate. 
• Consider insulin scale adjustment if CBG are
persistently above 12.0mmol/l within 6 hours
of commencing a VRIII or of subsequent scale
change, unless there is a steady improvement.

• Check ketones 4 hourly in patients with Type

1 diabetes and at least once in patients with
Type 2 diabetes.
 Safe maintenance of VRIII

• Review the need for VRIII at least on a daily

basis.
• At least daily clinical review of patient
including fluid status.
• Monitor urea and electrolytes every day (at
risk of hyponatremia and hypokalemia).
 Managing hypoglycemia on VRIII

• Stop the VRIII and treat the hypo (CBG <4.0

mmol/L)as per local hypo guidelines.
• VRIII should not be stopped for >20 minutes.
• STEP DOWN to the lower scale/ customized
scale when the VRIII is restarted. 
 Stopping the VRIII and safe switch to
subcutaneous insulin

• Ensure the patient is able to eat and drink

• CBGs are in the range 6.0‐10.0 mmol/L (4.0‐
12.0 mmol/L acceptable)
• Discontinue preferably with a meal (preferably
breakfast or lunch but evening meal is
acceptable)
 Insulin treated patients

• For patients on basal  bolus regimen  who

continued basal insulin whilst on VRIII,  restart
usual diabetes treatment together with a meal
and stop VRIII 30-60 minutes after the meal
time insulin has been given and patient has
eaten
• If basal had been stopped at the time of VRIII, it
must be restarted prior to stopping VRIII.
• VRIII can be stopped 30-60 after both the basal
AND meal time insulin has been given and
patient has eaten.  If it is necessary to stop VRIII
but basal insulin is not due for several hours,
give half the usual dose of the usual basal
insulin. This will provide background insulin
cover until the usual dose can be recommenced.
• For patients on biphasic/Mix insulin regimen, restart
usual dose of insulin when it is due (breakfast or
evening meal) and stop VRIII 30-60 minutes after
insulin has been given and patient has eaten.
• If it is necessary to stop VRIII but the mix insulin is
not due for several hours, give half the usual dose of
the insulin with lunch. This will provide background
insulin until the usual dose can be recommenced
• For insulin naïve patients 
• The insulin dose can be calculated on a weight basis or
by calculating the insulin requirement as per VRIII
rates.  
• For non-insulin treated patients
• Recommence the normal treatment prior to
discontinuing VRIII.
• Ensure that no contra‐indications to the previous
hypoglycaemic therapy.
Beware of 8 most commonly reported
VRIII errors

Medical errors: 
• Prescribing VRIII without substrate.
• Wrong insulin infusion rate or not adjusting as
per BMs
• Prescription without background insulin
• Delays in VRIII prescription
• Errors with IV to SC switch
• Nursing errors: 
• Use of VRIII infusion pump with no label on it
• Accidental overdose or accidentally
disconnection of infusion
• Poor CBG monitoring/green chart
documentation
• Errors with IV to SC switch
 Conclusion

All hospital patients should

have normal blood glucose
 Insulin
only
The most powerful
agent we have to control glucose
Thank you