How do you safely discontinue infusion insulin?

Safe Discontinuation of Insulin Infusion

To safely discontinue insulin infusion, administer the first dose of long-acting insulin 2-4 hours before stopping the IV insulin infusion, and continue the infusion for at least 2 hours after subcutaneous insulin administration to prevent rebound hyperglycemia. 1

When to Stop Insulin Infusion

The decision to transition from IV insulin to subcutaneous insulin should be made when:

• Blood glucose levels are stable for at least 24 hours 2, 1
• The patient has resumed oral feeding 2, 1
• IV insulin infusion rate is <3 U/h 2, 1
• Blood glucose levels are <180 mg/dL (10 mmol/L) 2, 1

Step-by-Step Protocol for Discontinuation

1. Calculate total daily insulin requirement:

   • Base this on the previous 24-hour IV insulin administration 1
   • If IV insulin was given for <24 hours and blood glucose remains elevated, start subcutaneous insulin at 0.5-1 IU/kg 2

2. Determine subcutaneous insulin dosing:

   • Convert 50-60% of the 24-hour IV insulin dose to subcutaneous insulin 1
   • Allocate 50% as basal (long-acting) insulin and 50% as bolus (rapid-acting) insulin divided between meals 2, 1

3. Transition timing:

   • Administer the first dose of long-acting insulin 2-4 hours before stopping IV infusion 1
   • Continue IV insulin for 2-4 hours after the first subcutaneous dose 1
   • Administer the first dose of rapid-acting insulin at the first meal, adjusting for carbohydrate content 2

4. Special considerations for insulin pump users:

   • For patients on insulin pump therapy, reconnect the personal pump as soon as the patient can manage autonomously 2
   • If the patient cannot manage the pump, initiate a basal-bolus subcutaneous insulin regimen 2
   • When transitioning back to the pump, connect and infuse basal rate for at least 2 hours before stopping IV infusion 2

Monitoring After Transition

• Continue blood glucose monitoring after transition to subcutaneous insulin 1
• Check blood glucose before meals and at bedtime 1
• Monitor for at least 48 hours after transition, as glycemic control may deteriorate rapidly 1

Managing Complications During Transition

Hypoglycemia Management

• For blood glucose <3.3 mmol/L (60 mg/dL), administer glucose immediately 2
• For blood glucose between 3.8-5.5 mmol/L (70-100 mg/dL) with symptoms, administer glucose 2
• Prefer oral glucose in conscious patients and IV glucose in unconscious patients 2

Hyperglycemia Management

• For blood glucose >16.5 mmol/L (300 mg/dL), check for ketosis 2
• In absence of ketosis, add ultra-rapid insulin analog and ensure hydration 2
• In presence of ketosis, suspect ketoacidosis and consider ICU transfer 2

Common Pitfalls to Avoid

1. Never stop IV insulin without appropriate subcutaneous coverage in place 1

   • This can lead to dangerous rebound hyperglycemia

2. Avoid poor coordination between insulin administration and meals 1

   • This can cause post-meal hyperglycemia or preprandial hypoglycemia

3. Don't overlook patient-specific factors 1

   • Age, glycemic variability, and pre-admission glycemic control affect insulin needs

4. Don't use the same approach for all patients 2, 1

   • Patients with type 1 diabetes, type 2 diabetes, and stress hyperglycemia require different transition strategies

By following this structured approach to discontinuing insulin infusion, you can minimize the risk of both hyperglycemia and hypoglycemia while maintaining effective glycemic control during this critical transition period.