How to initiate an intravenous insulin (IV insulin) drip?

From the Guidelines

To start an insulin drip, first gather necessary supplies including regular insulin, IV solution (typically 0.9% sodium chloride), an infusion pump, and blood glucose monitoring equipment, and prepare the solution by adding 100 units of regular insulin to 100 mL of 0.9% sodium chloride, creating a concentration of 1 unit/mL, as recommended by the most recent guidelines 1. The initial steps in starting an insulin drip involve calculating the initial rate based on the patient's weight, typically using a common starting dose of 0.05-0.1 units/kg/hour, or using a standardized protocol, and then connecting the IV to the patient through a dedicated line or port to prevent interference with other medications.

Key Considerations

• The solution should be primed to ensure insulin reaches the patient immediately upon starting the infusion.
• Blood glucose levels should be monitored frequently, typically every hour initially, then adjusting to every 2-4 hours once stable.
• The infusion rate should be adjusted according to the facility's protocol based on blood glucose readings, taking into account the patient's glycemic fluctuations and insulin dose, as emphasized in the guidelines 1.
• Regular insulin is used for IV infusions because of its quick onset and short duration of action, allowing for rapid titration.
• It is crucial to have dextrose solution available to treat hypoglycemia and to document all glucose readings, insulin rates, and any rate adjustments made during the infusion, as highlighted in the standards of care for diabetes management 1.

Protocol Administration

Intravenous insulin infusions should be administered using validated written or computerized protocols that allow for predefined adjustments in the insulin infusion rate, as recommended by the American Diabetes Association standards of medical care in diabetes 1.

• These protocols should account for glycemic fluctuations and insulin dose, ensuring safe and effective management of hyperglycemia in the hospital setting.
• The use of sliding-scale insulin in the inpatient hospital setting is strongly discouraged, and instead, a basal-plus-correction insulin regimen is preferred for patients with poor oral intake or those who are receiving nothing by mouth 1.

From the FDA Drug Label

The intravenous administration of Humulin R U-100 was tested in 21 patients with type 1 diabetes The patients' usual doses of insulin were temporarily held, and blood glucose concentrations were maintained at a range of 200 – 260 mg/dL for one to three hours during a run-in phase of intravenous Humulin R U-100 followed by a 6-hour assessment phase. During the assessment phase patients received intravenous Humulin R at an initial dose of 0. 5 U/h, adjusted to maintain blood glucose concentrations near normoglycemia (100 to 160 mg/dL).

To start an insulin drip, the initial dose of intravenous Humulin R U-100 is 0.5 U/h, adjusted to maintain blood glucose concentrations near normoglycemia (100 to 160 mg/dL) 2.

• The dose may need to be adjusted based on the patient's response and blood glucose levels.
• It is essential to closely monitor the patient's blood glucose levels during the infusion.

From the Research

Starting an Insulin Drip

To start an insulin drip, the following steps can be considered:

• Aggressive administration of intravenous fluids with appropriate replacement of electrolytes, primarily potassium, is the first step in acute management of diabetic ketoacidosis and hyperosmolar hyperglycemic syndrome 3.
• Insulin administration, usually via an intravenous insulin infusion, is crucial in the management of diabetic ketoacidosis [(3,4)].
• The choice between low-dose and high-dose insulin therapy can be considered, with low-dose continuous insulin therapy being compared to high-dose subcutaneous and intravenous insulin therapy in the treatment of diabetic ketoacidosis 4.
• Careful monitoring by experienced physicians is needed during treatment, with common pitfalls in management including premature termination of intravenous insulin therapy and insufficient timing or dosing of subcutaneous insulin before discontinuation of intravenous insulin 3.

Key Considerations

• Management of hyperglycemic emergencies, including diabetic ketoacidosis and hyperosmolar hyperglycemic state, requires a careful hydration strategy to restore volume and improve perfusion, intravenous insulin therapy, and electrolyte monitoring [(5,6)].
• The mainstays of therapy for diabetic ketoacidosis are the administration of low-dose insulin and volume repletion 7.
• Early diagnosis and management of hyperglycemic emergencies are paramount, with treatment focusing on aggressive rehydration, insulin therapy, electrolyte replacement, and treatment of underlying precipitating events 6.