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Home | Articles | Diabetes and Endocrinology | Variable Rate Insulin Infusion

Variable Rate Insulin Infusion

Last updated 11th October 2024

Introduction

  1. Indicated for people with diabetes who are undergoing surgery or who are acutely unwell and unable to tolerate oral intake.
  2. Patients less than 16 please refer to paediatric guidelines.
  3. VRII is not appropriate for patients who are eating and drinking or for patients with DKA.
  4. It is not intended for prolonged use >24 Hours.

Making Up The Infusion

Which Scale

  1. Use Regular scale for all insulin naive patients
  2. Use Low Scale for insulin sensitive patients on <30units/day before admission
  3. Use High Scale for insulin resistant patients ie BMI >30 and/or taking >1unit/kg before admission, pregnancy, or patients on high dose steroids.

Notes on Fluid Prescription

  1. Prescribe fluid on separate IV Fluid Chart.
  2. Standard prescription is 0.18% NaCl / 4% Glucose + 40mmol KCL @ 63mL/Hr.
  3. Patients with CKD 4/5, Heart Failure or raised ICP often require less fluid.
  4. If K>5.0mmol/L or CKD 4/5 Rx 10% Glucose without added KCL .
  5. Monitor U&E daily and more often if indicated.
  6. This infusion provides the minimum glucose for 24 Hours.
  7. Note risk of hyponatraemia in patients receiving prolonged glucose infusion so consider additional IV fluid eg 0.9% Saline or Hartmann’s if infusion required for >24 hours.

For Patients Already on Insulin

  1. Basal (Long Acting) subcutaneous insulins, ie Insulatard, Humulin I, Levemir, Lantus or Degludec (Tresiba) should be continued and prescribed on the Insulin Prescription and Administration Record as well as HEPMA.
  2. Patients on twice daily mixed insulin, (ie Novomix 30, Humalog Mix 25, Humalog Mix 50), calculate 70% of Total Daily Dose, divide into two equal doses, and prescribe as Humulin I Morning and Evening until VRII discontinued, then transfer back to their normal insulin regimen.
  3. Discuss insulin pump patients with Diabetes Team as soon as possible.  If out of hours default is to stop Insulin Pump whilst on VRII.
  4. Click here for section on Insulin Pumps.

Notes on Insulin Prescription

  1. Prescribe Actrapid on HEPMA, ensure Bolus (Quick Acting) subcutaneous insulin (NovoRapid, Humalog, Fiasp) are Suspended.
  2. If BG <4mmol/L Rx 150mL 10% Glucose IV at 999mL/min rate and change to Lower Scale.
  3. If BG 4.0-6.9mmol/L consider changing to Lower Scale.
  4. If BG >12mmol/L for >2 Hours consider change to a Higher Scale, unless the high has been preceded by a hypo in which case wait a further 2 Hours.
  5. Check ketones whenever BG >13mmol/L – if significant ketosis with blood ketones >1.5mmol/L and patient is not fasting or is vomiting, then consider DKA and check bicarbonate.
  6. Check finger prick glucose, infusion lines, site and cannula hourly.
  7. Check BG within 30 mins if change in scale prescribed, otherwise check BG hourly.
  8. Contact medical staff if BG >16mmol/L on High Scale

Review Regularly

Consider Stopping VRII If Tick Yes To Any Of Below:

  1. Is the patient Eating and Drinking?
  2. Has the patient had their Basal (Long Acting) Insulin?
  3. Are patient U&E’s within normal range?

How To Stop

  1. Actrapid has a very short action.
  2. Ideally stop across a mealtime.
  3. Ensure Basal (Long Acting) Insulin has been given, if omitted continue VRII for 2 Hours after Basal (Long Acting) Insulin given.
  4. Give usual Bolus (Quick Acting) Insulin to cover meal and stop VRII 30 minutes later.

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Content by Dr Gavin Stephenson