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About: Always check BNF or equivalent for prescribing advice

• Check BNF or equivalent for UpToDate prescribing advice

Details

• The infusion of intravenous Insulin at a variable rate according to regular capillary blood glucose measurements with the aim of controlling serum glucose levels within a specified range.
• The VRIII is usually accompanied by an infusion of fluid containing glucose to prevent Insulin-induced hypoglycaemia.
• Contact the diabetes team for advice if there is doubt about the best way to manage hyperglycaemia or if the blood glucose is not responding to treatment
• Continue patients usual basal* subcutaneous Insulin whilst on VRIII and stop rapid-acting or mixed Insulins.

Review VRIII frequently to ensure:

• a. Correct rates of infusion are achieving target glucose levels
• b. The ongoing need for the VRIII
• c. Safety measures are continually in place.

Hypoglycaemia

• Ensure Hypoglycaemia is treated promptly and adequately and VRIII re-started within 20 minutes in order to prevent rebound hyperglycaemia and possible ketosis

Indications for VRII

• Hyperglycaemia in: Patients with known diabetes or with hospital-related hyperglycaemia unable to take oral fluid/food and for whom adjustment of their own Insulin regime is not possible.
• Vomiting (exclude DKA), NBM and will miss more than one meal, Severe illness with the need to achieve good glycaemic control e.g. sepsis
• Special circumstances - Acute coronary syndrome, TPN/enteral feeding, Steroid use, Pregnancy

Making up a VRII

• Two registered nurses must check and prepare the VRIII and every time the rate of infusion is changed. Insulin MUST BE DRAWN UP USING AN Insulin SYRINGE. NO OTHER SYRINGE TO BE USED.
• Draw up 50 units of prescribed Human Actrapid Insulin* and add to 49.5 ml of 0.9% sodium chloride in a 50 ml Luer lock syringe. Mix thoroughly and this will provide a concentration of 1 unit/ 1 ml
• Complete the drug additive label in full; signed by 2 registered nurses and placed on the syringe barrel; not obscuring the numerical scale. Prime through an appropriate giving set with a non-return valve.
• Set up an intravenous Insulin syringe-driver pump. Discard any unused Insulin solution after 24 hours. Intravenous fluid must be administered using a volumetric infusion pump
• Delivery of the substrate solution and the VRIII must be via a single cannula or two lumens of a central line with appropriate one-way and anti-siphon valves
• Set the concurrent fluid replacement rate to deliver the hourly fluid requirements of the individual patient as prescribed which must take into account their individual circumstances.
• The rate must not be altered thereafter without senior advice. Insulin should not be administered without substrate unless done in a critical care setting and upon senior advice
• Insulin must be infused at a variable rate aiming for glucose of 6-10 mmol/L (acceptable range 4-12 mmol/L)
• Continue the substrate solution and VRIII until the patient is eating and drinking and back on their usual glucose-lowering medications
• Although human Actrapid is the most commonly used Insulin in VRIII, Insulin Aspart, Humulin Sand Insulin Lispro can also be used as an alternative and have a licence for intravenous use.
• However these are more expensive alternatives.
• In an attempt to increase safety, some hospital trusts in the UK use prefilled / pre-prepared Insulin syringes for use in a VRIII.
• These are prepared intrust pharmacies with rigorous quality controls or have been procured from commercial sources.
• There is no current published data to evidence that this leads to increased safety when compared to syringes prepared at the time of need.

Interactions

Cautions

• Needs closely monitored with regular assessments for hypo and hyperglycaemia

Contraindications

Side effects

• hypoglycaemia, poor diabetic control

References

Revisions