Continuous Insulin Infusion Nomogram (ICU)
Insulin drip protocol based on the Yale Insulin Infusion Protocol, for tight glycemic control in critically ill patients. Preparation, initial dose, and titration matrix by blood glucose and hourly rate of change.
Preparation and initial dose
Preparation: mix 1 unit Regular Human Insulin per 1 mL 0.9% NaCl. Administer via infusion pump, in increments of 0.5 unit/hr. Priming: flush 20 mL of the infusion through all IV tubing before starting (to saturate insulin binding sites in the tubing). Threshold: indicated in any critically ill patient with persistent BG > 140 mg/dL; consider if BG > 120 mg/dL. Target BG: 90–120 mg/dL.
Bolus & initial infusion rate: if initial BG ≥ 150 mg/dL, divide the value (mg/dL) by 70 and round to the nearest 0.5 unit — use this value for both the bolus and the initial infusion rate. If initial BG < 150 mg/dL, divide by 70 for the initial infusion rate only (no bolus).
Examples: BG 335 mg/dL → 335÷70 = 4.78 → round to 5: give a 5-unit bolus + start infusion at 5 units/hr. BG 148 mg/dL → 148÷70 = 2.11 → round to 2: start infusion at 2 units/hr (no bolus).
Titration matrix (current BG × rate of change)
| Action | 70–89 mg/dL | 90–119 mg/dL | 120–179 mg/dL | ≥ 180 mg/dL |
|---|---|---|---|---|
| Increase infusion by "2Δ" | — | — | BG ↑ by > 40 mg/dL/hr | BG ↑ |
| Increase infusion by "Δ" | — | BG ↑ by > 20 mg/dL/hr | BG ↑ by 1–40 mg/dL/hr OR BG unchanged | BG unchanged OR BG ↓ by 1–40 mg/dL/hr |
| No infusion change | BG ↑ | BG ↑ by 1–20 mg/dL/hr, unchanged, OR BG ↓ by 1–20 mg/dL/hr | BG ↓ by 1–40 mg/dL/hr | BG ↓ by 41–80 mg/dL/hr |
| Decrease infusion by "Δ" | BG unchanged OR BG ↓ by 1–20 mg/dL/hr | BG ↓ by 21–40 mg/dL/hr | BG ↓ by 41–80 mg/dL/hr | BG ↓ by 81–120 mg/dL/hr |
| Hold infusion × 30 min then decrease by "2Δ" | BG ↓ by > 20 mg/dL/hr † | BG ↓ by > 40 mg/dL/hr | BG ↓ by > 80 mg/dL/hr | BG ↓ by > 120 mg/dL/hr |
† Hold insulin infusion; check BG every 15–30 min; when ≥ 90 mg/dL, restart infusion at 75% of the most recent rate.
Rate change ("Δ") by current infusion rate
| Current infusion rate | Δ (units/hr) | 2Δ (units/hr) |
|---|---|---|
| < 3 units/hr | 0.5 | 1 |
| 3 – 6 units/hr | 1 | 2 |
| 6.5 – 9.5 units/hr | 1.5 | 3* |
| 10 – 14.5 units/hr | 2 | 4* |
| 15 – 19.5 units/hr | 3* | 6* |
| 20 – 24.5 units/hr | 4* | 8* |
| ≥ 25 units/hr | 5* | 10* |
* Depending on the clinical circumstances, infusion rates typically range between 2–10 units/hr. Doses in excess of 20 units/hr are unusual and, if required, the responsible provider should be notified to explore other potential contributing factors (including technical problems, such as dilution errors).
Source: Yale Insulin Infusion Protocol, adapted from Goldberg PA et al. Endocrine Practice, July/August 2006. This is an example institutional protocol — glycemic target and titration intensity should follow your institution's protocol.
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Frequently asked questions
- What is the target blood glucose for ICU insulin infusion?
- In the example protocol based on the Yale Insulin Infusion Protocol, the target is 90–120 mg/dL, but the glycemic target should follow your institution's protocol.
- How do you calculate the bolus and initial infusion rate?
- If initial BG is ≥150 mg/dL, divide the value by 70 and round to the nearest 0.5 unit — use this value for both the bolus and the initial rate. If <150 mg/dL, divide by 70 for the initial rate only, no bolus.
- How do you prepare the insulin infusion solution?
- Mix 1 unit Regular Human Insulin per 1 mL 0.9% NaCl, administer via infusion pump in increments of 0.5 unit/hr, and prime by flushing 20 mL through all IV tubing before starting.