The document is a presentation on the Yale Insulin Infusion Protocol, which is used to manage blood glucose levels in hospitalized patients receiving intravenous insulin therapy. It discusses the characteristics of an ideal insulin infusion protocol, outlines the steps of the Yale Protocol including initiating insulin infusion rates and adjusting rates based on blood glucose monitoring, and provides examples of applying the protocol. It also shows that using the Yale Protocol results in better glucose control and fewer episodes of hypoglycemia compared to historical controls.

1. http://www.flickr.com/photos/
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IV Insulin Therapy:
The Yale Insulin
Infusion Protocol
Iris Thiele Isip Tan MD, FPCP, FPSEM
Clinical Associate Professor, UP College of Medicine
Section of Endocrinology, Diabetes & Metabolism
Department of Medicine, Philippine General Hospital

2. Outline
•AACE/ADA Consensus on Inpatient Glycemic Control
•Characteristics of an ideal insulin infusion protocol
•PGH-Modified Yale Insulin Infusion Protocol

3. 140-180 mg/dL
(7.8-10 mmol/L)
Critically ill
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Consensus Statement
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Moghissi E et al. Endocrine Practice 2009;15(4):1-17

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IV insulin infusion preferred
Validated insulin infusion protocol:
effective with low rates of hypoglycemia
Moghissi E et al. Endocrine Practice 2009;15(4):1-17

5. IV insulin infusion protocol
More consistent glucose control
Reduction in trial & error patterns
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Maintain blood glucose
within desired range
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Earlier treatment of
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hypoglycemic events
Anger et al Pharmacotherapy 2006;26(2)214-28

6. An ideal insulin infusion protocol ...
http://www.sxc.hu/photo/1142176
... adapts to individual patient
responses to insulin
Anger et al Pharmacotherapy 2006;26(2)214-28

7. An ideal insulin infusion protocol ...
http://www.sxc.hu/photo/1142177
... balances stability
and responsiveness
to maintain target
blood glucose
Anger et al Pharmacotherapy 2006;26(2)214-28

8. An ideal insulin infusion protocol ...
http://www.sxc.hu/photo/1142175
... varies the frequency
of glucose monitoring
based on trends
Anger et al Pharmacotherapy 2006;26(2)214-28

9. An ideal insulin infusion protocol ...
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... addresses potassium
supplementation
Anger et al Pharmacotherapy 2006;26(2)214-28

10. An ideal insulin infusion protocol ...
http://www.sxc.hu/photo/1148437
... clearly communicates instructions to the
nurses responsible for titrating infusion
Anger et al Pharmacotherapy 2006;26(2)214-28

11. A ideal insulin infusion protocol ...
http://www.sxc.hu/photo/1148436
... streamlines decision making
& eliminates need for complex calculations
Anger et al Pharmacotherapy 2006;26(2)214-28

12. modified
Yale protocol

13. Yale Target blood glucose
Protocol 90-119 mg/dL
“Modified”
100-139 mg/dL
PGH-modified Yale
140-180 mg/dL
Goldberg PA et al (2004).
Implementation of a Safe and Effective Insulin Infusion Protocol
in a Medical Intensive Care Unit. Diabetes Care 27(2):461-7.

14. Yale Protocol
Not to be used for
DKA or HHS!
Call MD if
BG >500 mg/dL
http://www.sxc.hu/photo/1156296

15. Initiating the Insulin Infusion
Insulin infusion: 1 u human
regular insulin per 1 cc 0.9%
NaCl per infusion pump
(increments of 1 u/h)
Priming: Flush 50 cc through all
IV tubing before infusion begins
Yale Protocol
Threshold: Start IV insulin if BG
>180 mg/dL

16. Initiating the Insulin Infusion
Target blood glucose:
140-180 mg/dL
Bolus &
initial insulin infusion rate:
Initial BG 181-299: divide by 100,
round to nearest 1 unit for initial drip
rate (NO bolus)
Yale Protocol Initial BG >300: divide by 100,
round to nearest 1 unit for initial drip
rate AND bolus to be given
http://www.sxc.hu/photo/689723

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monitoring
Check BG hourly until stable
(3 consecutive values within target range)
Use blood from indwelling catheter
for hypotensive patients

18. Blood glucose
monitoring
Once stable for 12-24 h, check
BG q 2 h
May check BG q 4 h IF:
no significant change in clinical
condition AND no significant
change in nutritional intake
http://www.sxc.hu/photo/1215187

19. Blood glucose monitoring
Consider hourly BG monitoring
again (until stable) IF:
any change in insulin infusion rate (i.e.
BG out of target range)
significant changes in clinical condition
initiation/cessation of pressor/steroid,
renal replacement therapy, nutritional
support (TPN, PPN, tube feedings,
etc.)
http://www.sxc.hu/photo/1215187

20. Blood
<50 mg/dL 50-69 mg/dL 70-99 mg/dL
glucose
Insulin D/C
D/C D/C
infusion for 30 min
1 amp if
symptomatic;
D50 IV 1 amp None
1/2 amp if
asymptomatic
q 15 min if
Recheck symptomatic;
q 15 min q 30 min
BG q 30 min if
asymptomatic
If BG >100 mg/dL, wait 1 h. If repeat BG still If BG >100 mg/
>100 mg/dL, resume insulin drip at dL, resume
Insulin drip insulin drip at
50% of previous 75% of previous 75% of previous
rate

21. Determine the current BG level
BG 100-130 BG 140-179 BG 180-249 BG >250
mg/dL mg/dL mg/dL mg/dL
identifies a COLUMN in the table

22. Determine the rate of change from prior BG
BG 100-130 BG 140-179 BG 180-249 BG >250 Instructions
BG ↑ by >40 mg/
BG ↑ ↑ DRIP by “2Δ”
dL/h
BG
BG ↑ by 1-40
UNCHANGED
BG ↑ by >20 mg/ mg/dL/h OR
OR ↑ DRIP by “Δ”
dL/h BG
BG ↓ by 1-40
UNCHANGED
mg/dL/h
BG ↑ by >20 mg/
dL/h, BG
BG ↓ by 1-40 BG ↓ by 41-80 NO DRIP
BG ↑ UNCHANGED, OR
mg/dL/h mg/dL/h CHANGE
BG ↓ by 1-20 mg/
dL/h
BG unchanged
BG ↓ by 21-40 BG ↓ by 41-80 BG ↓ by 81-120
OR BG ↓ by ↓ DRIP by “Δ”
mg/dL/h mg/dL/h mg/dL/h
1-20 mg/dL/h
HOLD DRIP x 30
BG ↓ by BG ↓ by >40 mg/ BG ↓ by >80 mg/ BG ↓ by >120
min then ↓ DRIP
>20 mg/dL/h* dL/h dL/h mg/dL/h
by “2Δ”
* D/C insulin drip, check CBG q 30 min, when BG >100 mg/dL, resume drip at 75% of previous rate.

23. Changes in infusion rate (“Δ”)
determined by current rate
Current Rate Δ = rate 2Δ= 2x rate
(units/hr) change change
(units/hr) (units/hr)
<3 0.5 1
3-6 1 2
6.5 – 9.5 1.5 3
10-14.5 2 4
15-19.5 3 6
20-24.5 4 8
≥25 ≥5 10 (consult MD)

24. Let’s practice ...

25. Let’s practice ...
•64/F admitted for pneumonia; not a known diabetic

26. Let’s practice ...
•64/F admitted for pneumonia; not a known diabetic
•Initial CBG 321 mg/dL

27. Let’s practice ...
•64/F admitted for pneumonia; not a known diabetic
•Initial CBG 321 mg/dL
•321/100 = 3.21 so give HR 3 units bolus and start
insulin drip at 3 units/h

28. Let’s practice ...
•64/F admitted for pneumonia; not a known diabetic
•Initial CBG 321 mg/dL
•321/100 = 3.21 so give HR 3 units bolus and start
insulin drip at 3 units/h
•CBG after 1 h is 285 mg/dL

29. Let’s practice ...
•64/F admitted for pneumonia; not a known diabetic
•Initial CBG 321 mg/dL
•321/100 = 3.21 so give HR 3 units bolus and start
insulin drip at 3 units/h
•CBG after 1 h is 285 mg/dL
•321-285 = 36 mg/dL

30. Determine the rate of change from prior BG
BG 100-130 BG 140-179 BG 180-249 BG >250 Instructions
BG ↑ by >40 mg/
BG ↑ ↑ DRIP by “2Δ”
dL/h
BG
BG ↑ by 1-40
UNCHANGED
BG ↑ by >20 mg/ mg/dL/h OR
OR ↑ DRIP by “Δ”
dL/h BG
BG ↓ by 1-40
UNCHANGED
mg/dL/h
BG ↑ by >20 mg/
dL/h, BG
BG ↓ by 1-40 BG ↓ by 41-80 NO DRIP
BG ↑ UNCHANGED, OR
mg/dL/h mg/dL/h CHANGE
BG ↓ by 1-20 mg/
dL/h
BG unchanged
BG ↓ by 21-40 BG ↓ by 41-80 BG ↓ by 81-120
OR BG ↓ by ↓ DRIP by “Δ”
mg/dL/h mg/dL/h mg/dL/h
1-20 mg/dL/h
HOLD DRIP x 30
BG ↓ by BG ↓ by >40 mg/ BG ↓ by >80 mg/ BG ↓ by >120
min then ↓ DRIP
>20 mg/dL/h* dL/h dL/h mg/dL/h
by “2Δ”
* D/C insulin drip, check CBG q 30 min, when BG >100 mg/dL, resume drip at 75% of previous rate.

31. Changes in infusion rate (“Δ”)
determined by current rate
Current Rate Δ = rate 2Δ= 2x rate
(units/hr) change change
(units/hr) (units/hr)
<3 0.5 1
3-6 1 2
6.5 – 9.5 1.5 3
10-14.5 2 4
15-19.5 3 6
20-24.5 4 8
≥25 ≥5 10 (consult MD)

32. One more time ...

33. One more time ...
•54/M type 2 diabetic with pancreatitis; on NPO

34. One more time ...
•54/M type 2 diabetic with pancreatitis; on NPO
•Initial CBG 240 mg/dL

35. One more time ...
•54/M type 2 diabetic with pancreatitis; on NPO
•Initial CBG 240 mg/dL
•240/100 = 2.4 so start insulin drip at 2 units/h

36. One more time ...
•54/M type 2 diabetic with pancreatitis; on NPO
•Initial CBG 240 mg/dL
•240/100 = 2.4 so start insulin drip at 2 units/h
•CBG after 1 h is 170 mg/dL

37. One more time ...
•54/M type 2 diabetic with pancreatitis; on NPO
•Initial CBG 240 mg/dL
•240/100 = 2.4 so start insulin drip at 2 units/h
•CBG after 1 h is 170 mg/dL
•240-170 = 70 mg/dL

38. Determine the rate of change from prior BG
BG 100-130 BG 140-179 BG 180-249 BG >250 Instructions
BG ↑ by >40 mg/
BG ↑ ↑ DRIP by “2Δ”
dL/h
BG
BG ↑ by 1-40
UNCHANGED
BG ↑ by >20 mg/ mg/dL/h OR
OR ↑ DRIP by “Δ”
dL/h BG
BG ↓ by 1-40
UNCHANGED
mg/dL/h
BG ↑ by >20 mg/
dL/h, BG
BG ↓ by 1-40 BG ↓ by 41-80 NO DRIP
BG ↑ UNCHANGED, OR
mg/dL/h mg/dL/h CHANGE
BG ↓ by 1-20 mg/
dL/h
BG unchanged
BG ↓ by 21-40 BG ↓ by 41-80 BG ↓ by 81-120
OR BG ↓ by ↓ DRIP by “Δ”
mg/dL/h mg/dL/h mg/dL/h
1-20 mg/dL/h
HOLD DRIP x 30
BG ↓ by BG ↓ by >40 mg/ BG ↓ by >80 mg/ BG ↓ by >120
min then ↓ DRIP
>20 mg/dL/h* dL/h dL/h mg/dL/h
by “2Δ”
* D/C insulin drip, check CBG q 30 min, when BG >100 mg/dL, resume drip at 75% of previous rate.

39. Changes in infusion rate (“Δ”)
determined by current rate
Current Rate Δ = rate 2Δ= 2x rate
(units/hr) change change
(units/hr) (units/hr)
<3 0.5 1
3-6 1 2
6.5 – 9.5 1.5 3
10-14.5 2 4
15-19.5 3 6
20-24.5 4 8
≥25 ≥5 10 (consult MD)

40. Histogram of 2242 hourly BG recordings
after achievement of target BG levels
Goldberg PA et al (2004).
Implementation of a Safe and Effective Insulin Infusion Protocol
in a Medical Intensive Care Unit. Diabetes Care 27(2):461-7.

41. Yale IIP patients vs historical controls
Goldberg PA et al (2004).
Implementation of a Safe and Effective Insulin Infusion Protocol
in a Medical Intensive Care Unit. Diabetes Care 27(2):461-7.

42. !ank Y"
http://www.endocrine-witch.net