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Insulin — ICU Glucose Management Pregnancy: Safe — insulin is the drug of choice for hyperglycaemia in pregnancy (does not cross placenta)

Insulin (IV Infusion — ICU Glucose Control)

Brand names: Actrapid (Human Insulin)

Adult dose

Dose: Start at 1–2 units/hour IV; adjust per local insulin infusion protocol (sliding scale)
Route: IV infusion
Frequency: Continuous, adjusted hourly
Max: Protocol-dependent; typically 10–15 units/hour maximum on standard protocols
Target blood glucose in ICU: 6–10 mmol/L (NICE-SUGAR trial). Prepare as 50 units Actrapid in 50 mL sodium chloride 0.9% (1 unit/mL). Must co-infuse 10% glucose if patient is nil-by-mouth. Run via dedicated syringe pump line — do NOT piggyback.

Paediatric dose

Dose: 0.01–0.1 units/hour/kg
Route: IV infusion
Frequency: Continuous, adjusted per BG
Max: Titrated to blood glucose target
Paediatric ICU glucose control: 0.01–0.1 units/kg/hour under specialist guidance. Tight control (4.4–6.1 mmol/L) was harmful in children — target 6–10 mmol/L per Surviving Sepsis guidelines.

Dose adjustments

Renal

Insulin requirements often reduced in severe renal failure — metabolised partly by kidneys. Reduce infusion rate and increase monitoring frequency.

Hepatic

Insulin requirements may be unpredictable in severe hepatic failure — frequent glucose monitoring.

Paediatric weight-based calculator

Paediatric ICU glucose control: 0.01–0.1 units/kg/hour under specialist guidance. Tight control (4.4–6.1 mmol/L) was harmful in children — target 6–10 mmol/L per Surviving Sepsis guidelines.

Clinical pearls

  • NICE-SUGAR trial (2009): intensive glucose control (4.5–6 mmol/L) increased mortality vs. conventional control (6–10 mmol/L) — do NOT target normoglycaemia in ICU
  • Hyperkalaemia treatment: 10 units short-acting insulin + 50 mL 50% glucose IV shifts K+ intracellularly within 30 min (reduces K+ by 0.5–1.5 mmol/L); this is temporising — definitive removal needed
  • High-dose insulin-euglycaemia therapy (HIE) for CCB/beta-blocker overdose: 1 unit/kg bolus then 0.5–1 unit/kg/hour with dextrose infusion

Contraindications

  • Hypoglycaemia (blood glucose <4 mmol/L — pause infusion; give dextrose)

Side effects

  • Hypoglycaemia (most important complication)
  • Hypokalaemia (insulin drives K+ intracellularly)
  • Local reaction at infusion site (SC use)
  • Lipohypertrophy (SC — not relevant for IV)

Interactions

  • Steroids (antagonise insulin — increase dose requirements)
  • Beta-blockers (mask hypoglycaemia symptoms)
  • Octreotide (reduces insulin requirements — used in insulinoma)
  • Salbutamol (hypokalaemia — additive with insulin K+ shift)

Monitoring

  • Blood glucose every hour (or every 30 min during initiation)
  • Serum potassium (hypokalaemia)
  • Signs of hypoglycaemia (agitation, diaphoresis, tachycardia — masked in sedated ICU patients)

Reference: BNFc; BNF 90; NICE-SUGAR Trial (NEJM 2009); Surviving Sepsis Campaign 2021; TOXBASE (HIE protocol). Verify against your local formulary and the latest BNF before prescribing.

Related

Curated clinical cross-links plus same-class fallbacks.

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