Dose:    0.05 to 0.1 unit/kg/hour IV
              0.1 to 0.2 units/kg/dose IV or SubQ 
             

Frequency: Continuous infusion or Q 6 to 12 hours              

Comments: The dose, route, and frequency of insulin administration will depend upon the goal of insulin therapy. The present indications for its use in the NICU are for the treatment of hyperglycemia or hyperkalemia. Insulin may also be added to TPN or infused as a "piggy-back" infusion to improve tolerance of higher dextrose concentrations, though this is currently not our practice. Two approaches have been advanced for treatment of hyperglycemia, intermittent subcutaneous administration or insulin or continuous infusion.Subcutaneous insulin in a dose of 0.1 to 0.2 units/kg can be given every six to twelve hours until glucose levels are stable.   The second approach uses a continuous infusion of insulin.   An initial dose of 0.05 units/kg/hr is started as a "piggy-back" infusion. [Others have used 0.025 to 0.1 unit/kg/hr.] This dose can be adjusted to maintain normoglycemia, but is often not necessary.     Plasma half-life is 3 to 6 minutes, metabolized predominantly in the liver though this also occurs in the kidney (severe renal disease will prolong half-life more so than severe liver disease. For more information, see comments on insulin.

Toxicity:  The only described adverse effects associated with insulin therapy are hypoglycemia, hypokalemia, or hypophosphatemia.

Preparation: Insulin (Humulin) is available in 10 ml vial (100 units/ml). The pharmacy will prepare a 0.1 unit/ml concentration and send it in a syringe to be used with a programable infusion pump. When a continuous infusion is needed, write an order for a "continuous insulin infusion, 0.1 unit/ml concentration at x units/hr." The drip sheet pre 8/12 or the drip sheet after 8/12 can be printed out to double check the rate calculated by the programable pump. You do not need to calculate a volume for the syringe, the pharmacist will supply it. (Perform serial dilutions of 100 unit/ml regular human insulin to 1 unit/ml. Add 0.6 ml of the 1 unit/ml formulation to 5.4 ml of NS to prepare a 6 ml solution with a concentation of 0.1 unit/ml.) When you need a new infusion, please give pharmacy 2 hours to get a new one ready. Stable for 24 hours after dilution. Discard after 24 hours. 

 For the treatment of hyperkalemia, the recommended ratio of glucose to insulin ranges from 0.1 unit for each 200 mg of dextrose to 0.1 unit for each 400 mg of dextrose. The 0.1 unit/200 mg ratio can be achieved by adding 1 unit of regular insulin to 20 cc's of D10W. The 0.1 unit/400 mg ratio can be achieved by adding 0.5 units to 20 cc's of D10W. [Each cc of D10W contains 100 mg of dextrose.] The rate of the infusion will be dictated by the severity of the problem. It goes without saying that serum glucose and potassium concentrations will be monitored closely during and after the infusion. The length of the infusion will be determined by the response. The stability of this preparation is unknown, but the 20 cc's should be infused within 2 to 4 hours.

Link if using a continuous Disetronic pump. However, with lower fluid intakes during the first few days of life, hyperglycemia requiring this device is extremely rare. This is no longer used in our NICU.

For subcutaneous use: 0.1 units/ml is intended for IV infusion use.  1 unit/ml is both measurable and an acceptable dose volume for SQ in any baby who is over 1 kg in weight.  For infants less than 1 kg, a recipe for 0.5 units/ml can be prepared using a single dilution by adding 0.1 ml of 100 units/ml Humulin Regular insulin to 19.9 ml normal saline which will give 10 units in a final volume of 20 ml = 0.5 units/ml in saline, with 24 hour dating.   

Compatibility: Compatible with TPN and filter, though there will be adsorption of the insulin onto the surface of the filter. It is also compatible with D5W, D5 with saline, LR, and normal saline. The following drugs have at least "Y-site" compatibility: amiodarone, ampicillin, aztreonam, cefazolin, esmolol, famotidine, gentamicin, heparin, imipenem-cilastatin, indomethacin, lidocaine, magnesium sulfate, meropenem, metoclopramide, midazolam, morphine, potassium chloride, propofol, sodium bicarbonate, sodium nitroprusside, ticarcillin-clavulanate, tobramycin, and vancomycin.  Incompatible with chlorothiazide, dobutamine, dopamine, nafcillin, phenobarbital, and phenytoin. Insulin has equivocal solubility with aminophylline, digoxin dobutamine, and labetalol.