ICU IV insulin management - what to expect

T1D Tech & Daily Management Support
1

Hi everyone,

I’m posting here because I’m trying to understand something that happened to a very close friend of mine during an ICU admission at Stanford Hospital in June 2025. I am a Type 1 diabetic myself and have an upcoming surgery so I need am trying to understand hospital IV insulin management from a safety perspective in case I end up in the ICU.

My friend has pancreatic insufficiency but is not diagnosed as Type 1 or Type 2 and is not on steroid therapy. He normally uses approximately 20–30 units of insulin per day total. Historically, his insulin requirements would be are around 1–2 units per hour at most using a pump or IV. During this admission June last year, he was NPO (no food) for two days.

While in the ICU, he was placed on IV insulin and using an online “calculator” built into the hospital’s electronic medical record system the nurses adjusted his IV insulin rate. For approximately two periods of seven hours, he received between 5 and 9 units per hour of IV insulin without communication or consent with the patient or family. During that time, his glucose levels dropped rapidly. I had his Dexcom data remotely and could see the fast downward trend in real time and an IV dextrose rescue bolus was eventually administered.

To illustrate the above, the attached graph has the amount of insulin administered and the glucose levels over a period of three days. The blue bars represent IV insulin rate in units per hour, the yellow markers dots are hospital blood glucose measurements, and the green line shows the Dexcom continuous glucose monitor data.

I am trying to understand whether this type of dosing is typical in an ICU setting. Is it common for IV insulin calculator to generate 7–9 units per hour for someone with pancreatic insufficiency who is not on steroids, not in DKA, normally uses 20–30 units per day total, and has been NPO for 2 days? Do most hospitals rely on fixed sliding scales, dynamic calculators, or some hybrid? Is there usually a requirement for a second nurse or physician sign-off above a certain hourly threshold and are the doses given communicated with the patient? I was told by the doctor that this calculators does not take into account the diabetes type and the baseline insulin sensitivity of the patient.

It took 16 separate requests before I received the insulin dosing and glucose data from the hospital, I did have access to the Dexcom data immediately.

I requested an in-person meeting with endocrinology leadership to understand how the IV insulin calculator determines dosing and what safeguards exist, but those requests were declined and no explanation of the calculator thus far has been provided.

My question is: how do ICU IV insulin protocols typically work and what questions I should be asking anesthesiology (tomorrow) during my own surgery before consenting to hospital-managed insulin? Is the use of the calculator standard practice everywhere? What are the safeguards when a calculator is used?

If anyone here works in hospital endocrinology, ICU nursing, anesthesia, or has experience with IV insulin protocols, I would really appreciate your perspective. As someone living with Type 1 diabetes, the experience of my friend, has made me anxious about future hospital care, and I want to approach it informed rather than afraid.

Thank you very much for any insight you can share.

Insulin iv dosing and glucose trends
Insulin iv dosing and glucose trends960×540 93 KB

2

My experience with surgery is limited to outpatient and I’ve never been in ICU but since you are having a procedure tomorrow I will share what I can. I had one procedure where I attempted to inform the team of my CGM and instruct on what to do in if/then scenarios - only to be told those instructions would have to come from my doctor. I could postpone very last minute if wished to do that but I decided to take my chances.
That said there are people on the forum who have arranged - presumably in advance - to handle their own diabetes care while letting the medical team manage everything else. I don’t know if hospitals have their own policies. Hopefully you will get responses from people who have had success.
@Dennis
@joe

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Hello @vavi1 Welcome to Breakthrough T1D. I’ve had 2 surgeries, one an emergency appendectomy and for both I worked out insulin management with the doctor before hand. Also, and as a result of these pre surgery meetings, I left my pump on, and was allowed to check blood sugar using my own equipment, and administer insulin as I self directed. Since it was “in my chart” i was able to successfully take care of my short stays (the appendix was complicated so I stayed overnight in recovery) I can ask what hospitals do regarding iv insulin (I have a contact at NYU) but I can only assume it is not aggressive and that lows are over treated. It’ll take a week to get anything back if you think that would be helpful.

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Hi Joe,
That is very helpful indeed for everyoneI think, it’s a topic that is very important. I am working with Stanford anaesthesiology on keeping my pump on, however they did mention if something goes wrong during surgery and I need to be transported to an ICU I would need to get an insulin IV. This is where at Stanford these absurd amounts of insulin were given (5,7,9 units per hour for over 7 hours) even when the patient BG was only around 200.
Any experience or information is appreciated.
Valerie

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Can they take direction from your doctor regarding the insulin IV​:thinking:?

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My personal plan if I have to have surgery with anesthesia is go to my endo and get them to write and submit a plan. Then do what you did and meet with the anesthesiologist. And ask the surgeon what the recovery plan is with respect to glucose control. You and I know the endo department at Stanford has modern plans for handling many kinds of diabetes so we don’t have to worry about ye ol’ R and NPH regimen like I would at my local hospital run by Tennant. After every nurse I meet I’ll say “Hi I produce no insulin and my name’s Chris. Nice to meet you.”

Since you are still concerned and close to surgery there’s an endo at Stanford who I’m told attends the local BreakthroughT1D Chapter zoom calls and is super helpful. Reach out to Dr Marina Basima. She might be able to give you answers more specific to your situation.

I’ve mentioned on forum before I’ve got a family member that had a lung transplant. That was at Stanford. He spent at least a week in the ICU afterwards. Some people loose glucose control after transplants, the ICU managed his fine till his body was able to start helping again.

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The doctor you mentioned in your was responsible and in charge for these huge insulin overdoses for my friend and she will not answers any questions related to these two incidents.
My surgery is postponed until tomorrow and I have made all my support team aware what needs to happen in case I do get transferred to the ICU.

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@vavi1 Hi Valerie, and welcome to the Breakthrough T1D Community Forum!

In my experience, IV insulin certainly has not been “standard” procedure; I’ve had close to about a dozen surgeries that required total anesthesia and once resulted in a stay in cardio ICU where I was totally immobilized for my own safety - I instructed the nurses in pupp operation so I could be fed. In the two+ decades that I’ve used a pump, I’ve always managed my own insulin. Like @Joe, I’ve made arrangements ahead of time with physicians and clarifies insulin management at pre-admission testing. As a result, I was asked by two hospitals and one surgery to write/rewrite their procedure manuals.

What strength is the IV insulin that was used for your friend? Recall, in early insulin pumps the user had to dilute insulin with saline and then mathematically adjust “units of insulin”; consider the possibility that the 5, 7, 9 UPH received via Iv may have been actually 1.25, 1,75, 2.25 unit of U-100 strength insulin. This is a pre-opp question for you to ask. 9 units of U-100 insulin for my 115 grams carb supper would through me into hypoglycemia within 2 hours.

This isn’t medical advice, just my experience during 7 decades with autoimmune diabetes; my “numbers” will be different for you. You are wise gathering information before your date - begin with the doctor who knows you and ask her to convey a protocol suitable for YOU.

9

The strength was regular strength and you can see the sudden drop to his bg to about 50 mg/dl the first night the second time on June 2nd I was there and when I was told his insulin dose by the nurse I intervened and requested an immediate dextrose rescue injection which they needed a Dr to prescribe so we had to wait. After this the hospital made it very difficult to transfer my friend back to the pump. This is why I am freaking out because I am a type 1 myself and surgery scheduled and getting no answers from Stanford about why this dose was given in the ICU.

10

I wonder if she refused due to HIPAA, which would forbid her from discussing patient care with friends without patient consent or legal documentation? Perhaps your Endo would have better luck - she may be willing to discuss general details and their process with another medical professional.

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No we actually filed a HIPAA violation as my friend did not receive the medical data requested, Only after filing and 16 attemts to get the data we received it.

12

Hi. I was wondering if you were able to get the info and answers you needed, and when your procedure is scheduled (if that’s okay to ask). With all the releases hospitals have you sign you would think they would have one approving self administration of insulin if able, and following of orders provided by personal physician if not. All the best to you!

13

Thanks to all! Everything went well and no ICU visit luckily. However we are still frustrated not to understand the ICU IV dosing given to my friend and that we are unable to receive treatment information from Stanford Endocrinology for any future ICU visit.

1 Like
14

Thank you for the update. Great news (and frustrating as well).

15

Thanks for sharing that everything went well for you. Hope you can recover soon and get back to enjoying our early summer. I’m glad you joined the forum.

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@vavi1 following up. My contact at NYU had some insight. first, each hospital has an internal protocol for ICU. Yes they use a modified labelled insulin typically for IV use and typically formulated into “units” resembling the dosage we would be used to. So if someone were to need x units per hour a certain concentration per bag and a a certain bag drip rate would comprise a “basal rate”. The only difference is IV insulin works very much faster and has an extremely small “tail” whereas subcutaneous rapid insulin may have a 4 hour “active time or duration”.

Surgeons are not as good as internists. It is not uncommon for surgeons to mix up type 1 and type 2. Not all of them, mind you, but in a very general sense: internal medicine doctors would be better to get a insulin plan in your chart than a surgeon. when the hospital gets into trouble with a complicated blood sugar issue there are also staff endocrinologists that can be consulted.

the hospital is only concerned with not killing you with a low and not causing DKA. This is really important. A hospital would generally not treat a blood sugar of 240 mg/dl. they shoot for about 180 +/- 80 therefore 100mg/dl would be considered “low” in an ICU. Because 100 is not going to kill you they can and do lag in administration of dextrose into the bag.

The protocols are not public information and are guidelines often combining treatment of type 1 and type 2. This is where general knowledge that you are TYPE ONE is super important. A surgeon or other ICU doctor may stop insulin if you were 90 mg/dl because a type 2 still makes insulin and the chances of DKA are very low. In other words, an internist may alter your chart with explicit instructions as to a minimum basal rate and to never stop administration of insulin. However, without explicit instructions, a doctor might use a basal rate more consistent with Type 2 diabetes or consistent with a type 2 who has significant inflammation or is being administered a steroid anti inflammatory (the basal rates can be very high for patients receiving steroids). anyway I have to guess that that high of a basal rate might be an error and I can certainly imagine the hospital my not be super happy sharing their general plan with you. I don’t know if any of this helps but this was the contents of my conversation.

I am relieved you had success with your procedure! :four_leaf_clover: :peace_symbol:

Joe

1 Like
17

Hi Joe,
Thanks for the information, very helpful indeed, I have received IV insulin treatment protocols information from 2 other hospitals (still nothing from Stanford) and the absolute max insulin IV rate for both other hospitals was 4 U/hr.
As a patient you have the legal right to receive a copy of the specific protocol applied to you, documented in your medical records; we never received the protocol applied. When this incident occurred he was treated by endocrinology not the surgical team for diabetes management.
If anyone can share the ‘calculator’ protocol at Stanford that would help with our concerns about any future care there.
Valerie