In this section
Safe insulin therapy in the inpatient setting is paramount for all patients requiring insulin therapy. Patients in Diabetic Ketoacidosis (DKA) or other acute reasons may require intravenous (IV) insulin infusion therapy. An IV infusion of Regular short-acting insulin
– Actrapid HM™ or Humulin R Regular™ – will be used in critically ill patients who experience changes in insulin requirements as their clinical condition changes; see DKA Clinical Guidelines –
Transitions between IV and S/C insulin therapy are a critical time for patients, requiring a considerate and deliberate approach to avoid glycaemic excursions and ensure a safe transition.
The transition from IV to S/C insulin will be initiated by the Endocrinology and Diabetes medical team supported by unit-based nursing staff – therefore all nursing staff are required to understand the transition process required to allow a safe and successful transition to S/C insulin.
Knowing the type of insulin that has been used in IV infusion, and insulins to be used for the S/C injection is vital. IV insulin infusions are made up with Regular short-acting insulin, such as ACTRAPID HM™/Humulin R Regular™ (refer to Insulinssection of this Nursing Clinical Guideline) which is different to the insulins used
for transition to S/C insulin. There is a combination of rapid-acting insulin - NovoRapid®/Humalog® and a basal acting insulin - Optisulin® (glargine) used for the transition to S/C insulin. Rapid-acting insulin often used will be NovoRapid® and the long-acting insulin will be Optisulin® (glargine).
Regular short-acting insulin Actrapid HM™ is used in an IV as it is a human neutral insulin and has a half-life around 5 – 7 minutes. This allows for infusion rates to be readily adjusted to achieve glycaemic targets according to the biochemical assessment of the patient in DKA; see DKA Clinical Guidelines -
Provide guidance to nursing and medical staff in the transition of IV insulin to S/C insulin regimen to ensure:
Diabetic Ketoacidosis (DKA): the patient will present or display signs of hyperglycaemia (high blood glucose), metabolic acidosis (low pH), and blood ketone (high blood ketone).
The biochemical criteria for diagnosis of DKA are:
The patient must be medically ready to safely transition to S/C insulin regimen – see DKA Clinical Guideline -
Clinical Guidelines (Nursing) : Procedure Management Guideline (rch.org.au)
Consider the risks of transitioning, which include:
Ensure medical readiness of patient:
Ensure patient has remained within medical readiness parameters:
*Note: Special considerations
with Glargine and Levemir doses:
Glargine is usually given in the evening. The first dose of basal insulin, usually Glargine, is often given at the same time as the first Rapid acting insulin dose, as the insulin infusion will be ceased and therefore no background insulin will be present.
Often ½ the dose of Glargine calculated by the Endocrinology and Diabetes medical team will be given in the morning and the other ½ or another dose given in the evening. Clarify with Endocrinology and Diabetes Medical team if unsure about Glargine order in MAR.
Levemir can also be used as a first basal insulin to be given in the morning of transition. Later in the evening the Glargine dose can be given. This allows basal insulin coverage during the day.
*Nursing staff should encourage the patient, or parents or carers to use their own home device provided by DNE. They may have a Libre 2 sensor and the sensor glucose data this does not replace finger lancing blood glucose or ketone checking – however encourage them to scan device and then perform blood glucose
or ketone check too.
A combination of Rapid-acting insulin (Novorapid®/Humalog®) and long-acting insulin (Glargine) will be ordered on the MAR. Novorapid®/Humalog® prior to main meals, and Optisulin® once a day (on first day this may be given as a split dose for 1st 24 hours after IV insulin infusion
The Pharmacists associated with the unit are the best resource to accessing and ensuring insulin is available on your unit for patients use and when ordered on the MAR.
Refer to Appendix 2 – Imprest
of Insulins at RCH – details of unit location of insulins and pharmacy imprest of insulins.
*Please review in: Appendix 1 – Profile of insulins and
Insulins action for more detailed information about insulins
Short-acting – Regular insulin:
Humulin R Regular™
RCH Departmental Guideline
The evidence table for this guideline
can be viewed here.
Please remember to read the
The revision of this nursing guideline was coordinated by Rebecca Gebert, CNC, Department of Endocrinology and Diabetes, and approved by the Nursing Clinical Effectiveness Committee. Updated February 2023.