Inpatient hyperglycaemia and variable-rate insulin — Rapid

Synopsis

Assess inpatient hyperglycaemia systematically and use a variable-rate intravenous insulin infusion only when indicated, monitored and safely linked to nutrition and basal insulin.

First decide whether high glucose represents DKA, HHS, stress hyperglycaemia, steroid effect, feed-related dysglycaemia or known diabetes with inadequate delivery; the correct insulin pathway depends on that diagnosis.
A VRIII adjusts intravenous insulin to the current bedside glucose and is useful when acute illness or inability to eat makes subcutaneous treatment temporarily unreliable.
Do not use the general VRIII chart to treat DKA or HHS; those emergencies require their dedicated fixed-rate protocols, fluids, electrolytes and biochemical endpoints.

Key red flags

Insulin-deficient emergency

Vomiting, abdominal pain, ketonaemia, deep breathing or acidosis suggests DKA and must divert the patient from general VRIII to the fixed-rate emergency protocol.

Investigation priorities

Bedside glucose profileFirst step

Define severity, timing and relation to meals, feeds, steroids and current insulin delivery.

Management branches

TriageChoose the correct insulin pathway

An inpatient has persistent or severe hyperglycaemia, whether or not diabetes was previously diagnosed.

Assess ABCDE, symptoms, hydration, current diabetes type and treatment, then check ketones, venous acid–base status and osmolality whenever the clinical pattern warrants.
Route DKA, euglycaemic DKA and HHS to their dedicated fixed-rate emergency charts; correct remediable missed doses, nutrition or prescribing errors when a subcutaneous plan remains appropriate.

Key medicines

Variable-rate intravenous human soluble insulin infusionChoose the hourly rate from the current local JBDS-aligned scale according to bedside glucose and documented insulin sensitivity; never invent a universal rate or use this chart for DKA or HHS.

Intravenous substrate fluid with VRIIIPrescribe the locally approved glucose-containing fluid and rate alongside VRIII, selecting sodium and potassium content from clinical fluid need, renal function and measured electrolytes rather than a generic recipe.

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