safe insulin

8/3/2019 Safe Insulin

http://slidepdf.com/reader/full/safe-insulin 1/51

Safe Administration of Insulin

Prepared by Vicki Kraus, PhD, ARNP, CDE and

the Insulin Administration Task Force

May, 2005



Insulin Administration Task

Force

• Linda Chase, RN• Rhonda Fruhling, RN

• Pam Group, RN

• Susan Huff, RN

• Linda Johnson, RN

• Vicki Kraus, RN

• Jennifer Long, RN• Michael Murray, RPh

• Mary Sauers, RN

• Jeanne Sheetz, RN

• William Sivitz, MD



Insulin Administration Task

Force

• Reviewed significant and serious insulinerrors for July, 2003 to December, 2004

• Identified the issues involved in each one of

the errors, e.g, lack of knowledge• Developed a plan for reducing errors

– Provide education– Improve communication

– Develop policies and procedures as needed



Overview

• Review of differences between type 1 and type 2diabetes

• Concepts of basal and bolus insulin

• Insulin types and action patterns

• Changing insulin requirements in the hospitalized

patient• Hypoglycemia prevention, detection and treatment

• Preventing and solving blood sugar problems



Diabetes Mellitus

• Hyperglycemia caused by an absolute orrelative deficiency of insulin

• Body is unable to properly use

carbohydrates, proteins and fats



Type 1 Diabetes (T1DM)

• Absolute deficiency of insulin due todestruction of the beta cells of the pancreas

• Immunologic or idiopathic, i.e., no known

etiology and no autoimmunity



T1DM

• Onset at any age, usually before 30• Ketosis prone

• Insulin sensitive• Usually thin or normal weight

• Treatment consists of a balance of diet,insulin and exercise



Type 2 Diabetes (T2DM)

• Relative insulin deficiency due to decreasedliver, muscle, and fat sensitivity to insulin

and impaired beta cell function

• Genetic and environmental



T2DM

• Onset may be as early as during childhoodor adolescence, usually after age 30

• Not ketosis prone

• Normal or high insulin levels

• Insulin resistant

• Usually obese• Treatment consists of diet and exercise and

oral agents and/or insulin



Blood Glucose Targets

• Critical Care Units– 110 mg/dl

• Non-Critical Care Units– 110 mg/dl preprandial (range 90-130

mg/dl)– 180 mg/dl maximal

American Diabetes Association, 2005



Insulin Therapy

• Basal insulin– Controls glucose production by the liver

• Bolus insulin

– Food insulin

• Use and store carbohydrates eaten

– Correction (supplemental) insulin• Treat an acute elevation in blood glucose



Basal

Bolus



Insulin Preparations

• Rapid-acting Insulin Analogs

– Lispro (Humalog), Aspart (Novolog), Glulisine(Apidra)

• Short-acting Insulin

– Regular (Humulin R and Novolin R)

• Intermediate-acting Insulin

– NPH (Humulin N and Novolin N)• Long-acting Insulin Analog

– Glargine (Lantus)



Look Alike Sound Alike Names

• NovoLOG• NovoLIN

• HumULIN• HumaLOG



Insulin Action Patterns

Insulin

Preparation

Onset of

Action

Peak Action Effective

Duration

Rapid-acting

Analogs

5-15

minutes

30-90 minutes 3-5 hours

Short-acting 30-60

minutes

2-3 hours 5-8 hours

Intermediate-

acting

2-4 hours 4-10 hours 10-16 hours

Long-acting 2-4 hours Peakless 20-24 hours




Pre-Mixed Insulins

• Humulin/ Novolin 70/30 (human)– 70 % NPH and 30 % Regular

• Humalog Mix ® 75/25 (analog)

– 75 % lispro protamine and 25 % lispro

• NovoLog Mix® 70/30 (analog)

– 70 % aspart protamine suspension and 30 %

aspart




American Diabetes Association (2003). Insulin therapy in the 21st century.

Alexandria, VA: ADA.



Administration of Insulin

• Pre-meal Insulin

– Fast-acting: 5-15 minutes before eating (tray should beon the unit and patient ready to eat it)

– Short-acting: 30 minutes before eating

• Basal Insulin

– NPH: once or twice daily before breakfast and beforesupper or at bedtime; at bedtime only

– Glargine: once or twice daily before breakfast and/or atbedtime

• Correction Insulin

– Fast-acting or short-acting with pre-meal insulin



Insulin Injection Sites

• Rotation of sites is important to prevent tissuechanges, e.g., hypertrophy

• Rotate sites within one body area for each insulininjection/time of day, e.g., lispro abdomen, lantusarms

• Absorption varies by body area

– Abdomen– Arms

– Legs

– Buttocks



Injecting Insulin

• Clean injection site with alcohol

• Gently pinch up tissue to pull fat away frommuscle

• Insert needle (full length) at a 45-90º angleinto subcutaneous tissue (most people 90º)

• Inject at slow, steady rate• Remove needle and apply gentle pressure;

DO NOT massage the site



Increased Insulin Requirements

Related to Hospitalization

• Illness• Surgery

• Infection• Steroid Therapy

• Added calorie load (CVN, enteral feeding)



Prevention of Hyperglycemia

• Continue basal insulin or replace with continuousintravenous insulin

• Give fast or short-acting insulin before meals

• Use correction or sliding scale insulin doses thatmatch the current blood sugar and the insulinsensitivity (algorithms)*

• Monitor blood sugars at least 5 times per daywhen eating (before meals, at bedtime and at0200) or every 4-6 hours if NPO

(*Use sliding Scale Insulin Order sheet: Adult H9131)



Hypoglycemia: Common Risk

Factors

• Mismatch of insulin timing, amount or typefor carbohydrate intake

– Fast-acting insulin given and food delayed

– Unexpected transport after fast or short-acting

insulin

• Oral secretagogues, e.g., sulfonylureas,without appropriate carbohydrate intake

Tomky, D. (2005). Detection, prevention, and treatment of hypoglycemia in

the hospital, Diabetes Spectrum, 18(1), 39-43.




Factors

• Reduction in nutrient intake– NPO

– Nausea and vomiting

– Not finishing a meal or eating a snack

– Intravenous carbohydrate discontinued or rate

decreased– Interruption of enteral feeding

Tomky, D. (2005). Detection, prevention, and treatment of hypoglycemia in the

hospital, Diabetes Spectrum, 18(1), 39-43.




Factors

• History of severe hypoglycemia• General anesthesia or sedation that puts

patient in an altered state of consciousness

• Critical illnesses (hepatic, cardiac, and renal

failure; sepsis;and, severe trauma)

Tomky, D. (2005). Detection, prevention, and treatment of hypoglycemia in the

hospital, Diabetes Spectrum, 18(1), 39-43.



Prevention of Hypoglycemia

• Hold food insulin when NPO

• Replace carbohydrates if mealcarbohydrates not eaten or vomiting occurs

• Give fast-acting insulin within 15 minutesof eating (food should be present)

• Give bedtime snack as specified by mealplan or if blood sugar at bedtime is less than100 mg/dl




• Reduce dose/insulin infusion rate if enteralfeeding or CVN or intravenous glucose is

reduced or discontinued

• Use of intravenous glucose to replace

carbohydrates when NPO or vomiting as

indicated




• Base correction or sliding scale doses on current

blood sugar levels

• Avoid using sliding scale insulin as a replacement

for scheduled basal and bolus insulin• Accurate insulin dosing: double checks in

accordance with hospital policy

• No secondary set connections above the infusion

pump on continuous IV infusions of insulin



Hypoglycemia Management



Hypoglycemia: Definition

• Any blood sugar level of 70 mg/dl or lower• Symptoms may or may not be present

• Symptoms may occur and hypoglycemia is

not present

• Blood sugar level does not describe the

severity of hypoglycemia

– Severity based on whether person can treat self



Hypoglycemia: Symptoms

• Autonomic– Trembling/shaking, sweating, pounding heart,

fast pulse, changes in body temperature,

tingling in extremities, heavy breathing

• Neuroglycopenic

– Slow thinking, blurred vision, slurred speech,uncoordinated, numbness, trouble

concentrating, dizziness, fatigue/sleepiness

Gonder-Frederick, L. & Zrebiec, J (2003). Hypoglycemia. In M.J. Franz (Ed.),Core curriculum for diabetes education (pp. 277-310). Chicago: AADE.



Hypoglycemia: Symptoms

• Unknown etiology– Hunger, nausea, weakness, headache, general

feeling of something not right

Gonder-Frederick, L. & Zrebiec, J (2003). Hypoglycemia. In M.J. Franz (Ed.),

Core curriculum for diabetes education (pp. 277-310). Chicago: AADE.



Hypoglycemia: Emotional and

Social Behavior Changes

• Negative Moods: anxiety, nervousness,tension, irritation, frustration, anger,sadness, pessimism

• Positive Moods: giddiness, euphoria,disinhibition

• Behaviors: arguing, crying, resistingtreatment, aggressive acts, inappropriatesocial/sexual behaviors





Hypoglycemia should beconsidered a potential etiology in

any patient who has a change in

level of consciousness.

University HealthSystem Consortium (2005). Safe use of insulin. Chicago:UHC.



Hypoglycemia: Causes

• Excess of blood sugar lowering agents

(insulin or oral agents* that increase

insulin) in relation to food intake and

activity level

• More likely when food has not been eaten

for several hours or when activity hasincreased significantly



*glyburide, glipizide, glimepiride, repaglinide, nateglinide



Hypoglycemia: Management• Test blood sugar. If less than 70 mg/dl treat even

if symptoms are absent

• Take 15 grams of carbohydrate. 20-30 grams maybe needed if blood sugar is less than 50 mg/dl

• Retest blood sugar in 15 minutes. Repeattreatment if still less than 70 mg/dl

• Provide snack if scheduled meal/snack not withinthe next 30-60 minutes (6 saltines, 3 grahamcrackers, or 1 slice of bread)



Hypoglycemia: Management

15 Gram Carbohydrate Options

Fruit juice (1/3-1/2 cup)

Non-diet soft drink (4-6 ounces)

Skim milk (1 cup)

Honey/jelly/corn syrup (1 Tablespoon)

Sugar (3-4 Teaspoons)

Glucose tablets or gel



Hypoglycemia Management

• Relief of symptoms lags behind return of

blood sugar to normal (more is not better)

• Recovery of motor and mental function

takes a while when blood sugar levels have

been < 45 mg/dl (may take 45-75 minutes to

regain cognitive function)

f



Management of Severe

Hypoglycemia (Unable to self manage)

• If not at risk for aspiration, give oral

carbohydrates.

• If unconscious, provide treatment based on

level of care available

– Glucagon (1 mg IM)

– D50 intravenously (25 ml)– D5 (300 ml) or D10 (150 ml) intravenously



Hypoglycemia: Follow Up

• Retest blood sugar levels during recovery

and retreat as necessary

• Determine cause of hypoglycemia and make

regimen adjustments as appropriate

P i d S l i Bl d



Preventing and Solving Blood

Sugar Problems

• Blood sugar level

– Low, normal or high

• Carbohydrate

– Source (PO, IV Fluids, CVN)– Continuous or intermittent

• Insulin– Type (s) and action pattern (s) and dose

– Time and method of administration

C S d CVN ith t



Case Study: CVN without

Added Insulin

Insulin Low Blood

Sugar

High Blood

Sugar

Continuous IV Insulin Follow IV insulin

guideline

Follow IV insulin

guideline

Sliding Scale Insulin

Only

Treat using adult

Hypoglycemia

Management protocol.

Call HO to considerrevising sliding scale

insulin and/or giving

IVF containing glucose

Call HO to consider

revising sliding scale

insulin, adding

scheduled subcutaneousbasal* insulin or

initiating continuous IV

insulin

*NPH or Glargine (Lantus)

C St d CVN ith t



Case Study: CVN without

Added Insulin

Insulin Low Blood

Sugar

High Blood

Sugar

Scheduled Subcutaneous

Basal* Insulin

Treat using adult

Hypoglycemia

Management protocol.

Call HO to consider

decreasing scheduled

subcutaneous basal*

insulin or adding IVF

containing glucose

Call HO to consider

adding correction/sliding

scale insulin and/or

increasing scheduled

subcutaneous basal*

insulin


C St d CVN ith I li



Case Study: CVN with Insulin

Added

Insulin Low Blood

Sugar

High Blood

Sugar

Continuous IV Insulin Follow IV insulin

guideline

Follow IV insulin

guideline


Only

Call HO to consider

decreasing sliding scale

insulin and/or

decreasing insulin innext CVN bag and/or

adding IVF containing

glucose

Call HO to consider

increasing sliding scale

insulin and/or increasing

the insulin in the nextCVN or adding

scheduled subcutaneous

basal* insulin or starting

continuous IV insulin.


C St d CVN ith I li



Case Study: CVN with Insulin

Added

Insulin Low Blood

Sugar

High Blood

Sugar

Scheduled Subcutaneous

Basal* Insulin

Call HO to decrease

scheduled

subcutaneous basal*

insulin

Call HO to increase

scheduled subcutaneous

basal* insulin


C St d C ti T b



Case Study: Continuous Tube

Feeding Rate Adjustment

Insulin Low Blood

Sugar

High Blood

Sugar

Continuous IV Insulin Decrease rate using IV

insulin guideline. Call

HO to consider adding

IVF containing

glucose.

Increase rate using IV

insulin guideline.






Insulin Low Blood

Sugar

High Blood

Sugar


Only

Call HO to consider

decreasing sliding scale

insulin

Call HO to to consider

increasing sliding scale

insulin or starting

continuous IV insulin

or starting scheduled

subcutaneous basal*

insulin







Insulin Low Blood

Sugar

High Blood

Sugar

Scheduled

Subcutaneous Basal*

Insulin

Call HO to consider

starting IVF containing

glucose and

decreasing scheduled

subcutaneous basal*

insulin

Call HO to consider

revising

correction/sliding scale

insulin and increasing

scheduled

subcutaneous basal*

insulin


C St d C ti T b F di



Case Study: Continuous Tube Feeding

Discontinued

• Continuous intravenous insulin

– Call HO to reduce the rate and consider adding IVFcontaining glucose

– Check blood sugars every hour until stable

• Sliding scale insulin– Call HO to reduce sliding scale insulin if indicated

• Scheduled subcutaneous basal* insulin

– Call HO to consider reducing dose and adding IVFcontaining glucose

– Check blood sugars every hour until stabilized




Case Study: Blood Sugar < 70 mg/dl

• NPO for a test

– Call HO for order to hold scheduled fast-acting insulin(prevention)

– Call HO to consider starting IVF containing glucose

• Continuous NPO– Call HO to add/adjust IVF containing glucose and/or

adjust insulin

• Able to take food/fluids– Follow adult Hypoglycemia Management protocol

safe insulin

Documents