When to give insulin?

  1. 0 When it comes to diabetics and giving insulin, I have seen a few methods out there:

    -give the insulin only at meal times or at least have snack and juice in front of the patient.

    -give the insulin at the time after the accucheck even if no food is in front of them.

    I just wonder what the best way is and whats the rationale behind it?
    For example, I was at the hospital last week for clinical's for school. A patients BS was 356, so according to the sliding scale, he was to get 8 units of Novolog. The nurse would not give it to him until dinner had arrived. Is that standard practice?

    Help?
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  3. Visit  kriegerkriegr profile page

    About kriegerkriegr

    Joined Feb '12; Posts: 2; Likes: 1.

    24 Comments so far...

  4. Visit  kids profile page
    0
    It really depends on the type of insulin.
  5. Visit  SHGR profile page
    0
    Yes, it definitely depends on the insulin. Lantus/detemir- should be given at the same time of day every day, regardless of meal times. Regular, 30 min before eating. Novolog or humalog, 15 minutes to immediately before a meal. Apidra can be given during the meal but probably ideally like the novolog or humalog.
    No hospital patient should have BG in the 300's!!! something is wrong there. The doc should have been called. Sounds like regimen is inadequate, probably inadequate insulin dosing the time before. It's even more necessary for acutely ill pts to have well-controlled BG for optimal healing. Also not right if you feel you have to give a snack or juice!! A snack is 15g carb or less and does not require insulin. Insulin is for basal or mealtime; again, if pt is going low (below 70 or 80 depending on your facility?) then their regimen needs to be adjusted.
    Clinical Diabetes has some great resources on insulin.
  6. Visit  MN-Nurse profile page
    2
    Quote from hey_suz
    No hospital patient should have BG in the 300's!!! something is wrong there.
    This is unfortunately common, and could be why they are in the hospital, or as a result of treatment.

    I know quite a few patients that I am fine chilling at 300 while we bring their glucs down slowly (sometimes with a drip if they start hanging out around 500).

    Once you see a resident overcorrect a brittle diabetic and find yourself slamming D50 into a sweaty drooling bucket of a patient at 0645, you tend to acquire a less jaundiced view of those high 200's.

    To the OP: It depends, and it isn't always dependent on eating. Some patients are NPO and still get sliding scale doses. With experience, you learn to use your judgement. Until then, ask your preceptor or coworkers.
    sonja77 and redhead_NURSE98! like this.
  7. Visit  SHGR profile page
    0
    Hi MN-nurse,
    by jaundiced, do you mean judgemental, that is not at all what I meant- I mean tighter control of BG inpatient is crucial. You are right- you do not want to overcorrect- but hyperglycemia is not desired either.
    Here are some relatively recent guidelines.

    "A consensus statement of the American Association of Clinical Endocrinologists (AACE) and the American Diabetes Association (ADA) issues clinical recommendations on the proper treatment of hospitalized patients with high blood glucose levels. The new guidelines, which target healthcare professionals, supporting staff, hospital administrators, and others involved in improved management of hyperglycemia in inpatient settings, are published in the May/June 2009 issue of Endocrine Practice and in the May issue of Diabetes Care."
    Medscape: Medscape Access
    Recommendations for Critically Ill Patients
    Specific clinical recommendations for critically ill patients are as follows:
    • For treatment of persistent hyperglycemia, beginning at a threshold of no greater than 180 mg/dL (10.0 mmol/L), insulin therapy should be started.
    • For most critically ill patients, a glucose range of 140 to 180 mg/dL (7.8 - 10.0 mmol/L) is recommended once insulin therapy has been started.
    • To achieve and maintain glycemic control in critically ill patients, the preferred method is intravenous insulin infusions.
    • Validated insulin infusion protocols that are shown to be safe and effective and to have low rates of hypoglycemia are recommended.
    • To reduce hypoglycemia and to achieve optimal glucose control, frequent glucose monitoring is essential in patients receiving intravenous insulin.
    The article goes on with guidelines for less critically ill patients.

    Our hospital has sets of guidelines based on how insulin- sensitive each patient is. Outpatient- I have patients who use 300+ units a day, and some that use only a tenth of that.
  8. Visit  MN-Nurse profile page
    0
    Quote from hey_suz
    Hi MN-nurse,
    by jaundiced, do you mean judgemental, that is not at all what I meant- I mean tighter control of BG inpatient is crucial. You are right- you do not want to overcorrect- but hyperglycemia is not desired either.
    Here are some relatively recent guidelines.
    I meant depending on the patient, you don't get too excited about it. I know what the guidelines are.
  9. Visit  SHGR profile page
    0
    We had a patient with Type 1 that was admitted and released 2x this month for a semi-unrelated condition, I took a call today from the home care nurse and BG at home was 500 something. Pt had fluctuated fom 250's- 40's in the hospital, then got discharged and just didn't feel like taking her 7 units of lantus. Lots of different factors...but yeah, brittle patient, super sensitive to insulin, throw in kidney failure too...I know that's hard. I think the other thing that makes it hard is that people eat totally differently when they are inpatient too. Or maybe that makes it easier? You have more control, in a way, or at least more idea what people really are eating.
  10. Visit  Vespertinas profile page
    1
    Has anyone else had this thought? Death to the Sliding Scale!?
    curetype1 likes this.
  11. Visit  SHGR profile page
    2
    Quote from Vespertinas
    Has anyone else had this thought? Death to the Sliding Scale!?
    Yes!!! Oh, yes.
    curetype1 and Vespertinas like this.
  12. Visit  CapeCodMermaid profile page
    3
    Most people would agree that the sliding scale is not the optimal method to manage diabetes. Too bad most people doesn't include my medical director.
    curetype1, SHGR, and Vespertinas like this.
  13. Visit  redhead_NURSE98! profile page
    0
    Quote from MN-Nurse
    This is unfortunately common, and could be why they are in the hospital, or as a result of treatment.

    I know quite a few patients that I am fine chilling at 300 while we bring their glucs down slowly (sometimes with a drip if they start hanging out around 500).

    Once you see a resident overcorrect a brittle diabetic and find yourself slamming D50 into a sweaty drooling bucket of a patient at 0645, you tend to acquire a less jaundiced view of those high 200's.

    To the OP: It depends, and it isn't always dependent on eating. Some patients are NPO and still get sliding scale doses. With experience, you learn to use your judgement. Until then, ask your preceptor or coworkers.
    Yep it's pretty common when you have visitors who bring their family member a nice carb loaded meal to eat after they've already eaten their hospital meal.....
  14. Visit  CDEWannaBe profile page
    3
    I'm late joining the discussion, but had to add my two cents.

    Like others have said, any long acting insulins (like Lantus, Levemir, NPH) should be given at the same time, no matter what the patient's current blood sugar is or what they're eating.

    Fast acting insulin (Humalog, Novolog, Regular) usually takes about 15 minutes to be active, then works for 2-4 hours. If blood sugar is 180 or less it's good to wait until food is in front of the patient before giving the injection. But if blood sugar is higher, it's best to inject the insulin in advance to give it a head start in lowering blood sugar, before food elevates it even more.

    Blood sugars over 300 can easily happen if a person is insulin dependent and has missed a shot or not gotten the right dose.

    And no one should use the term "brittle diabetic." In my experience that term is not well defined and usually means someone who has highs and lows. But if a person's pancreas doesn't work, they WILL have highs and lows. I've never met a diabetic with extreme highs and lows who can't have improved numbers with a better treatment plan.
  15. Visit  classicdame profile page
    0
    Yes, waiting till a meal is present is appropriate for rapid acting insulin like Novolog. Regular should be given prior to meal if possible (up to 30 minutes as that is when it peaks). I recommend you google for insulin peaks, action time and active times and relationship to meals. There is a lot of good info out there.

    As for sliding scale, the ADA and the Am. Asso of Clinical Endocrinolgists put out a white paper in 2005 regarding in-hospital diabetic management. One phrase clearly stated "there is NO indication that regular insulin sliding scale is effective". For many years that is all we had and some people cannot change their mind. It is appropriate in home settings, but not in hospitals. This is how patient's BS runs from 300 to 70 and they crash. Read up on them and you will see.


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