When to NOT give insulin?

[natrgrrl]

I need some help understanding insulin therapy. Evidently, I need a lot of help. How do I understand the effect of different types of insulin on blood sugar? And how do meals and meal times relate?

I can't give insulin to a patient if I don't know when to withhold it!

This will probably be a long answer but I would really appreciate it if someone would take the time.

[talaxandra]

Sliding scales of regular aka short-acting - kicks in quickly and wears off (relatively) quickly, only treat short-term elevation and contribute to fluctuations in blood glucose levels. In patients who are acutely ill or exceptionally brittle they can be the best way (short of an actrapid infusion) to manage swinging or unstable diabetes, but are not appropriate in the longer term.

More commonly used now are standing orders for long acting or combined insulins, with a salvage scale to top up in the event that the blood sugar is elevated beyond what the usual insulin can manage.

This is good if the increase is a short term thing - less exercise than usual, new steroids, a 'naughty' snack. If the usual insulin regime is consistently ineffective (ie the salvage scale is being used frequently), then the standing order should be increased.

Hope that's not all clear as mud!

[vashtee, RN]

talaxandra - What I am usually seeing is long acting plus regular insulin on a sliding scale. (Is that what you mean by salvage scale?)

Perhaps what classicdame meant was that regular insulin ALONE is ineffective?

Sorry, I am such a newbie.

[SuesquatchRN, BSN, RN]

When I was in LTC all ss insulin was regular.

It really, as has been said, depends on your patient. I had one woman who was very brittle and non-compliant and I stopped giving her her PM regular if her bg was below 125 because she WOULD bottom out. I was nights and, of course, perfect nurse who relieved me would tut-tut at my holding it so we finally got the order clarified and, guess what! My instinct to hold it was confirmed to be correct.

Know your patients (if you can), LISTEN to them if they're competent, and get orders changed if necessary.

[talaxandra]

Hi natania -

Even experienced nurses can be stymied by diabetes and insulin :)

The unpleasant complications of diabetes are caused by persistantly elevated blood glucose and by rapid swings in blood glucose level, which is why patients with a really high BSL aren't given huge doses to bring it down quickly - the swinging (and risk of overshooting and causing hypoglycaemia) is more dangerous than the high BSL is.

In a non-diabetic person the pancreas produces/releases a constant low level of insulin (the basal rate), and releases additional insulin when energy is taken in.

Optimal T1 diabetes management aims to replicate this, usually in one of two ways. The more traditional method is to use a combination of long and mixed insulins - perhaps Mixtard 30/70 BD with meals, or Actrapid with meals and Protophane at night. The long acting insulin provides a basal dose and the short acting (contained in the Mixtard) covers the energy absorbed with meals.

With the development of very long acting insulins (like Lantus), we can now aim for tighter control. Patients may be prescribed a very long acting insulin (like Lantus), once a day, supplemented with a set meal time dose (which may vary depending on which meal it is) of a short acting insulin like Novorapid or Actrapid.

The aim is to keep the BSL within a narrow parameter. Sliding scales vary the amount of short acting insulin given depending on what the BSL is, but it's better practice (ie results in tighter control) to vary the long acting insulin dose if BSLs are routinely higher or lower than expected. Salvage scales means the patient has x units of fast acting insulin with lunch but if the BSL is higher than expected they also have y units.

Does that make any sense at all?

[vashtee, RN]

Talaxandra - thanks!

I tried to thank your post, but it's not showing up on my end.

[mysterious_one, ASN, RN]

I know this is a somewhat older thread, but I have a question pertaining this topic. I am a new RN and I had a patient who was on 70/30 plus sliding scale regular. His BS was between a 100 and 110 all day, so I gave him his 70/30 in the morning but held his sliding scale regular. He ate all his meals. Then at dinner time he had just received one unit of PRBC, his BS was 72 and he was due for his 70/30 again. Naturally I didn't give him any sliding scale regular insulin, and pt. stated he never takes his 70/30 when his BS is that low. Now my question, should I have given him the 70/30 for the night, since the nph should cover him for the night?

[classicdame, MSN, EdD]

The best answer is to contact the MD and look at your policies. You point up a very real problem with SSI - we are always chasing the tail of the dog and true control is difficult. This is why the American Diabetes Asso and the Am. College of Endocrinologist's joint position statement says that SSI is "not effective and not recommended" for hospitalized patients. Although the 70/30 contains NPH, it also contains Regular, which means about 2 hours after the injection (when pat may be sleeping) the BS may take a severe down turn. I would have held the insulin till I got word from MD, or at the very least provide 60 grams of carbs as a bedtime snack and recheck in a few hours.

[mysterious_one, ASN, RN]

Thanks classicdame, for your reply. I did not give him any coverage, because the patient did refuse, but I was curious. It's also a dilemma, once you go of your shift, you really can't control what the nurses will do in terms of double checking on the next shift.

[blondy2061h, MSN, RN]

That's why premixed insulins are AWFUL. You can't give the long acting (70) without giving some short acting (30). There's really never a good use for premixed insulins. If he was on NPH and R separately you could have held the R and given just NPH.

[NurseyBaby'05, BSN, RN]

Also, don't forget to be sure which 70/30 is ordered. There's Novolin 70/30 that has 30% of Regular and Novolog 70/30 that has 30% of rapid acting (5 min) insulin.

Often if someone is on the border with their blood sugar, I know they're going to be NPO after 00:00, or they have been vomiting, I will hold the night time maintanence dose and spot check them once or twice through the night. I would rather bring down a level than fight to elevate one anytime.