Insulin usage

  1. A nurse on my unit recently got an order for insulin for an unresponsive patient. This patient hadn't eaten anything for 24-36 hours, but her FSBS was over 500. Our nurse practitioner ordered 20u regular insulin q hour until her FSBS was below 200. This was at 11pm. The patient had already had 25u on the previous shift. The patient expired at 4:45am, but not before she had been given a total of another 120u regular insulin. Any thoughts?
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  2. 12 Comments

  3. by   CoffeeRTC
    Why was the pt unresposive to start? What was their adv directives? this smells reallly bad.....
  4. by   Ladydragon
    Patient had been unresponsive for at least two shifts...no intake, very little output. Did have a DNR and HCP, no contact with HCP duriny my shift. FSBS remained between 300 and 500 through the night.
    Last edit by Ladydragon on May 3, '03
  5. by   nowplayingEDRN
    Hmmmmmmmmm, diabetic coma that progressed to multi system failure?? Any pertinent medical Hx that you could give with out violating confidentiality? I agree with michelle...something just does not seem right?

    Christie
  6. by   Ladydragon
    The patient was end stage CA, but until this night her blood sugars had been well in control. I guess I'm just wondering if anyone else would have given that much insulin to an unresponsive patient, and if you would have called another MD/FNP questioning the original order. I know I wouldn't have given that much, especially since her BS went up after the first two doses of insulin.
  7. by   Rnltc
    I agree with you Ladydragon, I wouldn't have given that much of Reg insulin. Did anyone check to see if BS machine was working correct. Do a high and low control on it. When was the insulin opened?
    If the CA had reached to certain organs I am not sure any amount of insul would have helped much. Did she have a temp?
  8. by   smiling_ru
    As long as the blood sugar was being monitored, it would be appropriate. We frequently give 10 Units IV until the blood sugar is down.
    Patients on insulin drips may receive more than what was given to that patient. Again, as long as the blood sugar was monitored I can not see where there would be a problem. With the possible exception that an insulin drip would have provided better control.
  9. by   Disablednurse
    My question would be where was the cancer originated and what organs did it involve? Was it pancreatic cancer, etc?
  10. by   gwenith
    My personal bet is that she was intensly shutdown - just a guess but did she look very pale cool skin? I would hazard that she was too shut down to absorb the insulin. Did you do a core Temp on her? Wouldn't mind betting that while her skin temp was low her core temp was high.
  11. by   Ladydragon
    First, thanks to all for your input. As for the glucometer, it is checked daily, and they were new as of mid-March. Not sure exactly when the insulin was opened, but it is our police to discard all insulins over 30 days old. (And I know it's done- it's my job to check them!) The CA originally was breast CA. As for insulin drips, we are a nursing home, and have never done insulin drips, though I can see how you would get better control that way. Her skin was cool and dry, but a core temp was not done. (Some of these questions are difficult for me to answer as it was not my patient on the night in question.) I agree that she was probably too shut down to absorb the insulin. Given that, I'm wondering why that much insulin was even ordered?The patient was seen two shifts earlier by the FNP/MD.....
  12. by   Tim-GNP
    It actually sounds like Hyperosmolar hyperglycemic nonketotic coma (HHNC) to me. It has a mean age of onset early in the seventh decade of life, and Residents of nursing facilities who are elderly and demented are at the highest risk.

    In terms of pathophysiology: Dr's Sagarin & McAfee explain it the best:

    Unlike patients with DKA, patients with HHNC do not develop ketoacidosis, but the reason for this is not known. Contributing factors include the limitation on ketogenesis by hyperosmolarity, the lower levels of free fatty acids available for ketogenesis, the availability of insulin in amounts sufficient to inhibit ketogenesis but not sufficient to prevent hyperglycemia. Preceding or intercurrent illness is common, but the underlying cause may be difficult to ascertain. Pneumonia and urinary tract infections (UTIs) are the most common underlying causes of HHNC.

    No comment as to what I would have done....

    There is a fascinating article on the subject at:

    http://www.emedicine.com/emerg/topic264.htm

    Hope this helps!
  13. by   Flynurse
    Did anyone suggest that maybe the CA had reached her pancreas? I always think of that when CA and BS's are combined (had an aunt pass away...long story).

    But I have to agree with the others, something doesn't smell right!
  14. by   wif411
    I wouldn't have done it in a LTC. I would have tried to talk the NP into sending pt to er for evaluation. Yes, even thugh she was DNR. If not I would have asked for STAT blood work.
    I agree too many unknowns. There is a phrase............................... "I do not feel comfortable with---- and I would appreciate it if you would come to see pt."

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