Insulin usage

CoffeeRTC, BSN, RN · May 3, 2003

Why was the pt unresposive to start? What was their adv directives? this smells reallly bad.....

Ladydragon · May 3, 2003

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.

nowplayingEDRN · May 3, 2003

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

Ladydragon · May 4, 2003

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.

Rnltc · May 5, 2003

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?

smiling_ru · May 5, 2003

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.

Disablednurse · May 5, 2003

My question would be where was the cancer originated and what organs did it involve? Was it pancreatic cancer, etc?

gwenith, BSN, RN · May 5, 2003

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.

Ladydragon · May 5, 2003

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.....

Tim-GNP · May 7, 2003

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!

Flynurse · May 8, 2003

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!