Can someone PLEEEEASE explain INSULIN DRIPS?

wildlaurelrn · Apr 25, 2012

Our ED protocol is to start with 2 boluses NS to try and get the BG down. Then we reassess. If the patient is still hyperglycemic or in DKA (an anion gap is more diagnostic than the BG...you can have a BG of 220 and be in DKA) then we start the drip. We use a computerized program and when/if the patient eats, we plug the number of carbs into the program and it adjusts the drip. We check BG hourly and once the patient reaches 200, we continue the drip but switch them over to D51/2NS until the BG is down around 140. Then we start basal insulin and d/c the drip. It works well, you just have to stay on top of the BG checks, but the computer program alarms. You also have to watch their K+ because depending on the patient it can be really high or really low initially and once you start the insulin, it will change over several hours.

Also, it doesn't make sense to me that a doctor wouldn't be concerned about an elevated BG because that is what causes the acidosis. If you can correct that - you'll correct the DKA. Here's a good article about hyperglycemia: Medscape: Medscape Access

**LaurelRN, MSN · Apr 25, 2012

H_2_0

There are alot of things at play here.

1) as most everyone here has said, the insulin drip is not really to bring down the blood sugar ( I mean it does, but that is not the primary reason). In DKA, A) you have the absence of insulin B) you have acute dehydration C) electrolyte imbalances D) acidosis.

so A) give insulin- brings down blood sugar

B) Give NS until blood sugar is under 250-300 ( depends on your facility), corrects dehydration- helps correct the acidosis.

C)sometimes people with DKA will have K+ levels at 7 (The highest i've seen - well, and the patient is still alive is 7.6) Insulin chases potassium back into the cell.

D) This is the biggie- Ph of 7.30, 7.25, 7.2, I even seen 7.0 ( well and he was still breathing)- This is the real reason you're giving insulin and fluids. Correct the acidosis- its metabolic. You just have to do it slowly- because remember, for every tenth ph you go up, you potassium comes down by 0.6. You don't want to cause hypokalemia...most facilities start fluids with K+ added once the blood sugars normalize and the Ph starts to get near normal. (which is why we do labs so often)

Eating..well.... that's up to the doc. Some will let them eat- others won't. It makes it a bit difficult, but you're doing Q1 hr FSBS- so it really isn't a big deal.

Lantus- again, so do some don't. We have one endo guy that swears by it and one that won't start it until they are off the gtt.

You just have to be careful. Correct slowly. And if you have a question- you ask it. As a advocate for your patient- (and your license) you have the right to question any order a MD gives you.

Hope we've helped

KMULL002, BSN · Apr 25, 2012

I'm about halfway through my first year in the ICU at a community hospital and have had a few patients on insulin drips for various reasons over the past couple of weeks. As a new grad, I'm always trying to learn, and always wanting to make sure I know why I'm doing something. So I'm always asking questions and fortunately, coworkers are very helpful.
However, the issue that has seem to come up with insulin drips lately is something it seems nobody in the unit understands or can explain, and has me questioning if some of the physicians even really know what they're doing.
The issue revolves mostly around the actual purpose of the insulin drip, and whether or not patients on an insulin drip are allowed to eat.
I'll try to briefly explain two scenarios:
Example 1: 32y/o type 1 diabetic turned off his insulin pump while sick. Arrived in DKA with sugars in the 600s and on an insulin drip running at a constant rate of 5 units/hr. Doctor called later to see if the pt. is "ok," didn't even ask what his sugars were (they were running 200s to 300s) and said to start him on an 1800 ADA diet. Later the doc shows up and tells me he doesn't care about the sugars, just the acidosis (which had been resolving). He told me in DKA the insulin drip is just for the acidosis, not the sugars. Pt. went home with sugars under control and normal acetones later that night.
Insulin relieves the high blood sugar by allowing the sugars to go into the cells and the exchange of electrolytes and oxygen to occur. So yes, insulin helps acidosis by lowering the blood sugar level. The body's response to high blood sugars is to breathe rapidly to blow off co2. There is too much co2(acid) in the lungs because the sugar on the rbc is just sitting there and not allowing the exchange of co2 for o2 that occurs in the lungs when we breathe. In response to sugar problem we need insulin to fix it;think of insulin as a door to the cells. I hope this helps.

turnforthenurse, MSN, NP · Apr 25, 2012

Another fairly common reason for placing a pt on an insulin drip is the temporary reduction of high serum potassium. Insulin will drive the K+ back into the cells.
This is temporary as the only ways that I know of to permanently rid the body of excess K+ is kayexalate and/or dialysis.......

Yes. Over time, the K will begin to leak out of the cells so the insulin is only a temporary fix...as you said, kayexalate or dialysis would be done.

pas3cash · Apr 25, 2012

I would expect that physicians and/or more experienced nurses would help you out with this. I suspect they do not want to bother rather "not know what they are doing". There in not one correct response to your questions,I would suggest that you do a bit of research on your own and critically think it through yourself. Critical thinking is the most important skill a nurse needs, particularly in critical care. Good luck.

Vespertinas · Apr 26, 2012

When I worked transplant, we still had patients on an insulin gtt on the floor and here patients can be expected to eat. How is that solved? Simple- subq mealtime fast-acting insulin. The drip is for baseline problems which is why you can convert it to Lantus when you're ready. You can still manage food like food.

.We use a computerized program and when/if the patient eats, we plug the number of carbs into the program and it adjusts the drip.

Awesome!!

chocolateheals · Apr 26, 2012

Great questions. What I know about insulin gtts does not defy logic, so I hope I can help you understand. For our DKA'ers and HHS'ers, we have extremely detailed protocols and "decision trees" for titrating the insulin drips. This is so that we can take care of these poor patients with the highest standard of care- the whole protocol is based on a lot of research, and took our awesome diabetes team years to write. These are very complicated cases.. and the DKA or HHS diagnosis is on top of other medical or surgical problems that you and the doctors are trying to work on... even more to think about. Our protocol details when to draw labs (ABG, lactate, chemistries), and what fluids to use and when (once glucose is below a certain point, we add KCl to the fluids). It's also designed so that we don't bring the glucose down too quickly. I'll spare you all the details of it- it's pages long, back and front. After I post this, I'll rummage around to see if I can send you a copy.

A great thing about our protocol is that the doctors in the ED take an empty order form off the shelf, and check boxes that are appropriate for the patient, but most of the boxes are already checked (like lab frequencies, etc). So that at 3am, the exhausted new intern is less likely to make a mistake or overlook something vitally important.

Maybe one of the best things about having a strict protocol is that doctors cannot arbitrarily pick times, fluids, doses and types of insulin to give, and let a patient eat without it making sense. If you take one situation, and ask 15 different doctors to give you and order, I bet you'd get 15 different orders. You don't understand? Neither do the doctors. Not to cut them down, but they have to know a lot about a lot. And they're not going to keep it all in their heads. Unless they're an endocrinologist, they're bound to miss something.

As far as eating... if they are in DKA or HHS, they MUST BE NPO while on the insulin gtt. (As someone else mentioned, if they are on a continuous enteral feeding, it's fine to be on an insulin gtt for tight control.) Once someone is alert enough and aspiration is not a concern, they can ONLY have water and ice chips. They may beg and plead. Too bad. If we do it right, it really reduces the time they spend in the hospital. Plus, a lot of these folks have gastroparesis from their diabetes, and are likely to throw up once they eat anything, so I encourage them to go slooooow.

Our patients cannot eat on an insulin gtt until they've been at a goal glucose level for a set number of hours. The steady amount of insulin they are receiving = their BASAL insulin needs. In other words, the amount of insulin their body needs to carry out its metabolism, all the time, day and night, regardless of food intake (which is prandial and correctional). Then I call the doctor and ask for a diet. Then I proceed to tell the doctor that I will not let the patient eat any food until I have a sub Q insulin order IN THE CHART. Sometimes they say "yeah, good" on the phone but then it takes hours for them to get to the acute care to write that order. If I haven't let the patient eat yet, I carry on merrily with my now stable insulin gtt, with my patient still NPO. The doctors use a calculator that they access online, plug in the amount of insulin the patient has been getting on the gtt, and are able to convert that into an appropriate subcutaneous dose and type of insulin. Once I've got my subQ and diet orders, I give the patient the first sub Q insulin injection, and leave the drip on for 2 more hours, and let the patient eat.

I hope my answer helps you. I like **LaurelRN's answer a lot, too, and didn't want to be repetitive. It's really good that you care enough to ask these questions. I think you could be very instrumental at your community hospital and could be a part of a diabetes team, or help institute a protocol to manage these patients better. It will save your hospital money if these patients are managed correctly and could be great for your resume. A big idea, especially if you are getting used to your first year in the ICU. Perhaps you could just suggest the idea to your manager. What do you think?

JustMe · Apr 27, 2012

I had an interesting thing happen at a critical care CE class. One of the speakers was a pharmacist and the first thing he asked was "Who doesn't understand their Insulin Protocal?" Every hand in the auditorium went up!! :rotfl:

Robublind · Apr 28, 2012

cliff notes version: D5 or food with the insulin help your body get rid of the ketones.

rgroyer1RNBSN, BSN, RN · Apr 28, 2012

Another fairly common reason for placing a pt on an insulin drip is the temporary reduction of high serum potassium. Insulin will drive the K+ back into the cells.This is temporary as the only ways that I know of to permanently rid the body of excess K+ is kayexalate and/or dialysis.......

We use an insulin and D50 drip in an emergency to drive theK+ back down, if its not an emergency we use kayexelate we give it orally or down an ng tube, we also give an ena

rgroyer1RNBSN, BSN, RN · Apr 29, 2012

Sorry, the rest of what I was saying we also give enemas of kayexelate, in an emergency when the K++ is way too high we also give boluses and drips of calcium gluconate, and lidocaine as they lower K++ also, as far as giving the dka pt lantus they don't need it I know its a long acting insulin, but even though the drip is short acting regular insulin it is still going to work as long acting because they always have the drip going, As far as our dka's eating, well they don't, they are npo in the unit, unless the doc orders something else, if they don't get an order to eat in the unit, that means the doc wants them to wait until they stabilize, have the drip switched to sub-q insulin and moved to med-surg or step down, thats when they can eat, and we always leave 2 amps of D50W by the bedside, we also leave some

rgroyer1RNBSN, BSN, RN · Apr 29, 2012

We also leave some bicarb at the bedside, and as far as calculating the insulin drip, our docs our ignorant as well they'll just come in and throw orders for a drip, then he will tell us to figure out the dose based on the pts weight, because he does'nt "Have the time". And like when do us nurses have he time, moron.Rod RN, BSN, CEN, CCRN, CFRN, TNCC, CRNI, ACLS, PALS, Med/Surg cert, ed/sicu nurse manager, current med student.I just love having the whole alphabet behind my name, lol.