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.
Example 2: 72 y/o COPD'er that was started on 40 of IV solumedrol, sending his sugars into the 500s. Patient was put on our insulin drip protocol, which is rather confusing and assumes the patient is NPO. Sugars are down to 169 after being 200-300 all day (so he's almost off the drip). Primary doc arrived and said continue with the insulin drip, then put him on sliding scale when he's below 140 for two hours. When the pulmonologist arrives shortly after, and the patient begins complaining to him that I'm "starving" him by keeping him NPO. Pulmonologist then tells me to start him on an 1800 ADA or he's "going to go hypoglycemic and code" and "he will die". Cuts the solumedrol down to 20 but leaves me out to dry as far as the insulin drip goes and hurriedly runs out the door. So I call the primary, tell him what pulmonary said. He says OK, put him on medium dose sliding scale with q3h cbgs and let him eat. Three hours later he has a sugar of 453. I call the primary and he said to go ahead and give 20 units per sliding scale and check him again in 3 hrs. This was right before shift change so no idea what happened later...
Also, what about giving lantus while on an insulin drip? Some say yes, some say never.
My coworkers, some who have 30+ years ICU experience in major hospitals, all tell me they have never have a clue what the heck these doctors are doing with their insulin drips and that it defies logic - especially when it comes to eating on the drip. They tell me that in the old days, patients on insulin drips were ALWAYS npo.
Any explanations out there???
Apr 25, '12
Quote from MLB55
I've been in neuroICU for 2 yrs, and anytime they order a diet they switch them over to lantus daily and humalog qMeal + appropriate sliding scale for extra coverage. Someone that's eating does not need a gtt. What kind of facility do you work in? Are there residents? I work in a large teaching hospital and the mICU team are all fresh interns and have no idea, the other day they had a pt with bs in the 800s on insulin gtt and d5. (this was not my pt, and the d5 was turned off upon day shift arrival)
Umm all patients on an insulin drip should have a glucose source. If you turn off the D5 they will invariably bottom out once you get the BG down to "normal". The problem you describe seems to be a patient in DKA which is treated differently. We run our DKAs without D5 until they are below 300 then change to a glucose source per protocol. Otherwise our protocol has everyone on an insulin gtt on a glucose source.
Last edit by core0 on Apr 25, '12
: Reason: DKA stuff