Can someone PLEEEEASE explain INSULIN DRIPS?

[H_2_O]

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???

[MLB55]

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???

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)

[H_2_O]

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)

Or is it someone on a drip does not need to be eating?

The hospital is a small community hospital serving mostly upper middle/upper class patients.

No residents, interns, etc. Only docs, NPs, PAs. And wow about the D5.

[MLB55]

I don't see alot of dka, again I work in neuro and we use GTTs for tight glucose control in any sort of head injury. We use GTTs when pts are being fed enterally, continuously. It can be hard/unsafe to manage a pts bs when they are eating meals and titrating insulin.I'm not sure what the answer is for a pt in dka and should or should not be eating. If a pt can eat on their own, we cut the drip and start lantus and humalog.

[H_2_O]

If a pt can eat on their own, we cut the drip and start lantus and humalog.

Which is what I thought should have been done in example #2. Seems pretty basic to me, I'm just still so new I'm a little nervous to put my 2 cents in on some of these things and I'm wondering why none of the doctors pick up on this.

[MLB55]

That's why I like working in a big teaching hospital. Endocrine problems? Consult them. Endocrine does a conversion on how much insulin gtt the pt requires to lantus and humalog. The pt probably does not control there sugars at home, and probably need more than what they are using... Hence the basal lantus dose. Is the second pt DM?

[BelgianRN]

We use our insulin drips for tight control on 95% of our patients. Generally they won't eat meals (because they are still to sick). With continuous feeds it's no problem. Once our patients are able to eat meals we'll generally manage their blood sugars once they start swinging out of control. For this we use an insulin drip but mostly because we are much more experienced as nurses to predict the needed dosage and duration and we have little experience using a sliding scale (that is in use in the wards). But we might check sugar levels Q1h or Q2h to decide how fast they are dropping (I generally watch the trend from 24 hours before as well to "predict" how responsive the patient is to the insulin).

It becomes very labor intensive once they start eating meals. So that's usually the time we DC our insuline drip and get them out the door to the ward.

It helps of course that as soon as a patient is inside the ICU only the intensivist can give direct orders to us or enter them into the computer system. All other MDs can request us to do something if cleared with the intensivist or they can give us their advice when asked by us (e.g. how much suction on chest tube, their transfusion wishes post surgery) but still if our intensivist says no (and trust me he does that often) they stand there like mute chickens and we follow the directions of the intensivist.

We rarely start longer acting insulin only when it's not really possible to control blood sugars with short acting insulin drip.

And H_2_O don't let the MDs chew you out. In my hospital the DKA protocol is a complete nightmare. They think we have nothing better to do than draw blood sugars, ketones and adjust fluids all night long - and I know with a DKA we indeed have nothing better to do.

And why is the pulmonologist worrying before they code they'll probably stroke out first so it falls on neuro anyway... I hate cheeky MDs that make a run for it afterwards.

[MunoRN, RN]

I think it makes more sense to think of DKA as an absence of insulin, rather than an excess of blood glucose. Patients can come in with DKA and have near normal or even normal BG's, but still have an elevated ion gap and large ketones. The ketone production and related acidosis is due to catabolic energy production where the body can't make usable energy because it lacks the necessary insulin to convert the available glucose to usable energy, regardless if there is a normal or excessive amount of glucose available.

We typically put DKA patients on D5 or even D10 when their blood sugars are less than 250 to insure that we can continue to give the amount of insulin needed to clear the ketones.

We do feed DKA patients on insulin drip once their sugar is in reasonable control, although most DKA patients have trouble eating much or holding food down. It does make titrating an insulin gtt more difficult when they are eating, although not as much as when "tight control was still considered good practice. Other than being a hassle, I'm not really clear why a patient wouldn't be able to eat on the drip, it's just a more precise way of doing a S/S or long-acting, both of which still allow the patient to eat.

We do give lantus and even mealtime correction doses while on the drip, mainly because it helps transition them off the drip. Particularly for our open hearts, most of which have no previous lantus dose to refer to, we use the average drip rate to calculate the lantus dose and then hopefully titrate the drip to zero as the lantus kicks in. We do the same with mealtime correctional doses which we also start giving with the drip still in use, if they were dosed correctly you should be able to turn the drip off.

[mindlor]

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.......

[mindlor]

As for eating, most people on insulin drips are going to be in ICU/CCU.....when I was in ICU/CCU eating was far from my mind...usually insuling drips will coincide with some form of glucose given concurrently so BG does not crash........

[core0]

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.

[Esme12, ASN, BSN, RN]

In the case of the Diabetic Type I.....the acidosis is the issue. Diabetic ketoacidosis (DKA) is a condition of relative insulin deficiency resulting in acidemia due to altered metabolism. Yes the glucose is elevated but it is the acidosis that will kill you. The insulin is used "replace" the insulin that is absent and allows for the acidosis correction. Typically SQ insulin will not be restarted until acidosis is corrected but yes the patients do eat ...if they are conscious.

The following links will be very helpful.

Management of Diabetic Ketoacidosis (DKA) and Hyperosmolar Hyperglycemic Nonketotic Syndrome (HHS)

http://columbiaresidents.org/bb/DKA%20Protocol.pdf

Diabetic Ketoacidosis - May 1, 2005 - American Family Physician

Just because someone is hyperglycemic doesn't mean they are in DKA. The focus here is glucose control and the glucose being out of control from illness or meds like steroids. Acidosis isn't always a factor.

Some studies have shown that in DKA and severe acidosis the addition of lantus helps to lower the acidosis faster and longer with some documentation of discharge within 24 hours.

MD's will argue amongst themselves on just about everything. I have seen cardiologists argue over 12 leads on whether it VT or SVT. One thing that is certain about medicine......nothing is certain.