Fast acting insulin and meal time--it's just not that simple

[kanzi monkey]

Hello nurses!

Here's a clinical scenario that comes up pretty frequently where I work: a patient with diabetes is ordered for sliding scale Novolog to be given immediately before meals. The dose is based on the blood sugar, which is checked at the same time. There are many many variations of this scenario--maybe the patient has a standing order in addition to the sliding scale (that's not to be given if NPO), maybe the patient is taking metformin or other PO hypoglycemics also and has never used insulin at home, maybe the patient is getting other insulin for basal coverage, maybe the patient is a brittle type 1 diabetic, maybe the patient has an A1c of 13 and uses an entire insulin pen in 2 days but is rarely able to get a sugar level less than 200. There are thousands of scenarios, and each patient has a unique need. In addition to the patient's history and current treatments, there is also the day to day patient situation. What's the patient eating? How's his or her mental status? Appetite? Etc etc etc.

The orders for pre-meal insulin tend to be pretty broad and, if followed strictly without a lot of critical thinking and knowledge about the patient, not extremely effective. Here's a hypothetical example of a fairly common and uncomplicated situation that many of you may face pretty regularly:

Your pt is a 52 year old type 2 diabetic female POD 2 femur ORIF. Her diabetes is managed (not very well) on POs at home, her A1c is 8.6, and her post-op sugars have been running pretty high (200-300, let's say). The MD hasn't restarted her metformin yet, and an endocrine consult recommended the patient be on lantus and both standing and sliding scale novolog AC during her hospital admission. You're the nurse today, and the patient's AC blood sugar is 230. She ate breakfast 4 hours ago, is not really in the mood for lunch so doesn't order. So, now her "AC" isn't technically "AC"--but you checked the blood sugar anyway because she's "due" for both standing and sliding scale novolog (though the standing is not to be given if "NPO"--which she isn't, she's just not eating right now). For this test result, she would get 3 units novolog per scale, and the standing order is for 5 units.

If you don't call the doctor for advice (which I'm sure s/he REALLY would appreciate) you have to do something--give insulin/not give insulin. Give insulin with juice to cover your a$$ if you're worried the pt will drop too low (which is REALLY not likely, and probably not the best for the patient who should avoid the simple carbs--no carbs may be better than simple ones). Hold insulin because the patient's not eating. (But she had breakfast, and there's no reason to expect that she won't have dinner)

I recently witnessed a kind of tense conversation between a nurse and a diabetes NP--the nurse hadn't given insulin because the patient was confused and refusing to eat, but the blood sugar was high. The NP was saying the blood sugar was high--not only that, but it was consistently high, and the patient needed the insulin and the nurse should have given at least the sliding scale. While she's probably right, the NP wasn't taking the verbage of the order into account, nor the limits of what a nurse can do in that situation where to GIVE the insulin may be interpreted as going against the order (especially if, god forbid, the patient gets hypo after getting the insulin without sufficient po intake). Ultimately I think the pt probably needs more consultation and higher lantus dose-but the nurse had 4 busy patients, and this was not the only patient with sliding scale insulin ordered and a questionable appetite. She did NOT have the time to address the issue with the doc, who also did not have time to address the issue. At least the NP was there to make a new rec to the doc--but not without getting frustrated with the nurse who was basically just trying to not make a call that was outside her scope of practice. I feel that this kind of thing happens ALL THE TIME, and the nurse may find his or herself doing a substantial amount ,of coordinating/paging docs, nutrition, asking for consults, etc--just because a patient is not eating a meal, her blood sugar is high, and she has insulin ordered for "before meals"

Do any of you have thoughts on this? Similar problems, or maybe you've found a solution to this issue? Love to hear what you have to say.

-Kan

[netglow, ASN, RN]

No I don't, wonder if anybody does.

I have always been reminded... appetite or not, in situations like the patient you described, "The patient needs their insulin".

Also that I would have to take the time to teach/remind this person why the shot instead of the PO and why this now means they need to get some food down. I've found that the shot deal frightens many as they think they will forever be "sick" diabetic as they refer to people who must use insulin. This has worked (so far in my limited experience).

I would also be interested in other's comments.

I have read some stuff about how tight BG management might not be that great for the patient. Has anyone read this?

[beeble]

I would have given the SS and rechecked her blood sugar about 1/2 hour-hour later as Aspart is short acting.

[leslie :-D]

i always give my ss insulin with a beverage (depending on pt's presentation and data).

often, i'll put the juice/milk in a 30ml med cup and add a packet of sugar.

i make sure they drink it and don't worry.

leslie

[mamamerlee, LPN]

Well, on more than one occassion, I have taken my ac & ss humalog, then not eaten for an hour! My AC is 10, and I may need another 5 for coverage. So far, I have only ever gotten a bit shaky, and hungry.

At the very least, you must give the SS.

[nursej22, MSN, RN]

I think of the standing order as the "nutritional dose" and the sliding scale as the coverage or adjustment dose. So if they don't eat, no nutritional insulin, but 230 is too high so they need the adjustment or coverage dose. I wouldn't necessarily give juice or some carbohydrate, but would recheck in 30-40 minutes and see how the patient is tolerating it. And if she is being followed by an endocrinologist and or a diabetic NP, then they will review the amount of insulin given and glucose readings each day and adjust the Lantus and fast-acting doses. As she recovers and inflammation decreases, her insulin need may decrease.

[kanzi monkey]

i have always been reminded... appetite or not, in situations like the patient you described, "the patient needs their insulin".

while this is very true, you have a gray area when you're talking about administering fast-acting insulin on a sliding scale or in a standing "before meals" dose. rapid acting insulin with food with a peakless long-acting insulin (ie, lantus) are ideal in a patient who is eating. in a patient who isn't eating for a medical reason, rapid-acting insulin usually isn't given, since it's purpose is specifically to control post-prandial bg. if you give rapid-acting insulin to a brittle diabetic who is skipping lunch, even if her bg was 200 before you gave the insulin, she may dip dangerously low.

i have read some stuff about how tight bg management might not be that great for the patient. has anyone read this?

i think i've heard about this--i don't remember the details, but there is a bit of a controversy over how low a patient's goal a1c should be. one organization says 6.5, another did a study that found an increased mortality rate for diabetics with an a1c less than 7. i think i've got that right, but if anyone knows more specifically about this topic, could you post something? in general, however, i think when trying to help manage a diabetic's bg/insulin in the day to day hospital setting, keeping tight control should be the goal to avoid post-op or medical complications (ie, infection).

for reference, i copied a comparison between average bg and a1c from an article i found online--there's a link to the chart and article below that.

translating the a1c assay into estimated average glucose values

table 2-- estimated average glucose

mg/dl*mmol/l†a1c (%)    597 (76-120)5.4 (4.2-6.7)    6126 (100-152)7.0 (5.5-8.5)    7154 (123-185)8.6 (6.8-10.3)    8183 (147-217)10.2 (8.1-12.1)    9212 (170-249)11.8 (9.4-13.9)    10240 (193-282)13.4 (10.7-15.7)    11269 (217-314)14.9 (12.0-17.5)    12298 (240-347)16.5 (13.3-19.3)

http://care.diabetesjournals.org/content/31/8/1473/t2.expansion.html

i would have given the ss and rechecked her blood sugar about 1/2 hour-hour later as aspart is short acting.

i think this might be one of the most practical solutions and should be incorporated into the patient's plan of care. "hold if npo" should literally mean just that--the pt is taking nothing by mouth for an extended period of time (like, greater than 8 hours). if the patient's bg fluctuates a lot, or goes low at times, nurses can use their judgement as to the frequency they check the bg based on what the patient is eating or how the patient is feeling. but yeah, anyone whose sugar is running high should definitely be getting covered no matter what they're eating.

i always give my ss insulin with a beverage (depending on pt's presentation and data).

often, i'll put the juice/milk in a 30ml med cup and add a packet of sugar.

i make sure they drink it and don't worry.

leslie

as always, i like your style leslie. the only issue i have with this is based on the principle that each patient gets the most out of any medical treatments they're prescribed--for some patients, the juice/simple sugars may ultimately prevent the patient from achieving ideal diabetes management while in hospital. but there are a lot of things that aren't ideal in life, aren't there? there have been a number of studies that have shown that the risk of dangerous hypoglycemic episodes is far less than the risk of complications related to poorly controlled bg in the acute care setting. at the same time, providers are less likely to prescribe adequate coverage for fear of hypoglycemic events (which can be far more immediately dramatic than many of the consequences of sustained hyperglycemia). it's like people who drive in cities like new york or boston every day without giving it a thought, but who have a debilitating fear of flying.

but, you know, giving milk and sugar with insulin for a patient who declines to eat a meal is not a bad license-protecting strategy, considering you may only be minimally compromising whatever control might be attained--and you have pretty much ensured that the patient won't drop too low on you.

any more thoughts? i have lots, obviously, so thanks to all for taking the time to read my lengthy posts!

:)

[netglow, ASN, RN]

I believe what I read actually was about critical care ICU patients and possibly decreased death with BG values allowed to vary. What would normally be considered sub par management was found to have better outcome. It questioned best practice.

[nicole109]

Just curious, but those of you that are taking fingersticks and administering insulin and then rechecking fingersticks 30-40 minutes later, how many patients do you have and are they all diabetics? Because when I was in the hospital, I was on a neuro floor, so every single patient got fingersticks, whether they were diabetic or not...and about 98% of those patients got coverage at every meal. Granted, it was extremely rare that we ever had standing mealtime insulin orders, only sliding scale orders, but our techs did the fingersticks, and with one glucometer for 20+ patients, and a very irregular meal schedule and 70% of our patients unable to feed themselves...it was very likely that patients fingersticks were being checked up to an hour or an hour and a half before meal time and then to be checked again after meals--it would be another hour to hour and a half. Perhaps our system just doesn't work well...we also had very little success with aspart insulin on our floor. Again, maybe it was the system--I just don't know how you can be expected to check 6 fingersticks, administer 6 insulin shots, feed 6 people and recheck 6 fingersticks in 40 minutes. And heaven forbid you have to do something else in between--just a rant on "best practice" Have they done any best practice investigations on everything we have to do in a day? Sorry I'm grumpy tonight =)

[trulynurseatheart]

We had an inservice with one of the endocrinologists, and she advised us, in most cases, if the patient is NPO- and the glucose is high- give the Sliding Scale Cover... Its to cover the current glucose level. Other things have to be considered, and its a case by case scenario, and good judgment and follow up should be made.

[solneeshka, BSN, RN]

At my facility, we do what has been mentioned several times here, and it's part of the order set: The Novolog SS is given regardless of whether the pt is eating or not because it's corrective. If there is a pre-meal bolus dose, then that is withheld if the pt is not eating. We never give HS Novolog specifically with a snack (or a glass of juice with sugar in it) because that defeats the purpose of correcting the glucose level. (If the pt wants a snack they can have it, we just don't specifically provide the insulin with a snack.)

[leslie :-D]

As always, I like your style Leslie. The only issue I have with this is based on the principle that each patient gets the MOST out of any medical treatments they're prescribed--for some patients, the juice/simple sugars may ultimately prevent the patient from achieving IDEAL diabetes management while in hospital. But there are a lot of things that aren't ideal in life, aren't there? There have been a number of studies that have shown that the risk of dangerous hypoglycemic episodes is far less than the risk of complications related to poorly controlled BG in the acute care setting. At the same time, providers are less likely to prescribe adequate coverage for fear of hypoglycemic events (which can be far more immediately dramatic than many of the consequences of sustained hyperglycemia). It's like people who drive in cities like New York or Boston every day without giving it a thought, but who have a debilitating fear of flying.

But, you know, giving milk and sugar with insulin for a patient who declines to eat a meal is not a bad license-protecting strategy, considering you may only be minimally compromising whatever control might be attained--and you have pretty much ensured that the patient won't drop too low on you.

imo, many of these insulin calcs by the doctors, are hit or miss.

i do not randomly give all my diabetic pts 30cc of juice w/sugar...

only those who i know are either brittle, known to bottom out or npo.

it also is going to depend on type and amt of insulin, and fs reading.

i've started doing this after (too) many unconscious pts.

At my facility, we do what has been mentioned several times here, and it's part of the order set: The Novolog SS is given regardless of whether the pt is eating or not because it's corrective. If there is a pre-meal bolus dose, then that is withheld if the pt is not eating. We never give HS Novolog specifically with a snack (or a glass of juice with sugar in it) because that defeats the purpose of correcting the glucose level. (If the pt wants a snack they can have it, we just don't specifically provide the insulin with a snack.)

as you gain more experience in nsg, you will know that not every order is black and white, and that nursing judgment accounts for all decisions we make.

leslie