High dose insulin for Beta blocker OD

[beckster_01, BSN, RN]

Hello all :)

Today I initiated high dose insulin to treat a beta blocker overdose for the first time. We have done it before on our unit but it is quite rare (1-2 times in the 4 years I've been there). Our toxicologist gave me great literature so I don't have questions about the therapy itself right now but I guess I am interested in hearing from others about how often your docs recommend this treatment, how you write your protocols, and how you manage staffing on the unit. My hospital has a well written guideline to follow but due to the nature of the treatment it is difficult to write a protocol with titration parameters, so I'm curious to see if other facilities have different guidelines than we do.

We start with grabbing baseline labs premedicating with 25g D50, then we bolus the patient with 1unit/kg of IV insulin- In my case I administered 75 units of insulin as an Iv push 😱💀. Then we start the drip at 1unit/kg/hr, initiate a D20 gtt, and watch BG's q15 minutes until, and I quote "you get 2 consecutive BG's that are relatively similar," then space checks to q1. I kept an amp of D50 drawn and ready plus a couple extra for good luck. If BGs drop below 150 we give 1 amp, stop insulin, and call HO to change the rate of dextrose, if the insulin needs changed we are supposed to call toxicology. We check K+ q1hr. I think that is the jist of it but this guideline was 3 pages long.

My biggest problem is that using the guideline feels so nebulous. How similar do my BG's have to be to be "relatively" similar? My made up number was within 10points, but it obviously depends on what my interventions have been and how my sugars are trending. If my sugar was 280 and my next two checks are 165 and 161, I'm not waiting an hour to recheck. Even though I LOVE using my nursing judgement, And I trust my nursing judgement, I don't trust everyone's nursing judgement. My docs today were great, but what if they weren't? We have some questionable residents that rotate through, and I felt that if my team today had not been as good as it was, we could be in a dangerous situation. I just have to remember that this is why I work in an ICU- to be able to closely monitor my patient, use my brain, and work closely with the team to make the best decision.

Finally- our acuity is high right now, so when I told charge that the assignment needs to be split (hello q15minute BG's), she pushed back. I made her come into my room and look at my insulin drip running at 75 units per hour. Unless this patient stayed therapeutic for several hours I do NOT feel safe trying to care for a second patient, but our decisions to make a patient 1:1 is a bedside nurse assessment. Management is always on call if we are unable to safely staff. Do other units mandate that this patient will always have a 1:1 nurse? I guess I need some reassurance that I'm not being greedy and hogging or resources

I look forward to reading anyone's experiences!

[NurseyB]

I'm still fairly new, and have never seen this therapy used, but I think q15 titration needs a 1:1 if it's primary nursing. If you have techs that can check the sugars and report to you, it may be reasonable to have a second pt, provided that the OD is hemodynamically stable.

If staffing is tight and a 1:1 not possible, patient should be paired with a stable patient that is close to step down.

[Rabid Badger, BSN, RN]

I've never heard of high dose insulin therapy for beta blockers. Its usually treated with glucagon and supportive therapy.

High dose insulin therapy is usually reserved and well documented for calcium channel blocker overdose.

[MaxAttack, BSN, RN]

I've never heard of high dose insulin therapy for beta blockers. Its usually treated with glucagon and supportive therapy.

High dose insulin therapy is usually reserved and well documented for calcium channel blocker overdose.

First result on Google was an article posted in Clinical Toxicology found on PubMed

"CONCLUSIONS. While more clinical data are needed, animal studies and human case reports demonstrate that high-dose insulin (1-10 U/kg/hour) is a superior treatment in terms of safety and survival in both beta-blocker and calcium-channel blocker poisoning. High-dose insulin should be considered initial therapy in these poisonings."

I've seen it used twice where I work. I never worked directly with the patients, so I'm not of much help. I can tell you the nurses had two patients. I believe they were hourly blood sugar checks.

You can't realistically have two patients with q15min checks. However I have no idea how long it would take to stabilize the insulin dosing and I would expect to take the first admission once they do so.

[Linka]

This is cool. Does it have to do with cell potential of cardiac muscle?

[chare]

http://www.tandfonline.com/doi/full/10.3109/15563650.2011.582471

[beckster_01, BSN, RN]

Sorry it has been so long to reply, I haven't logged in for awhile. I think he ended up being 1:1 for the next two shifts so about 24 hours. He was on D30 and still needing amps of bicarb, and I think he was still hemodynamically unstable as well. It was definitely an interesting weekend and I got to see the whole treatment through. The article chare posted is the exact article my toxicologist gave me to learn how it works so I recommend giving that a read. As far as staffing it isn't unusual for 1 nurse to be expected to care for two patients on insulin drips, 2 weeks ago I had one DKA and one that was requiring hourly adjustments for reasons I can't recall. But q15 minute checks with insulin running at 75units an hour was a little much. It was a fun experience though, and it worked really well.