Insulin drips

[blondy2061h, MSN, RN]

We routinely do insulin drips on my unit. My floor, plus the ICU, are the only places in the hospital that are allowed to have patients on insulin drips. We have an IV insulin protocol we're suppose to follow. ICU pretty much follows this to the nose. We are more likely to use more personal judgement in dose adjustments (IE, if the patient is being tapered off steroids, not be so aggressive, if the patient has been having frequent hypoglycemia, go up in lower increments than the protocol calls for, etc). We've had good success with this.

However, when I think about it, this really is giving meds without an order. How do you feel about this? If you do insulin drips, do you follow your protocol word for word?

[blinks14]

We follow the protocol word for word, but our insulin gtts are open heart patients and it's important to follow the protocol on those patients. Plus the drip gets documented on a special flowsheet with the BS and the drip rate and all that stuff.

[blondy2061h, MSN, RN]

Well, I don't really think a BMT patient is any less "fragile" so to speak than an open heart patient (but I've never worked in such a unit), but I think protocol is generally important with any patient. However, when did we decide one size fits all? When did we become so cookie-cutter?

[RN1982]

I follow the protocol word for word. Surgical patients including open-hearts need tight glycemic control. We have a non-insulin sensitive protocol and an insulin sensitive protocol. The insulin sensitive protocol has smaller adjustments. We use it for patients that are brand new transplants, intubated patients, NPO or not with glucoses over 151. It's very indepth.

[BrnEyedGirl, BSN, MSN, RN, APRN]

All of our insulin gtts are on a glucomander, the computer sets the rates, so yes the protocol is followed to a tee.

[suanna]

There have been a number of protocals in the literature in the last couple of years- at least two of them take changing or labile glucoses into account- it may be good to look into other options-do a lit search for sliding scale insulin management. That being said- it the unit I work we also adjust the orders found in our protocal for unusual patients. Yes it's giving medication without an order but if you are concerned- would your attendings back you if you wrote a "verbal order" for an obvious adjustment in the rate untill he came around to sign off? If not you are looking at one of the more "complex" scales that we use in our MICU- 2-3 pages long and math involved with every q1-2 hr draw. It does cover every contingency- and the docs love to sign it because it take the problem out of thier hands. In my post-surgical ICU we use a 3 tier sliding scale depending on what the patient is doing and it almost always works out fine. Our endo group used to write thier own orders but we had such sucess with our 3 tier orders they just use it for a day or two post op. If you want a copy-email me. I'm sure my hospital has it copyrighted and wouldn't want it posted, be I could likely get away with sending you a copy for your docs and unit to look into.

[Tait, MSN, RN]

We follow our protocol to the T, however when you are checking BG Q1 hour it's pretty easy to see where the patient is headed.

I think anytime there is a protocol, it is safest to follow it to protect your job. However, if your floor is frequently finding they need more flexibility in the protocol it might be time to suggest a PI project to your manager and get the protocol changed!

Tait

[blondy2061h, MSN, RN]

There have been a number of protocals in the literature in the last couple of years- at least two of them take changing or labile glucoses into account- it may be good to look into other options-do a lit search for sliding scale insulin management. That being said- it the unit I work we also adjust the orders found in our protocal for unusual patients. Yes it's giving medication without an order but if you are concerned- would your attendings back you if you wrote a "verbal order" for an obvious adjustment in the rate untill he came around to sign off? If not you are looking at one of the more "complex" scales that we use in our MICU- 2-3 pages long and math involved with every q1-2 hr draw. It does cover every contingency- and the docs love to sign it because it take the problem out of thier hands. In my post-surgical ICU we use a 3 tier sliding scale depending on what the patient is doing and it almost always works out fine. Our endo group used to write thier own orders but we had such sucess with our 3 tier orders they just use it for a day or two post op. If you want a copy-email me. I'm sure my hospital has it copyrighted and wouldn't want it posted, be I could likely get away with sending you a copy for your docs and unit to look into.

By sliding scale, are you referring to an IV insulin drip? I'm just curious, cause we only use sliding scale to refer to subq insulin.

[blondy2061h, MSN, RN]

We follow our protocol to the T, however when you are checking BG Q1 hour it's pretty easy to see where the patient is headed.

I think anytime there is a protocol, it is safest to follow it to protect your job. However, if your floor is frequently finding they need more flexibility in the protocol it might be time to suggest a PI project to your manager and get the protocol changed!

Tait

The particular patient I'm referring to was on an insulin drip for, I'm not joking, like 2 months. I had him many, many nights. Everyday he'd need a ton of insulin during the day, reaching rates of like 15 units/hr. He got a HUGE dose of prednisone everyday at 9am, and you could actually see when the prednisone was peaking looking at his glucose trends. Then, I'd come in at 7pm, and he'd be like 150, which calls for an upward adjustment of 2 units via our protocol, then, by 8pm, he'd be in the 50s without fail. Every. Single. Night. So I started (and the other nurses did, as well) lowering the dose when I came in, even if he was still above where he was suppose to be. By 8pm he'd be at like 100 on the nose and stay there all night (versus rebounding from the hypoglycemia, crashing again, etc, etc).

[Tait, MSN, RN]

The particular patient I'm referring to was on an insulin drip for, I'm not joking, like 2 months. I had him many, many nights. Everyday he'd need a ton of insulin during the day, reaching rates of like 15 units/hr. He got a HUGE dose of prednisone everyday at 9am, and you could actually see when the prednisone was peaking looking at his glucose trends. Then, I'd come in at 7pm, and he'd be like 150, which calls for an upward adjustment of 2 units via our protocol, then, by 8pm, he'd be in the 50s without fail. Every. Single. Night. So I started (and the other nurses did, as well) lowering the dose when I came in, even if he was still above where he was suppose to be. By 8pm he'd be at like 100 on the nose and stay there all night (versus rebounding from the hypoglycemia, crashing again, etc, etc).

Wow, that definitely sounds like an extreme special case! Kudos on adjusting his care. :) I guess for legal reasons getting the doc to write special pump parameters based on what you had ascertained would have covered.

[Thunderwolf, MSN, RN]

We have insulin drips on my floor. It has a fairly tight protocol...and we follow it word for word.

[patwil73]

We have some judgement in following the protocols - for instance, if we had a patient described above with the routine hypoglycemic reaction we would moderate the adjustments and then call the doctor to get an order for the same (or if we had time to think ahead call before)

I once had a patient that started out around 10 units an hour. BS continued to stay about 400. Moved up per protocol. Next day came back and he was at 28 units. BS remained about 400. Continued to titrate up until I hit 50 units. BS remained 400. Thought something seems odd - turned off insulin. BS remained . . . you got it, 400. Called the doctor and let him know.

Turns out his dx process with his pancreas made him unable to utilize the insulin we were giving him - so the docs had the insulin removed.

Following protocols and orders are important, but knowing from measurable repeated incidents that bad outcomes are going to happen when we do follow protocols should allow us to adjust them (and of course get the doctors order to cover what happened).

Pat