Insulin question

[SNlena]

I had a patient (who had Congestive Heart Failure, pleural effusion, diabetes, and a history of hypertension, and emphysema)... my instructor claims that those medical conditions will make insulin (subcutaneously) take a much, much quicker effect (so if the book says that the onset is 15 min, in his case it will be 3-5 min)... Can someone please explain how this would happen and why? What do you think about this??

[TraumaICURN]

Yes, the guy was on a beta blocker (coreg tab 25mg), but even though it may mask s/s of hypoglycemia, would he really go into a coma after 5 minutes?

I mean, she was basically saying that if I give the insulin sq (novolog, which in my drug book that my school told me to purchase and follow, it says 15 min onset), so would his blood sugar really drop from 300 to 20 in 5 minutes? Seems a bit ridiculous to me...

The tray was right out in the hallway, so the guy was gonna eat 2 minutes later, it's not like there was no food nowhere in sight!

But she made me sound so unsafe, and that I was putting him in a life threatening situation, and that he would have been in a coma after 5 minutes...

I requested information which would back up her statements, so hopefully she will respond to that soon...

According to the website "NovoLog has a more rapid onset and shorter duration of action than regular human insulin. Because of the fast onset of action, the injection of NovoLog should be immediately followed by a meal. Because of the short duration of action of NovoLog, patients with diabetes also require a longer-acting insulin to maintain adequate glucose control."

You should let your teach read that and stress the fact that he was about to receive a meal.

http://www.novolog.com/professional/default.asp

[pepperann35]

I had a meeting a couple of days ago, and I pointed out those things... She just keeps saying her own things. That patient was not getting any anticoagulants (just ASA and Plavix), and she wrote in my evaluation that my patient could have had a "life threatening bleeding issue"...

I was trying to sort this out for 1.5 month already, and I am getting NOWHERE... In fact, they completely expelled me from this program.

These things are all very strange....there would be no indication to checks a patients PT/INR if they were not on anticoagulation therapy (baby aspirin and plavix are not indicators for a PT/INR routine order) I have never heard of those diagnosis's causing insulin to react faster. I would challenge her thinking on all of this. She sounds like a weirdo to me!:uhoh21:

[llg, PhD, RN]

I suspect there is a lot more going on in this situation than just the insulin issue. Being expelled from a program is serious business and I doubt any school would expel a student for that particular clinical situation alone.

[classicdame, MSN, EdD]

As a diabetic, and diabetic instructor, I wonder where she got her info. I tell patients to have the food in front of them before administering at home to avoid hypoglycemia because documented times are AVERAGES, and may vary among individuals. A patient with BS of 300 needs a different protocol than rapid acting insulin, in my opinion. So there are several issues here. The main one seems to be the instructor is not open to suggestions. This can inhibit learning.

[TraumaICURN]

I suspect there is a lot more going on in this situation than just the insulin issue. Being expelled from a program is serious business and I doubt any school would expel a student for that particular clinical situation alone.

I'm starting to feel like you. Are we really getting the whole story??

[BJLynn]

I found a really cool chart that has onset, peak, duration, administration in

relation to meals, and other information. I don't have anything directly related to this thread (my first instinct was that that guy would have his insulin processes slowed down...), but wanted to share this chart. I have it tacked inside my MAR at work.

http://www.musc.edu/pharmacyservices/DI/InsulinComparisonChart1.pdf

[SNlena]

"I suspect there is a lot more going on in this situation than just the insulin issue. Being expelled from a program is serious business and I doubt any school would expel a student for that particular clinical situation alone.I'm starting to feel like you. Are we really getting the whole story??"

It seems strange to everyone, including me. She failed me based on that probation (with those 2 reasons) and claiming that I didn't have the labs (I knew they were within normal limits first day, cause I looked it up but i didn't write them down, and the 2nd and 3d day I had a printout of them). So I went to talk to the Dean, the Chairperson, and the Ombudsmen about it. They said that they can see my point, but it's ultimately up to the teacher if she wants to change the grade.

I requested a meeting with the teacher, and she was "unavailable" for the first couple of weeks. Then they finally called me and set up a date for March 29th, which my teacher didn't show up for... So we re-scheduled for April 11th... On April 5th I got a letter saying that I am expelled for "unsafe conduct" (in a clinical setting), and that I can request a hearing to discuss this matter. So I did... I had that hearing a few days ago, which is where she made her strange statements (about the insulin acting much faster with those medical conditions, and so on).

[SNlena]

And to add on... I have another classmate who also failed, and she is also trying to contest... She went to Grievance department to file a complaint, and now the school is telling her that she either accepts the fail and be placed on a disciplinary probation for a year, or they will suspend/expel her too.

She is shocked...

It almost seems like they are trying to intimidate/screw over anyone who tries to contest.

[pepperann35]

I have a patient that is a brittle diabetic. She seems to bottom out about an hour after she urinates. Anybody ever here of such a thing???

[Myxel67]

Bottoming out is more likely related to time insulin was given. In my experience, the peak effect of rapid acting insulin is usually felt from 2 to 3 hours after injection. so if carb intake is not sufficient, that's the time risk for low BG is highest. Is it possible that this time coincides with "1 hr after she urinates"?

[Myxel67]

Yes, the guy was on a beta blocker (coreg tab 25mg), but even though it may mask s/s of hypoglycemia, would he really go into a coma after 5 minutes?

I mean, she was basically saying that if I give the insulin sq (novolog, which in my drug book that my school told me to purchase and follow, it says 15 min onset), so would his blood sugar really drop from 300 to 20 in 5 minutes? Seems a bit ridiculous to me...

The tray was right out in the hallway, so the guy was gonna eat 2 minutes later, it's not like there was no food nowhere in sight!

But she made me sound so unsafe, and that I was putting him in a life threatening situation, and that he would have been in a coma after 5 minutes...

I requested information which would back up her statements, so hopefully she will respond to that soon...

:balloons: :balloons: :balloons:

While beta blockers technically may mask s/s of low BG, that is not usually the case. Older beta blockers like propranolol may be more likely to cause problem. See link in earlier post. Coreg is a little different and may actually improve insulin sensitivity:

"Carvedilol is a combined alpha/beta-blocker. The 7% alpha-I blockade is enough to improve insulin sensitivity. Studies indicate that the difference in insulin sensitivity between carvedilol and a first or second generation beta-blocker is equivalent to that seen with adding a thiazolidinedione at high dose.[22,56,67] Simultaneous alpha blockade likely causes vasodilation of the vascular bed in skeletal smooth muscles, which in turn results in improved insulin sensitivity by increasing the surface area for exchange of glucose."

Thiazolidinediones (TZDs) are meds like Actos and Avandia which are strong insulin sensitizers. They don't cause hypoglycemia directly, but can lower insulin requirements due to increased insulin sensitivity. This is still not a reason to wait to give insulin. Especially if BG is 300.

[Juneria1]

thanx!! this is great! i love the MAR idea, too!