Insulin questions

[ekendall10]

This has been on my mind ever since I last worked the other day. I had a new patient that came to my floor. She had a history of uncontrolled diabetes and told me she had not received any insulin in her many hours in the ER. Upon checking her blood sugar she was in the 700's. I had orders to give her 25 regular insulin and 30 levemir. I also gave her something to eat with these. I figured it would be a safe bet to re evaluate her blood sugar in 2 hours since the regular would've peaked at this time. Her blood sugar was still about 570 and the dr ordered an insulin drip. By the time the drip arrived from pharmacy an hour had passed so rechecked her blood sugar and it was in the 300's. It almost aeemed unnecessary to start the drip at this point in fear of dropping her too quickly. I wonder if I didn't give enough time for the levemir to take effect? Should I have waited longer to recheck her blood sugar? I don't have a ton of experience with insulin drops so if anyone could give feedback it is much appreciated!

[Rose_Queen, BSN, MSN, RN]

Not too familiar with insulin drips since they're managed by the anesthesiologist during surgery, but I do know that we do frequent checks and titrate accordingly. 300 is still higher than ideal; depending on the reason for the ER visit and admission, the results could go back up due to the stress response. I definitely wouldn't wait longer to recheck- in surgery we check about every 30 minutes. The insulin drip should have titration orders for where to keep the blood sugar- we go for between 150 and 200. However, you always have the option of clarifying with the ordering physician if you are unsure.

[ixchel]

I would have started the drip provided there were titration orders including q1h finger sticks (or more often as needed), dextrose, and parameters for turning it off. I think the levemir would be going strong by that point. Remember with levemir, there isn't a peak. It just levels out and stays leveled out. Some people respond to the drip rapidly, which is fine. 300 is entirely too high, though. For regular insulin sliding scale coverage, we don't cover less than 150. For drips, we turn them off below 90. By the time you're at 90, though, the drip is down to 1 unit per hour. It not enough to sink a person. (And to be honest, when I hit 100 or so, I usually call to update the provider with the hopes they let me turn it off. Insulin drips are a time suck!)

Anyway, hope that helps!

[MunoRN, RN]

How you manage an insulin drip is based on trajectory as much as the current BG level. With the downward trend you've already got going, you really wouldn't want to speed that up any by starting the drip. If they level out and are still out of range, then starting the drip would be indicated. Although in general the recommendation is that you should avoid a drip. Many years ago, when goal ranges were often 80-110 or other low/tight goal ranges insulin drips were often needed to hit those goals. Under current recommendations however (typically 110-180), insulin drips should not be routinely used.