insulin question

Specialties Med-Surg

Published

*patient had levemir 30 units ordered and SSI. At 2100 pt fsbs indicated patient should get 8 units regular SSI in addition to levemir 30 units. Pts blood glucose bottomed out that night. The next night fsbs indicated another 8 units SSI should be given. Patient has active infection. So MD on call ordered to give SSI as ordered and hold levemir, at another facility we would have done just the opposite or decreased both doses. Can anyone explain the rationale behind this to me?.

Specializes in Palliative Care.

I don't understand the rationale, either. Our Diabetes Educator has always been adamant that long acting insulin is *always* given, regardless of CBGs or labwork. Giving the SSI and not long acting insulin would just allow for more swings in blood sugar.

That was my thinking to, this was an aprn giving the order. At the previous facility I worked we ALWAYS gave long acting unless levels were under 70. Furthermore we always held SSI if patients glucose indicated it if they had been having changes in there levels through the day as in the example above. The MD there may have decreased the amount of long acting insulin if we had increased the dose on admission or just started them on it as I worked on a stroke unit which caused increase in glucose after stroke which I was taught in nursing school infection increased glucose levels also, as the example above states. But this APRN says infection would make your sugar more labile or easily altered. I'd never been taught that so just trying to understand his perspective.

Specializes in Critical Care.

Which type of insulin needs to be held or adjusted due to low blood sugars is completely dependent on why their blood sugar was low, which can be due to either short acting or long acting. When a patient "bottoms out" in the middle of the night that is typically due to the long acting insulin since that is the one that is still active in the middle of the night (after the 2100 SSI dose has completed it's duration of action). How that should be adjust depends on the range the BG is running during the time that insulin is working. In general, when a hospitalized patient is having unstable BG levels, avoiding hypoglycemic events should be the first priority.

Specializes in UR/PA, Hematology/Oncology, Med Surg, Psych.

Agree completely. What time of night did the patient's blood sugar bottom out? Humalog hits its peak at 30-90 minutes with a duration of 3-5 hours.

Specializes in Med/Surg, Gyn, Pospartum & Psych.

I think we often take sick people off their long acting medications and just treat via the sliding scale so we are meeting their actual "sick day" needs. The medium and long actings are reintroduced before they go home. When they are in the hospital, they are not eating the same food or eating it on their "normal" schedule so the insulin schedule that works at home may not work at the hospital.

Specializes in Emergency, ICU.
I think we often take sick people off their long acting medications and just treat via the sliding scale so we are meeting their actual "sick day" needs. The medium and long actings are reintroduced before they go home. When they are in the hospital, they are not eating the same food or eating it on their "normal" schedule so the insulin schedule that works at home may not work at the hospital.

This is exactly what I've done in the hospital setting. It was actually put into a written protocol after events like what you describe. No long acting insulin until acute event is resolved. Patients were reintroduced to their home regimen prior to discharge.

Sent from my iPhone -- blame all errors on spellcheck

I always check the day priors glucose levels and see how they did with their long acting and sliding scale. I know with new admits this isn't always possible, but it helps see the trend the patient is following.

Typically, my rule of thumb is, If the patients levels are below normal (less than 70 at my facility), I will usually hold long acting just to be on the safe side (especially if they are NPO or something). If it's normal, between 70-110 I will give the long acting.

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