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??

[lsyorke, RN]

I've never heard this, and I'm married to a Type I diabetic. Ask her where she got this information.

[ritarunningfeet]

I also have never heard anything like this before?

[SNlena]

Me neither, but that teacher failed me after 3 days at clinical, and when we had a meeting to discuss what happened, she was saying that I put my patient in danger because the food wasn't directly in front of him (it was in the hallway being passed around), and that he would have went into a coma in 5 minutes (his blood sugar was almost 300 when I was about to give the insulin shot)... When I pointed out a 15 min onset, she said that I must take his medical conditions into account, because CHF and pleural effusion will make the insulin act so much faster...

I also gave Aspirin 81mg and Plavix, and she said that I didn't check INR, and that it's hospital's policy to check INR... I don't believe it either, and I am trying to get a copy of that policy...

I checked the platelet's in the patient's chart, which were normal, so I didn't write it down NEXT to the medication... and now she is claiming that I never knew it... It was my mistake not to actually WRITE it down, but it was the FIRST DAY!!!! and I was put on probation for that...

[NurseCherlove]

Me neither, but that teacher failed me after 3 days at clinical, and when we had a meeting to discuss what happened, she was saying that I put my patient in danger because the food wasn't directly in front of him (it was in the hallway being passed around), and that he would have went into a coma in 5 minutes (his blood sugar was almost 300 when I was about to give the insulin shot)... When I pointed out a 15 min onset, she said that I must take his medical conditions into account, because CHF and pleural effusion will make the insulin act so much faster...

I also gave Aspirin 81mg and Plavix, and she said that I didn't check INR, and that it's hospital's policy to check INR... I don't believe it either, and I am trying to get a copy of that policy...

I checked the platelet's in the patient's chart, which were normal, so I didn't write it down NEXT to the medication... and now she is claiming that I never knew it... It was my mistake not to actually WRITE it down, but it was the FIRST DAY!!!! and I was put on probation for that...

I've never heard of such a thing either and I am one of those who would know weird little factoids like that. I have also never heard of routinely checking the INR before giving plavix or baby aspirin, especially if patients have been on these meds. Even with invasive vascular procedures, MDs pretty much always want you to still give the plavix and ASA on the morning of (usually hold things like lovenox). Now, if the PTT/PT/INR was really out of whack, you would be calling the MD anyway, at which time you would then tell him about any anticoagulation drugs the patient is on and you would also mention that the patient is taking ASA.

She is nuts...I would have to contest her failing me if I were you! Tell her that you have asked several RNs about these matters and to please show you some kind of documentation of this info.

[SNlena]

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.

[Myxel67]

Most of this is news to me. There are many drugs that will either potentiate the action of insulin or diminish its action. Drugs may also afect insulin resistance or insulin sensitivity. In my hospital, Dietary now calls the floors when the meal trays are ready for delivery--floors get about a 15 minute notice of when trays are coming. The purpose of course is so that insulin can be given before the meal arrives.

Even though the onset of action of Novolog, Humalog, and Apidra is 5 to 15 minutes, the insulin concentration in the blood doesn't peak until about an hour later. The pt doesn't feel the physiologic effects of the insulin until 2 to 3 hours after injection (this is time risk for hypoglycemia is greatest). Insulin doesn't work instantaneously, even if it's given IV.

Waiting until the tray is in front of the pt is a little ridiculous and teaches nurses to be way too cautious where insulin is concerned. In hospitals pts are much more likely to be given too little insulin too late rather than too much insulin too soon.

Below is a link to an article that discusses the effects of beta blockers on diabetes control and insulin sensitivity.

http://www.drmirkin.com/heart/7642.html

[TraumaICURN]

What I think the teacher may be referring to since the pt has a history of HTN is beta blockers. Beta blockers tend to mask the s/s of hypoglycemia.

I don't know if your pt was on beta blockers or not, but that is my best guess.

[CRNI-ICU20]

First, one would have to know WHY a patient was put on Plavix and ASA in the first place....Afib? HX of CVA, TIA?

The target INR is different for different patient populations, with a different goal in mind.

So, writing an evaluation based on "life threatening bleeding issue" is vague and nebulous. ANY patient on coumadin, plavix, aspirin can have life threatening bleeding issues! It just depends on alot of factors...ie, platelet count, hemogram, liver function, and other underlying disease processes, including age, and even gender.

The evaluation seems a bit over the top....

I would agree that one must check the INR before continuing with anticoagulant therapy....we have had plenty of patients come into the hosp. from nursing homes with INR's of 7.0 and no one had checked the INR for days before administering anticoags.

It is quickly reversed with Vit K, and FFP, and sometimes transfusion therapy, along with stopping the drugs...

here is a scholarly article that may be of help to you:

http://doctor.medscape.com/viewarticle/515490_2

As for the insulin vs. CHF, Emphysema, Pleural effusion, HTN, Diabetes, etal:

I think that she is mistaken about the insulin working faster in a CHF/Pleural effusion patient....simply because these patients are typically on steroidal inhalers, and IV Solumedrol as a standard of treatment, which RAISES the blood sugar levels....so this criticism seems farfetched...

I would respectfully ask her to show me an article or some clinical documentation (study, drug insert, text book) that would back up her statements....I have never in 20 years of hard core ICU nursing ever heard this....

In fact, if you think about metabolic processes in a CHF patient with emphysema, most metabolic processes are decreased...not increased....because the oxygen/cO2 exchange is impaired....these patients are typically rarely hypoglycemic....

The only instance where I might be concerned about insulin reaction, and having a tray of food directly in front of the patient when monitoring blood sugars, would be when a fast acting insulin is given...ie NOVOLOG....or if they are on any oral fast acting diabetic medications...metaformin, for instance.

There are too many variables when it comes to carbohydrate metabolism and CHF....gastric absorption, for one....

I trolloped all over the web looking for an article to support her assumption, and was unable to find anything remotely close...

I will ask one of my intensivists when at work next about this....I suspect she is really out of bounds here, without an evidenced based leg to stand on....

I will get back to you on this...because, now it's got my curiosity perked....we should always wonder about things, as nurses....

I hope you get re-instated....hang in there...

[Myxel67]

Here's a link to an article printed in DocNews--an ADA publication. The article discusses the likelihood that beta blockers might blunt the s/s of hypoglycemia.

http://docnews.diabetesjournals.org/cgi/content/full/3/5/5

JAMA article:

http://jama.ama-assn.org/cgi/content/abstract/278/1/40

[Myxel67]

:balloons:

p her statements....I have never in 20 years of hard core ICU nursing ever heard this....

The only instance where I might be concerned about insulin reaction, and having a tray of food directly in front of the patient when monitoring blood sugars, would be when a fast acting insulin is given...ie NOVOLOG....or if they are on any oral fast acting diabetic medications...metaformin, for instance.

:balloons: :balloons: :balloons:

Even Novolog won't work so fast that you need to eat immediately after injection. In fact, with a BG of 300, it's better to give rapid acting insulin 30 minutes before the meal to give it a chance to bring the BG down a little before more carbs come onboard. One reason to give rapid acting insulin later is if pt has poor appetite (also good for children). Insulin can be given right at the end of the meal when you can take note of the carb content of the meal and adjust dose if poor intake. (This won't work with regular insulin though since it needs to be given 30 - 45 minutes ac.)

Metformin does not cause hypoglycemia--it's primary effect is lowering hepatic glucose output which can elevate BG. It does have a slight sensitizing effect, but again, this will not produce hypoglycemia. Hypoglycemia is not a risk with Actos, Avandia, or Januvia either.

The oral DM meds that can lead to hypoglycemia are those that stimulate the production and release of insulin: Glipizide, glyburide, Amaryl, Starlix. and Prandin are several. These can be taken a half hour before a meal. The biggest problem with the first three is that they are long acting. If pt takes med before breakfast, a delay of lunch may result in low BG. These are not good choices in the hospital when pt may be off floor for procedure or test. Also may result in low BG if kidney function is compromised and drug remains in system even longer.

[SNlena]

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...