Sliding scale insulin...give or hold?

[Annie Wilkes RN]

I am still orienting in LTACH (Long Term Acute Care Hospital.) I disagreed with both my preceptor AND my charge nurse today, but I did not argue with them. I did what they recommended because I am still orienting and they have the upper hand. A patient's fasting blood sugar was 159 and he should have had 2 units of Novolog based on his sliding scale. However, they recommended that I hold the insulin due to his lack of appetite/poor intake for breakfast.

Please correct me if I am wrong, but I thought that sliding scale insulin is to be administered based on blood sugar RESULTS, not based on food intake.

What would you guys do? What do you recommend I do in the future?

Thanks.

A.Wilkes, RN

[Annie Wilkes RN]

Not sure...I only had him as a patient today and yesterday. Today all his fingersticks were under 150 mg/dl so we did not have to utilize the sliding scale!

[Anna Flaxis, BSN, RN]

159?? Fasting glucose? That is high for a fasting glucose.

1. What does the orders say? If the physician orders state to give 2 units for 159 you should give it. YOU ARE CORRECT! Sliding scales are designed to treat hypoglycemia despite diet. Sliding scales are not to treat for future food intake. It is to bring a person BG back to a normal range. ITs FOR CORRECTION. We will never know how much a person will eat!

Wrong. Rapid acting insulin needs to be followed by food intake. If you use it to "correct" for a pre-prandial CBG, and then the patient doesn't eat, you risk hypoglycemia.

Think of it like this. Say normal fasting BG range is from 70- 110. Anything above 150 is abnormal. THAT'S A MINIMUM 40 POINT BUFFER RANGE! (150-110=40) 2 units of insulin given at 110 or less may cause hypoglycemia. With that being said, your preceptor and charge nurse are implying that 2 units will make someone with 159 BG hypoglycemic? That means they will drop more than 89 pts to get below 70 (159-70=89). Also many ppl are not symptomatic until their BG level is about 50 (average). My fasting BG was 59 when my PCP checked me. (I was NPO for cholesterol studies) I was hungry and had hunger pains but I was driving, walking conversing just fine. So considering that, it's no way 2 units of regular insulin with drop a BG by 100 pts to cause symptoms where you would have to return and treat.

Again, wrong. Have you ever heard of relative hypoglycemia? For some folks whose bodies have acclimated to running at higher CBG levels, a CBG WNL can make them symptomatic.

I've work in an CVICU for 6+yrs. We use sliding scales for diabetics and non diabetics who are having stress hyperglycemia. We give 2 units if they are 150-170. I've never seen anyone get hypoglycemic getting 2 units when starting out >150. NEVER.

Managing stress hyperglycemia and managing diabetes long term are two different things. Plus, I'll bet that your patients who aren't taking PO are getting dextrose intravenously.

2. Why do we treat hyperglycemia? It places them at higher risk for infection in addition to increasing the risk of damage to blood vessels end organs. Maybe you should provide some research to your preceptor and charge nurse about treating stress hyperglycemia and the use of sliding scales. Furthermore they are telling you to go against physician orders based off of ignorance and fears. So the patient suffers from hyperglycemia because of it.

No, her preceptor works in a different setting than you do. Aggressive blood glucose management in the post surgical setting is best practice well backed up by evidence. You might want to consider that management of blood glucose in other settings is not from the same cookie cutter.

Did the physician orders state, "Hold if pt has no appetite"? If they want you to hold it, you should have the preceptor/charge nurse call the physician to obtain and order to not give the medication to cover yourself. They have to have a better reason to go against a physician order than a low appetite. That's for holding ANY MEDICATION. Any nurse who feels the need to hold should call the physician and clarify the order or get orders to hold.

A thinking nurse who knows her meds and her pathophysiology is capable of using nursing judgment to determine whether it is safe to administer a medication or not. It's called "critical thinking", and it is what we are taught to do in nursing school.

I do agree that if the nurses are routinely holding the dose because of poor PO intake, then the physician needs to be notified. This could indicate a change in patient condition that needs to be medically evaluated.

But, knowing that if the patient is not eating, then rapid acting insulin should not be given (unless the patient is receiving some form of glucose, such as dextrose containing fluids) is basic nursing critical thinking.

[canigraduate]

From Novolog's website:

• NovoLog® is fast-acting. Eat a meal within 5 to 10 minutes after taking it.
  

From Humalog's website:

Hypoglycemia is the most common adverse effect of Humalog therapy. The risk of hypoglycemia increases with tighter glycemic control. Severe hypoglycemia may be life threatening and can cause seizures or death.

I think it's more important to hold it and let patients be a little high than give it and make them go too low.

[Bobjohnny]

One of the fundamental rules with fast acting insulin is not to give it if the patient is NPO, whether per order or voluntarily.

Sorry, but I have to disagree with this. There are many situations that patients are NPO & should still receive insulin, even with a BG under 200. It's not a rule, more like a general guideline. Admittedly, most situations that a patient is receiving insulin while NPO is due to receiving nutrition via a different route.

[canigraduate]

Sorry, but I have to disagree with this. There are many situations that patients are NPO & should still receive insulin, even with a BG under 200. It's not a rule, more like a general guideline. Admittedly, most situations that a patient is receiving insulin while NPO is due to receiving nutrition via a different route.

Oh? Can you give me an example? I only give it when the patient is receiving dextrose or is getting TFs.

[morte, LPN, LVN]

a sliding scale is to return a patient to normal, it is different than the routine carb counting premeal fast acting insulin, totally different use. yes, he should have gotten the 2 units, as proved by his later BS of over 200. good call.

[NobleLeo]

I would have given it and encouraged at least some juice. You can always test them if you end up being concerned that the patient is dropping to a concerning level. But always listen to people who are aware of how they react to insulin. Some people can drop dramatically and others it might not even touch.

[MunoRN, RN]

A correctional dose is to treat what their BG is right now and has nothing to do with eating. When used as a nutritional dose the patient does then need to eat, because the amount given isn't based on what the BG is now but what it's expected to be due to eating.

If they aren't eating the patient still needs the correctional dose, only the nutritional dose should be held.

The purpose of administering insulin is to allow for proper glucose metabolism. Without sufficient insulin to go along with circulating glucose, regardless of whether or not that glucose comes from food they're about to eat or from their body's stores of glucose, the patient won't produce and metabolize that glucose properly.

[MunoRN, RN]

No, her preceptor works in a different setting than you do. Aggressive blood glucose management in the post surgical setting is best practice well backed up by evidence. You might want to consider that management of blood glucose in other settings is not from the same cookie cutter.

That was thought to be true up until the last few years, all current recommendations are for less aggressive BG control, typically 110-180. The 'old' 80-110 recommendations for some post-op and critically ill patients no longer exist from any professional practice group, all advise a goal of

[KatieMI, BSN, MSN, RN]

A big, big positive of LTACH is that there are plenty of opportunities to figure out how a particular patient reacts on his meds. We do intensive diabetes management all the time and teach patients and families so they could do it at home.

Now, to the case. Insulin works in fat, muscle and liver, primarily. If patient is LOL who does not have a lot of fat and muscle, she therefore should have less active sites in her body for insulin to enter cells and do its job. Therefore, the rule of thumb "one unit of insulin equals 12 to 15 points of decrease of FCBG" will most probably slide to lower number -meaning that hypoglycemia will be less possible, providing that patient has relatively preserved liver functions.

Chronic critical illness syndrome, which is common among LTACH population, has resistant hyperglycemia as one of its most prominent features. The effects of hyperglycemia remain the same, of course, therefore it should be treated aggressively.

Unless the patient has known "baseline" of very high CBG like above 250 all the time and "relative hypoglycemia" is a known issue, I would give that LOL those 2 units whether she ate or not. Even if insulin will work as it is described in textbook, her expected CBG would be 159 - (15 x 2), or about 120, and most probably higher still for the reasons stated above. If she would have order for prandial coverage PLUS sliding scale, i would give prandial only. I would check CBG in an hour and decide from there.

Last but not least - I have to do med reconciliations with SNFs and home health and lost count of cases when old, frail patient was given every single pill and shot someone prescribed sometimes back for unknown reason with single indication "it was ordered, and so that nurse gave it". The classical finding is giving close meds from the same pharmacological group but with different names simultaneously, with corresponding rise of side effects, thus sending the poor old thing in ER. And do not even start about patients "resistant to Levophed" whilst taking those 100 mg of Lopressor, BID.

[Bobjohnny]

Oh? Can you give me an example? I only give it when the patient is receiving dextrose or is getting TFs.

In addition to the 2 examples you provided: DKA, TPN. Diabetic patient that is post-op but still NPO. Those are the easy ones, I'm sure there's something I'm not thinking of in my current sleepy state.

[Anna Flaxis, BSN, RN]

That was thought to be true up until the last few years, all current recommendations are for less aggressive BG control, typically 110-180. The 'old' 80-110 recommendations for some post-op and critically ill patients no longer exist from any professional practice group, all advise a goal of

Good to know. I've been out of the perioperative arena for a few years.