Very Low Dose Insulin Administration

calivianya, BSN, RN · Oct 9, 2015

That's ridiculous. I get that every little bit of insulin counts, but I honestly think I would roll my eyes pretty hard if I ever got told to give half a unit of insulin.

MunoRN, RN · Oct 9, 2015

There probably isn't much difference between given 0.5 units lispro and giving none at all, why are you giving 0.5 units?

mmc51264, BSN, MSN, RN · Oct 9, 2015

that is ridiculous. Our ss usually starts at glucose over 200 and goes up by 1 unit per 50 points over; up to 350 at which time, if it is >350, call provider.

ILoveMyJobRN · Oct 9, 2015

It is rare that we need to do this, but our diabetes team developed this Very Low scale for a few very insulin sensitive pts. (We also have Low, Medium, High scales--all start at FSBG of 150.)

KatieMI, BSN, MSN, RN · Oct 9, 2015

We had situation like that a few times with patients super-sensitive to short-term insulin (yes, there are some of them who react on 0.5 units... insulin-dependent ETOH abusers well onto their way to cirrhosis can be super-sensitive). The bosses' verdict was that if it is ordered 4,5 units, then it is gotta be 4,5 units, and it should be our problem how to manage without safety needles. In a few days (during which nobody was accidentally pocked) we got pens and problem was solved.

If absolutely, 100% nothing else and 0.5 units is ordered, I would wonder if it would be ok to draw 0.5 cc from standard drip bag made by pharmacy (1 ml=1 unit). It seems for me to be a little bit more precise than breaking one's eyes in between those tiny points and can be done with any standard syringe.

FineAgain · Oct 9, 2015

I honestly think I would roll my eyes pretty hard if I ever got told to give half a unit of insulin

I roll mine when I have to give only 1 :)

Dogen · Oct 9, 2015

Generally speaking, I find hospital sliding scales kind of ridiculous. Every hospital I've seen makes a mockery of counting carbs if they do it at all (how many, "My diabetic patient got macaroni, mashed potatoes, and a brownie with dinner" stories have you heard?), and correction factors are loosely connected to patient phsyiology. The only order set I've ever seen that made sense to me as a diabetic is insulin drips titrated to CBGs, rather than a 3-sizes-fit-all protocol. Based on my own insulin sensitivity and correction factor I don't fit into any of the protocols at my hospital... but I have a kickass endocrinologist who has promised to call in orders if I ever get admitted.

There's a reason Animas pumps can set basal rates as low as 0.025units/hr, and why most insulin pumps bolus as small as 0.05 units. Because there are people who are extremely sensitive to insulin and need doses that small. Sure, stress and illness will increase the need for insulin, but it's not weird to me - as a diabetic - that someone has a protocol for people with very high sensitivity. It seems about time, really.

OP, we don't have a protocol like yours, but if you can't get safety syringes in 0.5-unit increments then you really only have pens as an option, right?

Nurse Leigh · Oct 9, 2015

My mother was diagnosed with Type 1 diabetes more than fifty years ago. Of course, testing and treatment options were a far cry from what we have today.

One of her physicians told her a hospital is about the worst place for a Type 1 diabetic - they can't maintain the testing/medicating/eating schedule they have at home. And those sliding scales seem more suited for Type 2 IDDM.

My mother's endo NP is also kickass and we work well with him and trust his expertise.

I was so annoyed earlier this year when she was admitted by a family practice resident. Other specialties have really screwed up her routine by changing the type and amount of insulin she gets.

I pushed for the resident to consult the endo NP which she grudgingly did agree to. She told me he wouldn't round til the next day, which of course we realized. And yet, this eager resident *still* changed the insulin type and scale without talking to us, even though her specialist would be in the very next day. :rolleyes:

I know the residents have to learn, but they also need to understand when to consult, and learn from those specialists when possible.

It is my understanding that med school does not always give a thorough education on diabetic endocrinology.

Umm, sorry for jumping on my soapbox again! If they are going to continue to order small increments of insulin I hope they order the necessary supplies. (But I also know better than to hold my breath)

ILoveMyJobRN · Oct 9, 2015

Pens seem to be the answer we need because you can dial in 0.5 unit. Did not know that pumps can give that low of a dose. Thank you for your input!!

We have a system of timed FSBG's (0715/1130/1645) followed by Diabetic tray delivery at 0730/1145/1700 with phone texts to let RN's know all diabetic trays have been delivered on our floor. They can then give their patients Compensatory and Prandial (carbs are printed on a piece of paper on the tray) coverage as the pt starts to eat their meals (which they have ordered from Room Service.) Has worked well and reinforces the FSBG/give my insulin/eat my meal that patients should be following at home.

blondy2061h, MSN, RN · Oct 10, 2015

Sliding scale insulin, while commonly used in a hospital setting, is pretty dated in an outpatient/tight glycemic control sense. It seems with all of those sliding scale options, your providers are very interested in tight control.

It's not uncommon for young/skinny/ill type 1 diabetics to be extremely insulin sensitive. In times past, this was dealt with via diluted insulin (U-40, instead of standard U-100). Special U-40 syringes were sold. Some people would also dilute insulin at home. Dilutants are still available for some insulins, I believe, but in an era of pumps that can deliver 0.05 units, this has gone the way of the dodo. You can imagine the dire consequences of drawing up U-100 insulin in a U-40 syringe and giving over twice the intending amount. Early insulin pumps would also have a U-40 setting to use that insulin, and if loaded with U-100 insulin and set to U-40, the results could be awful. As you've mentioned, half unit syringes are available for home use as well.

Now with ever increasing type 2 populations with insulin resistance, the opposite is happening. U-200, and U-300 insulin formulations are becoming available to let these people take huge doses in smaller volumes. For safety reasons, these are being sold strictly in prefilled pens.

So going back to your issue- I could conceive a few possible solutions.

One would be to increase the half unit correction to a whole unit correction, but add a snack in or decrease the meal insulin dose to cover that amount. Give the person a whole unit and make them eat an extra 15 grams of carb with it?

Or, you could get use diluted insulin. For safety reasons, this would be a hard sell. You'd have to ensure that all of the diluting occurred in pharmacy, and likely have pharmacy send up individual prefilled syringes clearly labeled.

Even pens I've seen that dose in half units only will do half unit increments after the first unit.

MunoRN, RN · Oct 10, 2015

Pens seem to be the answer we need because you can dial in 0.5 unit. Did not know that pumps can give that low of a dose. Thank you for your input!!
We have a system of timed FSBG's (0715/1130/1645) followed by Diabetic tray delivery at 0730/1145/1700 with phone texts to let RN's know all diabetic trays have been delivered on our floor. They can then give their patients Compensatory and Prandial (carbs are printed on a piece of paper on the tray) coverage as the pt starts to eat their meals (which they have ordered from Room Service.) Has worked well and reinforces the FSBG/give my insulin/eat my meal that patients should be following at home.

I don't actually know of any pens where you can do 0.5 units, we use Lispro "Kwikpen" and they only do whole units. The Novopens I've seen also do only whole units.