Very Low Dose Insulin Administration

Dogen · Oct 10, 2015

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.

It's the super fancy Novolog Echo. The NovoPen Junior also did half-unit dosing, if I'm not mistaken, but I don't know much about it because I never used pens. There's a HumaPen that doses in half-units, but only after the first unit.

ILoveMyJobRN · Oct 10, 2015

Thanks for your comments! So you are saying that insulin pens will not give only a 0.5 unit?

You stated that "sliding scale...is pretty dated". What would be the best way to give insulin in the hospital (other than everyone having Continuous Glucose Monitors and Insulin Pumps?)

Yes, our practitioners are very interested in 'tight control.' We also use lantus with the Compensatory/Prandial coverage of many of our diabetics. I have had more difficulty lately encouraging my young/skinny diabetic pts to take in enough carbs...to cover their lantus, so asking them to eat more would be difficult. The diluted insulin is an idea we had not thought of, but see the potential for errors... It is very rare that we need the 0.5 unit, but when we do we have this dilemma. THANK YOU again for your input!!!

Dogen · Oct 10, 2015

Thanks for your comments! So you are saying that insulin pens will not give only a 0.5 unit?

The Echo, linked above, definitely does. It gives doses of 0.5-30 units. I'm just not sure about the others.

MunoRN, RN · Oct 10, 2015

It's the super fancy Novolog Echo. The NovoPen Junior also did half-unit dosing, if I'm not mistaken, but I don't know much about it because I never used pens. There's a HumaPen that doses in half-units, but only after the first unit.

I believe the echo is replacing the novopen junior as their pediatric pen, and while it's a very nice pen it's also not disposable and costs about $65 without any insulin in it, the replaceable insulin cartridge can put it over $100. It's pretty unlikely that a facility would pay for these just for inpatient insulin coverage, where a patient might need 4 units over the course of their whole stay.

canigraduate · Oct 10, 2015

Honestly, if I got an order like that, I'd call the doc and tell him to bring me some syringes. Especially if this was something new and we didn't have any practical way of following the orders.

I've always talked to the patient about their routine, then called the provider and talked them into giving the patient what works for them.

I've even gotten an order for the patient to manage their own BG in the hospital, with them notifying the RN of their BG levels and insulin units.

For the most part, though, I don't bother with 1 unit, much less half a unit. It makes zero difference on my patient population.

bloatedputti, MSN, RN · Oct 10, 2015

Let's be cost conscious here. Pens, drips from pharmacy, compounded diluted insulin?? Just use a non safety needle. Not all injections have safety needles. The old saying "don't recap" will work just fine here.

iluvivt, BSN, RN · Oct 10, 2015

The Migden Bill says that you can you a non=safety sharp if there is no other product that meets your needs that comes as a safety sharp! I use an echo tip needle that is non safety..no problem.

Dogen · Oct 10, 2015

The Migden Bill says that you can you a non=safety sharp if there is no other product that meets your needs that comes as a safety sharp! I use an echo tip needle that is non safety..no problem.

... in California.

Honestly, I think a non-safety, 0.5-increment syringe is the smartest option, but I'm not a hospital risk manager. Just a diabetic who has given himself 53,000+ injections and only stuck himself once or twice (once I was doing it in the dark and stuck myself in the thumb... briefly considered just putting the insulin in the pad of my thumb to see what would happen... didn't).

LindaThornton · Oct 10, 2015

I feel like its a waste of my time to draw up 1 unit sometimes but I do it anyway,I have a guilty conscious if I think about not doing it.But half?wow.I get it about the new ultra concentrated doses and the very sensitive people,If I was super pressed for time I might think about not poking the patient to give them that amount via regular old style needle because I do not believe they would get anything but pain.

Ideally I like to verbalize what the cbg is and what the dose of insulin is for that per ssi,it messes up my usual practice with this if Im not consistant.I always hope that people do care and want to know and want to keep cbgs in range.

Dogen · Oct 10, 2015

I feel like its a waste of my time to draw up 1 unit sometimes but I do it anyway,I have a guilty conscious if I think about not doing it.But half?wow.I get it about the new ultra concentrated doses and the very sensitive people,If I was super pressed for time I might think about not poking the patient to give them that amount via regular old style needle because I do not believe they would get anything but pain.

This doesn't make any sense. The reason they need so little is because they get so much out of insulin. Half-unit dosing is most common in thin, small kids who may have a correction factor of 1:100, 1:150, or even higher (that's 1 unit of insulin drops their CBG by 150 points). If their CBG was 210 and your protocol called for 0.5 unit and you gave 1 you could throw them into hypoglycemia, but giving them nothing is also a pretty bad idea.

The main point here, though, is that not giving a diabetic patient insulin just because it's a very small amount is kind of like not giving someone their 0.25mg of clonazepam, their 0.2mg beclomethasone, their formoterol 0.12mg, or their 0.3mg of atropine. If a small dose is what they need, then you give them the small dose. Period.

This thread is the reason I never let other RNs manage my diabetes.

VANurse2010 · Oct 11, 2015

For all the complaining that diabetics do about their insulin in the hospital -sometimes legitimately and sometimes overdramatically - tight control, many times, isn't even appropriate in the acute setting

jelnurse · Oct 11, 2015

It seems pretty reasonable to insist that you have proper equipment to administer all doses safely and accurately. If your superiors say the right syringes would cost too much, do a little research to find the cost of the syringes you need. Maybe another supplier can deliver them no more expensively than what you use now.

If the prescribers are also researchers, you might ask them how important accurate dosing is to finding reliable results from their research. If they're researching the very low dosing, they WANT to find an effect. Maybe if you get them to think the right syringes will make it more likely that they find an effect that allows them to publish the results, they'll get you the right syringes. It's worth a try. Researchers want to find results, and accurate measurement is essential to all research.

If you have any sort of regular staff meetings with superiors and coworkers all present, bring up this issue and express concern about the accuracy of the doses. Make sure you don't look or sound incompetent. Don't say you're not doing it right, but explain simply and briefly that the right syringes would make it more reliable that you give people the correct very low doses.

Don't try to embarrass superiors, but let them feel a little pressure in front of others to recognize that right dosing is essential and that the right syringes are necessary to administer the right doses. Bring it up in terms of patient safety and quality of care, and maybe you'll get the syringes you need. Doing it in a staff meeting - if you have regular such meetings with superiors, might put a little more pressure on superiors to do the right thing. That might be hoping for too much, but it's worth a try.

Getting the right syringes seems like a reasonable thing to expect. You're not asking for a million-dollar piece of equipment, simply the right size syringes.