When to give insulin?

[kriegerkriegr]

When it comes to diabetics and giving insulin, I have seen a few methods out there:

-give the insulin only at meal times or at least have snack and juice in front of the patient.

-give the insulin at the time after the accucheck even if no food is in front of them.

I just wonder what the best way is and whats the rationale behind it?

For example, I was at the hospital last week for clinical's for school. A patients BS was 356, so according to the sliding scale, he was to get 8 units of Novolog. The nurse would not give it to him until dinner had arrived. Is that standard practice?

Help?

[classicdame, MSN, EdD]

Yes, waiting till a meal is present is appropriate for rapid acting insulin like Novolog. Regular should be given prior to meal if possible (up to 30 minutes as that is when it peaks). I recommend you google for insulin peaks, action time and active times and relationship to meals. There is a lot of good info out there.

As for sliding scale, the ADA and the Am. Asso of Clinical Endocrinolgists put out a white paper in 2005 regarding in-hospital diabetic management. One phrase clearly stated "there is NO indication that regular insulin sliding scale is effective". For many years that is all we had and some people cannot change their mind. It is appropriate in home settings, but not in hospitals. This is how patient's BS runs from 300 to 70 and they crash. Read up on them and you will see.

[phillycpnp-pc, MSN, RN, NP]

And with pediatric diabetics espeically toddlers, i give the fast acting insulin after they eat their entire meal (post dose)because they usually have tantrums/food adversions and not eat what is infront of him and we have to find something else they will eat. And their BG will drop if they get insulin before hand while someone is running around rerording food and looking for something else for them to eat.

[nurs1ng]

i believe u give aspart immediately after a meal

[SHGR, MSN, RN, CNS]

The very fast acting insulins can be given right after a meal, especially in the above type of instance (when you are not sure what will be eaten).

[SHGR, MSN, RN, CNS]

Fast acting insulin (Humalog, Novolog, Regular) usually takes about 15 minutes to be active, then works for 2-4 hours.

The above is incorrect.

Novolog, humalog, and apidra (the fast-acting analogs) have more similar onset, peak, and duration, and are essentially interchangeable. Regular is different. It takes longer to start working, peaks later, and lasts somewhat longer. We only use regular anymore for cost reasons. I find no other reason to use regular for ongoing home use. The newer rapid-acting analogs are much easier to titrate, better control a postprandial BG, and have less risk of between-meal lows.

[CDEWannaBe]

Thanks for correcting my typo hey-suz. Regular shouldn't be included with the super fast actings like Humalog and Novolog.

I've actually been an insulin user for 35 years (diagnosed at age 4) and have used all of these insulins at one time or another. I remember when Regular was the new, high tech fast acting. =) I'm pretty insulin sensitive so Regular would usually be active for me in about 20 minutes, which isn't that different than the super fast acting hitting my system in 15 minutes. Where I notice the difference is that the Humalog I use now is out of my system in about 2 hours. It's great not to have that Regular lingering around for 4+ hours and I have a lot fewer lows because of it.

You're smart to recommend that the super fast acting can be given right after a meal. It's the best way to avoid lows and dose accurately. The only time I took Humalog before eating was when I was pregnant and wanted to avoid any post meal rise.

[AllynaBerry]

My approach to the use of Novolog and Humalog was to give the dose after the tray was already in front of the patient - if they are eating well. If they might not finish their entire meal, wait until after they finished eating whatever they were going to eat, then, give according to carb counting ratio set by the CDE/RD.

I was a CDE for 10 years and soon discovered that insulin was (ans still is) the most mis-understood medication out there. There are more med errors related to insulins than any other medication -- that include errors by health care professionals as well as patients and families.

As for sliding scale, a better way to think of it is as a "correction dose"...meaning, to bring a high BG back down to a range that would be closer to "normal". It is not intended to cover food intake.

When I served as Clinical Educator, this was a topic that had to be repeated often. The "older" nurses tended to still think of Regular Insulin and were confusing the "newer" nurses who were too unsure of themselves to argue or do something opposite of the rest of the nurses on their shift. I would find them holding Lantus/Levemir for low BG's, waiting to give sliding scale until trays arrived, and not wanting to treat lows too close to meal time...or holding mealtime insulin after treating a low an hour or two earlier.

AB

[CapeCodMermaid, RN]

I work in long term care. Our docs still order sliding scale insulins 4 times a day which has been shown to NOT improve quality of life. They order the sliding scale coverage for 630 1130 430 and HS. Trouble is, the breakfast trays don't come till almost 8 am. We got cited by DPH for not following the manufacturers' guidelines of giving fast acting insulin 15 minutes before a meal. Everyone has their own opinion and everyone can cite a study or two. Insulin regimins need to be based on the individual person.

[curetype1]

Sure would make the patient and RN's life easier (not to mention a healthy happy patient) if the brittle and even not so brittle type 1 diabetics would/could be on insulin pumps.

[bclem05]

Hi guys, I'm really interested in how you deal with morning glucose checks. I work on a busy tele floor, currently night shift is doing the morning glucose checks and coverage around 6 AM, trays aren't passed till around 730. As you can see this is problematic. A little background information, my hospital is still stuck in the past in regards to DM management in that only about half of the patients have basal coverage although we are starting to see more and more and the majority of blood glucose control comes from a sliding scale, typically with the use of Aprida. Also we do 12s 7 to 7. So my question is who (day or night shift) checks the blood glucose and at what time? who is administering the insulin and at what time? and how fast are trays received after insulin is administered?

Thanks in advance

[smleahy11]

@bclem I work on a tele floor too. We do our accuchecks at the same time you do. I find that most nurses don't mind if you don't give the insulin as long as you tell them that you didn't give it. I personally do not like to give Novolog until the person is eating. I always tell the oncoming nurse, there accucheck was this, I didn't give the sliding scale. I did not want the blood sugar to drop and create a bigger problem for you. Hope this helps.

[suanna]

The problem isn't purely nursing judgement, but the doctors orders. In the case you gave- I wouldn't have had a problem giving the patient the ordered insulin- you had a LOT of room before you were in danger of a significant hypoglycemic episode. If the sugar was 86 with orders to hold or reduce the dose if bg