Transcript Insulin Admin - Pitfalls & Perils

Chris Harrold
SpR Diabetes & Endocrinology
 Diabetes
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15% of all inpatients
50% of those are on insulin
20% of patients experienced an insulin error
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National Inpatient survey 2011
 NPSA
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is common
16th June 2010
Right insulin
Right dose
Right time
Right route
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Intermediate & Long:
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BNF has 25 listed insulins
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All U100
Does not list Humulin R U500
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Short:
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Hypurin Bovine Normal
Hypurin Porcine Normal
Actrapid
Humulin S
Insuman Rapid
Novorapid
Apidra
Humalog
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Levemir
Lantus
Hypurin Bovine Lente
Hypurin Bovine Isophane
Hypurin Porcine Isophane
Insulatard
Humulin I
Insuman Basal
Hypurin Bovine Protamine Zinc
Mixed / Biphasic:
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Novomix 30
Humalog Mix 25
Humalog Mix 50
Hypurin Porcine 30/70
Humulin M3
Insuman Comb 15
Insuman Comb 25
Insuman Comb 50
 Right
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insulin:
Which humulin is this?
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Humulin I
Humulin 3
Humulin M3
 Right
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insulin:
Insulin is the only drug prescribed by brand name
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Insulin detemir
Insulin aspart
Insulin glulisine
Insulin lispro
 Right
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Dose
Abbreviations “U” and “IU” are NEVER to be used
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Can be misread as 0
 Deaths have occurred from misreading & misadministering doses
 Right
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Right time for the right insulin
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time:
Mixed insulins – Breakfast and evening meal
Short / rapid insulins – Mealtimes
Long / intermediate – Bedtime (and breakfast)
Not always true!
Factors beyond our control (i.e. Nurses)
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Right Insulin:
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Brand name, not generic
Right Dose:
Clearly written
 Changes dated and initialled
 DO NOT USE “U” or “IU”
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Right time:
Mixed insulins – Breakfast and evening meal
 Short / rapid insulins – Mealtimes
 Long / intermediate – Bedtime (and breakfast)
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Right Way:
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Prefilled (disposable) or 3ml Cartridges
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Lantus / Apidra – Solostar
Novorapid / Novomix 30 / Levemir – Flexpen
Humalog / Humalog Mix – Kwikpen
www.diabetes.nhs.uk/safu_use_of_insulin
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Indications:
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Keto-acidosis – fixed rate infusion
Diabetic Ketosis
Pre-operative
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If no more than one meal will be missed (brief starvation) then
manage with adaptations to usual regimen.
Sick patients who are not eating and drinking
General rules:
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If they can eat and drink they should not be on VRII
Continue long acting insulin (Lantus / Levemir) if already
taking.
Should not be stopped except when converting back to
usual treatment (e.g. SC insulin)
Give SC insulin (rapid / mixed) with meal, then stop
sliding scale after 30-60 minutes.
 Hypoglycaemia
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“4 is the floor”
15-20g fast carbohydrate
Recheck after 15 mins and retreat as needed
Replace carbohydrate
Look for a cause!
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Usually sulfonylureas (dirty drugs)
Metformin & gliptins do not cause hypos
If not able to take orally / unconscious
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IV 10% dextrose (160mls over 10 mins)
 Not 50%
IM glucagon 1mg (single dose)
 Hyperglycaemia
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Type 1 or type 2
How high?
Why high?
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Steroids, sepsis, missed / omitted insulin
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Treat the patient (not the nurse)
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4-6 units of Novorapid (or patients usual fast)
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Not Actrapid (oxymoron)
1 unit corrects by ~ 3 mmol/l
Look at why and how it can be prevented
 Dose
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Watch for trends and look for causes
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Avoid reflex dose adjustments
Allow sufficient time to see results
Hyperglycaemia
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Adjustment
Increase dose of appropriate insulin by 10%
 E.g. 20 units  22 units, 60 units  66 units
Hypoglycaemia
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Reduce does of appropriate insulin by 20%
 Renal
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eGFR <30 is the cut off for:
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Metformin
Gliclazide
What is safe?
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failure:
Saxagliptin (to eGFR 15)
Repaglinide
Insulin
Stop the unsafe drugs, monitor and treat if
needed.
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4 full time
OP clinics
 Antenatal
 Ward referrals
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Inappropriate referrals (sort it yourselves)
Dose adjustment of insulin for hyper / hypoglycaemia
 Dose adjustment of oral medication
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If you ask for our help, take it.
 Diabetes
Nurses / SpRs / Consultants
 www.diabetes.nhs.uk
 www.diabetes.nhs.uk/safe_use_of_insulin
 www.diabetesbible.com
 www.mims.co.uk