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31.03 Insulin Drips

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Overview

Insulin infusions are commonly seen in the ICU in DKA, post-surgical, and critically ill patients. It is used to quickly decrease blood sugar levels in a very controlled environment.

Nursing Points

General

  1. Insulin infusion
    1. Understand WHY the patient needs it
      1. DKA
      2. Post-surgical
      3. Critically ill
  2. When initiating the infusion
    1. Follow your facility’s protocols
    2. Know the target blood glucose
    3. Insulin infusion is weight-based
  3. When starting the infusion
    1. Obtain a blood glucose
    2. If it is greater than 160 then start the insulin infusion at (kg x 0.025 units)= units per hour
    3. 70 kg x 0.025 units = 1.75 units /hour
    4. Recheck blood glucose in 1 hour
    5. Depending on the results and the protocol either titrate insulin up or down
    6. D5 NS to infuse in a separate line depending on blood glucose level
  4. Nursing considerations
    1. Monitor blood glucose every hour while on an insulin infusion
    2. Monitor for s/s of hypoglycemia
    3. Do not decrease blood sugar too rapidly
    4. Monitor potassium
      1. IV insulin can push potassium into cells decreasing serum potassium
      2. Hyperkalemia is treated with IV insulin

Assessment

  1. Insulin infusion
    1. Understand WHY the patient needs it
      1. DKA
        1. Rapid onset
        2. Easily titratable
      2. Critically Ill or post-surgical patient
        1. Elevated blood glucose levels can compromise healing/outcome
        2. Know the patient’s glucose baseline
        3. A1C
  2. When initiating the infusion
    1. Follow facility protocols
    2. Know the target blood glucose
  3. When starting the infusion
    1. Obtain a blood glucose
    1. If it is greater than 160 then start the insulin infusion at (kg x 0.025 units)= units per hour
      1. 70 kg x 0.025 units = 1.75 units /hour
    2. Recheck blood glucose in 1 hour
      1. Depending on the results and the protocol either titrate insulin up or down
    3. D5 NS to infuse in a separate line depending on blood glucose level
  1.  IV. Nursing considerations
        1. Monitor blood glucose every hour while on an insulin infusion
        2. Monitor for s/s of hypoglycemia
        3. Do not decrease blood sugar too rapidly
        4. Monitor potassium
          1. IV insulin can push potassium into cells decreasing serum potassium
          2. Hyperkalemia is treated with IV insulin

Nursing Concepts

  1. Glucose metabolism
  2. Acid Base balance
  3. Clinical judgement

Reference Links

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Video Transcript

Hey guys, in this lesson we’re going to talk about insulin drips. So basically an insulin infusion is a medication that should be taken very seriously. Patients can quickly become hypoglycemic because we have insulin infusing in their Iv continuously, it is very commonly seen in ICU patients in my hospital. If you’re going to be on an insulin drip, the patient needs to be in ICU. It’s not allowed to be on the floor. So usually you see it with the ICU patients, DKA or postsurgical or the very critically ill patients, even if they’re not diabetics. I’ve seen patients on insulin drips because they are hyperglycemic because of the stress their body is under because of the illness. So they need to get placed on an insulin drip. But the reason why it is done is because it quickly decreases blood glucose in a very controlled manner because people are checking the glucose regularly and titrating the insulin infusion. It’s easy to control it. Again, and this is something that we want to do because people who have tighter glycemic control have better healing with surgeries or whatever illness they have. So it’s again, very common. So let’s talk about this. So if you have a patient that has an insulin infusion or you just received an order that you need to start an insulin infusion, great, don’t freak out. The most important thing you can do is know why your patient needs it. Are they a diabetic? Are they in DKA? Is there ketones that somebody saw that you just don’t know about? Find out why the patient needs it because this will obviously make you a better nurse. When initiating the infusion, make sure that you follow the facility’s protocols. The facility I work at has a set of instructions on what to do when you do start an insulin infusion.

So make sure that you guys follow your facility protocol and know the target blood glucose. And of course the patient’s weight. The reason why you want to know the target blood glucose is because is the target blood glucose 150. Then that’s what we’re aiming for. Okay. If their blood sugars are 800 and they just want to get it down to 200. Okay so know your target blood glucose this is a very good starting point when you do start an insulin infusion. So when you start the drip, the first thing that you need to do is obtain a blood glucose. You got to know what baseline is. If you can look at the patient’s A1C, that’s even better because at least you know that they have been elevated. So if you have an A1C, great. If not, get a blood glucose, get no blood glucose for the last few hours.

So at least you know what you’re dealing with at my facility. If the blood glucose is greater than 160, then you start the insulin infusion at 0.25 units per hour. So let’s do some math really quickly. If any of y’all have listened to the dimensional analysis video, go check that one out cause we do several math problems. But just because let’s go ahead and do it over here. So I need to run it at 0.025 units per kg. Let’s say my patient weighs 70 kilos. So that would be 0.025 units times 70 kilos, which would make it 1.75 units per hour. Most insulin bags, when you get them, they are a hundred milliliters and it’s usually a one to one concentration, meaning it’s a one unit per ml. So just right off the bat, I would know that I would need to run it at 1.75 mls per hour.

This is very good and very easy and it’s very useful for the nurses because when you titrate it, you know what it’s going at so that at least you know exactly how many units per milliliter it is. So once you start this, so let’s say if we were going to start this on this patient that weigh 70 kilos and his blood sugar is 180 so we’re going to start at 1.75 units per hour. And let’s say I start it at 10 o’clock and then what I do after that is at 11 o’clock I’m going to come back and check his blood sugar. If for whatever reason his blood sugar is two or three depending on the protocol, I kind of look and I multiply this number maybe by like 1.2 or whatever. So this doesn’t change much. So maybe and again I’m not being exactly accurate, but maybe it would change to two mls per hour.

And then at 12 o’clock I check it again and let’s say at 12 it was one 73. Well then I would decrease it again according to the protocol and the little formula that they would give you. Let’s say I decrease it to 1.5 mils per hour and then at one o’clock I check it again and it’s one 70 well, I may go according to the protocol, either leave it running at 1.5 or decrease it or more than likely increase it. So again, check your facility protocol because it is very, very detailed and very laid out on how to adjust that insulin. One piece of advice that I can give you guys is I know that usually they say check the blood glucose in one hour, but if you’re going to start insulin Iv, check it a little bit more often when you first start just to make sure that you’re not dropping that blood sugar too quickly.

So, again, depending on the results and the protocol, either titrate the insulin up or down. And this is one of those things that you do this through the entire day. You check that blood sugar every hour and hopefully you get to a point where it just stays stable and you don’t have to titrate that insulin up or low, higher or lower. Now at my facility, usually we have to have D five normal saline to infuse in a separate line depending on the blood glucose level. Now what that means is if here’s my insulin and that’s going to be a 100 ml bag and here’s my tubing going to my patient over here, I’m going to the patient also in a separate line and this is usually done so that the blood sugar doesn’t drop too quickly. I mean you are giving them insulin in the Iv this kind of gives them a little bit of sugar.

Sometimes you can just do normal saline instead of of D five or normal saline. Depending on the orders, depending on what the doctor orders, depending on their blood sugar, you will do one or the other. Again, we usually do D5, either at 50 mils per hour or 25 mils per hour depending on the patient and depending on their blood sugars and if they’re eating or not. So again, as long as they’re on the insulin drip, you’re going to check this every hour or sooner if you need to. Nursing considerations, I feel like I’ve said this a hundred times, I can’t say it enough. Monitor the blood glucose every hour while they are on an insulin infusion. Remember that they can become hypoglycemic very easily. So continuously monitor for any hypoglycemia. Make sure that you don’t decrease the blood sugar too rapidly. You don’t want to do that because sometimes they can have signs and symptoms of hypoglycemia. Because of the fluid shifts they can also have cerebral edema.
So you don’t want to drop it too rapidly. You don’t want to go from 900 at 10 o’clock in the morning to 130 at 11 o’clock. This, you know, you would think, Hey, this is good. You did good. No, this is too much too quickly. They can have the cerebral edema, they can have signs and symptoms of hypoglycemia. They can have too many complications. So you want to take it slow ain bringing down that blood sugar. And then you also want to monitor their potassium. You do monitor all electrolytes, but specifically potassium. When insulin regular insulin is given IV, it actually pushes their potassium into the cells. So that decreases the serum Potassium meaning the potassium, the 3.5 to 5.5, it’ll go down because the potassium is going into the cells because of the insulin that we are giving.

So if somebody is on a continuous insulin infusion, you want to make sure that you monitor for them for hypokalemia or hyperkalemia or just monitor them so that their blood potassium doesn’t go down. I don’t know if any of y’all have ever, ever gotten an order, but one time I had a patient with a potassium of like 7.2 and I was a brand new nurse. I think I had six months in. I called the doctor and he’s like, okay, go ahead and give him 10 units of regular insulin in an amp of D 50. And I was like, um, I told you that the potassium was 7.2 his blood sugars are Okay. He was like, well yeah, Iv insulin is going to help bring down the potassium by pushing the potassium into the cells and the reason why I was giving the D 50 was just so that they didn’t become hypoglycemic because of the insulin.

So again, if they’re on an insulin drip, watch the potassium for that reason. So to recap on this little lesson, if you have a patient that’s on an insulin drip, it’s common in ICU patients. It’s common with DKA. Surgical patients. I work in CVICU, so our post cabbage patients, whether they are diabetic or not, we’ll come out with an insulin drip to make sure that their, their blood sugar levels stay low. Remember when you’re under stress, blood sugars can go up. So you want to keep them low so that it can help promote healing and make sure that you continuously monitor the patient, continuously monitor those blood sugars, make sure that they’re not showing signs and symptoms of hypoglycemia and check the blood glucose hourly, titrate that insulin as needed, watch your electrolytes and make sure that you continuously check on your patients. So I hope that this little lesson has helped you guys regarding insulin infusions and for those of y’all that do it. It’s fascinating and I hope that y’all love it. So make sure that you guys go out and be your best self today. And as always, happy nursing.

 
Module 0 – Pharmacology Course Introduction
Module 3 – Disease Specific Medications

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