Can someon please explain insulin therapy to me?

[HalcyonDays]

Okay so I'm running around these last few days like a chicken with its head cut off. I feel like I know next to nothing as an intern. But the thing I keep coming across and hope someone could explain to me is INSULIN THERAPY.
I've been paged on multiple occasions because a patient's blood glucose is >400...and based on the sliding scale protocol once that happens the nurse has to page the MD. Then there is the issue of sliding scale versus the Apidra insulin sliding scale. Yesterday I was told that a patient was switched to the Apidra sliding scale by a pretty nasty nurse. One of those nurses that take pleasure in knowing he knows more than you (I know this b/c I said what's Apidra? Any other nurse would have taken the extra 5 seconds to let me know but this one when I asked just said...pt blood glucose is 491 what do you want me to do?)

I also had another case where patient's blood sugar was 75 in the AM and had a order for Lantus 30units. The attending switched it to 22 units I believe...I was really confused because for the patient with 500 blood sugar on sliding scale I was told to order 14 units of regular insulin. How can 75 still get his 22 Lantus?

If someone can explain this whole insulin therapy and what exactly constitutes units of insulin I'd be sooooooo grateful. Things were so much easier on exams when all you had to know was to give insulin and not HOW MUCH to give. 🙄

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[San_Juan_Sun]

Okay so I'm running around these last few days like a chicken with its head cut off. I feel like I know next to nothing as an intern. But the thing I keep coming across and hope someone could explain to me is INSULIN THERAPY.
I've been paged on multiple occasions because a patient's blood glucose is >400...and based on the sliding scale protocol once that happens the nurse has to page the MD. Then there is the issue of sliding scale versus the Apidra insulin sliding scale. Yesterday I was told that a patient was switched to the Apidra sliding scale by a pretty nasty nurse. One of those nurses that take pleasure in knowing he knows more than you (I know this b/c I said what's Apidra? Any other nurse would have taken the extra 5 seconds to let me know but this one when I asked just said...pt blood glucose is 491 what do you want me to do?)

I also had another case where patient's blood sugar was 75 in the AM and had a order for Lantus 30units. The attending switched it to 22 units I believe...I was really confused because for the patient with 500 blood sugar on sliding scale I was told to order 14 units of regular insulin. How can 75 still get his 22 Lantus?

If someone can explain this whole insulin therapy and what exactly constitutes units of insulin I'd be sooooooo grateful. Things were so much easier on exams when all you had to know was to give insulin and not HOW MUCH to give. 🙄

I'm by no means an insulin expert. But a couple of quick thoughts:

1. The 75 glucose patient gets his Lantus because it's a slow-acting, long lasting formulation (has a 23 hour halflife). The patient will eat breakfast and put glucose into the bloodstream long before the Lantus will drop the glucose to a hypoglycemic level. Unless the patient is NPO or something, it's totally fine to give Lantus with a glucose of 75 before breakfast.

2. I have no idea what an Apidra sliding scale is.

3. Don't sweat not knowing insulin coverages. It can definitely seem very complicating, and I bet that a lot of your colleagues feel like you do, even though most new interns do their best to hide their insecurity. Try to find a senior resident that can teach you about insulin coverage, and frame the question specifically like "How do you approach a call in the middle of the night for a glucose above 400?"

If you frame the question that way, hopefully you'll get not only some info about the basic formulations of insulin, but also the practical, here's-how-I-do-it-in-the-middle-of-the-night answer that can be invaluable for your next call.

I'm sure someone can educate you more here too. Good luck.

 

[HalcyonDays]

Thanks San Juan...I forgot that Lantus was the long acting insulin. Since I like to keep things simple in my head I still automatically think of regular as short and NPH as long...only now can I know longer simplify insulin that way because the hospital has many many types of insulin (ie. Apidra which your hospital probably doesn't use).

Btw, my first month is night float. I'm the lucky intern who got that so every night feels like a call. I see no attendings until the AM and the only ones I can turn to are the nurses (God bless them...well most of them anyways) and the 2nd year residents who are generally very busy themselves.

 

[angel80]

In the hospital, I've found that using the rapid acting insulins (Novalog, Humalog, and Apidra) usually is better than using regular insulin. These insulins start to work in about 15 minutes and peak in 30-90 minutes. They can be taken at the time of the meal (or even afterwards). Regular insulin must be taken 30 minutes prior to the meal, and from my experience, this doesn't usually happen in a hospital setting. Also, a lot of times in the hospital, patients get their full dose of insulin, and then they don't feel like eating. Regular insulin lasts longer in the system and could give you more problems in this situation. Nevertheless, a lot of people still use regular insulin, and most of the time it's not a big deal what type of sliding scale you use.

 

[jdh71]

I'm not familiar with the Apidra scale either, but you can always look it up, and barring that, it should be in the chart in the orders section. You can do one of two things, 1) look at what is given for 350-399 and just tell them to give that [it won't completely correct the sugar, but it will bring it down, and at the next check the nurses can apply the scale at a lower blood sugar] or 2) give a couple of extra units of the insulin to the number at the top of the scale, or instance if the jumps between 300-349, and 350-399 are 4 units of your given insulin, for instance, you will be pretty safe in giving the same difference for every 50mg/dL jump in blood sugar above that.

 

[radslooking]

you may do better asking this in the im forum

 

[david713]

It is the first of July when all interns and residents start their rotations. You have now found that after about 8 years of school, you really don't know a thing. Don't worry, no one else does either. First, go get a copy of the Washington Manuel of Medical Therapeutics. Second, find out how to go to uptodate on the computer. Third, find your resident and ask him how to establish a sliding scale. I would give you some information but it would be incorrect as all teaching institutions have a different system. Your resident will definitely know how to set you up on this system. You could ask your staff, but likely he does not know how to do it either. One way of telling about his knowledge is to ask such a question. If he stops and takes time to answer the question in full then he is good and knowledgable. If he begins shouting and tries to make you feel like you are 2 inchs high then he has no idea what is going on. You are allowed to ask these types of questions for the next few months. After that you better have the knowledge tucked away or it will start showing up on your reports. One of the biggest mistakes is not asking the other is not reading.