Insulin for an Edematous patient

[MdBrndPhrmcst]

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An attending asked us this on rounds yesterday..

We have a patient who is admitted for decompensation CHF (not sure can't remember) which is being treated however right now the patient is very "edmatous" as the attending described. The Patient has DM and is currently given Lantus SQ however his blood glucose is not controlled adequately. Its been running in the 200's. The attending said that since the patient was so swollen the insulin is not penetrating his system that well and wanted to know if there were some other insulin options for this patient. I think the obvious answer is to give the pateint Insulin IV, but I wanted to know if I was missing anything. Is there an insulin of choice for an "edematous" patient?

 

[PRINCESS_IJ]

An attending asked us this on rounds yesterday..

We have a patient who is admitted for decompensation CHF (not sure can't remember) which is being treated however right now the patient is very "edmatous" as the attending described. The Patient has DM and is currently given Lantus SQ however his blood glucose is not controlled adequately. Its been running in the 200's. The attending said that since the patient was so swollen the insulin is not penetrating his system that well and wanted to know if there were some other insulin options for this patient. I think the obvious answer is to give the pateint Insulin IV, but I wanted to know if I was missing anything. Is there an insulin of choice for an "edematous" patient?

first, there is NO insulin designated for edematous patients. Also, is this patient on a sliding scale protocol, have they tried to put the patient on a standing order of humalog(which is fast acting)with every meal (TID),have they tried NPH/REGULAR insulin mixed.As last resort,if it is deemed that the insulin is not penetrating his system, he/she can be placed on a regular insulin IV protocol which requires a lot of titration and blood glucose monitoring but it goes directly into the system.

Types of insulin
Each type of insulin works at a different speed and lasts for a different length of time.

• Quick acting, such as insulin lispro (Humalog), begins to work very quickly (5 to 15 minutes) and lasts for 3 to 4 hours.
• Short acting, such as Regular (R) insulin, starts working within 30 minutes and lasts about 5 to 8 hours.
• Intermediate acting, such as NPH (N) or Lente (L) insulin, starts working in 1 to 3 hours and lasts 16 to 24 hours.
• Long acting, such as Ultralente (U) insulin, doesn't start to work for 4 to 6 hours, but lasts 24 to 28 hours.
• NPH and Regular insulin mixture, two types of insulin mixed together in 1 bottle, starts working in 30 minutes and lasts 16 to 24 hours

 

[npage148]

Where is the edema? Give it in a spot without any (upper arms maybe) but just remeber to be consistant with the site of admin. Use IV until the edema is gone and go back to sq insulin. Just with IV insulin, only regular insulin should be used (NO lantus or suspensions)

 

[PRINCESS_IJ]

Where is the edema? Give it in a spot without any (upper arms maybe) but just remeber to be consistant with the site of admin. Use IV until the edema is gone and go back to sq insulin. Just with IV insulin, only regular insulin should be used (NO lantus or suspensions)

first i am assumin the edema is generalised. Also regardless of the edema site, u should NOT BE CONSISTENT with the administration site however it is important that the patient know that the same dose should be injected into the same anatomical area (eg, the abdomen, an arm, a thigh, etc) daily. In using the same anatomical area, however, it is important to rotate the injection site within the area. Each injection should be an inch or more away from the previous injection site, to reduce the likelihood of developing local irritation or LIPODYSTROPHY. The development of lipodystrophy, atrophy, or hypertrophy of the skin may result in erratic absorption if that area is used for insulin administration. This erratic absorption can change the expected onset/peak times for the activity of the insulin, which may increase the risk for poor control and/or of hyper- or hypoglycemia.

 

[OHMAN0125]

An attending asked us this on rounds yesterday..

We have a patient who is admitted for decompensation CHF (not sure can't remember) which is being treated however right now the patient is very "edmatous" as the attending described. The Patient has DM and is currently given Lantus SQ however his blood glucose is not controlled adequately. Its been running in the 200's. The attending said that since the patient was so swollen the insulin is not penetrating his system that well and wanted to know if there were some other insulin options for this patient. I think the obvious answer is to give the pateint Insulin IV, but I wanted to know if I was missing anything. Is there an insulin of choice for an "edematous" patient?

Why not just do sliding scale first if he was only on Lantus? It seems like the easiest answer. Even with his edema, the sliding scale will allow multiple adjustments to control his glucose

 

[npage148]

first i am assumin the edema is generalised. Also regardless of the edema site, u should NOT BE CONSISTENT with the administration site however it is important that the patient know that the same dose should be injected into the same anatomical area (eg, the abdomen, an arm, a thigh, etc) daily. In using the same anatomical area, however, it is important to rotate the injection site within the area. Each injection should be an inch or more away from the previous injection site, to reduce the likelihood of developing local irritation or LIPODYSTROPHY. The development of lipodystrophy, atrophy, or hypertrophy of the skin may result in erratic absorption if that area is used for insulin administration. This erratic absorption can change the expected onset/peak times for the activity of the insulin, which may increase the risk for poor control and/or of hyper- or hypoglycemia.

You don't need to bold important terms like you are educating and enlightening us. I am plenty familiar it lipodystrophy and the whole rotating your injection location. SAme admin site = same body part. What do you take me for, a fool?

 

[konkan]

You don't need to bold important terms like you are educating and enlightening us. I am plenty familiar it lipodystrophy and the whole rotating your injection location. SAme admin site = same body part. What do you take me for, a fool?

Cat-fight? Let's throw some oil in

 

[npage148]

Cat-fight? Let's throw some oil in

People pay to see me oiled up

 

[golf299]

It sounds like he is inadequately being treated for his edema. The first thing to do would be to reevaluate his diuretic therapy, especially if he has been admitted for CHF. Afterwards, a continous infusion insulin drip should be started and titrated to respone. Tight glycemic control improves patient outcomes. A sliding scale, as someone else mentioned, is an inappropriate recommendation.

 

[dgroulx]

You don't need to bold important terms like you are educating and enlightening us. I am plenty familiar it lipodystrophy and the whole rotating your injection location. SAme admin site = same body part. What do you take me for, a fool?

It looks like she did a search, then cut and pasted the response. The bold words are probably hyperlinks. She should have prefaced her answer with, I got this from XXXX.

 

[sdn1977]

From the OP's suggestion of "very" edematous, he likely has left & right sided damage...so has edema in his legs - perhaps up to his thighs & perhaps in his abdomen.


Since they are treating him agressively for the CHF & you were indeed askef for your input on better control, I would have done exactly what you did & suggested IV insulin - especially if I had an existing central line with one port not being used.

The subcutaneous injections may or may not be going into the extracellular abdominal fluid, in which case - it is gone. But, the vascular coverage of any edematous area - legs, arms, abdomen - is compromised with edema. By giving it IV, you can evaluate the 24 hr requirements, which should change daily as the disease resolves & get him down to what his needs will be after stabilization. Remember, someone this sick is not eating in the normal fashion, so the whole dosage needs to get restabilized. Not so easy - just time consuming.

 

[MdBrndPhrmcst]

Thanks for the input guys... it was a very lively and educational discussion. I'm sorry I didnt have more details I couldnt remember much from rounds..and my preceptor wanted me to answer the question so i went with what my meager memory could recall