Intravenous insulin infusion should be continued for 2 hours after giving the subcutaneous insulin to maintain adequate plasma insulin levels. Immediate discontinuation of intravenous insulin may lead to hyperglycemia or recurrence of ketoacidosis.
Full Answer
When to switch from IV to subcutaneous insulin in diabetic patients?
For patients that did not have previously known diabetes, it is recommended that scheduled subcutaneous insulin be used if the insulin drip utilization is at least 20 units in a 24-h period [19]. Indications that It Is Not Safe to Transition from IV to SQ Insulin
How long should insulin drip be continued in diabetic ketoacidosis (DKA)?
Insulin drip should be continued until the closure of anion gap or absence of serum ketones. ( In UK, they measure hourly bedside ketones instead of glucose). Some physicians mistakenly assume low bicarb as equivalent to persistent DKA and may continue insulin drip until bicarb is normalized.
When to start insulin glargine after diabetic ketoacidosis (DKA)?
-After the DKA has resolved and when the patient is able to eat, start SC basal insulin (like insulin glargine). In addition, order a pre-meal insulin Lispro regimen, AC TID. -Continue IV insulin infusion for 2hrs after starting the SC insulin glargine to create a 2-hour bridge. The onset of action of insulin glargine is 2hrs.
How do you stop insulin infusion in diabetic ketoacidosis?
Metabolic treatment targets. In general, resolution of hyperglycemia, normalization of bicarbonate level, and closure of anion gap is sufficient to stop insulin infusion. Anion gap is calculated by subtracting the sum of chloride and bicarbonate from measured (not corrected) sodium concentration.
When do you stop IV insulin in DKA?
DKA is resolved when 1) plasma glucose is <200–250 mg/dL; 2) serum bicarbonate concentration is ≥15 mEq/L; 3) venous blood pH is >7.3; and 4) anion gap is ≤12. In general, resolution of hyperglycemia, normalization of bicarbonate level, and closure of anion gap is sufficient to stop insulin infusion.
How do you transition from IV insulin to subcutaneous DKA?
TransitionEnsure meal available and patient ready and willing to eat.Check POCT (point of care testing) blood glucose.Give rapid-acting insulin (NovoRAPID pen) via subcutaneous injection: see MAR (Medication Administration Record) for patient-specific dose.More items...
What is the difference in duration between regular insulin subcutaneous and regular insulin IV?
Sub- cutaneous administration of insulin analogs (14) has an on- set of action within 10 to 20 minutes, a peak within 30 to 90 minutes, and a duration of action of approximately 3 to 4 hours, which is shorter than with regular insulin that has an onset of action of 1 to 2 hours and a half-life of about 4 hours (1,15).
Which type of insulin starts to work within 2 4 hours after administration?
Intermediate-acting: These include Humulin N and Novolin N. They have an onset of two to four hours, a peak at four to 12 hours, and duration of 12 to 18 hours. Ultra long-acting: These include Toujeo.
When should insulin infusion be stopped?
Patients with resolving DKA, ceasing the intravenous insulin infusion and commencing subcutaneous insulin may be considered when two successive measurements of blood ketones are less than 1mmol/L (as measured on ward meter and appropriate strips).
When do you give IV insulin?
Intravenous insulin is administered only in a hospital ICU setting in selected critically ill patients with a diabetes emergency or other conditions affecting blood sugar who require rapid and efficient control of hyperglycemia.
Is IV insulin faster than subcutaneous?
Our studies suggest that, in normal lean subjects, insulin injection by the intramuscular route provides a faster absorption of insulin with a concomitant greater drop in plasma glucose than does injection by the subcutaneous route.
Is intravenous the same as subcutaneous?
SC injections are also known as 'subcut' or 'SQ' injections. These injections work more slowly than an IV or IM injection because the area does not have such a rich blood supply.
Can you give insulin IV push?
While the need to administer an IV push dose of regular or rapid acting insulin is rare, it is often urgent/emergent. Thus, a defined procedure should be established to ensure that supplies are readily available, and the process is uniform and safe.
Can you take long-acting and short-acting insulin at the same time?
Are there any combination options available for those who don't want to inject themselves so often? Yes. Some insulin products combine fast and longer-acting insulins that work together to help manage blood sugar between meals and at night, as well as blood sugar “spikes” that happen when you eat.
What is a Somogyi effect?
If the blood sugar level drops too low in the early morning hours, hormones (such as growth hormone, cortisol, and catecholamines) are released. These help reverse the low blood sugar level but may lead to blood sugar levels that are higher than normal in the morning.
Why is long-acting insulin given at night?
Aims/hypothesis: Insulin glargine is a long-acting human insulin analog often administered at bedtime to patients with type 2 diabetes. It reduces fasting blood glucose levels more efficiently and with less nocturnal hypoglycemic events compared with human neutral protamine Hagedorn (NPH) insulin.
What is IV infusion?
Intravenous (IV) infusion is the preferred route of insulin delivery in critical care, labor and delivery, and perioperative inpatient settings because the rapid onset and short duration of action associated with IV infusion allow for matching insulin requirements to rapidly changing glucose levels.
What is a transition protocol?
A transition protocol provides guidance regarding which patients are likely to require transition to subcutaneous insulin and when and how to make the transition. Patients with type 1 diabetes and most patients with type 2 diabetes who were treated with insulin before hospitalization will require such a transition.
Can you stop insulin infusion for hypoglycemia?
Some hypoglycemia protocols temporarily stop the insulin infusion for hypoglycemia and restart it at a lower rate once hypoglycemia has resolved. However, failure to restart the infusion can result in profound hyperglycemia and ultimately diabetic ketoacidosis (DKA) in patients with type 1 diabetes.
Is insulin infusion a basal bolus?
Open in a separate window. Insulin infusion may be an alternative to a basal-bolus insulin regimen outside of the critical care setting for perioperative and other patients who are not eating (NPO status) and patients whose glycemia is poorly controlled with subcutaneous insulin.
Is hypoglycemia more common in intensive care?
Although hypoglycemia was more common among patients in the intensive treatment group, the association of hypoglycemia with an increased hazard ratio for death was similar in the two groups, suggesting that hypoglycemia contributed to the excess mortality in the intensively treated group.15.
Is capillary blood glucose reading inaccurate?
Some situations may render capillary blood glucose monitoring inaccurate, including shock, hypoxia, dehydration, extremes in hematocrit, elevated bilirubin and triglycerides, and the use of some medications (e.g., mannitol, icodextrin/maltose, and acetaminophen).
What is the range of glucose in Q4HS?
Do glucose checks q4hs and give regular or rapid-acting insulin as needed to keep sugars between 100-180 range. When the patient is able to eat, d/c the dextrose solution and give pre-meal insulin.
When DKA has resolved but the patient cannot eat, should dextrose be continued?
When DKA has resolved but the patient cannot eat. “If the patient is still nauseated and cannot eat, dextrose infusion should be continued and regular or ultra-short-acting insulin should be administered SC every 4 hours, according to blood glucose level, while trying to maintain blood glucose values at 100-180 mg/dL.”. Medscape.
Why do you need to give pre-meal insulin?
Instead of changing the insulin drip, it’s best to give them the pre-meal insulin to cover this rise in sugar from the food. If you increased the insulin rate to cover the food, you will have to decrease the rate when the sugar has been digested and processed otherwise you would risk infusing too much insulin in them.
Can you eat before DKA?
A patient may eat before DKA has cleared. You may feed a patient before the DKA resolves. You just need to give them a pre-meal bolus of insulin to cover their meal and continue the other drips as you would in a patient who hadn’t eaten. The food will raise their blood sugars.
How long does it take for Rosella insulin to work?
Used for patients with BD (twice daily) insulin regimens or MDI (multiple daily insulin injection) regimens. Onset: 3-4 hours, Maximum effect: 9 hours, Duration 12-24 hours. Soon to be stocked on Rosella Imprest - must call Rosella Pharmacist, who will deliver the insulin pen and needles within 10 minutes.
When to give Lantus insulin?
The first Lantus insulin dose is often given at the same time as the first rapid-acting insulin dose. Although Lantus is generally given in the evening before bed (as it is a long-acting insulin), the first dose can be given as a half dose with the first meal, then the rest given that evening before bedtime.
Do you need to be in the ICU for DKA?
Patients in DKA often require ICU admission for IV insulin therapy and constant monitoring, as blood glucose levels must be lowered slowly to avoid neurological damage and electrolytes must be closely monitored. When the patient is clinically ready to transition from an IV insulin infusion to subcutaneous insulin injections, several specific steps must be followed. This includes ensuring the patient is truly ready for the transition, having the correct orders in place, and recognising when the transition has been successful.
What are the therapeutic goals of DKA?
The therapeutic goals of DKA management include optimization of 1) volume status; 2) hyperglycemia and ketoacidosis; 3) electrolyte abnormalities; and 4) potential precipitating factors. The majority of patients with DKA present to the emergency room. Therefore, emergency physicians should initiate the management of hyperglycemic crisis while a physical examination is performed, basic metabolic parameters are obtained, and final diagnosis is made. Several important steps should be followed in the early stages of DKA management: 1 collect blood for metabolic profile before initiation of intravenous fluids; 2 infuse 1 L of 0.9% sodium chloride over 1 hour after drawing initial blood samples; 3 ensure potassium level of >3.3 mEq/L before initiation of insulin therapy (supplement potassium intravenously if needed); 4 initiate insulin therapy only when steps 1–3 are executed.
How many hospitalizations for diabetic ketoacidosis in 2009?
In 2009, there were 140,000 hospitalizations for diabetic ketoacidosis (DKA) with an average length of stay of 3.4 days.1The direct and indirect annual cost of DKA hospitalizations is 2.4 billion US dollars.
Why is bicarbonate not indicated in mild and moderate forms of DKA?
Bicarbonate therapy is not indicated in mild and moderate forms of DKA because metabolic acidosis will correct with insulin therapy.3, 8The use of bicarbonate in severe DKA is controversial due to a lack of prospective randomized studies.
What is the name of the regimen that contains both long-acting and short-acting insulin?
The regimen containing both long-acting and short-acting insulin is called a basal-bolus insulin regimen; it provides physiological replacement of insulin. If a patient used insulin prior to admission, the same dose can be restarted in the hospital.
What happens if you don't have enough fluid intake?
Hyperglycemia-induced osmotic diuresis, if not accompanied by sufficient oral fluid intake, leads to dehydration, hyperosmolarity, electrolyte loss, and subsequent decrease in glomerular filtration rate. With decline in a renal function, glycosuria diminishes and hyperglycemia worsens.
Can DKA cause hypokalemia?
A “normal” plasma potassium concentration still indicates that total body potassium stores are severely diminished, and the institution of insulin therapy and correction of hyperglycemia will result in hypokalemia.
Is ketoacidosis a type 1 or 2 diabetes?
Diabetic ketoacidosis (DKA) is a rare yet potentially fatal hyperglycemic crisis that can occur in patients with both type 1 and 2 diabetes mellitus. Due to its increasing incidence and economic impact related to the treatment and associated morbidity, effective management and prevention is key. Elements of management include making ...
What is the key element in the pathogenesis of DKA?
Insulin: The key element in the pathogenesis of DKA is insulin deficiency and hence, replacing insulin is the cornerstone of DKA therapy, with or without iv fluids. Insulin will quickly shift the potassium into the cells resulting in hypokalemia, sometime very severe to the point of rsking life.
What are the two major hyperglycemic crises associated with diabetes?
There are two major hyperglycemic crises associated with diabetes: diabetic ketoacidosis and the hyperosmotic hyperglycemic state. Diabetic ketoacidosis primarily results from insulin deficiency and hyperglycemic hyperosmolar state (HHS) from severe insulin resistance. Both of the crises result in subsequent glucagon and counter-regulatory hormone excess from lack of suppression from insulin.
How long should insulin drip be followed by IV?
Intravenous insulin infusion should be continued for 2 hours after giving the subcutaneous insulin to maintain adequate plasma insulin levels.
What is somatostatin octreotide?
Octreotide (Somatostatin), a synthetically derived hormone that suppresses insulin release from beta islet cells, can act as a specific sulfonylurea antidote. It is given in a dose of 50 ug SC Q6.
How long does it take to get potassium in IV fluid?
Most commonly, physicians add 20meg kcl to the iv fluid bag and run it at 100cc/hr, to keep potassium above 4. please be aware that at 100cc/hr, it would take 10 hours for the patient to get 20meq of kcl. Some times, even with severe hypokalemia, we may fail to correct potassium soon enough thinking that they are already getting potassium as drip in the iv fluids. This may lead to adverse events. My personal preference is to correct potassium separately with extra doses of iv or oral Kcl.
Do DKA patients need insulin?
Patients in DKA not only needs the replacement of deficient doses of insulin but also ongoing needs. Also, if a person went into DKA due to an increased insulin requirements from infection, not only they need their basal insulin but also the excess requirements of their body.
Does insulin cause DKA?
Insulin will inhibit lipolysis and oxidation of free fatty acids. Insulin also increases oxidation of ketones in the peripheral tissues. Thus there is both overproduction ...
How much sulfate is given at breakfast?
Given at breakfast with a daily dose ranging from 30-40% of the total daily dose in an attempt to provide coverage on a fixed meal plan regimen at lunch
How long does it take for cerebral edema to develop?
Cerebral edema, which occurs in 0.5 – 1 % of all episodes of DKA, is the most common cause of mortality in children with DKA, Cerebral edema usually develops 4 – 12 hours into treatment, but it can occur at any time