chris harrold spr diabetes & endocrinology. diabetes is common 15% of all inpatients 50% of...
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Chris Harrold
SpR Diabetes & Endocrinology
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Diabetes is common15% of all inpatients50% of those are on insulin20% of patients experienced an insulin error
National Inpatient survey 2011
NPSA 16th June 2010Right insulinRight doseRight timeRight route
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BNF has 25 listed insulins All U100 Does not list Humulin R U500
Short: Hypurin Bovine Normal Hypurin Porcine Normal Actrapid Humulin S Insuman Rapid Novorapid Apidra Humalog
Intermediate & Long: Levemir Lantus Hypurin Bovine Lente Hypurin Bovine Isophane Hypurin Porcine Isophane Insulatard Humulin I Insuman Basal Hypurin Bovine Protamine Zinc
Mixed / Biphasic: Novomix 30 Humalog Mix 25 Humalog Mix 50 Hypurin Porcine 30/70 Humulin M3 Insuman Comb 15 Insuman Comb 25 Insuman Comb 50
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Right insulin:Which humulin is this?
Humulin I Humulin 3 Humulin M3
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Right insulin: Insulin is the only drug prescribed by brand
name Insulin detemir Insulin aspart Insulin glulisine Insulin lispro
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Right DoseAbbreviations “U” and “IU” are NEVER to be
used Can be misread as 0
Deaths have occurred from misreading & mis-administering doses
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Right time:Right time for the right insulin
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: Brand name, not generic
Right Dose: Clearly written Changes dated and initialled DO NOT USE “U” or “IU”
Right time: Mixed insulins – Breakfast and evening meal Short / rapid insulins – Mealtimes Long / intermediate – Bedtime (and breakfast)
Right Way: Prefilled (disposable) or 3ml Cartridges
Lantus / Apidra – Solostar Novorapid / Novomix 30 / Levemir – Flexpen Humalog / Humalog Mix – Kwikpen
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www.diabetes.nhs.uk/safu_use_of_insulin
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Indications: Keto-acidosis – fixed rate infusion Diabetic Ketosis Pre-operative
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: 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.
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Hypoglycaemia “4 is the floor” 15-20g fast carbohydrate Recheck after 15 mins and retreat as needed Replace carbohydrate Look for a cause!
Usually sulfonylureas (dirty drugs) Metformin & gliptins do not cause hypos
If not able to take orally / unconscious IV 10% dextrose (160mls over 10 mins)
Not 50% IM glucagon 1mg (single dose)
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HyperglycaemiaType 1 or type 2How high?Why high?
Steroids, sepsis, missed / omitted insulinTreat the patient (not the nurse)
4-6 units of Novorapid (or patients usual fast) Not Actrapid (oxymoron) 1 unit corrects by ~ 3 mmol/l
Look at why and how it can be prevented
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Dose AdjustmentWatch for trends and look for causes
Avoid reflex dose adjustments Allow sufficient time to see results
Hyperglycaemia Increase dose of appropriate insulin by 10%
E.g. 20 units 22 units, 60 units 66 units
Hypoglycaemia Reduce does of appropriate insulin by 20%
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Renal failure:eGFR <30 is the cut off for:
Metformin Gliclazide
What is safe? 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
Inappropriate referrals (sort it yourselves) Dose adjustment of insulin for hyper /
hypoglycaemia Dose adjustment of oral medication
If you ask for our help, take it.
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Diabetes Nurses / SpRs / Consultants
www.diabetes.nhs.uk
www.diabetes.nhs.uk/safe_use_of_insulin
www.diabetesbible.com
www.mims.co.uk