Question

Please review the Continuous Insulin Policy and the Insulin Order and Algorithm. Note, these are unrelated to Mr. Hamms Policy Care of the Patient Receiving Continuous Insulin Infusion docx Scenario - Patient is 72 years old. History of type 2 diabetes. Presents with polyuria, polyphagia, and polydipsia. Glucose is 800 mg/dL. ABGs are: pH 7.37 pCO2 40, PO2 99, HCO3 24. RR rate is 18/min, BP is 100/60, HR is 110 Creatinine is 2.3. Your Task. Using the Continuous Insulin Protocol, you will give units of IV insulin as a bolus, you will start the continuous insulin infusion at units/hour, and you will set the IV pump at ml/hr. Do you think this patient is in DKA or HHNK?

Answer 1

Insulin infusion protocol helps to achieve and maintain a desired target of blood glucose level in patients with diabetes mellitus. It is applicable for patients who are under close monitoring because the blood glucose lowering will be taking place in very quick under management using these protocols.

Diabetic ketoacidosis ( DKA) is a common and serious complication of type 1 diabetes mellitus which is characterized by increased production of ketones in the body which leads to metabolic acidosis.

Hyperosmolar hyperglycemic non-ketoacidosis (HHNK) is one of the complications mainly seen in elderly population due to the complication of type 2 diabetes mellitus which is characterized by high blood glucose level more than 600 mg / dl with polyuria and dehydration without acidosis.

In the given scenario,

The patients blood glucose value is 800 mg/dl

The creatinine level is 2.3 mg / dl

The ABG values are in normal limits

1) As per the given continuous insulin protocol step 2 , it is mentioned as for patients with serum creatinine over 2 mg / dl do not administer bolus. This patient has serum creatinine level 2.3 mg / dl, so the patient is not eligible for a bolus dose of insulin.

2) As per the given continuous insulin protocol step 3. The patient should start with Algorithm 1 first and If the blood glucose level is not controlled by Algorithm 1 then we can proceed to algorithm 2, 3, and 4 accordingly. According to algorithm 1, the insulin infusion rate for patients more than 360 mg / dl should start with 6 units per hour. The patients blood glucose level is 800 mg / dl, so we should start with 6 units / hr.

3) According to general guidelines given in the step 1 of continuous insulin protocol, the mix contains 100 units of regular insulin in 100 m L of normal saline which gives 1unit insulin / 1 m L of mix.

Concentration of mix = 1 unit / 1 mL

Desired dose = 6 units / hr

Flow rate (mL/ hr) = Desired dose / concentration of the mix

= 6/1 = 6 mL / hr

Thus the answer is, using continuous insulin protocol, you will give 0 or null units of IV insulin as bolus; you will start the continuous insulin infusion at 6 units / hr; and you will set the IV pump at 6 mL / hr.

• The patient has no acidosis in a ABG as well as patient is 72 year old with type 2 diabetes mellitus and blood glucose level is 800 mg / dl with polyuria. The symptoms suggestive of Hyperosmolar hyperglycemic non-ketoacidosis (HHNK)