Safety using Insulin

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SAFER ADMINISTRATION
OF INSULIN
Dr Helen Akester
Masham/Kirkby Malzeard Surgery
10th February 2011
NPSA (National Patient Safety
Alert) issued in June 2010
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WHY?
In UK 4-5% population have diabetes,
20-30% are treated with insulin
Insulin identified one of top 10 high risk
medications worldwide
• Errors are very common-First national
audit >14,000 diabetic pts in England and
Wales showed prescribing errors in 19.5%
cases
Errors
• U.S study-up to 33% of medication errors related
to Insulin. Errors twice as likely to cause harm as
errors for other prescribed drugs.
• Insulin has narrow therapeutic range, requiring
precise dosage adjustments with careful
administration and monitoring. NPSA report
shows that 62%insulin errors were around
administration with prescribing the most
common factor. 15,227 incidents inc 6 deaths
relating to Insulin in E and W between 2003 and
2009. Many incidents unreported.
Variations
• Over 20 different types of insulin in use in
various strengths and forms.
• Range of devices for delivery inc. insulin
syringes ( from vials), insulin pens
(prefilled/reusable) and insulin pumps.
Aims
• Refresh your knowledge and
understanding of insulin
• Outline differences in administering insulin
• Develop further understanding of range of
available insulins and injection devices
• Review common side effects of insulin and
how to effectively treat them
Insulins
• Available as treatment since the 1920s
• Most is genetically engineered
(recombinant human insulins) to be more
like the insulin the body makes
• Different insulin treatments available that
have been genetically modified to have
different absorption profiles-known as
insulin analogues ( see MIMS)
PRESCRIPTION AND
ADMINISTRATION OF INSULIN
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The right insulin
The right dose
The right time
The right way
The Right Insulin
• All have a proprietary name eg Apidra,
which must be stated when prescribing
• All have an approved name eg Insulin
glulisine
• Can be easy to muddle eg Humalog,
Humalog 25 and Humalog 50
4 main insulin categories
Over 20 different types of insulin, classified
according to their effect and action on the body:
Rapid Acting
Short Acting
Intermediate Acting
Long Acting
RAPID ACTING
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Works very quickly, <5-15mins
Take just before eating
Peaks between 30-90 mins
Duration 3-5 hours
Less likely to lead to hypoglycaemia than
some other types of insulin
SHORT ACTING
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Works <30-60mins after injection
Peaks at 2-3 hours
Duration 5-8 hours
Short lifespan, injected several times daily
INTERMEDIATE ACTING
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Longer lifespan, slower to work!
Starts <2-4 hours
Peaks 10-14 hours
Remains working 16 hours
LONG ACTING
• Starts < 6 hours
• Continuous level of activity for up to 36
hours
• (sheet-fill in gaps)
• Choosing type of insulin depends on
clinical need, personal choice and ability
to self manage their insulin regime
Insulin Regime
• O.D regime-T2DM in combination with oral agents
• B.D regime-consisting of soluble, or soluble plus
isophane or fixed formulations of a mixture of back
ground insulin plus fast acting
eg Novomix 30, Humulin M
• Multiple injections-several times daily (4-5), mimic
normal physiological profile. Inc. a SA or RA with meals
and intermediate acting (basal) OD
• IV insulin-variable rate insulin infusion-hospital
admission not eating/drinking- insulin half- life of 3-5mins
VARIABLE RATE INFUSION
• Prescribed with IV glucose
• 24hrs expiry date from when prepared
• Giving set-low absorption tubing, may
need to be primed
• In T1DM discontinuation to coincide with
commencement of usual regime and meal
time
• Cease 30 mins after Pts usual insulin
commenced
STRENGTH OF INSULIN
Two strengths available:
• U100-more frequently used
• U500-eg Humulin R, unlicensed in UK
Soluble, 5x more concentrated than
standard insulin, named pt basis by
specialist, may be given by hospital pump
PRESCRIBING
• Ensure correct dose: inc. frequency of
administration
• Check C.Is inc. allergies
• Check other medications inc. OTC eg Gliclazide
• Check illness not exacerbated by insulin
• Informed consent-ensure aware of proposed tx
and effects, symptom relief, side-effects and mx,
interactions with other meds inc. alcohol, need
for monitoring, sick day rules, DVLA
WRITING PRESCRIPTIONS
• Computer generated prescriptions are commonbut if writing (hospital, home visits) use indelible
ink
• Do NOT abbreviate drug names: the word
insulin should be used as well as brand name
• Do NOT use decimal places
• Clearly state drug dose,strength,route,frequency
• Draw line through any amendments and initial
change
WRITING PRESCRIPTIONS
(CONT)
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Date prescription
Sign and write contact details
Write UNITS in full
Write form of delivery eg disposable
pen/vial
• Inc FULL name and address of patient
• <12 years –inc Age or DOB
THE RIGHT DOSE
• In UK most use 100units per ml (U100 Insulin)
• A tiny drop can cause hypoglycaemia
• Dose is crucial-different people have different
needs
• e.g children, underwt, overwt, ill
• 5u can make one person unconcious and have
no difference on another
• Pts using SA insulin can adjust own dose to suit
diet, exercise and their blood glucose
THE RIGHT DOSE
(CONT)
• Common errors:
• Pen upside down eg 12 units instead of 21
• 10 x overdose due to use of abbreviation eg ‘U’
instead of ‘UNITS’ eg 6U can be mistaken for 60
units
• Using ‘I.U’ as abbreviation for international units
eg 6 iu can mistaken for 61 units
• Prescribing/administration wrong type of insulin
due to incomplete name eg Humulin ?I or S
ADMINISTRATION ERRORS
• Selecting wrong vial or cartridge
• Using syringe not designated for insulin use NB
Very concentrated so always use insulin syringe
100 units in 1ml ( or pen/pump)
• Usually insulin injected S.C with short needle eg
5mm. Given I.M it works very quickly and can
cause hypoglycaemia.
• IV insulin always used diluted eg 50 units
actrapid in 50ml 0.9% sodium chloride
INSULIN SYRINGES
• U100 syringe can hold 1ml/ 100 units
insulin
• Other types-0.5ml 50 units
0.3ml 30 units
• 0.3ml syringe has half unit doses marked
on if only small dose required
• 0.5ml syringe has single unit doses
marked
PRELOADED PENS
• No need to insert cartridges
• Packs of 5-pt should be advised to order
at end of 3rd pen
• Disposable needles-variety lengths-most
common 5mm,6mm,8mm
• Use new needle for each injection
• Discard used needle in sharps container
(safety clip device)
INSULIN PUMP
• Miniature pumping device worn outside body
• Connected to catheter located under the
abdominal skin
• Programmed to deliver insulin according to pt’s
daily regime
• Delivers steady small doses of insulin, Pt gives
themselves bolus for meals/snacks
• If disconnected-s/c insulin or variable rate
infusion according to Pts finger prick blood
glucose
INSULIN INJECTION
Demands-dexterity, concentration, good
vision, steady hand
Inject at 90o angle
Count to 10
Withdraw needle
INSULIN STORAGE
• Unopened vials/pens/cartridges-store in fridge
• Check not vulnerable to freezing as will
deactivate insulin
• Check individual products packages for length of
time can be used safely after opening e.g 4-6/52
• Once open store at room temperature. Cold
injection painful and absorption profile different
• Store cartridges in their original box as small
and be easily muddled
• Do not leave exposed to direct sunlight
• Never store pen with insulin pen needle intact
COMMUNITY SETTING
• Self Mx /Empower Pt!
• Unable to use pen/syringe involve health professional or carer
• Pt safety: Obtain written consent
Educate to ensure right insulin, right dose, right time, right way
Correct procedure to reduce infection
Correct storage of insulin
Ensure f/u
Raise awareness of risks of preloading insulin-DOH/MHRA advise
against predrawing insulin. If staff are asked to premix insulin the
employing trust takes responsibility as this practice is not
recommended
HYPOGLYCAEMIA
• Most common side effect of insulin
• Most feared by those receiving insulin
• ‘undersweet blood’: low levels of glucose in the
blood
• Those with D.M on insulin a glucose <4mmol/l
indicates hypoglycaemia
• Occurs when pharmacologically raised insulin
levels are not responsive to falling
insulin requirements
Body usually has good neuroendocrine defence
system
HYPOGLYCAEMIA
• 2 separate effects:
• ADRENERGIC-results in counter regulatory
process, adrenaline/ glucagon act to release
glucose from liver, ‘fight and flight’ symptoms
• NEUROGLYCOPEANIC-brain has high energy
requirements, relies almost entirely on glucose
for fuel, cerebral function measurably impaired
when glucose <3.5mmol/l-irrational
behaviour/aggression/drowsiness/seizures and
eventually coma
SYMPTOMS / TX
MILD
Hunger, shakiness,nervousness,sweating,dizzy,
light headed,sleepy,confused,
difficulty speaking,anxiety
Confirm BM reading
Able to swallow?
200ml non diet fizzy drink e.g coke, 200ml fruit
juice, 120ml lucozade,6 dextrose tablets or 3-4
teasp sugar
SYMPTOMS / TX
• Moderate:
• Conscious, confused or semi-conscious
but able to swallow
• Tx
• Glucogel- 2 ampoules inserted into oral
cavity-does not actually need to be
swallowed
SYMPTOMS / TX
Severe:
Unconscious, absent gag reflex
Tx: Give glucagon I.M, I.V 10-20% dextrose
Once alert rpt as for mild hypoglycaemia tx
Then once blood glucose risen give L/A
carbohydrate eg cereal/bics
CAUSES
• Too much insulin/ too many tablets
• Unplanned/ strenuous activity
• Not enough food esp. carbohydrates e.g
fasting/unwell
• Too much alcohol e.g limit to small amtand always eat with it
• Delayed/missed meal
• Drug interaction
LIPOHYPERTROPHY
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Known as ‘fatty lumps’
Can be large and unsightly
Rarely troublesome, but tend to persist
Must vary site of injection from day to day
If insulin repeatedly injected into a fatty
lump rate of absorption delayed
QUIZ
• BMJ ARTICLE
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