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SAFER%20ADMINISTRATION%20OF%20INSULIN

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Title: SAFER%20ADMINISTRATION%20OF%20INSULIN


1
SAFER ADMINISTRATION OF INSULIN
  • Dr Helen Akester
  • Masham/Kirkby Malzeard Surgery
  • 10th February 2011

2
NPSA (National Patient Safety Alert) issued in
June 2010
  • 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
    gt14,000 diabetic pts in England and Wales showed
    prescribing errors in 19.5 cases

3
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 62insulin 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.

4
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.

5
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

6
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)

7
PRESCRIPTION AND ADMINISTRATION OF INSULIN
  • The right insulin
  • The right dose
  • The right time
  • The right way

8
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

9
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

10
RAPID ACTING
  • Works very quickly, lt5-15mins
  • 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

11
SHORT ACTING
  • Works lt30-60mins after injection
  • Peaks at 2-3 hours
  • Duration 5-8 hours
  • Short lifespan, injected several times daily

12
INTERMEDIATE ACTING
  • Longer lifespan, slower to work!
  • Starts lt2-4 hours
  • Peaks 10-14 hours
  • Remains working 16 hours

13
LONG ACTING
  • Starts lt 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

14
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

15
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

16
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

17
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

18
WRITING PRESCRIPTIONS
  • Computer generated prescriptions are common-but
    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

19
WRITING PRESCRIPTIONS (CONT)
  • 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
  • lt12 years inc Age or DOB

20
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

21
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

22
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

23
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

24
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)

25
INSULIN PUMP
  • Miniature pumping device worn outside body
  • Connected to catheter located under the abdominal
    skin
  • Programmed to deliver insulin according to pts
    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

26
INSULIN INJECTION
  • Demands-dexterity, concentration, good vision,
    steady hand
  • Inject at 90o angle
  • Count to 10
  • Withdraw needle

27
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

28
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

29
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 lt4mmol/l
    indicates hypoglycaemia
  • Occurs when pharmacologically raised insulin
    levels are not responsive to falling
  • insulin requirements
  • Body usually has good neuroendocrine defence
    system

30
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 lt3.5mmol/l-irrational
    behaviour/aggression/drowsiness/seizures and
    eventually coma

31
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

32
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

33
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

34
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 amt-and
    always eat with it
  • Delayed/missed meal
  • Drug interaction

35
LIPOHYPERTROPHY
  • 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

36
QUIZ
  • BMJ ARTICLE
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