Clinical Guidelines (Nursing)

Transitioning from IV Insulin to Subcutaneous Insulin for DKA Patients

  • Introduction 

    Aim 

    Definition of Terms

    Assessment (signs patient is ready for transition)

    Management (timing of transition) 

    Assessment (signs transition was successful) 

    Ongoing Maintenance 

    Insulin 

    Links 

    Evidence Table

    Introduction

    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. 

    Aim

    • Provide guidance to nursing and medical staff in the transition of a DKA patient from IV insulin to subcutaneous insulin injections
    • Ensure a safe and medically appropriate transition
    • Streamline the transition process so patients are transitioned when medically ready and in a timely matter

    Definition of Terms

    • DKA: Diabetic ketoacidosis; the patient will display signs of hyperglycemia (high blood glucose), metabolic acidosis (low pH), and ketones are present. Criteria: 
      • pH < 7.30, HCO3 < 15
      • Presence of urinary or blood ketones
    • Normal pH level: 7.35-7.45 
    • Normal HCO3 (bicarbonate) level:  20-26 mmol/L
    • Normal blood sugar/glucose level: 4-8 mmol/L
    • Imprest: location of medication stocks, accessed by Pharmacists

    Assessment: Signs patient is ready for transition

    • Alert and oriented
    • Metabolically stable: pH > 7.30, HCO3 > 18, Lactate < 2
    • Blood glucose level 4-8 mmol/L
    • Able to eat and tolerate food

    Management: Timing of transition

    Night before anticipated transition

    • Diet order should be placed in EMR (Electronic Medical Record) to ensure breakfast delivery
    • Locate insulin pens and needles (see “Insulin” section), have available on current ward for the morning

    Morning of anticipated transition

    • Ensure patient within medical parameters (see “Signs patient is ready for transition” section)
    • Obtain a blood gas to assess pH and bicarbonate levels
    • Ensure food available ready for transition
    • Ensure Diabetes Educator contacted and aware of transition in order to start patient and family education
    • Request via EMR: “Orders > New order > Diabetes Educator Inpatient Referral”
    • If after-hours, referral will be followed-up during normal hours. Transition can still take place.

    Transition

    • Ensure 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
    • *Note: May also be giving Lantus at this time, see MAR and discuss with medical team
    • Patient needs to eat immediately, no later than 20 minutes after subcutaneous insulin
    • Turn off IV insulin infusion (and associated dextrose fluids) 30 minutes after subcutaneous injection
    • Check next blood glucose preprandial.

    Special Considerations with 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. Clarify with endocrine team before administering.

    Assessment: Signs transition was successful

    • Preprandial blood glucose 4-8 mmol/L
    • Alert and oriented
    • Patient tolerated meal

    Ongoing Maintenance

    • Blood glucose checks: Preprandial (pre-meal) before breakfast, lunch, and dinner, and at 0200
    • Blood glucose checks should be finger pricks now - use home device provided by diabetes educator
    • Patient needs to eat breakfast, morning tea/snack, lunch, afternoon tea/snack, and dinner

    Insulin

    • Specific Insulin Orders
      • Insulin Pens - for subcutaneous injection
        • Insulin Aspart (NovoRAPID FlexPen) pen
          • Rapid-acting insulin
          • To be given immediately before meals
          • Used on wards and at home for day-to-day maintenance
          • Onset: 15 mins, Maximum effect: 1 hour, Duration 3-5 hours
        • Insulin Glargine (Lantus) pen
          • Long-acting insulin
          • Given before bedtime
          • For first transition, half dose can be given during the day (first day on injections only)
          • No peak, steady action, Duration 24 hours
      • Other Insulins
        • Insulin neutral (ACTRAPID/humULIN R) vial
          • Short-acting insulin
          • Used to prepare insulin infusions
          • Onset: 30 mins, Maximum effect: 2-3 hours, Duration 6-8 hours
        • Levemir (insulin detemir)
          • Intermediate-acting insulin
          • 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.
    • Insulin Stock Locations at the Royal Children’s Hospital
      • Insulin Aspart (NovoRAPID FlexPen)
        • Soon to be stocked on Rosella Imprest - must call Rosella Pharmacist, who will deliver the insulin pen and needles within 10 minutes
        • After hours: Cockatoo ward (level 4), Kelpie ward (level 1). Special injection needles for insulin pens are stored with insulin pens in medication rooms
      • Insulin Glargine (Lantus) pen
        • Soon to be stocked on Rosella Imprest - must call Rosella Pharmacist, who will deliver the insulin pen and needles within 10 minutes
        • After hours: Cockatoo ward (level 4). Special injection needles for insulin pens are stored with insulin pens in medication rooms
      • Insulin pen needles
        • Preferably <6 mm needle length, generally 4 mm or 5 mm
        • Located with Insulin Pens
      • Insulin neutral (ACTRAPID/humULIN R) vial
        • Rosella ICU (level 3)

    Links

    Evidence Table

    The evidence table for this guideline can be viewed here


    Please remember to read the disclaimer.

    The development of this nursing guideline was coordinated by Katie Klatt, RN, PICU, and approved by the Nursing Clinical Effectiveness Committee. Updated May 2018.