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F1 anesthetics > Insulin > Flashcards

Insulin Flashcards

1
Q

Insulin regimens and types of insulin based on length and duration of activity

A
  • Once daily
  • Twice daily
  • Basal plus
  • Basal Bolus- Intermediate or ultralong acting insulin
  • Intravenous insulin infusion
  • Continuous insulin pump therapy
  • Types: Very rapid acting, rapid acting, short acting, intermediate acting, long acting, pre-mixed
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2
Q

How does once daily insulin regimens work?

A

Intermediate or long acting insulin given once

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3
Q

What is twice daily regimen?

A

A mixture of rapid and longer acting insulin given twice a day

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4
Q

What is basal plus insulin regimen?

A

Offers a basal intermediate acting insulin with short or fast acting with meals

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5
Q

What is a basal bolus- intermediate or ultralong acting insulin regimen?

A

Ultralong acting insulin with short or fast acting with meals

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6
Q

What are intravenous insulin infusion regimens?

A

This insulin regimen delivers insulin via an insulin pump. They are only used in the hospital setting

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7
Q

What are continuous insulin pump therapy?

A

Insulin is given over a 24 hour period via an insulin pump and self inserted cannula. These are used by people with type 1 diabetes and are managed by them alone

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8
Q

Very rapid acting insulin example and characteristics

A

Examples: Fiasp, Lyumjev
- Given at beginning of the meal or within 20 minutes after
- Peaks at 60 mins
- Duration 30-90 minutes

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9
Q

Rapid acting insulin example and characteristics

A

Examples: Novorapid, humalog, apidra, insulin lispro sanofi
- Take up to 15 minutes before or after eating
- Peaks at 50-90 minutes
- Duration 2-5 hours

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10
Q

Short acting human insulin example and characteristics

A

Examples: Actrapid, Humulin S, Insuman Rapid
- Take 15-30 minutes before eating
- Peak 2-4 hours
- Duration up to 8 hours

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11
Q

Intermediate- acting insulin example and characteristics

A

Examples: Insulatard, Humulin I, Insuman Basal
- Onset 2 hours
- Peaks 4-6 hours
- Duration 14-16 hours

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12
Q

Pre-mixed human insulin examples and characteristics

A

Examples: Humulin M3, Novomix 30, Insuman comb 25
- Take 15-30 minutes before eating
- Onset within 30 minutes
- Peak 2-4 hours
- Duration up to 14 horus

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13
Q

Long acting insulin examples and characteristics

A

Examples: Abasaglar, Lantus, Levemir, Semglee, Tresiba, Toujeo
- Onset 2 hours
- Peak none
- Duration 24-36 hours
- The time of action can vary with different priducts, for example, Toujeo can last up to 36 hours, Tresiba can last up to 42 hours

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14
Q

What is premixed analogue insulin

A
  • Pre-mixed insulin contains a mixture of rapid acting insulin and an intermediate or longer acting insulin
  • The number given (e.g. NovoMix 30) indicates the proportion of rapid insulin included in the preparation
  • Needs to be taken up to 15 minutes before or after eating
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15
Q

When is rapid acting insulin used?

A

This type of insulin is commonly used to lower post prandial blood glucose in people with significant hyperglycaemia or as part of a basal bolus regimen in combination with an intermediate or long acting insulin

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16
Q

When is short acting insulin used?

A

This type of insulin is commonly used to lower post prandial blood glucose in people with significant hyperglycaemia or as part of a basal bolus regimen in combination with an intermediate or long acting insulin

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17
Q

When is pre-mixed human insulin used

A
  • This insulin is commonly used in people with type 2 diabetes who eat at regular times
  • It can be used in people with type 1 diabetes who do not want to take a multiple dose (basal Bolus) regimen
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18
Q

When is intermediate acting insulin used?

A

This type of insulin is used in:

  • People with type 2 diabetes in combination with oral or non injectable therapies and taken once or twice daily
  • People with type 1 diabetes who also take a short or rapid acting insulin with meals as part of a basal bolus regimen
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19
Q

When is pre-mixed insulin used?

A

This insulin is commonly used in:
- People with type 2 diabetes who eat at regular times
- It can be used in people with type 1 diabetes who do not want to take a multiple dose (Basal Bolus) regimen

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20
Q

When is long acting insulin used?

A

This type of insulin is used in

  • People with type 2 diabetes in combination with oral or non injectable therapies
  • People with type 1 diabetes who also take a short or rapid acting insulin with meals as part of a basal bolus regimen
21
Q

When is very rapid acting insulin used?

A

These are used in people who want to inject with the meal and who want it to work quickly to reduce glucose levels

22
Q

What is higher concentration insulins?

A
  • High concentration insulin is a medication that contains insulin at a concentration of more than 100 units/ml but in less fluid volume.
  • These insulin products are more concentrated so there is less volume.
  • They only come in pre-filled pens.
  • Beware - packaging can be similar.
23
Q

What is a biosimilar insulin?

A

A “biosimilar” is a biological copy of an original insulin that shares similar quality, efficacy, and safety

24
Q

Are biosimilar insulin and reference products interchangeable?

A
  • Biosimilar insulin and the reference product are not interchangeable. For example, Insulin Glargine 100 units/mL & Abasaglar are not bioequivalent. You cannot use one or the other intermittently.
  • Dose adjustments may be required when transferring to biosimilar insulin.
  • This should always be prescribed using the brand name.
25
Q

What is cheaper biosimilar insulin or reference products?

A

Biosimilar insulin is less expensive to develop than other analogue insulin.

26
Q

What to do if deciding to switch insulin brands or to a biosimilar

A
  • Always discuss and educate individuals on the new device when changing to biosimilar insulin.
  • Always ensure that only the intended prescribed brand is used following a switch.
  • Always issue a new “insulin safety card” to everyone new to insulin or when changing to biosimilar insulin.
  • Do not interchange the biosimilar insulin with the original product.
  • Individuals should not be changed on to a biosimilar without consultation and if there is a clinical need.
27
Q

What are some errors seen with insulin prescribing?

A
  • Using the pre-fix U or IU after the number of units has led to 10-fold overdoses of insulin, so check the units carefuly
  • Prescribing the wrong insulin
  • Transcribing an insulin prescription to a new medication chart and making a mistake
  • Prescribing when transferring to a new ward, or another place of care, using wrong insulin
  • Not prescribing correctly when transferring from an intravenous insulin regimen to a subcutaneous regimen.
    Incorrect prescription (especially on admission to hospital)
  • It is crucial to note that insulin should never be drawn from a cartridge or a pre-filled pen with a syringe
  • Abbreviation of ‘units’ (poor handwriting with ‘U’ or ‘IU’ read as 0 or 10)
  • Poor documentation of dose administration (especially in-patient/ care home charts drug charts)
  • Errors in calculation of insulin doses for IV infusions
  • The individual does not know how much they should be taking
  • Incorrect monitoring of blood glucose and dose adjustment of insulin
  • Duplicate dose administration
  • Incorrect programming of electronic infusion devices
28
Q

What should always be done when prescribing insulin?

A
  • Always prescribe by brand name and check units
  • For the Right person
  • The Right insulin
  • In the Right concentration
  • The Right dose
  • Written for the Right time
  • Prescribed with the Right device
29
Q

Blood glucose monitoring requirements in Type 1 and type 2, gestational diabetes, drivers, and end of life

A

= Many people with Type 1 diabetes are on a basal bolus regimen or insulin pump. They may test up to 8 times per day or more.
- People with Type 2 diabetes may test between 2-4 times per day depending on the insulin regimen they are using
- Patients with Gestational Diabetes may test up to 8 times per day.
- Drivers using insulin need to test at least 2 hours before driving, and 2 hourly if on a long journey.
- Inpatients need to be monitored a minimum of 4 times per day
- People with Type 1 and Type 2 diabetes who are insulin treated need to have a test at least once per day to rule out hypoglycaemia and significant hyperglycaemia leading to osmotic symptoms.

30
Q

Devices used to inject insulin

A
  • Insulin syringes and vials of insulin
  • Pre-filled insulin pens with insulin cartridges
  • Disposable pre-filled pens
  • Insulin pumps
  • Intravenous insulin infusions
31
Q

Insulin pen devices unit capabilities

A

= Insulin pens can be used to give up to 50, 60, 80 or 160 units.
- Some pens will give doses in 0 . 5-unit increments, some in 1-unit increments and some in 2-unit increments – you need to be sure which type you are using.

32
Q

How many times can the pen needle, insulin syringe, and lancet be used?

A

Once

33
Q

What to remember when preparing insulin for subcutaneous use?

A
  • If you are using a syringe and vial – you need to use an insulin syringe.
  • If you are using an insulin pen, check it is the correct device.
  • Check that the name of the insulin is correct.
  • Check the device is the correct one for the type of insulin prescribed.
  • Check that the timing of the insulin is as written.
  • Check that the needles you use with an insulin pen are 4, 5 or 6mm.
34
Q

Subcutaneous administration of insulin steps

A
  • Wash hands
  • Remove pen cap, For cloudy insulin, roll pen 10 times between the palms.
  • Gently invert the pen 10 times to achieve a milky appearance.
  • Select a new needle. Peel off paper seel. Apply new needle in line with pen.
  • Screw needle, Pull off protective caps
  • Ensure needle and pen are working, Correctly select 2 units on dose button. Hold pen with needle pointing upwards. Fully depress dose button looking for insulin to appear from the needle tip. If not seen, repeat steps until insulin seen at needle tip
  • Dial the required dose
  • Fully insert the needle into the skin at 90 degrees, keeping the pen stable. Press dose button until dose fully injected.
  • Before removing the needle from the skin count to 10 to ensure the full dose is given
  • Safely remove the needle from the pen. Dispose of the needle into a sharps bin.
35
Q

Insulin injection sites

A
  • It is important to choose the correct site for the injection but equally it is important not to overuse sites as this can cause problems such as lipohypertrophy.
  • It is important to use a simple rotation process to ensure that no one site is overused.
  • Always advise rotating within the site making sure each injection is given 1cm away from the last.
36
Q

What is lipohypertrophy?

A
37
Q

Types of IV insulin infusion and indication

A

There are two ways to give insulin using an insulin infusion, depending on the indication for use:
- Fixed-rate intravenous insulin infusions; these are used initially in the treatment of diabetic ketoacidosis and hyperosmolar hyperglycaemic state.
- Variable-rate intravenous insulin infusions are used for those people undergoing surgery and elective procedures and in those nil by mouth.

38
Q

Insulin infusion indications

A

Insulin infusions are commonly used in hospitals to treat:
- Diabetic ketoacidosis.
- Hyperosmolar Hyperglycaemic State.
- Pre and post surgery.
- Post cardiac event.
- Where the individual is nil by mouth.
- In pregnancy and in oncology patients when steroid therapy is given.

39
Q

Intravenous insulin infusion monitoring

A
  • Regular monitoring of patients on intravenous insulin is essential, as their condition can change rapidly, particularly with the risk of hypoglycaemia. For the first 12 hours, hourly monitoring is recommended, while more stable patients may require monitoring every two hours.
  • When patients are eating and drinking, it becomes challenging to maintain blood glucose levels within the desired range while on intravenous insulin
40
Q

Preparation of IV insulin infusion

A
  • To ensure accurate measurement and preparation of insulin for intravenous infusion, always use a 50 mL insulin syringe. When preparing insulin on the ward for infusion, fill the 50 mL syringe with 49.5 mL of 0.9% sodium chloride and add 50 units of insulin in 0.5 mL.
  • Some departments may opt for ready-to-administer infusion products, such as pre-filled syringes containing fast-acting insulin, which typically provide 50 units in 50 mL of 0.9% sodium chloride.
  • Equipment needed : An intravenous insulin pump and cannula, A “Y” connecter, Low-absorption tubing.
41
Q

How long does intravenous insulin last in the body once an infusion is discontinued? Why is subcutaneous different?

A
  • The half-life of intravenous insulin is less than 5 minutes
  • Subcutaneous insulin is not absorbed immediately.
42
Q

How to discontinue an insulin infusion

A

Never stop IV insulin in a person with type 1 diabetes if they have not had their usual background insulin previously.
- The basal insulin should have been continued while the intravenous infusion was in situ if the individual was previously on a basal-bolus regimen.
- Restart the usual regimen when the individual is ready to eat e.g. twice daily mixed insulin or rapid or short-acting insulin or oral therapies.
- There should be a 30 to 60-minute overlap period before stopping intravenous insulin.
- Glycaemic control may be erratic for 24 – 48 hours after restarting subcutaneous insulin.

43
Q

Hyperglycemia levels

A

Hyperglycemia occurs when the blood glucose levels are more than 7.0 mmol/L when fasting or more than 11.0 mmol/L after food (WHO)

44
Q

Which people are more at risk of hypoglycemia?

A
  • There is a history of previous hypoglycaemia
  • They have had diabetes for a long time
  • If the glucose targets are too “tight”
  • If they are insulin treated or take a Sulphonyurea
  • If they are frail
  • If they are older
  • If kidney function is poor
  • If they have dementia
45
Q

Early signs vs late signs of hypoglycemia

A
  • Early signs are adrenergic: palpitations, anxiety, tremors
  • Late signs include confusion, unsual behavior, speech difficulties, lack of coordination, seizure, and coma
46
Q

Effects of severe hypoglycemia on CV system

A

Can lead to serious acute vascular events like stroke, MI, acute cardiac failure, ventricular arrythmia, or even death

47
Q

Drives an dhypoglycemia

A

If they are a class 2 driver and have a single episode of hypoglycaemia at any time they will need to inform the DVLA and stop driving until assessed.

48
Q

When is ketone test warranted in hyperglycemia?

A

People with type 1 diabetes and those with type 2 diabetes who are clinically unwell will need a ketone test if their blood glucose is 12mmol/L or more.

49
Q

Management of hyperglycemia

A

F1 anesthetics (39 decks)

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