SAFER ADMINISTRATION OF INSULIN

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 >14,000 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 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.

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, <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

11. SHORT ACTING • Works <30-60mins 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 <2-4 hours • Peaks 10-14 hours • Remains working 16 hours

13. 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

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 • <12 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 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

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 <4mmol/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 <3.5mmol/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