Insulin ======= þ Lantus (glargine insulin) - less hypoglycemia than with other insulin - however, may have prolonged hypoglycemia, treat like oral agent hypoglycemic þ Insulin OD: - check c-peptide to see if insulin excess is external or internal -- if internal, from insulinoma or from sulfonylurea, will have elevated C-peptide that is a byproduct of normal internal insulin production. - check insulin levels - if appropriate, check sulfonylurea levels - may want to consider octreotide if NOT a diabetic -- has helped in unpublished case reports (Keith Burckhardt, M.D., Hershey Medical Center) as will suppress endogenous insulin that responds to IV glucose. þ Diabetics who are not eating - Per Jann Johnston (Endocrine, MH), don't hold insulin entirely, just cut in half or so. (communicated to Mercy DEM staff meeting, 3/99) þ Insulin Drips - best seems to be 1 unit/cc, as easiest to deal with - However, Mercy pharmacy insists on mixing 250 units in 500 cc NS - "Rules of thumb" are as follows: + start with 10 units IV push, then 2 units per hour + use NS for hydration until blood sugar about 200, then change to D5NS or D51/2NS for hydration (to avoid bottoming out glucose level) - use small bags to avoid potential overdose - can use McGaw but not Baxter bags for it (the Baxter ones soak up too much insulin) - should run a moderate amount through the IV tubing to allow the plastic to soak up insulin and become saturated first þ Types of Insulin Onset of Peak Effect Usual Duration Action of Action Lispro 5 min 60 min 2-4 hours Human Regular 30-60 min 2-3 hours 3-6 hours Human 2-4 hours 4-10 hours 10-16 hours NPH Human 3-4 hours 4-12 hours 12-18 hours Lente Human Ultralente 6-10 hours No real peak 18-20 hours Lispro (Humalog) should be injected within 15 minutes prior to the meal. Used SQ, even in acute emergencies. Best for meal coverage. (Information from Dr. R. Eder, Mercy pager 1407, Center for Drug Information)