Insulin for Paramedic 2008(Basic)MIRI

8/3/2019 Insulin for Paramedic 2008(Basic)MIRI

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WILLIAM CANNON ESSAU AK HENDRY

PPP U29

HOSPITAL BETONG


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ObjectivesParamedic would be able to know the different types of insulin,onset/peak action, correct timing and the various insulin regime.

Paramedic would be able to assess and know which is the mostappropriate insulin regime to suit patients need.

Has confidence to educate patient all about insulin therapy.

Recognize signs and symptoms of hypoglycemia and its action plan


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Content

What is Insulin? / How insulin works? Why needs insulin? Who needs insulin? Types of insulin/storage

What sort of insulin therapy? Types of insulin delivery device Insulin Injection technique/rotation sites

Insulin dosage/adjustment Hypoglycaemia / action plan


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Hormone produced by the beta-cells of thePancreas

Release in response to food uptake

Assists uptake of glucose from the bloodinto the body cells

Keeps blood glucose normal

Helps Triglycerides be stored as fat in fatcells

Helps liver and muscle tissue store

glycogen for future use


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After an injection, insulin is picked up by thebloodstream & carried throughout the body,binds itself onto the muscle & fats cells.

Like a key, it opens up a lock (receptor onbody cell) allowing glucose to enter the cellsfor energy.


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Fungsi insulin dalam pergerakan gula darah

ke dalam sel-sel badan:

DARAH

SEL

G

G

TENAGA

G G

Gula darah mengalir ke seluruh badan.

Insulin (dari pankreas) juga mengalir dalam darah ke seluruh badan.

Insulin

Gula G

G

G

Insulin melekat pada bahagian tertentu sel-sel badan .

Insulin membuka pintu pada sel untuk membolehkan gula darahmasuk ke dalam sel.

Tenaga dihasilkan untuk keperluan badan.


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Beta- cell failure

Absolute Type 1 Type 2 with OHA failure

Relative Type 2, Stress


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No endogenous insulin secretion.

Patient is dependent on exogenousinsulin administration for control of bloodsugar and survival.

Type 1 Diabetes Mellitus


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UKPDS results 3rd.yr.of diagnosis, 50% of patients required

combination of OAD + insulin therapy.

6th year, 50% patients required full insulin therapy toattain normoglycaemia.

50% of insulin reserve lost at diagnosis -1:6 needinsulin 5-6 yrs after diagnosis)

Studies demonstrated that postprandialhyperglycaemia is associated with increasedmortality (DECODE Study, 1999).

Type 2 Diabetes Mellitus


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Treatment is individualized to suit thepatients life, sugar profile, and concurrent

illness.

Treatment to reach target.

To initiate a regime thats most comfortableand preferred by patient

Simple regime would enhance compliance

although may not be physiological.

Ultimately, the aim is to achieve as near normalblood glucose level throughout 24 hours

without HYPOGLYCAEMIA


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TYPES OF INSULIN


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Humulin ROnset : within 30 mins of s/c injection Peak : 2 - 4 hrs Duration of action : 6 8 hrs

Available in cartridge 3 mls

Actrapid HMOnset of action : within 30 minutes of s/c injection

Peak : 1 - 3 hrs Duration of action : 8 hoursAvailable in vial 10 mls and cartridge 3 mls

Titrate dose according to premeal blood sugar.

Short Acting Soluble


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NovoRapid (Insulin Aspart)

X Humalog (Lispo)

Onset:10 - 20 mins after s/c injection

Peak:1 3 hrs

Duration of action: 3 - 5 hrs

Available in penfill /Novolet (3 ml)

(Can be given immediately before food or after food)

Rapidacting Human Insulin

Analogue


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Humulin N

Onset : within 1hr after s/c injectionPeak : 4 10 hrs

Duration of action: 16 18 hrsAvailable in 3 ml cartridge

Insulatard HM

Onset of action : within 1.5 hrsMaximum effect : 4 12 hrsDuration of action : 24 hrsAvailable in 10mls vial and 3 mlscartridge

Intermediate-acting insulin


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Mixtard 30/70Onset within hr of s/c injection Peak 2 to 8 hrs Duration of action 24 hrs

Available in 3mls cartridge

Humulin 30/70

Onset- within hr of s/c

Peak- 2-12 hrs

Duration- 16 -18 hrs

Available in 3mls cartridge

Premix insulin


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Novo Mix 30

Biphasic insulin- 30% rapid insulin aspart

- 70% intermediate-acting protaminated

insulin aspart

Soluble insulin aspart is rapidly absorbed,predictable onset of action and rapidelimination to match the phsiologicalpostprandial peak.

Protaminated insulin aspart is released moreslowly, having a longer duration of action,thus provides a smooth basal insulin profile.


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Novo Mix 30

Onset: 10-20 min

Peak: 1-4 hrs

Duration: up to 24 hrs Available in Flex Pen (Novolet)

Can be given immediately before food or after food


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Lantus (Glargine)- from Sanofi Aventis

Peakless insulin analogue

Used Once daily and can be given anytime of the day butmust be same time everyday

Onset: 1-2 hrsPeak: peakless (appears to mimic normalphysiological basal insulin

Effect: 24 hrs

Provide 24 hours basal glycaemic control withless nocturnal hypoglycemia and early morning

hyperglycemia compared to intermediate insulin


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Stored HORIZONTALLY in refrigerator at 2-8 c at the

door/lower compartment away from freezer

If no fridge available: store at room temperature temp

Find the coolest possible place

Avoid extreme temperature and direct sunlight

Loss of potency after in use > 1 month

Evidence of loss potency

clumping

frosty

precipitation change of colour

Insulin Storage


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DIET + OHA (BIDS)CommonInsulin

Regimes

Options to suit patient:

BIDS

BD (self-mixing or

pre-mixed) Basal-bolus


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ORAL COMBINATION (BIDS)

Continue oral antidiabetic drugsInject intermediate insulin between 1012

at nightStart 0.1 - 0.2 units/kg/day or 10 units at

bedtime

Adjust by 2-4 units every 3-4 days to

achieve target FBG

Maximum dose 20-30 units.

Common Insulin Regimes

C I li R i


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MORNING AFTERNOON EVENING BEDTIME

BREAKFAST LUNCH DINNER SUPPER

Combination of short and intermediate acting insulin twice daily - hr. b4breakfast and dinner. (start at 0.4unit/kg/day)

DOSE usually 2/3 of total dose at AM, 1/3 at PM

2/3 Intermediate, 1/3 short acting insulin

The morning short acting insulin controls blood glucose from breakfast (effect isshown at blood test before lunch). The morning intermediate acting insulin controlblood sugar from lunch (effects shown at blood test before dinner). The eveningshort acting insulin controls blood sugar from dinner (effects shown at blood testbefore bedtime). The evening intermediate acting insulin controls blood sugar

through the night (effects shown at blood test the next morning).

BD Self-Mixing /BD Premixed


C I li R i


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Premixed insulin twice daily - hr. b4 breakfast and dinner. (start at0.4unit/kg/day)

DOSE usually 2/3 of total dose at AM, 1/3 at PM

2/3 Intermediate, 1/3 short acting insulin

BD Premixed


C I li R i


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Short acting insulin pre meals ie 3 times a day - hour prior Breakfast,

Lunch & Dinnerplus intermediate acting (basal) insulin at bedtime.

With this regime, the amt. of food eaten and timing of meals is moreflexible. The dose of insulin can be matched to the size of the mealwhich gives the best overall glucose control.



Basal Bolus Regime



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Common insulin regimesRegimes Frequency of

useAdvantages Disadvantages

BIDS

Humulin N /Insulatard at night

Once a day ie

pre bed

Common inOHA failure

Gentleintroduction toinsulin therapyhence moreacception

Continue OAD and

Inject night insulin

Basal Bolus

Short acting TDS

Intermediate ON

4 times a day

Type 1DM

DM leadingactive lifestyle

DM with acuteillness eg.Infection, severestress, surgery

GDM andpregnant diabetes

Amt of foodeaten and timingof meal moreflexible

Dose of insulincan be titrated tomatch size ofmeal/activityhence betteroverall glucosecontrol

Frequent injection

ie 4 x a day


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Common insulin regimesRegimes Frequency of

use

Advantages Disadvantages

BD Premixed

Humulin 30/70 or

Mixtard

Twice a day DM not complyingwith prescribed mixedinsulin regime (self)

DM with difficultydrawing up andmixing 2 differentinsulin

DM leadingsedentary lifestyle,not much viaration inmeals/activity

Convenience ofpremixed henceeliminate risk ofmixing mistakes

only 2 timesinjection

simple to use fornew insulin user

Enhance compliantfor active lifestyle DM

Elderly with visualproblem

Difficult to titrate doseto meet pts

needs/lifestyle

BD Self mixing

(short acting withintermediate)

Twice a day

DM not keen onbasal bolus regime

Dose can betitrated to meet pts

requirement oraccording pts blood

sugar profile

Need to self mix insulin

Not suitable for poor eyesight/unable to do

Danger of wrong dosage

Need other people toassist


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How to choose the suitable regime

Assess on:

Lifestyle/occupation

Physical activity Dietary practice

Ability to self-inject insulin

Eyesight Social suppport

Various types of insulin delivery devices


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Various types of insulin delivery devices

***Do not used tuberculin syiringe***


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Inject at 90 degree angle using 6

mm -8 mm fine needle except thin

individual or children at 45 pinchInject up to the hub o f the needle

Ensure the plunger has been pushed in

Count 5 to10.Change needle/syringe after 4 injections

maximum. Rotate each injection about 2cm away

from the last site of injection


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Rotation of the injection site is important to prevent pitting or lumpiness of theskin (lipoatrophy & lipohypertrophy) that result in poor insulin absorption.The abdomen is the best injection site, as it has the fastest & even insulinabsorption rate and is least painful, followed by the arms, thighs & buttocks.

Front Rotation allows completehealing of traumatized tissue

Rotate at 2 cm. across / 2 cm.up or down in one region

Selection of injection sites and rotation sites


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Upper outer arms

Above the waistat the back

buttock

Side area of thethigh

Upper outer arms

Above the waistat the back

buttock

Side area of thethigh

Back

Other injection sites


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Before adjusting insulin dosage :

Watch level of glucose for 2-3 days

Identify the problem :Correct gross error in DIETEnsure ADHERENCE to treatmentAny stress ?/ Infection ?Exercise intensity ?

Over treatment ?

Usually aim for fasting firstWait 2-3 days

Insulin Dose Adjustment


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Somogyi Effect

Rebound hyperglycaemia (rise in early AM blood sugar) followingnocturnal hypoglycaemia which may not be recognized.

Glucose counter regulatory responseRise likely due to dawn phenomenon or relative lack of insulin

How to detect? Check blood sugar at pre-bed, at 2-3am and FBS

How to recognise if no meter available? Pt. complain of headache in the morning sleeping partner notice pt. sweating H/o hypoglcaemia symptom at night

Other factor to consider

in insulin dose adjustment


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Identify symptoms ? What to do for prompt treatment if has

symptoms Why ? Find out the cause and learn from it

Skipped meal / delayed meal

Insufficient food intakeWrong insulin / too much insulinInappropriate timingUnusual physical activity

HYPOGLYCEMIA


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Signs & symptoms of hypoglycaemia

Tiredness Weakness

Nervousness, trembling or shaking

Unusual hunger Palpitation

Cold sweat

Dizziness, Headache

late stage - blurred vision, change in behavior,unconsciousness


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Check blood sugar if meter available to confirm

hypo.

If patient is conscious :

take sweetened drink (1 table spoon sugar) or

sweets or syrup drink or others- followed by complex carbohydrate eg, crackers 3 pcs

- Check blood sugar after 15 min.

If next meal/snack is more than 30 min away, giveextra snack of CHO and protien

(If pt is unconscious, dont give orally)

Action Plan During Hypoglycemia


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Insulin for Paramedic 2008(Basic)MIRI

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