Insulin can also be administered as a continuous subcutaneous insulin infusion (CSII), by means of a small pump that delivers insulin subcutaneously into the abdominal wall through a butterfly needle. Insulin is usually infused at a continuous basal rate with preprogrammed boluses just before meals. Both hypoglycemia and ketoacidosis are more frequent in patients with CSII. For emergency department patients with CSII who develop hypoglycemia, marked hyperglycemia, or DKA, it is best to shut off the pump in the emergency department while standard glucose or insulin therapy is administered.
A working knowledge of the pharmacology, including time to peak effect and duration of action of the various insulin and oral hypoglycemic preparations, should enable the emergency physician to make adjustments in a patient's usual insulin or oral hypoglycemic regimen, especially if the patient arrives with a home blood glucose diary. It is a good general rule not to change the total number of units of insulin by more than a 10 percent increase or decrease in a single day. Adjustment of oral agent dosage can generally be left to the primary care provider because it requires careful and close monitoring. If that option is not readily available, oral hypoglycemic agent dosing should generally not exceed a 20 percent increase or decrease. If the patient is not doing regular home glucose monitoring, be sure that he or she has the equipment and the knowledge to test regularly during the adjustment period to avoid severe hypoglycemia or hyperglycemia. When the availability of a primary physician is in question, some emergency departments are able to send a home health nurse to the patient's home for teaching and assessment.
A good home blood glucose-testing regimen is to take measurements prior to meals and at bedtime. Less than four home-monitored glucose values per day has been associated with poor glycemic control.11 The "intensive therapy" was described earlier.
An alternate rotating testing regimen of taking measurements (before breakfast, 3 days; before lunch, 3 days; before the evening meal, 3 days; and before bedtime, 3 days) decreases the number of fingersticks per day. It is less useful, however, when adjusting insulin or oral agent dosages, but may increase compliance. If a patient is unwilling or unable to test his or her blood glucose regularly during an adjustment and is not at high risk for metabolic decompensation, any adjustment of regimen and further education should be left to a primary care provider or endocrinologist.
Was this article helpful?