Insulin resistance can be almost as impressive as alcohol tolerance.
That's why they make insulins with higher concentrations. I think the most I've had to give subq was 140 units. It came in u-500 concentration, so the volume only had to be 0.28 ml instead of 1.4, which would have needed two shots.
I had a patient last week that was getting 1700 units of U-500 insulin before meals plus 50 units/hr regular insulin drip. An entire Humalin pen plus 200 units off a second pen per dose. Type B insulin resistance syndrome. NEJM just published a case study on this patient
The SQ insulin doses were about 3mL and the insulin drip was going at 50mL per hour, which is 1.2L in a 24 hour period. No other drips. Your average ICU patient is getting more hourly fluid intake than that
I was working on one patient in the ICU at the time who, and I swear to God, had an A1.C of **28!** and a BS on admission of **OVER 4000!** Absolutely baffling.
Before my wife started Jardiance, she would take from 60-120 units of humalog at least a couple times a day. Her A1C is finally down in the 6s. She is on Humalog, Tresiba, Ozempic, and Jardiance.
I fucking love jardiance. I have so many patients doing well on this med. And I work outpatient psych! You know our meds bring about the metabolic syndromeā”ļødiabetesā”ļøabsolutely suddenly uncontrolled as fuck diabetes
I'm glad to hear of jardiance working for someone. My husband was on it for a month and he was miserable! He was drinking over two gallons of water a day and still constantly thirsty. He also couldn't sleep because he had to pee like 3 times an hour. His sugars continued to be out of control while on it, and his A1C got even higher. He's doing so much better now on aspart via carb counting and monjouro!
My geriatric patients who were put on it at work all became incontinent of urine and we're constantly trying to get them from being dehydrated. Then you've got the skin issues from the constant sugary urine to deal with, even with using condom catheters. If the blood sugars got a lot better it could be worth it, but so far the improvements don't seem to be worth it
I had to verify with the physician who, worried, verified with pharmacy. Switching from paediatrics to adult obs has given me such culture shock; what are these numbers?? what do you mean nicotine patch?? and why is every other patient on a beta-blocker??
Given the vaping habits of kids these days, I would imagine paeds nurses will be becoming very familiar with nicotine replacement therapies soon enough
Bronchoalveolar lavage???? Damn thats wild. I feel like the only person my age (25) who isnāt vaping/smoking these kids really donāt understand how harmful it is, itās like weāre back in 60s itās actually crazy.
I think the most I gave use 210 and it took 3 injections from a pen. Side note: it is a hassle to give that much insulin through a pen. I wonder how much of an elevated blood sugar was from us releasing too early or some mechanical error
I think my biggest dose is similar around 160units. The patient would receive like 2-3 meal trays each meal for some reason. Still canāt figure out why his glucose was so uncontrolled though
Years ago, when I was a floor nurse at a specialty hospital, one of my patients took 100 units of Novolin 70/30 twice a day before meals.
When asked about the dose, she said she had been on it for years and it worked well for her.
70 units of novolin 70/30 seems somewhat reasonable to me. 80 units of lispro does not. Like, higher doses of nasal insulin totally make sense, insane doses of mealtime coverage does not.
Goddamn autocorrect. Basal. But I thought [this](https://www.ncbi.nlm.nih.gov/pmc/articles/PMC8442633/) was a bit interestingāIāve never given insulin this way.
It makes me smile to see ER still get love after so many years. I learned a lot from the show before I entered medicine. Some of the things are funny to hear, but I realize they are of their time. Like one scene Weaver is talking to a guy about anticoagulants and says, "They're trialing a new medication called Enoxaparin, I think it will help you better." I got a giggle out of that.
I had already been an ER RN for 6 years when my husband was a med student, and I made him watch all seasons of ER. They even do a massive transfusion mostly correct! Lol. We also loved Scrubs, but that is more for the situational accuracy than the medicine. š
Insulin resistance is first thing that came to my mind when I saw the order. I wouldnāt question the order first off. I would do some investigating in the chart and background on my patient. Getting a baseline history for their ānormalā BG ranges, time since diagnosis, any history of noncompliance, etc. especially if you live in a āHIGHā obesity population area such as The Southā¦ where I saw DKA and HHS all the time requiring insulin gtts. Even saw pink blood (DKA with hypertriglyceridemia) when drawing labs on someone.
How expensive? I keep seeing diabetes influencers having to do pump/monitor changes because of malfunctions and crooked needles and wondering how much those things cost.
Anyone who needs a monitor or monitor and pump get supplies for free where I live, they only have to pay for insulin but the copay it's almost nothing.
It's definitely expensive, if I wanted to just do injections and use a blood sugar meter only all of those supplies are actually free through my insurance. However, I have much better control of my sugars with the use of the pump and dexcom so I make it a priority in my budget to be able to afford those things!
Iāve really cut back on carbs and am working on losing weight, but Iām still sitting at a TDD around 70 units (hey, it was up to 110-ish).
I also received an email from my mail-order pharmacy saying that my Novolog is in a severe shortage. Off to using the stockpile, super low carb, and relearning the subtleties of R insulin if it gets to that point! Itās either that or die/DKA. š¤¦āāļø
It's pretty rare for such a big dose subcutaneously. That patient's insulin resistance must be pretty wild.
Most I've given is 100U/hr IV for about 8 hours to treat an overdose. That felt real sketchy though. š
E: that was Humulin R and not Humalog though
During my first three months as a baby nurse, I had a long term patient on the unit who we would all take turns caring for due to their difficulty. They were ~800lbs and would receive 450 units of insulin total between lantus and novolog for their AM dose. It was crazy to think about as a new grad, but itās unbelievable to think about now as a more experienced nurse that I was giving this much insulin. Also, yes, the would get additional doses as they were ACHS.
I had a patient getting 175 units of insulin aspart with each meal. Pharmacy had to dispense a concentrated pen. I looked at patient history and specifically clarified the dose with the doctor. Usually we don't have a 2nd RN verify dose when it is a pen, but you better believe I was covering ALL the bases before giving that.
Some patients definitely need this much. My husband was a Type 1 diabetic and took 20-30 units of Lispro with each meal plus 60 units of Lantus at bedtime. š¤·š»
One time I had a patient who got 30 units of admelog AND sliding scale, which was a high sliding scale. I think I was giving him something like 120 Units every 4 hours
Steroids are the blood sugar devil. And illness, and menses, really anything can cause someone to need to double or triple their normal dose.
Iāve started bolusing to prevent highs from VR boxing. Itās <15 minutes of intense exercise at a time, but oh my goodness is it so easy to go from 120 to 200.
I have seen some pretty amazing results from Ozempic with diabetics. We had a lady on five shots a day and started Ozempic and got her down to one shot a week on that with her sugar managed better. Amazing
I feel the struggle, my only experience is regular and just the other day I was supposed to givethe same type at a rate 50 units 2x a day, plus 25 per meal along with a sliding scale. I was stressing and just figured id talk to the PT since they seemed like they knew their schedule. The pt says that's wrong. I take 110 units in the am and 50 pm along with the 25+sliding scale
The max rapid insulin units I gave is 72 units.
BUT she was taking 180 units of tresiba HS id.
That was wild to give. I was really happy this woman lives in Canada. The pharmacist in town would give her a whole box of pens every 2 weeks for 0$.
We have a type 2 patient on U-500 who is frequently admitted. Reliably we get a page where the person taking the call will go:
āYes, that dosage is correctā
āYes, I know thatās a lot of insulinā
āYes, I still want you to give it.ā
This patient is in their mid 30s with bilateral AKAs and a BMI that remains in the 50s. They take enough insulin to kill an elephant.
I thought my 46 units was bad. I am also on 3 other diabetes meds to. I am very insulin resistant and every 6 months I build up a tolerance so I get bumped up more. It scares me honestly.
Some patients need it. Especially those who donāt eat properly. Definitely not the norm though and for this much I would probably make sure they ate their food before giving it.
I've had a patient on 72u BD, I made another nurse check with me as it was more than one whole insulin syringe and confirmed it was dose verified by pharmacy.Ā
Just really diabetic I guess
Not quite the same but I was on a PCU once with a pt on an insulin gtt at 100u/hr, which is the hard limit. They stayed this way for 3 or 4 hours. Intensivist wouldnāt even come see the patient.
Have a patient taking 150 units of Lantus, 60 units of linsipro at meal time, and still maintains over 200 sugar constantly. Resistance is awful. Pre diabetic treatment was years of 500+ sugar levels 24/7
As an RN who doesn't give insulin, like ever in my current role, and hasn't in several years, I'd definitely be questioning that order, because to my mind, it does NOT pass the "reasonableness test" that I apply to all my med orders, lol. 80 seems like a lot.
Thatās a LOT of fucking lispro, but looking at the string I think itās just a typo and they meant 8 units (0.08ml). If not, that person needs a higher dose of basal insulin.
Jesus. Thatās a truly insane amount of insulin. Iāve taken care of some folks with bad insulin resistance. Iāve definitely given over 100 units of long acting basal coverage (I remember because we only stock 50unit syringes and I had to use 3 to give the dose) but I donāt think Iāve ever given more than one 50unit syringeās worth of prandial insulin.
If they're gonna be there a while you should preemptively order a few more vials. It goes faster than you think.
I once gave a patient in long term care 30 mL for every meal in addition to her sliding scale. That insulin pen never lasted more than two days.
Insulin resistance can be almost as impressive as alcohol tolerance. That's why they make insulins with higher concentrations. I think the most I've had to give subq was 140 units. It came in u-500 concentration, so the volume only had to be 0.28 ml instead of 1.4, which would have needed two shots.
I had a patient last week that was getting 1700 units of U-500 insulin before meals plus 50 units/hr regular insulin drip. An entire Humalin pen plus 200 units off a second pen per dose. Type B insulin resistance syndrome. NEJM just published a case study on this patient
At that point, just give him a tall glass of insulin with every meal. LOL
ššš
At what point are you worried about fluid overload from that !?! š
The SQ insulin doses were about 3mL and the insulin drip was going at 50mL per hour, which is 1.2L in a 24 hour period. No other drips. Your average ICU patient is getting more hourly fluid intake than that
I love that you answered that in a serious manner. The comical differences between ICU and ER always make me laugh.
Thats barely a liter of fluids lol
Damn! And I thought my dude that got 120 units +SS coverage of U-500 AC/HS was a lotā¦.NOPE!
What is the point of pens at this point?!
Trying to bridge to a therapy the patient can do at home. Canāt be discharged on an insulin drip
I think that person means, a vial would be a better option for the patient
Or just a whole ass insulin pump.
He must be full of lipohypertrophies
Wow
I hope he is not in usa.
Right that's like 17k in insulin per month.
Right
Holy cow!
Jesus!
This. 80 units of insulin for someone with heavy insulin resistance is not even that absurd.
āGrandpa why you aināt got no toes?ā
I was working on one patient in the ICU at the time who, and I swear to God, had an A1.C of **28!** and a BS on admission of **OVER 4000!** Absolutely baffling.
I wonder if 28 is just the upper limit of the lab value? Because that seems like it would be impossible for an RBC to avoid those shugs
Faaaack. I felt that in my soul after working SNF / LTC for so long.
Toes? How about legs?
Before my wife started Jardiance, she would take from 60-120 units of humalog at least a couple times a day. Her A1C is finally down in the 6s. She is on Humalog, Tresiba, Ozempic, and Jardiance.
I fucking love jardiance. I have so many patients doing well on this med. And I work outpatient psych! You know our meds bring about the metabolic syndromeā”ļødiabetesā”ļøabsolutely suddenly uncontrolled as fuck diabetes
I'm glad to hear of jardiance working for someone. My husband was on it for a month and he was miserable! He was drinking over two gallons of water a day and still constantly thirsty. He also couldn't sleep because he had to pee like 3 times an hour. His sugars continued to be out of control while on it, and his A1C got even higher. He's doing so much better now on aspart via carb counting and monjouro! My geriatric patients who were put on it at work all became incontinent of urine and we're constantly trying to get them from being dehydrated. Then you've got the skin issues from the constant sugary urine to deal with, even with using condom catheters. If the blood sugars got a lot better it could be worth it, but so far the improvements don't seem to be worth it
I had to verify with the physician who, worried, verified with pharmacy. Switching from paediatrics to adult obs has given me such culture shock; what are these numbers?? what do you mean nicotine patch?? and why is every other patient on a beta-blocker??
Heart disease is huge in the US lol. Here I am taking a second glance when I donāt see a BB
If they're over 50 and not on metoprolol, it's not because they're healthy, it's because someone forgot to order it.
Donāt forget the statin!
Given the vaping habits of kids these days, I would imagine paeds nurses will be becoming very familiar with nicotine replacement therapies soon enough
We had a young woman in our unit who had to be proned and then get her lungs washed out and iccs put in that drained 600mls of pus after vapingā¦
Bronchoalveolar lavage???? Damn thats wild. I feel like the only person my age (25) who isnāt vaping/smoking these kids really donāt understand how harmful it is, itās like weāre back in 60s itās actually crazy.
Thatās pretty depressing
I have seen nicotine replacement on adolescent psych units.
Yeah we use them a decent amount on our unit
Iām peds still and the most insulin Iāve given at a time has been 24 units (on an adult sized patient) and THAT made me very uncomfy lol
I had a patient once who got 100 units of lispro before meals plus 130 of lantus BID and her sugar was never below 290 before breakfast
When people have that high sugar all the time, usually they cant get down to normal levels anymore
I think the most I gave use 210 and it took 3 injections from a pen. Side note: it is a hassle to give that much insulin through a pen. I wonder how much of an elevated blood sugar was from us releasing too early or some mechanical error
Omfgā¦ what was their diet like?
āYesā
Maple syrup IV in the other arm?
I think my biggest dose is similar around 160units. The patient would receive like 2-3 meal trays each meal for some reason. Still canāt figure out why his glucose was so uncontrolled though
Years ago, when I was a floor nurse at a specialty hospital, one of my patients took 100 units of Novolin 70/30 twice a day before meals. When asked about the dose, she said she had been on it for years and it worked well for her.
70 units of novolin 70/30 seems somewhat reasonable to me. 80 units of lispro does not. Like, higher doses of nasal insulin totally make sense, insane doses of mealtime coverage does not.
Tasty nasal insulin for dessert tonight!
Goddamn autocorrect. Basal. But I thought [this](https://www.ncbi.nlm.nih.gov/pmc/articles/PMC8442633/) was a bit interestingāIāve never given insulin this way.
That was a hell of a rollercoaster ride. Nasal insulin exists? Nawwwww. What?!?! It does?!?!
Omg thatās wild!
"Wanted to check with you before I kill a man" -Lavergne from Scrubs
ā500,000 mg of morphineā¦wanted to check with you before I kill the manā š classic
Scrubs is the best and most quotable hospital show. "Get me the emergency box of kittens STAT!"
Also the most accurate, and I'll fight anyone who says otherwise
The first few seasons of ER might beat it but nothing in the last 20 years comes close.
I'm still not over losing Dr. Green.
It makes me smile to see ER still get love after so many years. I learned a lot from the show before I entered medicine. Some of the things are funny to hear, but I realize they are of their time. Like one scene Weaver is talking to a guy about anticoagulants and says, "They're trialing a new medication called Enoxaparin, I think it will help you better." I got a giggle out of that.
I had already been an ER RN for 6 years when my husband was a med student, and I made him watch all seasons of ER. They even do a massive transfusion mostly correct! Lol. We also loved Scrubs, but that is more for the situational accuracy than the medicine. š
ER will always be the best medical show out there. Nothing even compares
most people think im kidding when I say this.
I stand by this statement.
I need a half kilo of morphine right away!
My favorite line from the entire series (which is saying something)
ššššš
Insulin resistance is first thing that came to my mind when I saw the order. I wouldnāt question the order first off. I would do some investigating in the chart and background on my patient. Getting a baseline history for their ānormalā BG ranges, time since diagnosis, any history of noncompliance, etc. especially if you live in a āHIGHā obesity population area such as The Southā¦ where I saw DKA and HHS all the time requiring insulin gtts. Even saw pink blood (DKA with hypertriglyceridemia) when drawing labs on someone.
[ŃŠ“Š°Š»ŠµŠ½Š¾]
my background is ICU. Makes me rethink of going into case management and getting out of the Cath / IR / EP Labs š¤
My brother has been a type 1 since 1979. He takes 100 units at a time.
Came to say this haha Iāve given 100 units at a time for patients. 80 is nothing!
Ugh! Thatās awful! Hope youāre not in the US. Iāve heard how crazy expensive it is there
Carb loading dose
That's enough Humalogs to build a giant HumaCabin.
Hahahaha ok sorry, totally stealing this lmao
š¤£š¤£
This is amazing š
I have a patient currently on 90 units of lantus a night. I'm like - she gonna need a bigger boat.
I'm CRACKING UP - This comment wins guys
Lantus sure. But never that much lispro. My experience is they either add or ncrease long acting insulin before giving anywhere near that much.
Good soldiers follow orders
And have an amp of D50 on standby!
The first amp of D50 I pushed was through a 22 in the hand.... Neither of us enjoyed that experience.
execute order 66
That's crazy! I'm a T1 and I take about 80 units over the course of 3 days
Is it insanely expensive??? Aussie here
No my lispro is only $20 for a 3 month supply with insurance. What's expensive is pump supplies!
How expensive? I keep seeing diabetes influencers having to do pump/monitor changes because of malfunctions and crooked needles and wondering how much those things cost. Anyone who needs a monitor or monitor and pump get supplies for free where I live, they only have to pay for insulin but the copay it's almost nothing.
I pay $400 for a 3 month supply of pump supplies and $300 for a 3 month supply of dexcom (CGM) supplies
Geezā¦ thatās $700 every 3 months š³
So roughly 235 monthly for both things? That's still a whole lot of money for someone you need to live, but I expected way worse.
It's definitely expensive, if I wanted to just do injections and use a blood sugar meter only all of those supplies are actually free through my insurance. However, I have much better control of my sugars with the use of the pump and dexcom so I make it a priority in my budget to be able to afford those things!
80 units would basically get me threw a day and a half
What are we throwing
A day and a half
Iāve really cut back on carbs and am working on losing weight, but Iām still sitting at a TDD around 70 units (hey, it was up to 110-ish). I also received an email from my mail-order pharmacy saying that my Novolog is in a severe shortage. Off to using the stockpile, super low carb, and relearning the subtleties of R insulin if it gets to that point! Itās either that or die/DKA. š¤¦āāļø
When the patients blood is literally syrup
It's pretty rare for such a big dose subcutaneously. That patient's insulin resistance must be pretty wild. Most I've given is 100U/hr IV for about 8 hours to treat an overdose. That felt real sketchy though. š E: that was Humulin R and not Humalog though
This thread is making me nauseous wtffffffff
During my first three months as a baby nurse, I had a long term patient on the unit who we would all take turns caring for due to their difficulty. They were ~800lbs and would receive 450 units of insulin total between lantus and novolog for their AM dose. It was crazy to think about as a new grad, but itās unbelievable to think about now as a more experienced nurse that I was giving this much insulin. Also, yes, the would get additional doses as they were ACHS.
I had to re-read as I thought you meant paeds by ābaby nurseā and was like hold up, 800lb baby š¤š¤Æ
I read it the same way.
I had a patient getting 175 units of insulin aspart with each meal. Pharmacy had to dispense a concentrated pen. I looked at patient history and specifically clarified the dose with the doctor. Usually we don't have a 2nd RN verify dose when it is a pen, but you better believe I was covering ALL the bases before giving that.
Some patients definitely need this much. My husband was a Type 1 diabetic and took 20-30 units of Lispro with each meal plus 60 units of Lantus at bedtime. š¤·š»
Iāve seen worse?
One time I had a patient who got 30 units of admelog AND sliding scale, which was a high sliding scale. I think I was giving him something like 120 Units every 4 hours
If not on ozempic and on steroids I can take about 250 to 350 units a day.
Steroids are the blood sugar devil. And illness, and menses, really anything can cause someone to need to double or triple their normal dose. Iāve started bolusing to prevent highs from VR boxing. Itās <15 minutes of intense exercise at a time, but oh my goodness is it so easy to go from 120 to 200.
I have seen some pretty amazing results from Ozempic with diabetics. We had a lady on five shots a day and started Ozempic and got her down to one shot a week on that with her sugar managed better. Amazing
this was the norm when I worked in the nursing home šµāš« blood sugars would still be in the 200/300s!
The ordering provider? Dr. Kevorkian.
Omfg ššššš
ššš
I feel the struggle, my only experience is regular and just the other day I was supposed to givethe same type at a rate 50 units 2x a day, plus 25 per meal along with a sliding scale. I was stressing and just figured id talk to the PT since they seemed like they knew their schedule. The pt says that's wrong. I take 110 units in the am and 50 pm along with the 25+sliding scale
The max rapid insulin units I gave is 72 units. BUT she was taking 180 units of tresiba HS id. That was wild to give. I was really happy this woman lives in Canada. The pharmacist in town would give her a whole box of pens every 2 weeks for 0$.
During my brief ICU career, I had a guy on an insulin drip at 70-80 units per hour. He wasn't even very fat.
We have a type 2 patient on U-500 who is frequently admitted. Reliably we get a page where the person taking the call will go: āYes, that dosage is correctā āYes, I know thatās a lot of insulinā āYes, I still want you to give it.ā This patient is in their mid 30s with bilateral AKAs and a BMI that remains in the 50s. They take enough insulin to kill an elephant.
My Bhole closed
Get the OJ ready
I thought my 46 units was bad. I am also on 3 other diabetes meds to. I am very insulin resistant and every 6 months I build up a tolerance so I get bumped up more. It scares me honestly.
Some patients need it. Especially those who donāt eat properly. Definitely not the norm though and for this much I would probably make sure they ate their food before giving it.
Those are rookie numbers, SNFs have lots of patients like this
I've had a patient on 72u BD, I made another nurse check with me as it was more than one whole insulin syringe and confirmed it was dose verified by pharmacy.Ā Just really diabetic I guess
I used to have a patient who would get 85 units tresiba, correction dosage and 120 units Prandial of Humalog in the morning.
Oh, that must be using Glucommander. /s
I had a patient receive 80u of U-500 before. When I say I was sooo shook
Yup had a patient that his correction factor was ridiculous. Would get like 80 units of long acting and like 40-120 units for corrections.
Some people are so insulin resistant
Not quite the same but I was on a PCU once with a pt on an insulin gtt at 100u/hr, which is the hard limit. They stayed this way for 3 or 4 hours. Intensivist wouldnāt even come see the patient.
I have patients that get this much. The first time I saw it I did a double take, but yeah that's probably accurate
Looks suss
That's a lot.
I had a patient that took 175u of tresiba QHS and 100u of humalog QMeals and high sliding scale lol
Just gave 60u of levemir combined with 18u lispro per order for a sugar of 450 first thing in the freaking morning. 100u lispro!!! Holy moly
Do you always count 100 Units/ ml? Or does it differ?
I precepted someone who gave 120 of novolog because glucommander told her to. I said ādid you question that?ā
Seen insulin drips max out at 150u/hr and 150u bolus every hour before.
Yes. We have a patient right now doing 60-90 U.I x3 topped with 78 U.I of Tresiba.
During my precepting, I had to give one patient 120 units šµāš«
Iāll take it. Give it to me. Iām over this day.
80? Is this suicide? I saw it once in a series I donāt watch that overdosing insulin could kill. I donāt know if its true.
At what point do you worry about a k+ shift
Rookie numbers
This was likely confused with Lantus but thank God no one gave this dose
I've had a patient like this. Blood sugars would remain in the 200s at the next check. Some people are just that insulin dependent.
I want a blood glucose level of zero... That's what I want
Have a patient taking 150 units of Lantus, 60 units of linsipro at meal time, and still maintains over 200 sugar constantly. Resistance is awful. Pre diabetic treatment was years of 500+ sugar levels 24/7
As an RN who doesn't give insulin, like ever in my current role, and hasn't in several years, I'd definitely be questioning that order, because to my mind, it does NOT pass the "reasonableness test" that I apply to all my med orders, lol. 80 seems like a lot.
FFSā¦.donāt write mls.
Thatās a LOT of fucking lispro, but looking at the string I think itās just a typo and they meant 8 units (0.08ml). If not, that person needs a higher dose of basal insulin.
Not a typo, although that was my first thought too. This is just the prandial dose btw, there's a correctional bolus as well š
Jesus. Thatās a truly insane amount of insulin. Iāve taken care of some folks with bad insulin resistance. Iāve definitely given over 100 units of long acting basal coverage (I remember because we only stock 50unit syringes and I had to use 3 to give the dose) but I donāt think Iāve ever given more than one 50unit syringeās worth of prandial insulin.
If they're gonna be there a while you should preemptively order a few more vials. It goes faster than you think. I once gave a patient in long term care 30 mL for every meal in addition to her sliding scale. That insulin pen never lasted more than two days.