Inpatient Insulin Management: Avoiding Highs and Lows

Having a child admitted to the hospital can bring a flood of emotions. For parents and caregivers who have children requiring daily insulin therapy, this can add to the emotional toll. Insulin is a high-risk medication used to treat high blood sugar caused by different types of diabetes, by medications (such as steroids), or by significant stress while hospitalized. Blood sugar management during a hospital admission can be complicated by a range of contributing factors.

Blood Glucose Monitoring:

The only blood glucose monitoring approved for in-hospital use is via finger stick/glucometer or serum glucose by lab draw. All insulin administration is based off glucose values obtained by one of these two methods. At home, many children wear a continuous glucose monitor (CGM), which measures glucose in the interstitial fluid, but this method is not approved for insulin dosing in the hospital setting.

In the hospital, routine blood glucose checks are performed before each meal, at bedtime, at 12:00am and at 3:00am. If children are having symptoms of low blood sugar (e.g. shaky, sweaty, dizzy, confused) at any other time, blood sugar should always be checked.

Factors Contributing to High Blood Sugar:

Children are admitted to the hospital for a wide variety of reasons, all of which have their own contributing factors to high blood sugar. It is therefore imperative that all factors are considered individually for each child. A few examples of key components that may contribute to high blood sugars are:

• Infection
• Medications (steroids, asparaginase, etc.)
• Intravenous Fluids (IV Fluids)
• Total Parenteral Nutrition (TPN)
• Tube Feeds
• Stress
• Diet

Factors Contributing to Low Blood Sugar:

It is equally important to minimize the occurrences of low blood sugar in children. Low blood sugars can require other interventions such as extra sugar through an IV if children are unable to drink. Below are some examples of factors that can contribute to low blood sugars:

• Nausea or vomiting
• Unexpected stopping of IV fluids, TPN or tube feeds
• Increased daily activity
• Medications (beta-blockers such as atenolol, Sulfonylureas and insulin)

Insulin Dosing:

There are three primary methods of administering insulin in the hospital: basal-bolus injections, insulin pumps, and IV insulin drip. All methods of insulin management require experienced oversight by specialty trained providers.

• Basal-Bolus Insulin Injections: Insulin is administered into the subcutaneous tissue via a small pen needle. There are two types of insulin that are commonly used with this method of administration: 1) basal insulin, also known as long-acting insulin, and 2) short/fast-acting insulin, also known as bolus insulin. This is often the preferred method of dosing insulin while in the hospital, especially for children who newly need insulin.
  • Basal Insulin: Most commonly administered once daily. This insulin is considered a “background insulin” that works to maintain normal blood sugars during times when children are resting/sleeping and not eating. Basal insulin lasts for an average of 24 hours, which is why it is only given once daily.
  • Bolus Insulin: Fast-acting insulin used to treat high blood sugar and/or carbohydrates or ketones. Bolus insulin can be administered every 3-4 hours for high blood sugar /carbohydrates or ketones. When taking bolus insulin for carbohydrates, it is important to take the insulin 10-15 minutes before eating, unless they may not tolerate eating (e.g due to nausea), where dosing would likely occur after eating.
• Insulin Pump: This is a device that administers fast-acting insulin through a small catheter into the subcutaneous tissue. Insulin pumps can be used in the hospital (outside of the intensive care unit (ICU)) with close oversight and at the direction of a specialty trained provider. If appropriate, parents may sign a home insulin pump consent, allowing their child to remain on their home insulin pump. A hospital insulin pump can also be used by trained hospital personnel in certain cases.
• IV Insulin Drip: This method of insulin administration is primarily used in the ICU or for children experiencing diabetic ketoacidosis (DKA). Insulin is administered continuously by a catheter placed in the child’s vein and IV fluids containing dextrose are used at the same time, with IV fluids and/or insulin drip titrated to keep blood sugar in range.