A 62-year-old man with type 1 diabetes mellitus
was admitted to the hospital for coronary artery bypass graft
surgery. His diabetes had been managed with an insulin pump while
he was an outpatient. During his preparation for surgery, the
patient asked the staff to leave his insulin pump in place and
running at a basal rate. After surgery, he was transferred to the
coronary care unit where orders were written to start him on a
standard intravenous insulin infusion protocol. After he was
extubated, the patient asked the nurse for his hourly finger stick
blood glucose results. Unbeknownst to the nurse, the patient would
then adjust his insulin pump in response to the glucose readings.
At the same time, the nurse adjusted the intravenous insulin
infusion rate based on the standardized protocol. The patient's
blood glucose levels fluctuated, and he experienced hypoglycemia
(with blood glucose levels in the range of 50-60 mg/dL) on several
occasions. When the nurse mentioned the insulin pump at case
management rounds, the medical director inquired further and, after
discussion with the patient, the double dosing was discovered. The
patient then agreed to turn off his insulin pump while he was
receiving the intravenous insulin infusion.
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Box. Suggested Procedures for Patients
Admitted to the Hospital While on Insulin Pump Therapy.
Presence of insulin pump, brand of pump, and
insulin type are identified.
Blood or capillary glucose level is
Contraindications for continued use of insulin
pump are assessed.
Physician order for alternate insulin therapy is
obtained if CSII must be discontinued.
Patient's consent for CSII is obtained.
Admitting physician writes initial order for
insulin pump therapy using the preprinted order form.
Endocrinology, diabetes education, and nutrition
consultations are ordered.
Insulin pump basal-bolus blood glucose record is
placed at the patient's bedside.
subcutaneous insulin infusion.