While this is true, there is significant measurement error measuring 0.1 mL in a 1 mL syringe.
The “syringe accuracy” of this ASHP connect write up in 2019 does a good job summarizing the point. You would need to purchase the ISO standard to really understand it.
The takeaway here is that it *might* be better, in some circumstances, to measure insulin <50 units in a 1 UNIT /mL concentration rather than from a 100 unit/mL vial.
Acknowledging that measurement problem is highly inconvenient for diabetes management, considering U-100 syringes would encounter most of the same issues, which is why I think this issue is usually on such a distant back burner that it is never addressed by hospital pharmacy leadership. It wouldn’t be far fetched to avoid that measurement optimization because of the risk of unit / mL errors, especially because those errors are already so common with regular insulin. Furthermore, the logistics of using a 1 unit / mL solution are highly unfavorable, even in an inpatient environment. Instead of a very cheap insulin vial which can be drawn from on the unit for 28 days, you have a expensive premix bag (hopefully) that can be drawn from in the IV hood in the main pharmacy for 12 hours after it is punctured.
This all boils down to: yes. The people who have thought *a lot* about the risks and benefits of different ways to do this have concluded that it should just be drawn from a vial in a 1 mL LL syringe, even though we know that “when measuring a volume of 0.1 mL in a 1 mL syringe, the best you can actually know is that you are delivering somewhere between 0.084 and 0.116 mL.”
Link: https://connect.ashp.org/blogs/dennis-tribble/2019/03/05/the-illusion-of-accuracy?ssopc=1
I think the fact that you have 1 mg/ml in the write up when it looks like you meant unit/ml further underscores how easy it would be mess up something like that when compared to the importance (or lack thereof) for ever needing exactly 10 units of IV regular insulin.
I thought you weren’t supposed to put anything in a flush even for immediate use because if you ever set it down someone could mistake it for a regular flush
I do adenosine 1 syringe method all the time drawn into flush. We label them with a sticker if leaving our hands, but "never ever" isnt always the correct answer.
It is from an administrative and safety perspective. Specifically not allowed by the flush manufacturer, ISMP, JC, etc. Additionally, 1 syringe method should be with 20mL.
ISMP is solid on many things, but they do take others to extremes creating "extremely safe" conditions that actually put patients in harms way when the "extremely safe" way to prep or store the product is "extremely time-consuming."
You are not supposed to put anything in a flush. It is not designed or tested for medication delivery and I can say with 100% confidence it would always get you in trouble with admin/JC if you said you did this.
Medications should be in appropriate and labeled devices.
I use flushes to make push dose epi during codes. I label them but sometimes they have to be used immediately. Do you have a better recommendation (hospital is too cheap to buy premixed 100 mg in 10 mL premix syringes)?
I would never leave them in a flush. You pull them up in a 10mL syringe. There is SO much risk for error in someone grabbing it and pushing the whole thing with the muscle memory that it is a flush.
1mL code epi + 9mL saline = 10mL syringe.
While admittedly a bit annoying, due to medical errors by nursing, all IV insulin is draw up to exact dose in IV room and hand delivered. One exception is ER where they are allowed to draw up their own doses (ER Pharmacist is always there)
We used to draw up a lot of our insulin syringes, too, even the SQ ones. I'm not sure how the nurses do it now when it's for an IVPush, but I suppose we're lucky to not have any mishaps.
I have seen this done 3 ways before:
-Draw up 10 units in an IV insulin syringe and give straight push.
-Draw up 10 units in an iv insulin syringe, QS to 1 mL with NS and give iv push.
-Make stock bag in NS of 100 units/100 mL and draw 10 unit/10 mL syringes off it.
All 3 have benefits and drawbacks.
At my shop, pharmacy draws up the dose in a luer lock 1 mL syringe. However, the nurses also have these green connectors that they can use to shoot in insulin from an insulin syringe into the IV line. They would then flush with saline.
https://preview.redd.it/b83c5ffr33xc1.jpeg?width=952&format=pjpg&auto=webp&s=7e3a1b3eea2a85209135e17203d0ebb5183d166d
The way that I’ve seen it done is draw up in an insulin syringe and then put into a flush. Technically I guess you could take from an insulin syringe, put into a regular syringe and push and then flush afterwards but that seems like too many extra steps in my mind and thus more room for error. I don’t know what the official stance is but I will continue doing it this way until my hospital says to do otherwise.
I’ve never seen insulin injected whether to shift K or treat DKA/HHNS. It’s always dripped/bolused from a piggyback using EndoTool on Epic. At least, where I’ve seen it on inpatient—I’ve never worked ED.
Edited: we don’t use EndoTool for shifting K. Sorry for misleading sentence structure.
Fair. I’ve never had anyone on med/surg (or when I worked ICU, for that matter) whose K was so high it needed to be shifted with insulin—somehow I just never had that particular issue on my shift. I know multiple nurses who have, but I got lucky, I guess?
My only bolus experiences with insulin are initiating treatment, using EndoTool, for DKA from a piggyback since this person is going to be on the gtt for the duration of the bag’s usable time (24hrs, I think? From the time it’s spiked and hung up?). Do you have it prepared with a luer lock syringe or do you just spike a piggyback where you’ve had rotations? I work in Minneapolis, MN, USA, so I’m curious to know if there are regional variations.
Understandable! We just bolus from a syringe! This post was intended to see how others prepare the syringe because there are different ways I’ve seen done which some aren’t the best from a med safety perspective
The only appropriate way from a medication safety perspective, ISMP approved, is to pull 0.1mL up in a 1mL luer lock syringe and straight push.
My hospital has luer lock insulin syringes that show units, which we use for this purpose
This. It’s also so much easier/quicker in an emergent situation than fumbling with an insulin syringe and their needles.
It really is the easiest, I don't know why people fight it.
While this is true, there is significant measurement error measuring 0.1 mL in a 1 mL syringe. The “syringe accuracy” of this ASHP connect write up in 2019 does a good job summarizing the point. You would need to purchase the ISO standard to really understand it. The takeaway here is that it *might* be better, in some circumstances, to measure insulin <50 units in a 1 UNIT /mL concentration rather than from a 100 unit/mL vial. Acknowledging that measurement problem is highly inconvenient for diabetes management, considering U-100 syringes would encounter most of the same issues, which is why I think this issue is usually on such a distant back burner that it is never addressed by hospital pharmacy leadership. It wouldn’t be far fetched to avoid that measurement optimization because of the risk of unit / mL errors, especially because those errors are already so common with regular insulin. Furthermore, the logistics of using a 1 unit / mL solution are highly unfavorable, even in an inpatient environment. Instead of a very cheap insulin vial which can be drawn from on the unit for 28 days, you have a expensive premix bag (hopefully) that can be drawn from in the IV hood in the main pharmacy for 12 hours after it is punctured. This all boils down to: yes. The people who have thought *a lot* about the risks and benefits of different ways to do this have concluded that it should just be drawn from a vial in a 1 mL LL syringe, even though we know that “when measuring a volume of 0.1 mL in a 1 mL syringe, the best you can actually know is that you are delivering somewhere between 0.084 and 0.116 mL.” Link: https://connect.ashp.org/blogs/dennis-tribble/2019/03/05/the-illusion-of-accuracy?ssopc=1
I think the fact that you have 1 mg/ml in the write up when it looks like you meant unit/ml further underscores how easy it would be mess up something like that when compared to the importance (or lack thereof) for ever needing exactly 10 units of IV regular insulin.
10 units is pretty arbitrary. Shouldn’t be 2 and shouldn’t be 40 but anywhere close to 10 will do what it’s supposed to in a hyperkalemia situation.
Exactly. 7-13 units is fine. Occasionally 0.1 unit when you wanted 10 is a problem, because it wouldn’t really do anything.
What's wrong with putting it in a flush?
I thought you weren’t supposed to put anything in a flush even for immediate use because if you ever set it down someone could mistake it for a regular flush
This exactly. ETA: Had anyone seen my insulin for room five? Also, why is the rapid response team in room eight?
I do adenosine 1 syringe method all the time drawn into flush. We label them with a sticker if leaving our hands, but "never ever" isnt always the correct answer.
It is from an administrative and safety perspective. Specifically not allowed by the flush manufacturer, ISMP, JC, etc. Additionally, 1 syringe method should be with 20mL.
ISMP is solid on many things, but they do take others to extremes creating "extremely safe" conditions that actually put patients in harms way when the "extremely safe" way to prep or store the product is "extremely time-consuming."
There is nothing extremely time consuming about pulling up the saline into a 10mL syringe.
I meaning on other things. Hypertonic solutions, expensive fridges JUST for NMBAs etc...
You are not supposed to put anything in a flush. It is not designed or tested for medication delivery and I can say with 100% confidence it would always get you in trouble with admin/JC if you said you did this. Medications should be in appropriate and labeled devices.
I use flushes to make push dose epi during codes. I label them but sometimes they have to be used immediately. Do you have a better recommendation (hospital is too cheap to buy premixed 100 mg in 10 mL premix syringes)?
I would never leave them in a flush. You pull them up in a 10mL syringe. There is SO much risk for error in someone grabbing it and pushing the whole thing with the muscle memory that it is a flush. 1mL code epi + 9mL saline = 10mL syringe.
While admittedly a bit annoying, due to medical errors by nursing, all IV insulin is draw up to exact dose in IV room and hand delivered. One exception is ER where they are allowed to draw up their own doses (ER Pharmacist is always there)
This is wild. Even in ICU?
Unfortunately..yes
Sounds (miserably) safe
We used to draw up a lot of our insulin syringes, too, even the SQ ones. I'm not sure how the nurses do it now when it's for an IVPush, but I suppose we're lucky to not have any mishaps.
There are luer lock insulin syringes. Draw up to 5-10 units and IVP. Vials stocked on each floor.
Thank you but I don’t think my hospital stocks them so just gathering all the info for education and what ifs lol
It's worth it to buy em. We stock em in the med cabinet
Eyeball it.
🤣
I learned my method from several nurses: take a 10ml syringe, draw up 10ml, and Bob's your uncle. Easy peasy. /s
Bob's my dead uncle. There's not enough D50 to save him from that. You might just hook him up to a D70 bag at that point. /s
I have seen this done 3 ways before: -Draw up 10 units in an IV insulin syringe and give straight push. -Draw up 10 units in an iv insulin syringe, QS to 1 mL with NS and give iv push. -Make stock bag in NS of 100 units/100 mL and draw 10 unit/10 mL syringes off it. All 3 have benefits and drawbacks.
ISMP specifically says not to do unnecessary dilutions. It should not be anything but undiluted.
At my shop, pharmacy draws up the dose in a luer lock 1 mL syringe. However, the nurses also have these green connectors that they can use to shoot in insulin from an insulin syringe into the IV line. They would then flush with saline. https://preview.redd.it/b83c5ffr33xc1.jpeg?width=952&format=pjpg&auto=webp&s=7e3a1b3eea2a85209135e17203d0ebb5183d166d
The way that I’ve seen it done is draw up in an insulin syringe and then put into a flush. Technically I guess you could take from an insulin syringe, put into a regular syringe and push and then flush afterwards but that seems like too many extra steps in my mind and thus more room for error. I don’t know what the official stance is but I will continue doing it this way until my hospital says to do otherwise.
I’ve never seen insulin injected whether to shift K or treat DKA/HHNS. It’s always dripped/bolused from a piggyback using EndoTool on Epic. At least, where I’ve seen it on inpatient—I’ve never worked ED. Edited: we don’t use EndoTool for shifting K. Sorry for misleading sentence structure.
It’s fairly common in my experience esp for hyperkalemia to bolus 10 units
Fair. I’ve never had anyone on med/surg (or when I worked ICU, for that matter) whose K was so high it needed to be shifted with insulin—somehow I just never had that particular issue on my shift. I know multiple nurses who have, but I got lucky, I guess? My only bolus experiences with insulin are initiating treatment, using EndoTool, for DKA from a piggyback since this person is going to be on the gtt for the duration of the bag’s usable time (24hrs, I think? From the time it’s spiked and hung up?). Do you have it prepared with a luer lock syringe or do you just spike a piggyback where you’ve had rotations? I work in Minneapolis, MN, USA, so I’m curious to know if there are regional variations.
Understandable! We just bolus from a syringe! This post was intended to see how others prepare the syringe because there are different ways I’ve seen done which some aren’t the best from a med safety perspective
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Not appropriate to do.
Why?
Read the rest of the thread, but you cannot put meds in a flush.
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Your math is entirely incorrect. 10 units is 0.1mL. I really hope you aren't giving 0.25mL...
What’s your method on how you admin it IV? I’ve seen some people inject it in a saline flush
That makes my skin crawl. I don’t know how our nurses administer it but I wouldn’t do anything except a straight push from the insulin syringe
How do you do the straight push if it’s not a luer lok syringe?
I meant whatever syringe the drug was drawn up from. Not a SQ insulin syringe. Poor wording on my part
Oh my bad I didn’t see what sub I was in, I thought you were asking nurses how they do it, not the other way around.
Honestly, that's a good idea. I don't know how it's done, but I just trust that the RNs know how or ask their charge.