inpatient glycemic control coordinating nutrition and insulin management

Inpatient Glycemic ControlInpatient Glycemic Control

Coordinating Nutrition and Coordinating Nutrition and Insulin ManagementInsulin Management

What is Guiding our Nutrition What is Guiding our Nutrition TherapyTherapy

Need for standardized Carbohydrate Need for standardized Carbohydrate intake at mealintake at mealKnowledge of carbohydrate content of Knowledge of carbohydrate content of Tube feedingsTube feedingsManaging carbohydrate infusion via TPNManaging carbohydrate infusion via TPN

All of the above to be based on an All of the above to be based on an appropriate nutritional assessmentappropriate nutritional assessment

Research StudiesResearch Studies

Rush University Guidelines, Nov.2006Rush University Guidelines, Nov.2006– The Diabetes Educator 32(6):954-962. The Diabetes Educator 32(6):954-962.

Nov/Dec 2006.Nov/Dec 2006.

ASPEN Nutrition Support Practice ManualASPEN Nutrition Support Practice Manual– 22ndnd edition, 2005. edition, 2005.

McMahon M McMahon M – Mayo Clinic Mayo Clinic – Nutrition in Clinical Practice 19:120-128. April Nutrition in Clinical Practice 19:120-128. April

2004. 2004.

ResearchResearch

Grainger A, Eiden K, Kemper J, Reeds DGrainger A, Eiden K, Kemper J, Reeds D– Nutrition in Clinical Practice 22:545-552. Oct 2007.Nutrition in Clinical Practice 22:545-552. Oct 2007.

Clement S et al: 2004Clement S et al: 2004– Diabetes Care 27:553-591. Feb 2004.Diabetes Care 27:553-591. Feb 2004.

Leahy J.Leahy J.– Endocrine Practice, 12(13):86-90. July/August 2006.Endocrine Practice, 12(13):86-90. July/August 2006.– ACE/ADA Inpatient Diabetes and Glycemic Control ACE/ADA Inpatient Diabetes and Glycemic Control

Consensus ConferenceConsensus Conference

BASAL

NUTRITIONAL SUPPLEMENTAL

ILLNESS-RELATED

Physiologic Insulin needsPhysiologic Insulin needs

Insulin Requirements in HealthInsulin Requirements in Health and Illnessand Illness

Copyright © 2004 American Diabetes Association. From Clement S, et al. Diabetes Care.

2004;27:553–591. Reprinted with permission.

Units

Healthy Sick/Eating Sick/NPO

Correction

Nutritional

Prandial

Basal

MMC’s Diabetic DietsMMC’s Diabetic Diets

45-59 gm CHO/meal (1200-1500 kcal)45-59 gm CHO/meal (1200-1500 kcal)

60-74 gm CHO/meal (1500-1800 kcal)60-74 gm CHO/meal (1500-1800 kcal)– Meets nutrient needs for most patient Meets nutrient needs for most patient

populations.populations.


100 gm CHO/meal (2400 kcal)100 gm CHO/meal (2400 kcal)

Meal Consumption on CHO Fresh Meal Consumption on CHO Fresh Start Diet (60-74g/meal)Start Diet (60-74g/meal)

Meal PeriodMeal Period # of Patients# of Patients Avg # of gms of Avg # of gms of CHO selected for CHO selected for

meal periodmeal period

Avg # of gms of Avg # of gms of CHO consumed CHO consumed for meal periodfor meal period

BreakfastBreakfast 8282 6868 5050

(73%)(73%)

LunchLunch 9595 6464 4040

(62%)(62%)

DinnerDinner 7878 7171 5050

(68%)(68%)

TotalsTotals 255 meals255 meals 68 gms CHO68 gms CHO 47 gms CHO47 gms CHO

(67%)(67%)

MMC Aug 6,2008-Sept 5, 2008

Elements of Carbohydrate (CHO) Elements of Carbohydrate (CHO) Counting for RN EducationCounting for RN Education

Carbohydrate foods raise blood sugars w/in 15 Carbohydrate foods raise blood sugars w/in 15 minutes of food intakeminutes of food intake

Converted to glucose w/in 2-4 HrsConverted to glucose w/in 2-4 HrsCount only foods with carbohydrate from mealsCount only foods with carbohydrate from meals– Grams of CHO per food will be provided on Grams of CHO per food will be provided on

tray tickettray ticket– Floor stock Reference list available in unit Floor stock Reference list available in unit

kitchenkitchen

Portion ControlPortion Control

Over 150 recipes were analyzed for Over 150 recipes were analyzed for Carbohydrate contentCarbohydrate content

Serving portions for all these recipes were Serving portions for all these recipes were weighed and serving sizes were weighed and serving sizes were standardized for each recipestandardized for each recipe

Education sessions with all the cooks and Education sessions with all the cooks and food servers were given to control portion food servers were given to control portion sizesize

Menu SelectionMenu Selection

Palm Pilot (programmed to include CHO’s)Palm Pilot (programmed to include CHO’s)

Education to our Nutrition Care Education to our Nutrition Care Representatives for Carbohydrate Representatives for Carbohydrate CountingCounting

Serves to educate patient while choosing Serves to educate patient while choosing mealsmeals

Nursing EducationNursing Education

Collaborative approach with Nursing Collaborative approach with Nursing Diabetes SpecialistsDiabetes Specialists3 Hour classes (2-4 classes/week)3 Hour classes (2-4 classes/week)– Includes 1 hr of nutrition protocols that include Includes 1 hr of nutrition protocols that include

the “how to” of carbohydrate counting as well the “how to” of carbohydrate counting as well as tube feeding and TPN guidelinesas tube feeding and TPN guidelines

Traveling Glycemic FairTraveling Glycemic Fair– Set up on individual clinical units and some Set up on individual clinical units and some

units have made this mandatoryunits have made this mandatory

Carbohydrate Content of Tube Carbohydrate Content of Tube Feeding FormulasFeeding Formulas

NeproNepro– 167g CHO / L167g CHO / L

2 Cal HN2 Cal HN– 219g CHO / L219g CHO / L

Peptamen AFPeptamen AF– 107g CHO / L107g CHO / L

Peptamen 1.5Peptamen 1.5– 188g CHO / L188g CHO / L

Jevity 1.2 Jevity 1.2 – 169g CHO / L169g CHO / L

PromotePromote– 130g CHO / L130g CHO / L

Ensure PlusEnsure Plus– 211g CHO / L211g CHO / L

OsmoliteOsmolite– 144g CHO / L144g CHO / L

This information is now included in all tube feed orders

Enteral Tube Feedings Enteral Tube Feedings Considerations/QuestionsConsiderations/Questions

Glycemic control can be difficultGlycemic control can be difficult– Varying toleranceVarying tolerance– Unplanned discontinuation of feedsUnplanned discontinuation of feeds

Limited literature Limited literature (Clement 2004,(Clement 2004, Grainger 2007)Grainger 2007)

When to start insulin therapy When to start insulin therapy

Variety of feeding schedulesVariety of feeding schedules– Bolus vs Continuous with or without oral dietBolus vs Continuous with or without oral diet

What are the target glucose rangesWhat are the target glucose ranges

Literature ReviewLiterature Review

Grainger in NCP: 2007Grainger in NCP: 2007

Pilot study using a glargine and lispro Pilot study using a glargine and lispro schedule during tube feedingsschedule during tube feedings– 52 CICU type 2 DM patients (18-99 yo)52 CICU type 2 DM patients (18-99 yo)– Control group (N=24) retrospectively studied Control group (N=24) retrospectively studied

for mean glucose controlfor mean glucose control– Study group (N=28) were placed on an insulin Study group (N=28) were placed on an insulin

protocolprotocol

Grainger Study (cont)Grainger Study (cont)

CriteriaCriteria Retrospective DataRetrospective Data Insulin Protocol DataInsulin Protocol Data

Number of PatientsNumber of Patients

Male/FemaleMale/Female

2424

13/1113/11

2828

15/1315/13

AgeAge 69 69 + + 1010 66 66 + + 1313

BMIBMI 28 28 + + 77 30 30 + + 1010

Hours to BG 80-140Hours to BG 80-140 60.260.2 21.521.5

DiagnosisDiagnosis

AMIAMI

Cardiac (non-MI)Cardiac (non-MI)

NoncardiacNoncardiac

77

44

1313

1313

66

99

Glucose Management ProtocolGlucose Management Protocol

Glucose target: 80-140mg/dlGlucose target: 80-140mg/dlBolus Tube Feeding Regimens (Q4H, 6 feeds)Bolus Tube Feeding Regimens (Q4H, 6 feeds)Known DM or FBS >200mg/dl on admitKnown DM or FBS >200mg/dl on admitOnly insulin therapy (no oral agents)Only insulin therapy (no oral agents)2 Cal HN or Nepro2 Cal HN or NeproBMI <15 received 35KKDBMI <15 received 35KKDBMI 15-19 received 30KKDBMI 15-19 received 30KKDBMI 20-29 received 20KKDBMI 20-29 received 20KKDBMI 30-40 received 15KKDBMI 30-40 received 15KKD

Grainger Protocol (cont)Grainger Protocol (cont)

Tube feeds initiated by day 3Tube feeds initiated by day 3

Retrospective group received preprandial insulin Retrospective group received preprandial insulin per MD ordersper MD orders

Study group (glucose check before feeds)Study group (glucose check before feeds)– Fixed dose of glargine (not held if feeds held)Fixed dose of glargine (not held if feeds held)

BMI <30 got 10 units, BMI >30 got 20 unitsBMI <30 got 10 units, BMI >30 got 20 units

– Variable doses of lispro (dosed pre-feed)Variable doses of lispro (dosed pre-feed)BMI <30 got 1 unit for each 15g of CHO in feedsBMI <30 got 1 unit for each 15g of CHO in feeds

BMI BMI >>30 got 1 unit for each 10g of CHO in feeds30 got 1 unit for each 10g of CHO in feeds

Correctional if BG >140mg/dl Correctional if BG >140mg/dl

Sliding Scale LisproSliding Scale Lispro

If glucose If glucose << 100 give Lispro after tube feed 100 give Lispro after tube feed startedstarted

If glucose >100 give lispro at start of feedsIf glucose >100 give lispro at start of feeds

Correctional “Sliding Scale” Lispro was Correctional “Sliding Scale” Lispro was weight based and given with the nutritional weight based and given with the nutritional dose of Lisprodose of Lispro

Lispro dose increased by 3 units if 2 Lispro dose increased by 3 units if 2 consecutive glucoses were >200mg/dlconsecutive glucoses were >200mg/dl

Grainger: Glucose ControlGrainger: Glucose Control

Blood GlucoseBlood Glucose RetrospectiveRetrospective ProtocolProtocol P valueP value

Mean BGMean BG 225.1225.1 148.9148.9 <.0001<.0001

<< 79mg/dl 79mg/dl 12(1.7%)12(1.7%) 49(4.14%)49(4.14%)

1% <65mg/dl1% <65mg/dl

.02.02

80-140 mg/dl80-140 mg/dl 58(8.3%)58(8.3%) 576(48.6%)576(48.6%) .01.01

>> 141 141 632(90%)632(90%) 559(47.2%)559(47.2%) <.0001<.0001

ConclusionsConclusions

A SQ insulin protocol reduced average A SQ insulin protocol reduced average blood glucoses by approx 80mg/dlblood glucoses by approx 80mg/dl

Tighter control resulted in a modest Tighter control resulted in a modest increase in hypoglycemia (with no adverse increase in hypoglycemia (with no adverse events found)events found)

Further studies are needed to determine if Further studies are needed to determine if adjustments in lispro baseline could lead adjustments in lispro baseline could lead to tighter controlto tighter control

Observation Letter: Glargine and Observation Letter: Glargine and Continuous Tube FeedsContinuous Tube Feeds

Diabetes Care 2002 (25:1889-1890)Diabetes Care 2002 (25:1889-1890)

60 yo male with type 2 DM with squamous ca of oral 60 yo male with type 2 DM with squamous ca of oral cavity with recurrent aspirationcavity with recurrent aspiration– HbA1c 7.5% HbA1c 7.5%

Continuous feeds started with glargine @HS Continuous feeds started with glargine @HS

Glargine dose was increased gradually by 2-4units at 3 Glargine dose was increased gradually by 2-4units at 3 day intervals to attain BG of 100-140mg/dlday intervals to attain BG of 100-140mg/dl

Good control was achieved with 45units glargine with no Good control was achieved with 45units glargine with no hypoglycemiahypoglycemia

After 6 months patient’s HbA1c was 6.1%After 6 months patient’s HbA1c was 6.1%

Additional Considerations for Additional Considerations for Enteral Tube FeedingsEnteral Tube Feedings

Avoid increasing tube feeding delivery until adequate BG Avoid increasing tube feeding delivery until adequate BG control is achievedcontrol is achievedBasal insulin generally no more than 40% of daily insulin Basal insulin generally no more than 40% of daily insulin to avoid hypoglycemiato avoid hypoglycemiaNutritional insulin to be given as programmed doses of Nutritional insulin to be given as programmed doses of regular or rapid acting insulinregular or rapid acting insulinNPH insulin’s profile better fits a nocturnal feeding NPH insulin’s profile better fits a nocturnal feeding schedule (peaking at 6-8 hrs)schedule (peaking at 6-8 hrs)If tube feeds are unexpectedly stopped start a D10% IV If tube feeds are unexpectedly stopped start a D10% IV at same rate of feeds to avoid hypoglycemia and at same rate of feeds to avoid hypoglycemia and increase glucose checksincrease glucose checksAvoid high fat formulas (gastroparesis)Avoid high fat formulas (gastroparesis)

Glucose Management with Glucose Management with Parenteral NutritionParenteral Nutrition

ASPEN Guidelines:ASPEN Guidelines:– Check glucoses Q6hrs on TPNCheck glucoses Q6hrs on TPN– Only Regular insulin is compatible w/ TPNOnly Regular insulin is compatible w/ TPN– Limit initial dextrose in TPN solution for Limit initial dextrose in TPN solution for

patients with hyperglycemia to 150-200g/daypatients with hyperglycemia to 150-200g/day– Do not increase dextrose calories via TPN Do not increase dextrose calories via TPN

until glucoses are consistently <180mg/dluntil glucoses are consistently <180mg/dl– 5-15% of insulin in TPN adheres to the tubing 5-15% of insulin in TPN adheres to the tubing

therefore insulin requirements may appear therefore insulin requirements may appear highhigh

Glucose Control and TPNGlucose Control and TPNM McMahon MDM McMahon MD

Measure glucose before TPN and 2 to 4 times Measure glucose before TPN and 2 to 4 times daily after start of TPNdaily after start of TPNAvoid overfeeding calories in TPN patients Avoid overfeeding calories in TPN patients (importance of Nutritional Assessment)(importance of Nutritional Assessment)Majority of DM patients willMajority of DM patients will require supplemental require supplemental insulininsulin– Start TPN with 0.1 unit of insulin per g of Dextrose, Start TPN with 0.1 unit of insulin per g of Dextrose,

(this ratio should (this ratio should not not result in hypoglycemia)result in hypoglycemia)– If glucoses remain above target increase insulin in If glucoses remain above target increase insulin in

TPN by 0.05 units per g of Dextrose to 0.2 units/g of TPN by 0.05 units per g of Dextrose to 0.2 units/g of dextrose (ASPEN allows up to 0.3units/g of dextrose)dextrose (ASPEN allows up to 0.3units/g of dextrose)

McMahon (cont)McMahon (cont)

Do not increase dextrose in TPN until Do not increase dextrose in TPN until target glucoses are met for previous 24hrstarget glucoses are met for previous 24hrs

Increase insulin proportional to Dextrose Increase insulin proportional to Dextrose once the appropriate ratio is attainedonce the appropriate ratio is attained

Hypoglycemia after discontinuation of TPN Hypoglycemia after discontinuation of TPN should not occur unless given excess should not occur unless given excess dextrosedextrose

MMC TPN OrderingMMC TPN Ordering

TPN is ordered in grams of protein, TPN is ordered in grams of protein, dextrose and lipids for 24 hrs per nutrition dextrose and lipids for 24 hrs per nutrition assessmentassessment– Ex: 80g of aminosyn, 200g of Dextrose and Ex: 80g of aminosyn, 200g of Dextrose and

50g of Liposyn for 45% carbohydrate calories50g of Liposyn for 45% carbohydrate calories

Insulin is ordered as units per day vs literInsulin is ordered as units per day vs literElectrolytes and minerals are ordered per Electrolytes and minerals are ordered per literliter– Ex: NaCl 50 mEq/LEx: NaCl 50 mEq/L

Collaborative ReviewCollaborative Review

Literature ReviewLiterature Review

Other Hospital ProgramsOther Hospital Programs

Open DiscussionsOpen Discussions

MD, RD, RN and RPh developed Protocols

MMC Insulin ProtocolsMMC Insulin Protocols

Nutrition ComponentNutrition Component

Nutritional InsulinNutritional InsulinTypes nutritional insulinTypes nutritional insulin ActionAction TimingTiming

Novolog ® (aspart) MMCNovolog ® (aspart) MMC

Rapid Acting InsulinRapid Acting Insulin

Onset: 0-15 minutesOnset: 0-15 minutes

Peak: 1-2 hoursPeak: 1-2 hours

Duration: 3-4 hoursDuration: 3-4 hours

**Within 15 minutes **Within 15 minutes

of mealof meal

Regular Human InsulinRegular Human Insulin

Short ActingShort Acting

Onset: 30-60 minutesOnset: 30-60 minutes

Peak: 90 min-2 hoursPeak: 90 min-2 hours


30 minutes ac meal30 minutes ac meal

NPHNPH

Intermediate ActingIntermediate Acting

Onset: 2-4 hoursOnset: 2-4 hours

Peak: 4-10 hoursPeak: 4-10 hours


Start of Tube feedingStart of Tube feeding

Insulin ProfilesInsulin Profiles

MMC’s Diabetic DietsMMC’s Diabetic Diets


60-74 gm CHO/meal (1500-1800 kcal)60-74 gm CHO/meal (1500-1800 kcal)– Meets nutrient needs for most patient Meets nutrient needs for most patient

populations.populations.


100 gm CHO/meal (2400 kcal)100 gm CHO/meal (2400 kcal)

Prandial /Nutritional Insulin Dosing Prandial /Nutritional Insulin Dosing Oral DietOral Diet

Dosing will be pre-selected based on:Dosing will be pre-selected based on:– Patient’s Patient’s BMI & mealBMI & meal plan requirement plan requirement– Percent of CHO consumed from mealsPercent of CHO consumed from meals..

Questioning food consumption, give prandial dose at end of the Questioning food consumption, give prandial dose at end of the meal.meal.If pre meal BG>150= nutritional + correctional scale ac meal.If pre meal BG>150= nutritional + correctional scale ac meal.If pre-meal BG 70-110 mg/d, give meal coverage pc mealIf pre-meal BG 70-110 mg/d, give meal coverage pc meal

Insulin may be given up to 30 minutes Insulin may be given up to 30 minutes AFTERAFTER the the patient eatspatient eats

HOLD nutritional dose insulinHOLD nutritional dose insulin if patient is NPOif patient is NPO

SC ProtocolSC ProtocolPrandial or Nutritional insulin coveragePrandial or Nutritional insulin coverage

62 yo T1DM s/p RBKA 62 yo T1DM s/p RBKA Diet:Diet:– Diabetic, 60-74 gm CHO/mealDiabetic, 60-74 gm CHO/meal

Scheduled Prandial Insulin dose per BMI + meal plan:Scheduled Prandial Insulin dose per BMI + meal plan:– 6 units ac meals6 units ac meals

ac BG at 1150:ac BG at 1150:– 301mg/dl 301mg/dl

Pt sad, verbalizes “stomach upset, not very hungry”Pt sad, verbalizes “stomach upset, not very hungry”Lunch tray arrives. Lunch tray arrives. Plan for patient?Plan for patient?

SC Protocol Example SC Protocol Example PlanPlan

Hold pre-meal insulin Hold pre-meal insulin dosedose

PartnershipPartnership– NurseNurse– CNACNA– PatientPatient– FamilyFamily

Review meal ticket Review meal ticket carbohydrate amountcarbohydrate amount

Review carbohydrate Review carbohydrate consumed from plateconsumed from plate

Check tray ticket for Check tray ticket for total CHO gm total CHO gm reference vs % amt reference vs % amt eateneaten

SC Protocol SC Protocol Example Example

Example: total gm CHO on tray: 60 gmExample: total gm CHO on tray: 60 gm

– If >75% total gm CHO on tray consumed: give If >75% total gm CHO on tray consumed: give full dose full dose (>45gm)(>45gm)

– If 25-74% total gm CHO on tray consumed: If 25-74% total gm CHO on tray consumed: give 3 units give 3 units (15-45 gm)(15-45 gm)

– If <25% total gm CHO on tray eaten consumed: If <25% total gm CHO on tray eaten consumed: no insulin coverage no insulin coverage ( <15 gm)( <15 gm)

Insulin OrdersInsulin Orders

**Nutritional****Nutritional** Insulin Aspart, SC, 6.0 daily Insulin Aspart, SC, 6.0 daily

with lunchwith lunchBased on 60-74 CHO mealBased on 60-74 CHO meal

6.0 units if full Meal-% of Carbs 6.0 units if full Meal-% of Carbs Eaten 75-100Eaten 75-100

3.0 units if half Meal-% of Carbs 3.0 units if half Meal-% of Carbs Eaten 25-74 Eaten 25-74

0 units if NO meal-% of Carbs 0 units if NO meal-% of Carbs Eaten 0-24Eaten 0-24

*Correctional Coverage**Correctional Coverage*

Insulin Aspart, SC, tid-meals, Insulin Aspart, SC, tid-meals,

PRN for BG level : PRN for BG level :

2 units if BG 151-2002 units if BG 151-200





• RN & patient agree 50% meal CHO RN & patient agree 50% meal CHO consumedconsumed• BG was 301 mg/dl acBG was 301 mg/dl ac What will your total insulin dose be?What will your total insulin dose be?

SC Protocol Example SC Protocol Example PlanPlan

RN & patient agree 50% meal CHO consumedRN & patient agree 50% meal CHO consumed

BG was 301 mg/dl acBG was 301 mg/dl ac

– AnswerAnswer

– What will your total insulin dose be?What will your total insulin dose be? – Total dose = 11 units aspart post mealTotal dose = 11 units aspart post meal

Glycemic ManagementGlycemic Management

Tube Feeding Insulin Tube Feeding Insulin ProtocolsProtocols

Enteral Nutrition/Tube feedingEnteral Nutrition/Tube feeding

ContinuousContinuous– Infusing over 24hrsInfusing over 24hrs

BolusBolus– Mimics mealsMimics meals

NocturnalNocturnal– Infusion at night: typically 12hr infusionInfusion at night: typically 12hr infusion– Can be NPO or eating during dayCan be NPO or eating during day– Usually transitioning stageUsually transitioning stage

Basal, Nutritional, Correctional Basal, Nutritional, Correctional Enteral Tube FeedingEnteral Tube Feeding

Need 3 components of insulinNeed 3 components of insulin

Basal insulin Basal insulin Pre-existing DM/hyperglycemia:Pre-existing DM/hyperglycemia:Continue the basal insulin dose (glargine/detemir)Continue the basal insulin dose (glargine/detemir)

– If patient has not been treated with basal insulin + has Random BG >200:If patient has not been treated with basal insulin + has Random BG >200:MD can initiate basal dose of glargine on weight/BMIMD can initiate basal dose of glargine on weight/BMI

(Consider adjust basal if reached Prandial Insulin threshold + BG remains over 150mg/dl)(Consider adjust basal if reached Prandial Insulin threshold + BG remains over 150mg/dl)

Nutritional to cover CHO in TFNutritional to cover CHO in TF– Type of insulin + dosage dependent on:Type of insulin + dosage dependent on:

Glucose levelsGlucose levelsTF scheduleTF scheduleBMIBMITF formula/rateTF formula/rate

Correctional to cover high BG q 6 hoursCorrectional to cover high BG q 6 hoursRegular InsulinRegular Insulin

ContinuousContinuous ETF ETF

Glucose Monitoring: Glucose Monitoring: – Check BG q 6 hours all ETF patientsCheck BG q 6 hours all ETF patients– Goal glucose during feeding: Goal glucose during feeding: 90-15090-150 for standard pt for standard pt

– If BG levels < 150mg/dl x 24h, + tolerating at goal rate:If BG levels < 150mg/dl x 24h, + tolerating at goal rate:▪↓ ▪↓ BG testing q 12 hoursBG testing q 12 hours

– If TF CHO content ↑ (i.e. increasing rate, changing formula)If TF CHO content ↑ (i.e. increasing rate, changing formula)Continue q 6 hour BG checksContinue q 6 hour BG checks

Prandial coveragePrandial coverage: : – Scheduled: Regular insulin q6h Scheduled: Regular insulin q6h – Dose Based on BMI/CHO infusion Dose Based on BMI/CHO infusion

CorrectionalCorrectional – Regular insulin Regular insulin

DosingDosing

Regular Insulin q 6h:Regular Insulin q 6h:– BMI <30: 1 unit per 15 gm CHOBMI <30: 1 unit per 15 gm CHO– BMI >30: 1 unit per 10 gm CHOBMI >30: 1 unit per 10 gm CHO

Example:Example:– 1Cal Tube feeding (144 gm/L) @ 50 ml/hr:1Cal Tube feeding (144 gm/L) @ 50 ml/hr:

43.5 gm CHO infused q 6h43.5 gm CHO infused q 6h

BMI <30, 3 units Regular q 6hBMI <30, 3 units Regular q 6h

BMI >30, 4 units Regular q 6hBMI >30, 4 units Regular q 6h

ContinuousContinuous Enteral Tube Feeds- Enteral Tube Feeds-ExampleExample

Correctional insulin is given if Correctional insulin is given if BG q 6 hours is elevatedBG q 6 hours is elevated

ExampleExamplePatient on 1.2 Cal formula Patient on 1.2 Cal formula (169 gm CHO/L) continuous (169 gm CHO/L) continuous 70 ml/hr ETF 70 ml/hr ETF BMI > 30 (1 unit Regular BMI > 30 (1 unit Regular Insulin per 10 gm CHO)Insulin per 10 gm CHO)BG check at 0615 =217mg/dlBG check at 0615 =217mg/dl

What is total dose of insulin What is total dose of insulin you will give?you will give?Total CHO q 6 h: 71 gmTotal CHO q 6 h: 71 gm11 units11 units

Orders:Orders: – GlargineGlargine 10 units q HS 10 units q HS– Regular insulinRegular insulin 7 units q 6 7 units q 6

hours with TFhours with TF

– Correction scale:Correction scale:

IF BG >150 IF BG >150 151-200 2 units R151-200 2 units R201-250 4 units R201-250 4 units R251-300 6 units R251-300 6 units R301-350 8 units R301-350 8 units R>350mg 10 units R>350mg 10 units R

Nocturnal ETFNocturnal ETF

NPH recommended for overnight ETFNPH recommended for overnight ETF– Intermediate acting insulin Intermediate acting insulin – Time action best covers TF durationTime action best covers TF duration

10-16 hrs10-16 hrs

– Dose based on weight/BMIDose based on weight/BMIBMI <30: 10 units NPH at onset of TF BMI <30: 10 units NPH at onset of TF

BMI >30: 20 units NPH at onset of TFBMI >30: 20 units NPH at onset of TF

– Give at Give at start of nocturnal tube feedingstart of nocturnal tube feeding

Check BG q 6 hoursCheck BG q 6 hours

BasalBasal, Nutritional, , Nutritional, CorrectionalCorrectional TF ConsiderationsTF Considerations

Trend of BG levels over 24 hours Trend of BG levels over 24 hours – if BG consistently exceed target rangeif BG consistently exceed target range

↑ ↑ Regular Regular

↑ ↑ NPH for coverage of nocturnal TF NPH for coverage of nocturnal TF

– Critically ill/SCU patients typically managed Critically ill/SCU patients typically managed on Insulin Infusionon Insulin Infusion

TF ConsiderationsTF Considerations Hypoglycemia Hypoglycemia

Be aware of changes in clinical or nutritional Be aware of changes in clinical or nutritional statusstatus– Metabolic needs may change as will insulin needs, Metabolic needs may change as will insulin needs,

Glucose monitoring is key. Glucose monitoring is key.

If TF to be interrupted for > 1 hour:If TF to be interrupted for > 1 hour:– Start IV infusion of 10% dextrose at same rate as TFStart IV infusion of 10% dextrose at same rate as TF– Continue until TF resumed at former rateContinue until TF resumed at former rate– Interruptions, clogging, disconnectionsInterruptions, clogging, disconnections

Major concernsMajor concerns

Inpatient Insulin Management Inpatient Insulin Management

Parenteral Nutrition:Parenteral Nutrition:

TPN insulin protocolsTPN insulin protocols

Parenteral NutritionParenteral Nutrition

Why need:Why need:– Dysfunctional GI tractDysfunctional GI tract– OncologyOncology

Includes Dextrose (CHO source) for Includes Dextrose (CHO source) for nutritionnutrition

Varies with individualVaries with individual

OrderedOrdered– Grams of Dextrose per day or per bag Grams of Dextrose per day or per bag

Insulin ManagementInsulin ManagementTPNTPN

Patients with diabetes or significant Patients with diabetes or significant hyperglycemia may need additional insulin hyperglycemia may need additional insulin coverage for dextrose in TPNcoverage for dextrose in TPN

Check BG on all TPN patients Check BG on all TPN patients – Check BG every 6 hours Check BG every 6 hours

Guidelines= add 0.1 unit Regular per gram of Guidelines= add 0.1 unit Regular per gram of dextrose dextrose – Example: TPN 225 gram dextrose x 0.1units regular Example: TPN 225 gram dextrose x 0.1units regular – = Add 22.5 units regular insulin to TPN bag= Add 22.5 units regular insulin to TPN bag

TPN considerationsTPN considerations

Trend of BG levels over 24 hours Trend of BG levels over 24 hours – ↑ ↑ Regular if BG >150 for standard target:Regular if BG >150 for standard target:

Guidelines: Increase by 0.05 units Regular Insulin per gram Guidelines: Increase by 0.05 units Regular Insulin per gram DextroseDextroseThreshold: 0.3 units regular insulin/gm dextrose, bag/dayThreshold: 0.3 units regular insulin/gm dextrose, bag/day

If ↑ grams of nutritional dextrose If ↑ grams of nutritional dextrose – =↑ amount of Regular insulin with same insulin: gm dextrose =↑ amount of Regular insulin with same insulin: gm dextrose

ratio required to keep BG in target range ratio required to keep BG in target range

SQ insulin or an infusion may be added if BG cont out of SQ insulin or an infusion may be added if BG cont out of goal range + insulin:dextrose threshold reachedgoal range + insulin:dextrose threshold reached

Thank YouThank You

Questions?Questions?

inpatient glycemic control coordinating nutrition and insulin management

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