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Enteral nutrition
In the patient receiving enteral nutrition, short-acting insulin should be administered until the patient is tolerating IV feeding.24 If there is any possibility that the tube feedings will be interrupted, eg, for a surgical procedure, the use of short-acting insulin alone is also recommended to minimize the risk of hypoglycemia.
When continuous infusion enteral feeding is required and the rate of delivery has reached 30 mL/hr, administration of a programmed, intermediate-acting (NPH) or long-acting (glargine) insulin preparation may be considered.24 If tube feedings are to be administered continuously during the day, a starting dose of intermediate- or long-acting acting insulin that is equivalent to one half the patient's preadmission basal insulin dose may be administered.24
When bolus enteral tube feedings are administered, fingerstick BG levels should be assessed before the bolus is administered and may be checked again 1 hour after a bolus of rapid-acting insulin, or 2 hours after a bolus of regular insulin, has been delivered, to assess the postprandial level of control. Either regular or rapid-acting insulin before each bolus or twice-daily regular or rapid-acting insulin mixed with intermediate-acting insulin may be used.
Parenteral nutrition
Various approaches to the delivery of insulin in patients with diabetes receiving parenteral nutrition (PN) can be taken. Although insulin can be added directly to the total PN (TPN) bag, use of this method as the initial, sole method of administration may require several days to achieve optimal glycemic control. McMahon and Rizzi recommend that dextrose in the PN bag be limited to approximately 200 grams on the first day of nutrition supplementation, eg, 1 liter of 20% dextrose or 2 liters of 10% dextrose. Most patients with diabetes who are on TPN will require supplemental insulin. Glucose concentrations in this patient setting should be measured every 4 to 6 hours.24 |
