1. Inpatient Glycemic Control
Coordinating Nutrition and Insulin Management

3. What is Guiding our Nutrition Therapy
Need for standardized Carbohydrate intake at meal
Knowledge of carbohydrate content of Tube feedings
Managing carbohydrate infusion via TPN
All of the above to be based on an appropriate nutritional assessment

4. Research Studies Rush University Guidelines, Nov.2006
The Diabetes Educator 32(6): Nov/Dec 2006.
ASPEN Nutrition Support Practice Manual
2nd edition, 2005.
McMahon M
Mayo Clinic
Nutrition in Clinical Practice 19: April 2004.

5. Research Grainger A, Eiden K, Kemper J, Reeds D Clement S et al: 2004
Nutrition in Clinical Practice 22: Oct 2007.
Clement S et al: 2004
Diabetes Care 27: Feb 2004.
Leahy J.
Endocrine Practice, 12(13): July/August 2006.
ACE/ADA Inpatient Diabetes and Glycemic Control Consensus Conference

6. Physiologic Insulin needs
ILLNESS-RELATED
SUPPLEMENTAL
NUTRITIONAL
BASAL

7. Insulin Requirements in Health and Illness
Correction
Nutritional
Prandial
Basal
Units
Insulin Requirements in Health and Illness
Components of insulin requirements are defined physiologically and are divided into basal, prandial (mealtime) or nutritional, and correction insulin. Insulin required to cover “nutritional” needs may include insulin needed to cover intravenous dextrose, total parenteral nutrition, enteral feedings, and nutritional supplements. The basal and prandial/nutritional orders as written as scheduled insulin while correction dose insulin tends to be written as an algorithm to supplement scheduled insulin.
Clement S, Braithwaite SS, Magee MF, et al. Management of diabetes and hyperglycemia in the hospital. Diabetes Care. 2004;27:553–591.
Healthy
Sick/Eating
Sick/NPO
Copyright © 2004 American Diabetes Association. From Clement S, et al. Diabetes Care ;27:553–591. Reprinted with permission.

8. MMC’s Diabetic Diets 45-59 gm CHO/meal (1200-1500 kcal)
Meets nutrient needs for most patient populations.
75-90 gm CHO/meal ( kcal)
100 gm CHO/meal (2400 kcal)

9. Meal Consumption on CHO Fresh Start Diet (60-74g/meal)
Meal Period
# of Patients
Avg # of gms of CHO selected for meal period
Avg # of gms of CHO consumed for meal period
Breakfast 82 68 50
(73%)
Lunch 95 64 40
(62%)
Dinner 78 71
(68%)
Totals
255 meals
68 gms CHO
47 gms CHO
(67%)
MMC Aug 6,2008-Sept 5, 2008

10. Elements of Carbohydrate (CHO) Counting for RN Education
Carbohydrate foods raise blood sugars w/in 15 minutes of food intake
Converted to glucose w/in 2-4 Hrs
Count only foods with carbohydrate from meals
Grams of CHO per food will be provided on tray ticket
Floor stock Reference list available in unit kitchen

11. Portion Control
Over 150 recipes were analyzed for Carbohydrate content
Serving portions for all these recipes were weighed and serving sizes were standardized for each recipe
Education sessions with all the cooks and food servers were given to control portion size

13. Menu Selection Palm Pilot (programmed to include CHO’s)
Education to our Nutrition Care Representatives for Carbohydrate Counting
Serves to educate patient while choosing meals

14. Nursing Education
Collaborative approach with Nursing Diabetes Specialists
3 Hour classes (2-4 classes/week)
Includes 1 hr of nutrition protocols that include the “how to” of carbohydrate counting as well as tube feeding and TPN guidelines
Traveling Glycemic Fair
Set up on individual clinical units and some units have made this mandatory

15. Carbohydrate Content of Tube Feeding Formulas
Jevity 1.2
169g CHO / L
Promote
130g CHO / L
Ensure Plus
211g CHO / L
Osmolite
144g CHO / L
Nepro
167g CHO / L
2 Cal HN
219g CHO / L
Peptamen AF
107g CHO / L
Peptamen 1.5
188g CHO / L
This information is now included in all tube feed orders

16. Enteral Tube Feedings Considerations/Questions
Glycemic control can be difficult
Varying tolerance
Unplanned discontinuation of feeds
Limited literature (Clement 2004, Grainger 2007)
When to start insulin therapy
Variety of feeding schedules
Bolus vs Continuous with or without oral diet
What are the target glucose ranges

17. Literature Review Grainger in NCP: 2007
Pilot study using a glargine and lispro schedule during tube feedings
52 CICU type 2 DM patients (18-99 yo)
Control group (N=24) retrospectively studied for mean glucose control
Study group (N=28) were placed on an insulin protocol

18. Grainger Study (cont) Criteria Retrospective Data
Insulin Protocol Data
Number of Patients
Male/Female 24
13/11 28
15/13
Age
BMI
28 + 7
Hours to BG
60.2
21.5
Diagnosis
AMI
Cardiac (non-MI)
Noncardiac 7 4 13 6 9

19. Glucose Management Protocol
Glucose target: mg/dl
Bolus Tube Feeding Regimens (Q4H, 6 feeds)
Known DM or FBS >200mg/dl on admit
Only insulin therapy (no oral agents)
2 Cal HN or Nepro
BMI <15 received 35KKD
BMI received 30KKD
BMI received 20KKD
BMI received 15KKD

20. Grainger Protocol (cont)
Tube feeds initiated by day 3
Retrospective group received preprandial insulin per MD orders
Study group (glucose check before feeds)
Fixed dose of glargine (not held if feeds held)
BMI <30 got 10 units, BMI >30 got 20 units
Variable doses of lispro (dosed pre-feed)
BMI <30 got 1 unit for each 15g of CHO in feeds
BMI >30 got 1 unit for each 10g of CHO in feeds
Correctional if BG >140mg/dl

21. Sliding Scale Lispro
If glucose < 100 give Lispro after tube feed started
If glucose >100 give lispro at start of feeds
Correctional “Sliding Scale” Lispro was weight based and given with the nutritional dose of Lispro
Lispro dose increased by 3 units if 2 consecutive glucoses were >200mg/dl

22. Grainger: Glucose Control
Blood Glucose
Retrospective
Protocol
P value
Mean BG
225.1
148.9
<.0001
< 79mg/dl
12(1.7%)
49(4.14%)
1% <65mg/dl
.02
mg/dl
58(8.3%)
576(48.6%)
.01
> 141
632(90%)
559(47.2%)

23. Conclusions
A SQ insulin protocol reduced average blood glucoses by approx 80mg/dl
Tighter control resulted in a modest increase in hypoglycemia (with no adverse events found)
Further studies are needed to determine if adjustments in lispro baseline could lead to tighter control

24. Observation Letter: Glargine and Continuous Tube Feeds
Diabetes Care 2002 (25: )
60 yo male with type 2 DM with squamous ca of oral cavity with recurrent aspiration
HbA1c 7.5%
Continuous feeds started with
Glargine dose was increased gradually by 2-4units at 3 day intervals to attain BG of mg/dl
Good control was achieved with 45units glargine with no hypoglycemia
After 6 months patient’s HbA1c was 6.1%

25. Additional Considerations for Enteral Tube Feedings
Avoid increasing tube feeding delivery until adequate BG control is achieved
Basal insulin generally no more than 40% of daily insulin to avoid hypoglycemia
Nutritional insulin to be given as programmed doses of regular or rapid acting insulin
NPH insulin’s profile better fits a nocturnal feeding schedule (peaking at 6-8 hrs)
If tube feeds are unexpectedly stopped start a D10% IV at same rate of feeds to avoid hypoglycemia and increase glucose checks
Avoid high fat formulas (gastroparesis)

26. Glucose Management with Parenteral Nutrition
ASPEN Guidelines:
Check glucoses Q6hrs on TPN
Only Regular insulin is compatible w/ TPN
Limit initial dextrose in TPN solution for patients with hyperglycemia to g/day
Do not increase dextrose calories via TPN until glucoses are consistently <180mg/dl
5-15% of insulin in TPN adheres to the tubing therefore insulin requirements may appear high

27. Glucose Control and TPN M McMahon MD
Measure glucose before TPN and 2 to 4 times daily after start of TPN
Avoid overfeeding calories in TPN patients (importance of Nutritional Assessment)
Majority of DM patients will require supplemental insulin
Start TPN with 0.1 unit of insulin per g of Dextrose, (this ratio should not result in hypoglycemia)
If glucoses remain above target increase insulin in 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)

28. McMahon (cont)
Do not increase dextrose in TPN until target glucoses are met for previous 24hrs
Increase insulin proportional to Dextrose once the appropriate ratio is attained
Hypoglycemia after discontinuation of TPN should not occur unless given excess dextrose

29. MMC TPN Ordering
TPN is ordered in grams of protein, dextrose and lipids for 24 hrs per nutrition assessment
Ex: 80g of aminosyn, 200g of Dextrose and 50g of Liposyn for 45% carbohydrate calories
Insulin is ordered as units per day vs liter
Electrolytes and minerals are ordered per liter
Ex: NaCl 50 mEq/L

30. Collaborative Review Literature Review Other Hospital Programs
Open Discussions
MD, RD, RN and RPh developed Protocols

31. MMC Insulin Protocols
Nutrition Component

32. Types nutritional insulin
Action
Timing
Novolog ® (aspart) MMC
Rapid Acting Insulin
Onset: 0-15 minutes
Peak: 1-2 hours
Duration: 3-4 hours
**Within 15 minutes
of meal
Regular Human Insulin
Short Acting
Onset: minutes
Peak: 90 min-2 hours
Duration: 6-8 hours
30 minutes ac meal
NPH
Intermediate Acting
Onset: 2-4 hours
Peak: 4-10 hours
Duration: hours
Start of Tube feeding

33. Insulin Profiles

34. MMC’s Diabetic Diets 45-59 gm CHO/meal (1200-1500 kcal)
Meets nutrient needs for most patient populations.
75-90 gm CHO/meal ( kcal)
100 gm CHO/meal (2400 kcal)

35. Prandial /Nutritional Insulin Dosing Oral Diet
Dosing will be pre-selected based on:
Patient’s BMI & meal plan requirement
Percent of CHO consumed from meals.
Questioning food consumption, give prandial dose at end of the meal.
If pre meal BG>150= nutritional + correctional scale ac meal.
If pre-meal BG mg/d, give meal coverage pc meal
Insulin may be given up to 30 minutes AFTER the patient eats
HOLD nutritional dose insulin if patient is NPO

36. SC Protocol Prandial or Nutritional insulin coverage
62 yo T1DM s/p RBKA
Diet:
Diabetic, gm CHO/meal
Scheduled Prandial Insulin dose per BMI + meal plan:
6 units ac meals
ac BG at 1150:
301mg/dl
Pt sad, verbalizes “stomach upset, not very hungry”
Lunch tray arrives. Plan for patient?

37. SC Protocol Example Plan
Hold pre-meal insulin dose
Partnership
Nurse
CNA
Patient
Family
Review meal ticket carbohydrate amount
Review carbohydrate consumed from plate
Check tray ticket for total CHO gm reference vs % amt eaten

38. Example: total gm CHO on tray: 60 gm
SC Protocol Example
Example: total gm CHO on tray: 60 gm
If >75% total gm CHO on tray consumed: give full dose (>45gm)
If 25-74% total gm CHO on tray consumed: give 3 units (15-45 gm)
If <25% total gm CHO on tray eaten consumed: no insulin coverage ( <15 gm)

39. Insulin Orders RN & patient agree 50% meal CHO consumed
*Correctional Coverage*
Insulin Aspart, SC, tid-meals,
PRN for BG level :
2 units if BG
4 units if BG
6 units if BG
8 units if BG
10 units if BG
**Nutritional**
Insulin Aspart, SC, 6.0 daily with lunch
Based on CHO meal
6.0 units if full Meal-% of Carbs Eaten
3.0 units if half Meal-% of Carbs Eaten 25-74
0 units if NO meal-% of Carbs Eaten 0-24
RN & patient agree 50% meal CHO consumed
BG was 301 mg/dl ac
What will your total insulin dose be?

40. SC Protocol Example Plan
RN & patient agree 50% meal CHO consumed
BG was 301 mg/dl ac
Answer
What will your total insulin dose be?
Total dose = 11 units aspart post meal

41. Tube Feeding Insulin Protocols
Glycemic Management
Tube Feeding Insulin Protocols

42. Enteral Nutrition/Tube feeding
Continuous
Infusing over 24hrs
Bolus
Mimics meals
Nocturnal
Infusion at night: typically 12hr infusion
Can be NPO or eating during day
Usually transitioning stage

43. Basal, Nutritional, Correctional Enteral Tube Feeding
Need 3 components of insulin
Basal insulin Pre-existing DM/hyperglycemia:
Continue the basal insulin dose (glargine/detemir)
If patient has not been treated with basal insulin + has Random BG >200:
MD can initiate basal dose of glargine on weight/BMI
(Consider adjust basal if reached Prandial Insulin threshold + BG remains over 150mg/dl)
Nutritional to cover CHO in TF
Type of insulin + dosage dependent on:
Glucose levels
TF schedule
BMI
TF formula/rate
Correctional to cover high BG q 6 hours
Regular Insulin

44. Continuous ETF Prandial coverage: Correctional Glucose Monitoring:
Check BG q 6 hours all ETF patients
Goal glucose during feeding: for standard pt
If BG levels < 150mg/dl x 24h, + tolerating at goal rate:
▪↓ BG testing q 12 hours
If TF CHO content ↑ (i.e. increasing rate, changing formula)
Continue q 6 hour BG checks
Prandial coverage:
Scheduled: Regular insulin q6h
Dose Based on BMI/CHO infusion
Correctional
Regular insulin

45. Dosing Regular Insulin q 6h: Example: BMI <30: 1 unit per 15 gm CHO
1Cal Tube feeding ( ml/hr:
43.5 gm CHO infused q 6h
BMI <30, 3 units Regular q 6h
BMI >30, 4 units Regular q 6h

46. Continuous Enteral Tube Feeds-Example
Correctional insulin is given if BG q 6 hours is elevated
Example
Patient on 1.2 Cal formula (169 gm CHO/L) continuous 70 ml/hr ETF
BMI > 30 (1 unit Regular Insulin per 10 gm CHO)
BG check at 0615 =217mg/dl
What is total dose of insulin you will give?
Total CHO q 6 h: 71 gm
11 units
Orders:
Glargine 10 units q HS
Regular insulin 7 units q 6 hours with TF
Correction scale:
IF BG >150
units R
units R
units R
units R
>350mg 10 units R

47. Nocturnal ETF NPH recommended for overnight ETF Check BG q 6 hours
Intermediate acting insulin
Time action best covers TF duration
10-16 hrs
Dose based on weight/BMI
BMI <30: 10 units NPH at onset of TF
BMI >30: 20 units NPH at onset of TF
Give at start of nocturnal tube feeding
Check BG q 6 hours

48. Basal, Nutritional, Correctional TF Considerations
Trend of BG levels over 24 hours
if BG consistently exceed target range
↑ Regular
↑ NPH for coverage of nocturnal TF
Critically ill/SCU patients typically managed on Insulin Infusion

49. TF Considerations Hypoglycemia
Be aware of changes in clinical or nutritional status
Metabolic needs may change as will insulin needs, Glucose monitoring is key.
If TF to be interrupted for > 1 hour:
Start IV infusion of 10% dextrose at same rate as TF
Continue until TF resumed at former rate
Interruptions, clogging, disconnections
Major concerns

50. Inpatient Insulin Management
Parenteral Nutrition:
TPN insulin protocols

51. Parenteral Nutrition Why need:
Dysfunctional GI tract
Oncology
Includes Dextrose (CHO source) for nutrition
Varies with individual
Ordered
Grams of Dextrose per day or per bag

52. Insulin Management TPN
Patients with diabetes or significant hyperglycemia may need additional insulin coverage for dextrose in TPN
Check BG on all TPN patients
Check BG every 6 hours
Guidelines= add 0.1 unit Regular per gram of dextrose
Example: TPN 225 gram dextrose x 0.1units regular
= Add 22.5 units regular insulin to TPN bag

53. TPN considerations Trend of BG levels over 24 hours
↑ Regular if BG >150 for standard target:
Guidelines: Increase by 0.05 units Regular Insulin per gram Dextrose
Threshold: 0.3 units regular insulin/gm dextrose, bag/day
If ↑ grams of nutritional dextrose
=↑ amount of Regular insulin with same insulin: gm dextrose ratio required to keep BG in target range
SQ insulin or an infusion may be added if BG cont out of goal range + insulin:dextrose threshold reached

54. Questions?
Thank You