For patients receiving enteral bolus feedings, approximately 1 unit of regular human insulin or rapid-acting insulin per 10–15 g carbohydrate should be given subcutaneously before each feeding. Correctional insulin should also be administered subcutaneously every 6 h using human regular insulin or every 4 h using a rapid-acting insulin such as lispro, aspart, or glulisine. For patients receiving continuous tube feedings, the total daily nutritional component may be calculated as 1 unit of insulin for every 10 –15 g carbohydrate per day or as a percentage of the total daily dose of insulin when the patient is being fed (usually 50–70% of the total daily dose of insulin). However, if no basal insulin was used, consider using 5 units of NPH/detemir insulin subcutaneously every 12 h or 10 units of insulin glargine every 24 h ( 64).
One may use the patient's preadmission basal insulin dose or a percentage of the total daily dose of insulin when the patient is being fed (usually 30–50% of the total daily dose of insulin) to estimate basal insulin requirements. This is particularly important for people with type 1 diabetes to ensure that they continue to receive basal insulin even if the feedings are discontinued. Conversely, higher glucose ranges may be acceptable in terminally ill patients, in patients with severe comorbidities, and in inpatient care settings where frequent glucose monitoring or close nursing supervision is not feasible.įor patients receiving enteral or parenteral feedings who require insulin, insulin should be divided into basal, prandial, and correctional components. More stringent goals, such as <140 mg/dL (7.8 mmol/L), may be appropriate for selected patients, as long as this can be achieved without significant hypoglycemia. Once insulin therapy is started, a target glucose range of 140 –180 mg/dL (7.8 –10.0 mmol/L) is recommended for the majority of critically ill and noncritically ill patients ( 2). Insulin therapy should be initiated for treatment of persistent hyperglycemia starting at a threshold ≥180 mg/dL (10.0 mmol/L). Recent randomized controlled studies and meta-analyses in surgical patients have also reported that targeting perioperative blood glucose levels to <180 mg/dL (10 mmol/L) is associated with lower rates of mortality and stroke compared with a target glucose <200 mg/dL (11.1 mmol/L), whereas no significant additional benefit was found with more strict glycemic control (<140 mg/dL ) ( 23, 24). Hypoglycemia is discussed more fully below.Ī meta-analysis of over 26 studies, including the Normoglycemia in Intensive Care Evaluation–Survival Using Glucose Algorithm Regulation (NICE-SUGAR) study, showed increased rates of “severe hypoglycemia” (defined in the analysis as blood glucose <40 mg/dL ) and mortality in cohorts with tight versus moderate glycemic control ( 22). See Table 15.1 for levels of hypoglycemia ( 21). Lastly, level 3 hypoglycemia is defined as a severe event characterized by altered mental and/or physical functioning that requires assistance from another person for recovery. Level 2 hypoglycemia (defined as a blood glucose concentration <54 mg/dL ) is the threshold at which neuroglycopenic symptoms begin to occur and requires immediate action to resolve the hypoglycemic event. Level 1 hypoglycemia in hospitalized patients is defined as a measurable glucose concentration <70 mg/dL (3.9 mmol/L) but ≥54 mg/dL (3.0 mmol/L). An admission A1C value ≥6.5% (48 mmol/mol) suggests that diabetes preceded hospitalization (see Section 2 “ Classification and Diagnosis of Diabetes”) ( 2, 20). Blood glucose levels that are persistently above this level may require alterations in diet or a change in medications that cause hyperglycemia. Hyperglycemia in hospitalized patients is defined as blood glucose levels >140 mg/dL (7.8 mmol/L) ( 2, 20).
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