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Inpatient Glycemic Control Coordinating Nutrition and Insulin Management.

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Presentation on theme: "Inpatient Glycemic Control Coordinating Nutrition and Insulin Management."— Presentation transcript:

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 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 ASPEN Nutrition Support Practice Manual –2 nd edition, McMahon M –Mayo Clinic –Nutrition in Clinical Practice 19: April 2004.

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


7 Insulin Requirements in Health and Illness Copyright © 2004 American Diabetes Association. From Clement S, et al. Diabetes Care. 2004;27:553–591. Reprinted with permission. Units Healthy Sick/EatingSick/NPO Correction Nutritional Prandial Basal

8 MMC’s Diabetic Diets gm CHO/meal ( kcal) gm CHO/meal ( kcal) –Meets nutrient needs for most patient populations 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 Breakfast826850(73%) Lunch956440(62%) Dinner787150(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 Nepro –167g CHO / L 2 Cal HN –219g CHO / L Peptamen AF –107g CHO / L Peptamen 1.5 –188g CHO / L Jevity 1.2 –169g CHO / L Promote –130g CHO / L Ensure Plus –211g CHO / L Osmolite –144g 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/Female2413/112815/13 Age BMI Hours to BG Diagnosis AMI AMI Cardiac (non-MI) Cardiac (non-MI) Noncardiac Noncardiac

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 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 RetrospectiveProtocol P value Mean BG <.0001 < 79mg/dl 12(1.7%)49(4.14%) 1% <65mg/dl mg/dl 58(8.3%)576(48.6%).01 > (90%)559(47.2%)<.0001

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 Nutritional Insulin Types nutritional insulin ActionTiming Novolog ® (aspart) MMC Rapid Acting Insulin Onset: 0-15 minutes Peak: 1-2 hours Duration: 3-4 hours **Within 15 minutes of meal 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 gm CHO/meal ( kcal) gm CHO/meal ( kcal) –Meets nutrient needs for most patient populations 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 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 **Nutritional** Insulin Aspart, SC, 6.0 daily with lunch Based on CHO meal 6.0 units if full Meal-% of Carbs Eaten units if half Meal-% of Carbs Eaten units if NO meal-% of Carbs Eaten 0-24 *Correctional Coverage* Insulin Aspart, SC, tid-meals, PRN for BG level : 2 units if BG units if BG units if BG units if BG units if BG RN & patient agree 50% meal CHO consumed RN & patient agree 50% meal CHO consumed BG was 301 mg/dl ac BG was 301 mg/dl ac What will your total insulin dose be? 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 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 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: –BMI <30: 1 unit per 15 gm CHO –BMI >30: 1 unit per 10 gm CHO Example: –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 > units R units R units R units R >350mg 10 units R

47 Nocturnal ETF NPH recommended for overnight ETF –Intermediate acting insulin –Time action best covers TF duration 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 ↑ 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: 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 Thank You Questions?

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