9.0.0.0 STAN­DARDS FOR SPE­CIAL SIT­U­A­TIONS

9.1.0.0 Enteral/Paren­ter­al Feed­ings

For pa­tients re­ceiv­ing en­ter­al or paren­ter­al feed­ings who re­quire in­sulin, in­sulin should be di­vid­ed into basal, pran­di­al, and cor­rectional com­po­nents. 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. 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. 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). 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). 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 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 cov­er­age should be added as need­ed be­fore each feed­ing. For pa­tients re­ceiv­ing con­tin­u­ous pe­riph­er­al or cen­tral paren­ter­al nu­tri­tion, human reg­u­lar in­sulin may be added to the so­lu­tion, par­tic­u­lar­ly if >20 units of cor­rectional in­sulin have been re­quired in the past 24 h. A start­ing dose of 1 unit of human reg­u­lar in­sulin for every 10 g dex­trose has been rec­om­mend­ed (65), to be ad­just­ed daily in the so­lu­tion. Cor­rec­tion­al in­sulin should be ad­min­is­tered sub­cu­ta­neously. For full en­ter­al/ paren­ter­al feed­ing guid­ance, the read­er is en­cour­aged to con­sult re­view ar­ti­cles de­tail­ing this topic (2,66).