Gerald Schmidt, PharmD, BCNSP
Nutritional Support Pharmacist
Shands Jacksonville Medical Center
Jacksonville, Florida
Disclosure information not submitted.
Title: Insulin algorithm safe and effective in managing glucose levels in parenteral nutrition patients
Background: Hyperglycemia is a frequent complication of parenteral nutrition (PN) in hospitalized patients. Insulin management is difficult in these patients for a variety of reasons. Some practitioners prefer to control serum glucose levels by administration of subcutaneous insulin, where others prefer to add insulin to the PN solution. In addition, insulin requirements vary significantly between patients, and overzealous administration of insulin can result in hypoglycemia. The challenge is to control serum glucose rapidly while avoiding hypoglycemia. An algorithm was developed after reviewing current literature on insulin administration in parenteral nutrition patients.
Methods: The insulin dose was calculated using the average glucose readings between 6 AM and 6 PM and adding the correctional insulin given between 6 PM and 6 AM and adding it to the PN bag. As hypoglycemia was our biggest concern, the primary safety goal was no point of care (POC) glucose levels less than 70 mg/dL. Efficacy was defined as average POC glucose was below 200 mg/dL for 2 consecutive days. Patients on PN/insulin less than 7 days, patients on pulse steroid therapy and patients with sepsis were excluded from the study. Patients receiving subcutaneous basal insulin were included in the analysis.
Results: A medication use analysis was performed to determine the safety and efficacy of the insulin adjustment algorithm for PN patients. Thirty patients were included in the analysis. Of the 30 patients, 1106 POC glucose readings were documented ranging from 70 – 375 mg/dL, and PN was not held in any patient due to hypo or hyperglycemia. There were 3 POC glucose readings less than 80 mg/dL (70, 77 and 79 mg/dL). Twenty nine of the 30 patients met the efficacy criteria.
Conclusion: The insulin adjustment algorithm for PN patients developed by this institution has standardized the process for adjusting insulin in PN patients. Both pharmacists and endocrine practitioners feel more comfortable adjusting insulin in PN patients utilizing this algorithm. The algorithm appears to be both safe and effective, with no POC glucose levels less than 70 mg/dL and 29 out of 30 (96%) patients meeting efficacy criteria. The insulin adjustment algorithm for PN patients has been a valuable tool when adjusting insulin in PN patients.