Diabetes Mellitus:  Lipids

Patient on Hyperalimentation

Typically insulin is added to the TPN solution bag. A better initial technique, allowing more rapid glucose control, and more rapid estimate of total insulin needs, is to have a separate IV insulin drip (as described for NPO - perioperative patients). When the glucose is controlled, the insulin may then be added to the TPN solution. Similar methods to this have been successfully tested in the past. (Sajbel TA, Dutro MP, Radway PR. Use of separate insulin infusions with total parenteral nutrition. JPEN J Parenter Enteral Nutr 1987; 11:97-9 )  Not only did this form of insulin management improve glucose control, there was a savings of >7 liters of TPN solution per patient.

In reality, a sort of step approach to this works well.  In the first step, an IV insulin algorithm allows the insulin to be quickly titrated to the needs of the patient.  Based on the amount of insulin given to the patient in 24 hours this way, that amount of insulin can then be calculated to be given to the patient per 24 hours in their TPN.  Again, there are different types of IV insulin algorithms that can be used here, I prefer the type that can be used anywhere in the hospital (again to see this click here).

Once the insulin has been moved to the TPN solution, you could continue the IV insulin for fine tuning, but that is a lot of work for the nursing staff and everyone involved.  A reasonable solution is to use the subcutaneous insulin form, check off the box for "NPO or TUBE Feeds"  and just use the correction insulin.  Yes this is basically an old fashion sliding scale, but it is on top of the insulin the patient is getting in the TPN.  You can see how much "correctional" or supplemental insulin is required and change the amount of insulin added to the TPN.  An example of this will be shown on the next screen.

TPN and Diabetes

Step 1:

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Use separate IV insulin drip with NPO protocol

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As glucose controlled add insulin to the TPN solution based on the IV insulin drip

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Allows reduction in TPN solution waste

 

Step 2:

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Insulin has been added to the TPN solution

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Use SQ insulin order sheet to order correctional insulin doses

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adjust the amount of insulin in the TPN based how much insulin has been required for the correctional insulin doses.