What is the recommended approach for managing hyperglycemia in patients on Nasogastric (NG) feeding?

Managing Hyperglycemia in Patients on Nasogastric (NG) Feeding

For patients on NG feeding, a basal-bolus insulin regimen with correctional insulin is the preferred approach to managing hyperglycemia, targeting blood glucose levels of 140-180 mg/dL. 1

Blood Glucose Targets and Monitoring

• Target blood glucose range: 140-180 mg/dL for most hospitalized patients on NG feeding 1
• Monitoring frequency:
  • Every 4-6 hours for patients on continuous NG feeding 1, 2
  • Before meals and at bedtime for patients on intermittent NG feeding 1
  • More frequent monitoring (every 30 min to 2 hours) when using intravenous insulin 1

Insulin Regimen for Patients on NG Feeding

For Continuous NG Feeding:

1. Basal insulin:

   • Calculate total daily dose at 0.3-0.5 units/kg/day 2
   • Administer long-acting insulin (glargine or detemir) once or twice daily 1

2. Correctional insulin:

   • Add short-acting insulin every 4-6 hours based on blood glucose readings 1, 2
   • Use a standardized correction scale based on insulin sensitivity:

   Blood Glucose (mg/dL)	Low-Dose Scale	Moderate-Dose Scale	High-Dose Scale
   140-180	1 unit	2 units	3 units
   181-220	2 units	4 units	6 units

3. Important safety measure: If NG feeding is interrupted, start 10% dextrose infusion at 50 mL/hr to prevent hypoglycemia 1

For Intermittent NG Feeding:

1. Basal insulin: Same as continuous feeding
2. Prandial insulin: Administer short-acting insulin at the start of each feeding 1
3. Correctional insulin: Add as needed based on pre-feeding blood glucose levels

Special Considerations

Diabetes-Specific Formulas (DSFs)

Consider using diabetes-specific enteral formulas which typically have:

• Lower carbohydrate content
• Higher proportion of complex carbohydrates
• Modified maltodextrin and fructose
• Higher unsaturated fatty acid content
• Higher fiber content 1, 3

These formulas can improve glycemic control and potentially reduce insulin requirements 1, 3

Hypoglycemia Prevention and Management

• Define hypoglycemia as blood glucose <70 mg/dL (moderate) or <54 mg/dL (severe) 1
• Establish a hypoglycemia protocol:
  • For patients who can swallow: 15-20g oral carbohydrate
  • For NPO patients: IV glucose or glucagon 1, 2
• Review and modify insulin regimen after any hypoglycemic episode 1, 2

Avoiding Common Pitfalls

• Never rely solely on sliding scale insulin - this reactive approach treats hyperglycemia after it occurs rather than preventing it 1, 2
• Don't ignore nutritional interruptions - have protocols for unplanned discontinuation of NG feeding 1
• Avoid overfeeding - excessive caloric provision can worsen hyperglycemia 1
• Don't overlook monitoring frequency - inadequate monitoring can lead to dangerous glycemic excursions 1

Transitioning from Hospital to Outpatient Care

• Schedule follow-up within 1-4 weeks of discharge 1
• Return to home regimen 1-2 days before discharge 1
• Consider changes to outpatient regimen based on inpatient glycemic control 1

By following this structured approach to managing hyperglycemia in patients on NG feeding, you can optimize glycemic control while minimizing the risks of both hyperglycemia and hypoglycemia, ultimately improving patient outcomes.