Role of Dextrose with Insulin for NBM Patients
For patients who are nil by mouth (NBM), a basal-plus-correction insulin regimen with concurrent dextrose infusion is the preferred treatment approach to manage blood glucose levels and prevent hypoglycemia. 1
Glycemic Management in NBM Patients
Preferred Insulin Regimen
- A basal-plus-correction insulin regimen is the recommended approach for hospitalized patients with poor oral intake or those who are NPO (nothing by mouth) 1
- The sole use of sliding-scale insulin (correction insulin without basal insulin) is strongly discouraged in the inpatient setting 1
- For patients in critical care settings, continuous intravenous insulin infusion is the most effective method for achieving glycemic targets 1
Target Blood Glucose Levels
- Inpatient glucose targets of 140-180 mg/dL (7.8-10 mmol/L) are recommended for most hospitalized patients, including those who are NPO 1
- More stringent targets of 110-140 mg/dL (6.1-7.8 mmol/L) may be appropriate for selected patients such as cardiac surgery patients or those with acute ischemic cardiac or neurologic events, if achievable without significant hypoglycemia 1
Role of Dextrose in NBM Patients
Indications for Dextrose
- Dextrose infusion is indicated as a source of carbohydrate calories in patients whose oral intake is restricted or inadequate to maintain nutritional requirements 2
- Dextrose helps minimize liver glycogen depletion and exerts a protein-sparing action in NBM patients 2
- Concurrent dextrose administration is essential to prevent hypoglycemia in patients receiving insulin therapy while NPO 3, 4
Administration Considerations
- For NBM patients receiving insulin, starting intravenous 10% dextrose infusion at 50 mL/h is recommended if enteral feeding is interrupted 1
- Slow infusion of hypertonic dextrose solutions is essential to ensure proper utilization of dextrose and avoid production of hyperglycemia 2
- Isotonic solutions such as 0.9% saline are more evenly distributed into extracellular spaces and may be better than hypotonic solutions (like 5% dextrose) for patients with acute ischemic conditions 1
Monitoring and Safety Considerations
Blood Glucose Monitoring
- For NBM patients, bedside glucose monitoring should be performed every 4-6 hours 1
- More frequent monitoring (every 30 minutes to 2 hours) is required when using intravenous insulin 1
- Patients at higher risk for hypoglycemia require more vigilant monitoring, particularly when receiving insulin and dextrose 4, 5
Hypoglycemia Prevention
- Hospital-related hypoglycemia is associated with higher mortality 1
- Risk factors for hypoglycemia include lower pretreatment blood glucose (<110 mg/dL), lower weight, renal insufficiency, older age, and absence of diabetes 4, 5
- Higher dextrose doses (50g vs 25g) may be beneficial in select patient populations, such as patients without type 2 diabetes or those with baseline blood glucose <110 mg/dL 5
Management of Hypoglycemia
- Hypoglycemia (<60 mg/dL) can be corrected rapidly with intravenous administration of 25 mL of 50% dextrose 1
- A standardized hospital-wide and nurse-initiated hypoglycemia treatment protocol should be in place to immediately address hypoglycemia 1
Special Considerations
Transitioning from IV to Subcutaneous Insulin
- When transitioning from intravenous insulin therapy to subcutaneous insulin, a structured protocol reduces morbidity and costs 1
- Subcutaneous insulin should be given 1-2 hours before intravenous insulin is discontinued 1
- Converting to basal insulin at 60-80% of the daily infusion dose has been shown to be effective 1
Patients Receiving Parenteral Nutrition
- For patients receiving parenteral nutrition, admixing short-acting insulin into the parenteral bag may be beneficial compared to subcutaneous insulin administration alone 1
- Continuous monitoring of blood glucose levels is essential to adjust insulin and dextrose rates appropriately 1