Enteral feeding (EF) consists of delivering nutrition directly to the gut via a feeding tube, bypassing the oral cavity and oesophagus. Enteral nutrition (EN) is required in those individuals who are unable (or sometimes unwilling) to take in oral nutrition for more than a short duration of time, and are therefore at risk of malnutrition.
The main indications for EF and the routes through which EF is undertaken are listed in Table 1. Enteral feeds can be delivered as a bolus with a syringe (small volumes at regular intervals mimicking normal eating), intermittently for a few hours via a pump, or continuously via a pump (Jones et al, 2017; Fletcher, 2019). In patients with diabetes who have delayed gastric emptying and gastroparesis, nasojejunal or jejunal feeding is undertaken to bypass the stomach.
Table 1. Indications and routes for enteral feeding modified from BAPEN – all access routes and tube types
| Enteral Feeding Type | Timeframe | Common Indications |
|---|---|---|
| NasogastricFeeding tube inserted through the nose into the stomach | Short-term (generally less than 30 days) | Early post strokeInadequate oral intake eg postoperativelyAcute swallowing problems |
| NasoduodenalFeeding tube inserted through the nose into the duodenum | Short-term (generally less than 90 days) | Reduced gastric emptyingPathology in oesophagus or stomach |
| NasojejunalFeeding tube inserted through the nose into the jejunum | Short-term (generally less than 90 days) | Reduced gastric emptyingPathology in oesophagus or stomach |
| GastrostomyFeeding tube inserted through skin of the abdomen directly into stomach e.g. percutaneous endoscopic gastrostomy (PEG) | Long-term (generally over 30 days) | Neurological disease causing swallow problemsOesophageal pathologyHead and neck cancerBrain injury |
| JejunostomyFeeding tube inserted through skin of the abdomen directly into the jejunum | Long-term (generally over 30 days) | GastroparesisAs nasojejunal but longer term |
From: Fletcher (2019)
Various types of enteral feeds are available, each with differing content of protein, carbohydrate (CHO), electrolytes, and minerals, and are used for specific indications.
Hyperglycaemia during enteral feeding
The most commonly used enteral feeds are pre-digested and have CHO as the main source (around 50%) of energy (Pearce and Duncan, 2002). They are therefore easily absorbed, causing rapid rise in blood glucose (BG) levels. Since intermittent or continuous EF delivers a constant CHO load, the BG rise is sustained and continues for at least 2–4 hours after the feed has been discontinued.
In addition to the CHO content of feeds, a number of other factors cause hyperglycaemia. Insulin resistance is increased during critical illness, leading to dysglycaemia. Concomitant use of medications that cause hyperglycaemia (steroids, inotropes, biguanides, sulphonylureas, beta-blockers, anti-arrhythmics and indomethacin) can also contribute.
Management of hyperglycaemia during enteral feeding
In 2017, The Joint British Diabetes Societies (JBDS) issued revised guidelines on the glycaemic management during inpatient EF of stroke patients with diabetes mellitus (DM) (JBDS, 2018), which form the basis of treatment strategies for EF-associated dysglycaemia in the UK. Stroke patients form the biggest cohort, receiving EF with an incidence of 8.5–29% (Broadley et al, 2003); however, the basic principles of management can be extrapolated to include other groups of patients.
Patients who already have a diagnosis of DM are more likely to need treatment for hyperglycaemia. In patients with undiagnosed DM or without prior DM, hyperglycaemia can ensue on commencement of EF. Hence capillary blood glucose (CBG) must be measured every 4–6 hours during EF, and treatment commenced if there are more than two episodes of hyperglycaemia.
The JBDS guideline on EF does not specify a CBG criterion for hyperglycaemia in patients without DM, but recommends treatment for hyperglycaemia for those with DM for CBG is above 12mmol/l. Other JBDS guidelines in inpatient diabetes management (JBDS, 2012; JBDS 2013) also define an acceptable CBG range for inpatients as 5–12mmol/l. However, the American Diabetes Association (ADA) recommends a glycaemic target of 7.8–10mmol/l for inpatients with DM, and recommends commencement of treatment for hyperglycaemia if CBG is above 10mmol/l on two occasions during EF (ADA, 2019). The definition of hyperglycaemia during EF in patients without DM is therefore open to interpretation and must be locally agreed.
Hyperglycaemia during EF, with or without a prior diagnosis of DM, is challenging to manage. Whilst the use of enteral feeds that are low in CHO content appears to be the obvious answer to the hyperglycaemia problem, the current body of evidence does not support its routine use. Apart from Metformin, oral hypoglycaemic agents and non-insulin injectable hypoglycaemic agents have no role in the management of EF-related dysglycaemia. As such, insulin therapy remains the mainstay of treatment.
Treatment of hyperglycaemia during enteral feeding
Insulin therapy
Insulin route
Subcutaneous (SC) insulin therapy is the preferred mode of management of EF-associated hyperglycaemia in the majority of patients. There is no evidence for the routine use of intravenous (IV) insulin infusions for glycaemic management in EF, other than in critically ill patients where it achieves better glycaemic control (Yuan et al, 2015; Vennard et al, 2018).
Insulin type
Several types of insulin are available, varying in speed of onset and duration of action. Any type of SC insulin may be used to manage hyperglycaemia, but the duration of action of the insulin used should be matched to the duration of the feed. As a general principle, insulin action should continue for 2–4 hours after EF has stopped in order to control hyperglycaemia, but not longer as hypoglycaemia can result. Table 2 explains how a specific insulin can be suited to a specific duration of EF, depending on duration of insulin action.
Table 2. Duration of enteral feed covered by one dose of subcutaneous insulin
| Type of Insulin | Duration of Action of Insulin | Feed Covered by One Dose of Insulin |
|---|---|---|
| Rapid Acting | 3–5 hours | Bolus feed |
| Short Acting | 5–8 hours | 4 to 6 hour feed |
| Intermediate Acting | 10–16 hours | 10 to 12 feed |
| Pre-mixed | 8–12 hours | 12 feed |
| Long Acting | 18–24 hours | 24 feed |
Insulin regimen
Common insulin regimens used in the management of DM are once daily (long or intermediate acting), twice daily (intermediate acting or pre-mixed), basal (long acting), and bolus (rapid/short acting) insulin regimens. Any of these regimens can be used to manage hyperglycaemia associated with EF; however the regimen that is most appropriate for EF duration must be used.
For example, in a patient with type 2 diabetes (T2DM), 12-hour EF may be managed with a single dose of intermediate acting insulin at the start of the feed. Alternatively, a single dose of pre-mixed insulin may also be used. Anecdotal experience has shown that pre-mixed insulin provides better glycaemic control due to the presence of the rapid-acting insulin component. EF is often undertaken overnight to allow the patient to attempt oral intake during the day. In this case, daytime hyperglycaemia will result. This can be managed by a dose of intermediate acting or pre-mixed insulin (depending on oral intake) in the morning.
Patients with type 1 diabetes (T1DM) are invariably on a basal bolus insulin regimen for diabetes management, and continuation of this during EF is the easiest and most logical option. Basal insulin cover must always be provided in these patients as they are completely insulin deficient and there is a high risk of ketoacidosis. The number of bolus insulin doses depends on the length of the feed, and is usually given at the start of EF and then every 4–6 hours during EF. Thus, a 12-hour feed would be managed by continuing the basal insulin and administering two boluses of short or rapid acting insulin – one at the start of EF and the other 6 hours into EF. If additional oral intake is present, then additional bolus insulin will be needed to cover this. However, other insulin regimens can also be used to cover longer feed durations – but care must be taken to provide 24-hour insulin cover. Therefore, a 12-hour overnight feed could be managed with one dose of intermediate acting insulin at the start of the feed. Another smaller dose of intermediate acting insulin will need to be administered at the end of the feed (in the morning) in order to provide basal insulin cover for the hours during the day.
Possible insulin regimen options for different feed durations are illustrated in Table 3. More than one choice of insulin regimen may be suitable for a particular feed duration. Other considerations apart from feed duration, as described in the section on multidisciplinary (MDT) team working, would influence the final choice.
Table 3. Insulin regiments suitable for differernt feeding regimens
| Feed Duration | Suitable Insulin Regimens | |
|---|---|---|
| Type 1 Diabetes | Type 2 Diabetes | |
| Bolus feed | Basal insulin once daily + 1 dose of bolus insulin at the start of the feed | 1 dose of bolus insulin at the start of the feed |
| 6 hour feed | Basal insulin once daily + 1 dose of bolus insulin at the start of the feed | 1 dose of bolus insulin at the start of the feed |
| 10 hour feed | Basal insulin once daily + 2 doses of bolus insulin, one at the start of the feed and one 5 hours into the feed | 1 dose of intermediate acting insulin at the start of the feed |
| 12 hour feed | Basal insulin once daily + 2–3 doses of bolus insulin, one at the start of the feed and the others 4–6 hours apartOR2 doses of intermediate acting insulin 12 hours apart - one bigger dose at the start of the feed, and a second smaller dose at the end of the feed to provide basal insulin cover for the remaining 12 hours | 1 dose of intermediate acting insulin at the start of the feedOR1 dose of pre-mixed insulin at the start of the feed |
| 16 hour feed | Basal insulin once daily + 2–3 doses of bolus insulin, one at the start of the feed and the others 4–6 hours apartOR2 doses of pre-mixed insulin – one at the start of the feed and the other at the midpoint of the feed | 2 doses of pre-mixed insulin – one at the start of the feed and the other at the mid-point of the feed |
| 20 hour feed | Basal insulin once daily + 3 doses of bolus insulin, one at the start of the feed and the others 4–6 hours apartOR2 doses of pre-mixed insulin – at the start of the feed and at the mid-point of the feed | 2 doses of pre-mixed insulin – one at the start of the feed and the other at the mid-point of the feedOR2 doses of intermediate acting insulin – one at the start of the feed and the other at the midpoint of the feed |
| 24 hour feed | Basal insulin once daily + 4 doses of bolus insulin, one at the start of the feed and the others 4–6 hours apartOR2 doses of pre-mixed insulin – one at the start of the feed and the other at the midpoint of the feed | 2 doses of pre-mixed insulin – one at the start of the feed and the other at the mid-point of the feedOR2 doses of intermediate acting insulin – one at the start of the feed and the other at the midpoint of the feed |
- Patients with poorly controlled T2DM may have hyperglycaemia when feeding is not taking place, and may require additional insulin to control this if not on a basal bolus regimen.
- Additional insulin will also be required if oral feeding is taking place concomitantly and can be administered as basal (intermediate acting) or pre-mixed insulin depending on oral intake.
- When using a basal bolus regimen, additional bolus doses will be required to control hyperglycaemia arising from additional oral intake.
Few clinical trials examine the efficacy of different insulin regimens in managing EF, and as such there is no evidence to confirm the superiority of a particular regimen (Drinicic et al, 2017). There is some evidence that the addition of basal insulin offers better glycaemic control than bolus insulin alone (Korytkowski et al, 2009; Umpierez et al, 2011). Also, in continuous 24-hour EF, three doses of pre-mixed insulin at regular intervals may achieve better control than two doses (Hsia et al, 2011).
Particular care must also be taken to prescribe and administer insulin at the time specified in relation to the feed. For example, a pre-mixed insulin regimen for a 16-hour feed must be prescribed and administered as Insulin Name X units at the start and at the midpoint of the feed, and not Insulin Name X units twice daily.
Insulin dose
The JBDS guideline suggests that the total insulin dose required to cover the enteral feed can be calculated from the CHO content of the feed OR presumed carbohydrate to insulin ratio (CIR).
The CHO content of the prescribed feed volume for the day can be determined from the feed label.
The CIR is the amount of CHO that is covered by 1 unit of insulin. The guideline suggests the use of 1 unit of insulin for 10g of CHO in insulin naïve patients, 1 unit of insulin for 8g of CHO in those usually on less than 40 units of insulin a day, and 1 unit of insulin for 6g of CHO in those usually on more than 40 units of insulin a day.
The total insulin dose required for the feed is calculated by multiplying the total CHO content of the feed by the CIR. This is then administered in divided doses as per the regimen.
Additional basal insulin will be required in patients with T1DM, and occasionally in patients with poorly-controlled T2DM, during the rest period. In those patients who are already on Variable Rate Insulin Infusion (VRII) with EF, the total daily insulin dose can be determined from the hourly IV insulin infusion rate. 30-50% of this can be given as basal insulin and the rest as boluses in divided doses, when converting to SC insulin.
In reality, insulin requirement is influenced by multiple factors other than just CHO content of the meal, and as such can be difficult to determine.
Box 1. Example showcasing how to estimate insulin requirementExample: Mr A has T2DM and is usually on pre-mixed insulin 28 units BD. He is currently on a 16 hour feed, running at 50 ml/hr. The CHO content of the feed is 20 g/100ml. Estimate his insulin requirement.
- Total volume of feed = 50ml/hr × 16hr = 800ml
- 100 ml of feed contains 20g of CHO, therefore 800 ml of feed will contain 20×800/100 = 160g of CHO
- He is on more than 40 units of insulin a day. For 6g of CHO he will require 1 unit of insulin. Therefore, for 160g of CHO he will require 160/6 = approximately 27 units of insulin to cover the feed
Continuous subcutaneous insulin infusion – insulin pump therapy
Some patients with T1DM use an insulin pump to deliver basal insulin continuously and bolus insulin at mealtimes to manage their BG. The insulin pump is controlled solely by the patient; to facilitate its use during enteral feeding the patient should be fully alert, well, and able to make ongoing decisions about insulin doses. Inpatient ward staff are not trained in the use of insulin pumps. Insulin pumps are hence not used during EF. However, in patients who have a well-established and fixed long-term feeding regimen, there is no reason why continuous subcutaneous insulin infusion may not be used if the patient is willing and able to manage the insulin pump. There are some reports of its successful use. (Bergman et al, 1984; Bergman et al, 1986; Piccini et al, 2013)
Metformin
In patients with T2DM who have mild hyperglycaemia with EF, re-suspended Metformin powder can be administered via the feeding tube.
Diabetes Specific Enteral Feeds
Diabetes Specific Enteral Feeds (DSEFs) have a lower CHO content and a higher proportion of fats and fibre compared to standard enteral feeds (Hise and Fuhrman, 2009). DSEFs slow down gastric emptying and delay intestinal reabsorption of CHO thereby significantly reducing postprandial BG rise and peak BG concentrations without adversely affecting lipid metabolism (Elia et al, 2005; Craig et al, 1998; McCargar et al, 1998). DSEF use is also associated with lower insulin requirement, less hypoglycaemia and fewer complications (Mesejo et al, 2003; Mayr et al, 2005; Elia et al, 2005; Craig et al, 1998). DSEFs are expensive however, and at present there is no recommendation for their widespread use (Hise and Fuhrman, 2009).
Monitoring effectiveness of treatment
Glycaemic targets and blood glucose measurement
The JBDS guideline recommends a glycaemic target of 6-12mmol/l during EF and 5–8 mmol/l during fasting and rest period. This is higher than the ADA recommended target of less than 10mmol/l, although the ADA target applies to all inpatients with diabetes and is not specific to EF. The JBDS guideline was instituted specifically for patients requiring EF after a cerebrovascular event; these patients are thought to be at significant risk of hypoglycaemia, especially since many may be unable to communicate symptoms of hypoglycaemia. Hypoglycaemia is thought to cause critical cerebral damage to stroke patients. This explains the less stringent BG target. However, a significant number of non-stroke patients receive EF and are likely to benefit from tighter blood glucose control as recommended by the ADA.
In order to achieve the recommended - or individualised - glycaemic targets, regular bedside CBG monitoring must take place. As a general principle, CBG must be measured at the start of the feed (prior to insulin administration), every 4–6 hours during EF and 2 hours after EF is complete. If more than one insulin injection is administered, then CBG should be measured prior to each insulin dose. In addition, CBG must be measured approximately every 4 hours during long rest periods between feeds as patients may require additional treatment for hyperglycaemia, especially if they are allowed oral intake.
Frequent measurement of CBG will allow addition of a small correction dose to the prescribed insulin dose next due, if there is significant hyperglycaemia. This will also enable the prescribed insulin doses to be increased or decreased as appropriate for the following day. Insulin doses must be reviewed on a daily basis against blood glucose targets.
Hypoglycaemia: avoidance and management
Hypoglycaemia (CBG less than 4 mmol/l) can occur with insulin therapy and must be treated promptly with immediate administration of 15–20mg of quick-acting CHO. In a patient who is able to swallow, 200ml of Lucozade, Enlive or Fortisip may be given as treatment. In patients unable to swallow, these treatments may be administered via the EF tube followed by a water flush. If this is not possible, then an IV infusion of glucose should be administered immediately as 100ml of 20% glucose, 200ml of 10% glucose, 400ml of 5% glucose etc.
Intramuscular glucagon (10mg, once only) may be used in hypoglycaemia, but will not work in patients who remain malnourished as it relies on releasing glycogen stores from the liver.
Once hypoglycaemia has resolved, long-acting CHO must be given – in this case, continuation of EF. If this is not possible, then an IV infusion of glucose must be commenced.
Hypoglycaemia must be pre-empted when there is a downward CBG trend, when EF has stopped unexpectedly (including tube displacement), insulin has been administered inappropriately, acute kidney injury has developed, medications causing hyperglycaemia have been withdrawn, CHO content of the feed has reduced (reduced feed volume, change in feed type); the patient has undertaken physical activity; or the patient has had a major amputation.
If the EF tube becomes dislodged but insulin has already been administered, an IV glucose infusion must be commenced as an alternate substrate. In patients with T1DM who have not received basal insulin, VRII must be commenced to provide background insulin, alongside an IV glucose infusion as substrate.
The role of the multidisciplinary team in the management of hyperglycaemia during enteral feeding
Several professionals will be involved in the management of inpatients requiring EF, each bringing a specific expertise to patient's care. The role of each professional is individually important but the overall care should be managed using an MDT approach.
Dietician
The dietician assesses the nutritional status of the patient and makes the recommendation for EF if nutritional requirements are not being met. They recommend an individualised feeding regimen, specifying the type, duration and hourly rate of the feed. The duration and hourly rate of the feed may change on a day-to-day basis initially, until the final feeding regimen is established. The dietician will also make recommendations about whether the feed is the sole means of nutrition or whether concomitant oral intake will be ongoing, and also whether the EF is short- or long-term.
Parent clinical team
The parent medical team deals with the day-to-day management of glycaemic control once EF and insulin regimen have been decided. They prescribe and titrate insulin doses, deal with hyper- and hypoglycaemia, and manage problems with feeding as they arise.
Nursing team
The nursing team is responsible for administering the insulin regimen appropriately, and monitoring the patient's BG levels, whilst also directly managing the feed. They will also alert the medical team and the diabetes specialist if problems arise with feeding or BG control. They are the first responders in the event of hypoglycaemia, and must be equipped to pre-empt, detect, manage and prevent hypoglycaemia.
Diabetes Specialist
The diabetes specialist (DS) will match the feeding regimen to an appropriate insulin regimen, and also advise on insulin doses. They will also take into consideration a number of other factors when choosing an insulin regimen: type of diabetes, diabetes knowledge of the parent team, whether the feeding regimen is changing or is established, whether day time oral feeding is being allowed, whether the patient will be discharged home with EF and if support is available on discharge, the patient's ability to administer insulin and tolerate insulin injections, risks of hypoglycaemia etc. The DS must be contacted at the earliest opportunity after a decision to commence EF has been made, so that management plans for glycaemic control are in place before EF commences. The DS will formulate these plans after careful consideration of information gathered from the other professionals involved in the patient's care.
Where possible, all efforts must be made to understand and accommodate the patient's concerns and expectations when choosing a feeding and insulin regimen.
All professionals involved in the management of EF and hyperglycaemia must be knowledgeable and confident in their own area of expertise in order to carry out the management safely and effectively. In addition, any change in the feeding or insulin regimen, or any special instructions, must be communicated to all members of the MDT in a timely fashion.
Simplifying the management of hyperglycaemia during enteral feeding
It is clear that the management of hyperglycaemia during EF is not straightforward, and that a ‘one size fits all' approach is unlikely to work. It is for this reason that the JBDS guideline on EF and diabetes allows clinicians flexibility in the use of insulin regimens. However, in order to take advantage of this flexibility in a safe and efficient manner, teams involved in managing this cohort of patients must have a good working knowledge of insulin action. Unfortunately, not all hospitals have adequately staffed inpatient diabetes teams with relevant expertise. In such centres, local guidelines on EF and hyperglycaemia must be tailored to maximise safety for most patients, sometimes at the expense of choice. These options may be tried:
Option 1
Manage all individuals with hyperglycaemia (CBG > 10 mmol/l on two occasions regardless of prior diagnosis of diabetes) as you would manage an individual with T1DM, for the duration of feeding. This would involve:
a) Administration of basal insulin
- Carry on the usual basal insulin dose if on a basal bolus regimen OR
- Give 10 units of glargine once daily or NPH insulin 5 units 12 hours apart OR
- Give 30-50% of the required total daily dose (TDD) of insulin as basal insulin, once daily.
The TDD of insulin could be estimated using the following guide (Mabrey et al, 2015):
- Lean, elderly, insulin naïve patient = 0.3 units/kg/day
- Patient of normal weight = 0.4 units/kg/day
- Overweight patient or patient with diabetes = 0.5 units/kg/day
- Obese patient or patient on steroids = 0.5 to 0.8 units/kg/day.
Reduce doses in case of reduced creatinine clearance.
b) Administration of bolus insulin to cover the feed
- Give the remaining 50–70% of the TTD into 4 to 6 hourly boluses depending on the length of the feed OR
- Give 1 unit of insulin for 10–15g of CHO This approach is recommended by the American Diabetes Association (American Diabetes Association, 2019).
This option is particularly advantageous in those individuals whose feed duration is being lengthened or shortened, as bolus doses can be added in or subtracted as the feed duration changes. Patients who are in critical care areas (who are often on 24-hour EF) with difficult to control BG levels, including those with changing inotrope requirements, will benefit from having bolus doses of insulin, as rising or falling BG levels can be managed by increasing or decreasing the dose of the next insulin bolus. However, this regimen is labour intensive, and may not be appealing to a conscious patient due to the number of injections.
Option 2
Limit the number of feed duration options that can be prescribed, to a maximum of four. This should be decided locally in each organisation, after consultation with specialist dieticians (diabetes, pancreatic, stroke) and taking into consideration the most commonly prescribed feed durations. This will enable suitable insulin regimens to be pre-selected to match the feed, therefore limiting the number of insulin regimen choices. In addition, fixing the times at which the feed should commence daily, will allow insulin to be prescribed and administered at the appropriate time.
This approach is a suggestion from the authors of this article. Table 4 is an example of how this could be implemented.
Table 4. Authors' suggestions for simplification of insulin regimens
| Feed Duration | Suitable insulin regimens | |
|---|---|---|
| Type 1 Diabetes | Type 2 Diabetes | |
| Bolus feed | Basal insulin once daily + 1 dose of rapid acting insulin at the start of the feed | 1 dose of rapid acting insulin at the start of the feed* |
| 12 hours | Basal insulin once daily + 2 to 3 doses of bolus insulin, one at the start of the feed and the others 4 to 6 hours apart | 1 dose of intermediate acting insulin at the start of the feed * |
| 16 hours | 2 doses of pre-mixed insulin – one at the start of the feed and the other at the midpoint of the feed | 2 doses of pre-mixed insulin – one at the start of the feed and the other at the mid-point of the feed |
| 24 hours | 2 doses of pre-mixed insulin – one at the start of the feed and the other at the midpoint of the feed | 2 doses of pre-mixed insulin – one at the start of the feed and the other at the mid-point of the feed |
Fix the time of feed commencement: either 8 am or 6 pm. For 12 or 16 hour feed, choose:
- 8am start in the priority is to avoid overnight insulin injections
- 6pm start if the priority is to encourage oral intake during the day
*
May need additional basal insulin
The insulin requirement for the feed may be calculated using the formula suggested in the J BDS guideline. Alternatively, a starting dose of insulin can be fixed as part of the local protocol and up titrated as necessary.
Conclusion
Dysglycaemia associated with EF is complex and challenging to manage, supported by scant research evidence, and covered by guidelines that are necessarily flexible and open to interpretation. All health care organisations that manage patients receiving EF should have clear guidelines on this subject that have been adapted for local use by an MDT led by a diabetes specialist. This area also highlights the importance of ensuring that all professionals involved in the management of these patients have necessary training and skill in order to maintain a good standard of care and outcomes for these patients and prevent harm.
Key Points
- Hyperglycaemia commonly occurs with enteral feeding and its management is complex
- Subcutaneous insulin therapy is the mainstay of treatment for enteral feeding associated hyperglycaemia
- The correct insulin type should be chosen based on it's action profile – ensuring it covers the duration of the feed and few hours after to control hyperglycaemia but avoiding hypoglycaemia
- Patients with TTDM must have an insulin regimen that provides 24 hour insulin cover regardless of feed duration
- Overall care of the patient should be managed by an MDT approach with the diabetes specialist recommended to be consulted early
CPD reflective questions
- Other than carbohydrate intake, what other factors influence inpatient insulin requirement?
- What insulin regimen(s) is suitable for a patient with type 1 diabetes receiving a 16 hour feed?
- How would you manage a patient with type 2 diabetes on a 12 hour overnight feed who is allowed to eat during the day?
- Review how this article might change your approach to managing hyperglycaemia associated with enteral feeding
- Consider how to implement local guidelines on enteral feeding and hyperglycaemia at your trust