Should Insulin be Withheld When Nothing By Mouth is Ordered in Patients Who Require Insulin?

Should Insulin be Withheld When Nothing by Mouth is Ordered in Patients Who Require Insulin?

Purpose: The purpose of this study was to perform comparative analysis of practice guidelines and current evidence for the management of hyperglycemia in hospitalized patients.

Methods: An integrative literature review was conducted using Cochrane, CINAHL Plus, PubMed and the National Guideline Clearing House. Key words searched included hyperglycemia, inpatient diabetes, pre-operative, surgical, NPO, hospitalized, Type 1, Type 2 diabetes, Nothing by mouth, Adult, basal bolus, Hypoglycemia, management, insulin, rabbit two trial.

Results: Hyperglycemia and hypoglycemia are both serious and costly health care problems in hospitalized patients. The risk for sepsis, pneumonia, and wound infections increase with hyperglycemia; however, fear of hypoglycemia, is a leading barrier to improving glycemic management in the hospital setting (Umpierrez et al, 2007, 2012). Individuals with Type 1 diabetes lack endogenous insulin, thus requiring treatment with basal (once daily --glargine or detemir) or twice daily--Neutral Protamine Hagedorn (NPH) bolus correction (rapid acting insulin analog (aspart, lispro, glulisine,) or regular) insulin regimens to avoid severe hyperglycemia and diabetic ketoacidosis. Patients with type 2 diabetes, receiving insulin therapy before admission, are at risk for severe hyperglycemia, when insulin is discontinued. Peer-reviewed literature supported practice guidelines for all patients using insulin before hospital admission.  Guidelines recommend continuing basal scheduled subcutaneous (SC) insulin with modifications, to maintain target glucose levels.  Additionally, evidence supported current recommendations for patients with Type 1 diabetes undergoing surgical intervention to receive either continuous insulin infusion (CII) or subcutaneous basal insulin with correction insulin as required to prevent hyperglycemia during the perioperative period (Umpierrez, et al, 2012).

Conclusion: A basal insulin plus bolus correction regimen is the preferred treatment for non-critically ill patients, not eating or drinking. Blood glucose should be monitored every 4-6 hours while nothing by mouth, and corrected with short-acting insulin as needed (American Diabetes Association, 2016).