Management of Insulin for Patients on Insulin Pump Requiring TPN

Initial Assessment and Setup

The American Diabetes Association recommends disconnecting the insulin pump when initiating TPN therapy, as pump therapy is not appropriate during periods requiring TPN 3, 4
The British Journal of Anaesthesia suggests initiating a basal-bolus subcutaneous insulin regimen based on the patient's previous total daily dose (TDD) from the pump 5, 6
The American College of Clinical Endocrinologists recommends adding regular insulin directly to the TPN solution at a starting dose of 1 unit per 10g of carbohydrate in the TPN 2, 7
The Endocrine Society advises monitoring blood glucose every 4-6 hours and adjusting insulin doses accordingly 8, 1

The American Association of Clinical Endocrinologists recommends adding regular human insulin to the TPN solution at an initial dose of 1 unit per 10g of carbohydrate 1, 2
The American Diabetes Association suggests adjusting the insulin dose daily based on blood glucose monitoring results 2
The Endocrine Society recommends increasing the amount of insulin added to the TPN solution if more than 20 units of correctional insulin have been required in the past 24 hours 7

The British Journal of Anaesthesia recommends calculating the patient's 24-hour basal insulin requirement from the pump settings 5
The American Society of Anesthesiologists suggests administering this as subcutaneous long-acting insulin (glargine or detemir) in 1-2 daily doses 3, 4
The American College of Clinical Endocrinologists recommends starting with 5 units NPH/detemir every 12 hours or 10 units glargine daily if previous basal rates are unknown 7

The American Diabetes Association recommends providing subcutaneous correctional insulin using regular insulin every 6 hours or rapid-acting insulin every 4 hours for hyperglycemia 1, 2
The Endocrine Society suggests developing a patient-specific correction scale based on insulin sensitivity 9

The American College of Clinical Endocrinologists recommends starting a 10% dextrose infusion immediately if TPN is interrupted to prevent hypoglycemia 2
The American Diabetes Association advises ensuring blood glucose targets remain between 140-180 mg/dL (7.8-10.0 mmol/L) during TPN therapy 8, 1

The American Society of Anesthesiologists recommends reconnecting the insulin pump once the patient is clinically stable, eating normally, and able to manage the pump independently 3, 4
The British Journal of Anaesthesia suggests starting the pump at least 1-2 hours before discontinuing TPN and any IV insulin 5
The American College of Clinical Endocrinologists recommends monitoring blood glucose closely during the transition period 6

The American Diabetes Association recommends immediately starting 10% dextrose infusion if TPN is interrupted to prevent hypoglycemia 2
The Endocrine Society suggests increasing insulin in TPN solution and/or correctional insulin doses for hyperglycemia 1, 2
The American Society of Anesthesiologists recommends monitoring for ketosis if blood glucose exceeds 16.5 mmol/L (300 mg/dL), especially in type 1 diabetes 4