in patients who have a variable appetite or who have difficulty with hospital diets. In these cases, it may be appropriate to administer insulin immediately after each meal. A usual approach is to administer half the dose when a patient consumes half of the meal and to withhold the dose if less than half of the meal is consumed. Although adequate inpatient-based studies on postprandial administration of rapid-acting insulin are lacking, this practice has been evaluated in other patient populations and found to provide satisfactory glycemic control.59,60
Conclusion
There is an underappreciation of the contribution of nutritional intake, or lack thereof, to glycemic management in the hospital setting. This chapter has provided an approach to the management of patients on clear liquid and regular diets, in which case the issue of matching insulin dosing to the number of carbohydrates consumed is identical. In addition, we have provided a review of the currently available literature describing approaches to use of pharmacologic glycemic-lowering therapy in patients who are in the fasting state in preparation for surgery or other medical procedures. We described the difficulty in making one recommendation for all insulin-treated patients given the number of different regimens that are prescribed in the greater medical community, with some basal-heavy regimens requiring more significant reductions and some basal-appropriate regimens requiring minimal reductions in dosing. Little data have been published to guide the management of these patients. This means that many of the recommendations reflect consensus opinion that incorporates knowledge of the pharmacokinetics of different insulin and oral preparations, published literature, and extensive personal clinical experience.
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