Inpatient enteral and parenteral [corrected] nutrition for patients with diabetes

Glycemic Management of Hospitalized Patients Receiving Nutrition Support

Enteral nutrition (EN) and parenteral nutrition (PN) increase the risk of hyperglycemia and adverse outcomes, including mortality, in patients with and without diabetes. A blood glucose target range of 140-180 mg/dL is recommended for hospitalized patients receiving artificial nutrition. Using a diabetes-specific EN formula, lowering the dextrose content, and using a hypocaloric PN formula have all been shown to prevent hyperglycemia and associated adverse outcomes. Insulin, given either subcutaneously or as a continuous infusion, is the mainstay of treatment for hyperglycemia. However, no subcutaneous insulin regimen has been shown to be superior to others. This review summarizes the evidence on and provides recommendations for the treatment of EN- and PN-associated hyperglycemia and offers strategies for hypoglycemia prevention. The authors also highlight their institution's protocol for the safe use of insulin in the PN bag. Randomized controlled trials evaluating safety and efficacy of targeted insulin therapy synchronized with different types of EN or PN delivery are needed.

Parenteral nutrition-associated hyperglycemia: Prevalence, predictors and management

BACKGROUND & AIMS

Hyperglycemia is among the common complications of parenteral nutrition (PN) and is often associated with increased mortality despite being treatable. Studies of parenteral nutrition causing hyperglycemia are limited and even available studies lack methodological conduct. This study aimed to evaluate the prevalence, predictors and management of PN-associated hyperglycemia (PN-AH).

METHODS

A retrospective study was conducted at a tertiary hospital. Patients ≥ 18 years old who received parenteral nutrition from 2015 to 2018 were conveniently selected. The demographic data, diagnosis, clinically relevant data, blood glucose readings and management of hyperglycemia were gathered from electronic medical records.

RESULTS

Among 300 patients included in the study, 140 (46.7%) reported the PN-AH events. Multivariate logistic regression analysis showed female sex, Malay ethnicity, underlying type 2 diabetes mellitus, liver impairment, elevated pre-PN glucose level > 180 mg/dL and ICU admission were independently associated with hyperglycemia (p < 0.05 for all variables). Furthermore, factors such as ICU admission, underlying diabetes mellitus and hyperglycemia before starting PN, cause earlier development of PN-AH. More frequent monitoring of PN was observed in the ICU, guided by a protocol, as compared to the non-ICU setting.

CONCLUSION

The prevalence of PN-AH is a significant complication to require medical attention. The predictors such as female gender, Malay ethnicity, underlying Diabetes Mellitus, liver impairment, hyperglycemia before starting PN, and ICU admission should be applied in clinical settings to improve the detection of PN-AH. A guideline outlining the risk factors, monitoring strategies and treatment plans should be developed to improve the detection and management of PN-AH.

Management of Type 1 Diabetes in the Hospital Setting

PURPOSE OF REVIEW

The purpose of this article was to review recent guideline recommendations on glycemic target, glucose monitoring, and therapeutic strategies, while providing practical recommendations for the management of medical and surgical patients with type 1 diabetes (T1D) admitted to critical and non-critical care settings.

RECENT FINDINGS

Studies evaluating safety and efficacy of insulin pump therapy, continuous glucose monitoring, electronic glucose management systems, and closed loop systems for the inpatient management of hyperglycemia are described. Due to the increased prevalence and life expectancy of patients with type 1 diabetes, a growing number of these patients require hospitalization every year. Inpatient diabetes management is complex and is best provided by a multidisciplinary diabetes team. In the absence of such resource, providers and health care staff must become familiar with the features of this condition to avoid complications such as severe hyperglycemia, ketoacidosis, hypoglycemia, or glycemic variability. We reviewed most recent guidelines and relevant literature in the topic to provide practical recommendations for the inpatient management of patients with T1D.

Verification of glycemic profiles using continuous glucose monitoring: cases with steroid use, liver cirrhosis, enteral nutrition, or late dumping syndrome

Glycemic control is often difficult to achieve in patients with diabetes, especially in the presence of comorbid diseases or conditions such as steroid-use or liver cirrhosis, or in patients receiving enteral nutrition. Moreover, reactive hypoglycemia due to late dumping syndrome in people having undergone gastrectomy is also a matter of concern. Empirically and theoretically, the typical glycemic profiles associated with these conditions have been determined; however, what actually happens during a 24-h span is still somewhat obscure. In order to verify and provide information about the 24-h glycemic profiles associated with these conditions, 8 patients with the 4 above-mentioned conditions were monitored using a continuous glucose monitoring system (CGMS). For all 8 patients, CGMS provided detailed information regarding the 24-h glycemic profiles. The CGM results showed typical glycemic patterns for each condition, and we were moreover able to observe the effects of various practical treatments. Based on these cases, we conclude that the CGMS is highly useful for determining the glycemic patterns of patients with the aforementioned conditions in a practical setting; and this system may be used to monitor the treatment success of such cases.

Continuous versus bolus tube feeds: Does the modality affect glycemic variability, tube feeding volume, caloric intake, or insulin utilization?

Introduction:

Enteral nutrition (EN) is very important to optimizing outcomes in critical illness. Debate exists regarding the best strategy for enteral tube feeding (TF), with concerns that bolus TF (BTF) may increase glycemic variability (GV) but result in fewer nutritional interruptions than continuous TF (CTF). This study examines if there is a difference in GV, insulin usage, TF volume, and caloric delivery among intensive care patients receiving BTF versus CTF. We hypothesize that there are no significant differences between CTF and BTF when comparing the above parameters.

Materials and Methods:

Prospective, randomized pilot study of critically ill adult patients undergoing percutaneous endoscopic gastrostomy (PEG) placement for EN was performed between March 1, 2012 and May 15, 2014. Patients were randomized to BTF or CTF. Glucose values, insulin use, TF volume, and calories administered were recorded. Data were organized into 12-h epochs for statistical analyses and GV determination. In addition, time to ≥80% nutritional delivery goal, demographics, Acute Physiology and Chronic Health Evaluation II scores, and TF interruptions were examined. When performing BTF versus CTF assessments, continuous parameters were compared using Mann–Whitney U-test or repeated measures t-test, as appropriate. Categorical data were analyzed using Fisher's exact test.

Results:

No significant demographic or physiologic differences between the CTF (n = 24) and BTF (n = 26) groups were seen. The immediate post-PEG 12-h epoch showed significantly lower GV and median TF volume for patients in the CTF group. All subsequent epochs (up to 18 days post-PEG) showed no differences in GV, insulin use, TF volume, or caloric intake. Insulin use for both groups increased when comparing the first 24 h post-PEG values to measurements from day 8. There were no differences in TF interruptions, time to ≥80% nutritional delivery goal, or hypoglycemic episodes.

Conclusions:

This study demonstrated no clinically relevant differences in GV, insulin use, TF volume or caloric intake between BTF and CTF groups. Despite some shortcomings, our data suggest that providers should not feel limited to BTF or CTF because of concerns for GV, time to goal nutrition, insulin use, or caloric intake, and should consider other factors such as resource utilization, ease of administration, and/or institutional/patient characteristics.

Nutrition management of diabetes in acute care

Nutrition therapy in hospital includes the integration of diabetes into the care plan for the presenting condition, basic self-management education and care coordination to promote optimal glycemic control in hospital and an appropriate plan for discharge. Estimated nutrient requirements for people with diabetes are the same as those for the general population, and diets should be designed based on individual metabolic needs. Distribution of meals and snacks should employ a consistent carbohydrate meal-planning approach for both patient safety and management of glycemia. Referral to a registered dietitian for a full assessment is warranted for those at higher risk for hyperglycemia, including those on insulin or nutrition support. Consideration may be given to the use of lower carbohydrate oral nutrition supplements. A team approach should be employed to ensure there is coordination among blood glucose testing, insulin administration and meal timing. Self-management education should focus on patient safety, and an appropriate plan for discharge should be created to manage the ongoing needs of patients with this chronic disease.

Evaluation of the role of enteral nutrition in managing patients with diabetes: a systematic review

The aim of this systematic review is to evaluate the role of enteral nutrition in managing patients with diabetes on enteral feed. The prevalence of diabetes is on the increase in the UK and globally partly due to lack of physical activities, poor dietary regimes and genetic susceptibility. The development of diabetes often leads to complications such as stroke, which may require enteral nutritional support. The provision of enteral feeds comes with its complications including hyperglycaemia which if not managed can have profound consequences for the patients in terms of clinical outcomes. Therefore, it is essential to develop strategies for managing patients with diabetes on enteral feed with respect to the type and composition of the feed. This is a systematic review of published peer reviewed articles. EBSCOhost Research, PubMed and SwetsWise databases were searched. Reference lists of identified articles were reviewed. Randomised controlled trials comparing enteral nutrition diabetes specific formulas with standard formulas were included. The studies which compared diabetes specific formulas (DSF) with standard formulas showed that DSF was more effective in controlling glucose profiles including postprandial glucose, HbA1c and insulinemic response. The use of DSF appears to be effective in managing patients with diabetes on enteral feed compared with standard feed.

Management of the hospitalized patient with type 1 diabetes mellitus

Patients with type 1 diabetes mellitus (T1DM) have minimal to absent pancreatic β-cell function and rely on the exogenous delivery of insulin to obtain adequate and life-sustaining glucose homeostasis. Maintaining glycemic control is challenging in hospitalized patients with T1DM, as insulin requirements are influenced by the presence of acute medical or surgical conditions, as well as altered nutritional intake. The risks of hyperglycemia, ketoacidosis, hypoglycemia, and glycemic variability are increased in hospitalized patients with T1DM. Diabetic ketoacidosis and severe hypoglycemia are the 2 most common emergency conditions that account for the majority of hospital admissions in patients with T1DM. The association between hyperglycemia and increased risk of complications and mortality in patients with type 2 diabetes (T2DM) is well established; however, the impact of glycemic control on clinical outcomes has not been determined in patients with T1DM who present without ketoacidosis. To decrease complications associated with insulin therapy, health care professionals must be well versed in the use of insulin because it is a common source of medication error. For non-critically ill, hospitalized patients, subcutaneous insulin given to cover basal and prandial needs instead of sliding scale is the preferred method of insulin dosing. Protocols are available for initiating and titrating insulin doses, as well as for transitioning from an insulin infusion to a subcutaneous regimen. In our review, we identify and discuss special considerations related to inpatient glycemic control of non-ketotic patients with T1DM. Additionally, point differences and similarities associated with the management of patients with T2DM are discussed.

The future of inpatient diabetes management: glucose as the sixth vital sign

Diabetes is an ever increasing health problem in our society. Due to associated small and large vessel conditions, patients with diabetes are two- to four-fold more likely to require hospitalization than nondiabetic individuals. Furthermore, hyperglycemia in hospitalized patients results in increased susceptibility to wound infections, worse outcomes postcardiac and cerebrovascular events, longer hospital length of stay and increased inpatient mortality. Several studies suggest that tight control of glucose levels yields improvement in these factors. Conversely, other studies have suggested increased mortality after tight glucose management, perhaps as a result of an increased incidence of hypoglycemic events. The most reasonable approach to control of hyperglycemia is to normalize glucose levels as much as possible without triggering hypoglycemia. In the hospital, insulin therapy of hyperglycemia is preferred due to the ability to flexibly manage glucose levels without side effects associated with many alternative antidiabetic agents. Due to the increasing burden of inpatient diabetes, and the detrimental effects of both hyper and hypoglycemia, the authors predict that blood-glucose levels will become the sixth vital sign to be frequently monitored in hospitalized patients and controlled in a narrow range. The future is in the use of insulin pumps controlled by continuous glucose monitors. This technology is complex and has not yet become standard. The development of future inpatient diabetes care will depend on adaptation of hospital systems to advance the new technology.

Management of hyperglycemia during enteral and parenteral nutrition therapy

Hyperglycemia is a frequent complication of enteral and parenteral nutrition in hospitalized patients. Extensive evidence from observational studies indicates that the development of hyperglycemia during parenteral and enteral nutrition is associated with an increased risk of death and infectious complications. There are no specific guidelines recommending glycemic targets and effective strategies for the management of hyperglycemia during specialized nutritional support. Managing hyperglycemia in these patients should include optimization of carbohydrate content and administration of intravenous or subcutaneous insulin therapy. The administration of continuous insulin infusion and insulin addition to nutrition bag are efficient approaches to control hyperglycemia during parenteral nutrition. Subcutaneous administration of long-acting insulin with scheduled or corrective doses of short-acting insulin is superior to the sliding scale insulin strategy in patients receiving enteral feedings. Randomized controlled studies are needed to evaluate safe and effective therapeutic strategies for the management of hyperglycemia in patients receiving nutritional support.

Insulin therapy for the management of hyperglycemia in hospitalized patients

It has long been established that hyperglycemia with or without a prior diagnosis of diabetes increases both mortality and disease-specific morbidity in hospitalized patients and that goal-directed insulin therapy can improve outcomes. This article reviews the pathophysiology of hyperglycemia during illness, the mechanisms for increased complications and mortality due to hyperglycemia and hypoglycemia, and beneficial mechanistic effects of insulin therapy and provides updated recommendations for the inpatient management of diabetes in the critical care setting and in the general medicine and surgical settings.

Medical nutrition therapy in hospitalized patients with diabetes

Medical nutrition therapy (MNT) plays an important role in management of hyperglycemia in hospitalized patients with diabetes mellitus. The goals of inpatient MNT are to optimize glycemic control, to provide adequate calories to meet metabolic demands, and to create a discharge plan for follow-up care. All patients with and without diabetes should undergo nutrition assessment on admission with subsequent implementation of physiologically sound caloric support. The use of a consistent carbohydrate diabetes meal-planning system has been shown to be effective in facilitating glycemic control in hospitalized patients with diabetes. This system is based on the total amount of carbohydrate offered rather than on specific calorie content at each meal, which facilitates matching the prandial insulin dose to the amount of carbohydrate consumed. In this article, we discuss general guidelines for the implementation of appropriate MNT in hospitalized patients with diabetes.

Hyperglycemia is associated with increased hospital complications and mortality during parenteral nutrition

OBJECTIVE

Hyperglycemia is a recognized complication of parenteral nutrition (PN). We aimed to determine the impact of hyperglycemia during PN unaccompanied by tight blood glucose (BG) control on hospital complications and mortality.

METHODS

We reviewed the medical records of 276 medical and surgical patients receiving PN to determine the impact of hyperglycemia on survival after adjusting for known prognostic factors, and to determine whether BG levels before initiation of PN, within 24 hours of PN initiation, or during PN therapy are predictive of adverse outcomes.

RESULTS

A total of 276 medical (35%) and surgical (65%) patients receiving PN initiated 12 ± 12 days after admission for a mean of 15 ± 24 days. Deceased patients (27.2%) were older, had higher Acute Physiology and Chronic Health Evaluation II scores, and had higher BG levels during PN therapy versus survivors (all, P < 0.01). Deceased patients had higher BG levels within 24 hours of PN initiation (162 ± 55 mg/dL vs 139 ± 37 mg/dL; P = 0.003) and higher BG levels during days 2 to 10 of PN (161 ± 53 mg/dL vs 142 ± 34 mg/dL; P = 0.013) compared with survivors. Blood glucose levels were associated with increased odds ratio (OR) for mortality pre-PN (P = 0.008), within 24 hours of PN initiation (P < 0.001), and during days 2 to 10 of PN (P < 0.001). In multiple regression models adjusted for age, sex, and history of diabetes, mortality was independently associated with pre-PN BG levels 121 to 150 mg/dL (OR, 2.2; 95% confidence interval [CI], 1.1-4.4), 151 to 180 mg/dL (OR, 3.41; 95% CI, 1.3-8.7,), and > 180 mg/dL (OR, 2.2; 95% CI, 0.9-5.2), and with BG levels within 24 hours of PN initiation > 180 mg/dL (OR, 2.8; 95% CI, 1.2-6.8). A BG level > 180 mg/dL within 24 hours of PN initiation was associated with increased risk of pneumonia (OR, 3.1; 95% CI, 1.4-7.1) and acute renal failure (OR, 2.3; 95% CI, 1.1-5.0).

CONCLUSION

Hyperglycemia during PN without tight BG control is associated with increased risk of hospital complications and mortality. Randomized controlled trials are needed to determine benefits of intensified glycemic control on clinical outcomes in hospitalized subjects receiving PN.