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Management of Hyperglycemia During Enteral and Parenteral Nutrition Therapy

  • Hospital Management of Diabetes (G Umpierrez, Section Editor)
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Abstract

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.

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References

Papers of particular interest, published recently, have been highlighted as: • Of importance •• Of major importance

  1. •• Umpierrez GE, Hellman R, Korytkowski MT, et al. Management of hyperglycemia in hospitalized patients in non-critical care setting: an endocrine society clinical practice guideline. J Clin Endocrinol Metab. 2012;97:16–38. These guidelnies represent the most up to date recommendations on management of hyperglycemia in hospitalized non-critically ill patients.

    Article  PubMed  CAS  Google Scholar 

  2. Cook CB, Kongable GL, Potter DJ, et al. Inpatient glucose control: a glycemic survey of 126 U.S. hospitals. J Hospital Med. 2009;4:E7–E14.

    Article  Google Scholar 

  3. Umpierrez GE, Isaacs SD, Bazargan N, et al. Hyperglycemia: an independent marker of in-hospital mortality in patients with undiagnosed diabetes. J Clin Endocrinol Metab. 2002;87:978–82.

    Article  PubMed  CAS  Google Scholar 

  4. Jiang HJ, Stryer D, Friedman B, Andrews R. Multiple hospitalizations for patients with diabetes. Diabetes Care. 2003;26:1421–6.

    Article  PubMed  Google Scholar 

  5. Pleva M, Mirtallo JM, Steinberg SM. Hyperglycemic events in non-intensive care unit patients receiving parenteral nutrition. Nutr Clin Pract. 2009;24:626–34.

    Article  PubMed  Google Scholar 

  6. Rosmarin DK, Wardlaw GM, Mirtallo J. Hyperglycemia associated with high, continuous infusion rates of total parenteral nutrition dextrose. Nutr Clin Pract. 1996;11:151–6.

    Article  PubMed  CAS  Google Scholar 

  7. Arinzon Z, Shabat S, Shuval I, et al. Prevalence of diabetes mellitus in elderly patients received enteral nutrition long-term care service. Arch Gerontol Geriatr. 2008;47:383–93.

    Article  PubMed  Google Scholar 

  8. Pancorbo-Hidalgo PL, Garcia-Fernandez FP, Ramirez-Perez C. Complications associated with enteral nutrition by nasogastric tube in an internal medicine unit. J Clin Nurs. 2001;10:482–90.

    Article  PubMed  CAS  Google Scholar 

  9. Baum D, Porte Jr D. Stress hyperglycemia and the adrenergic regulation of pancreatic hormones in hypoxia. Metabolism. 1980;29:1176–85.

    Article  PubMed  CAS  Google Scholar 

  10. Ortiz-Alonso FJ, Herman WH, Zobel DL, et al. Effect of epinephrine on pancreatic beta-cell and alpha-cell function in patients with NIDDM. Diabetes. 1991;40:1194–202.

    Article  PubMed  CAS  Google Scholar 

  11. Dungan KM, Braithwaite SS, Preiser JC. Stress hyperglycaemia. Lancet. 2009;373:1798–807.

    Article  PubMed  CAS  Google Scholar 

  12. Gosmanov AR, Umpierrez GE. Medical nutrition therapy in hospitalized patients with diabetes. Curr Diab Rep. 2012;12:93–100.

    Article  PubMed  CAS  Google Scholar 

  13. McCowen KC, Bistrian BR. Hyperglycemia and nutrition support: theory and practice. Nutr Clin Pract. 2004;19:235–44.

    Article  PubMed  Google Scholar 

  14. McCowen KC, Malhotra A, Bistrian BR. Stress-induced hyperglycemia. Crit Care Clin. 2001;17:107–24.

    Article  PubMed  CAS  Google Scholar 

  15. Alibegovic AC, Hojbjerre L, Sonne MP, et al. Impact of 9 days of bed rest on hepatic and peripheral insulin action, insulin secretion, and whole-body lipolysis in healthy young male offspring of patients with type 2 diabetes. Diabetes. 2009;58:2749–56.

    Article  PubMed  CAS  Google Scholar 

  16. Bienso RS, Ringholm S, Kiilerich K, et al. GLUT4 and Glycogen Synthase are key players in bed rest-induced insulin resistance. Diabetes. 2012;61:1090–9.

    Article  PubMed  Google Scholar 

  17. Ljungqvist O. Jonathan E. Rhoads Lecture 2011: insulin resistance and enhanced recovery after surgery. JPEN. J Parenter Enteral Nutr. 2012;36:389–98.

    Google Scholar 

  18. Preiser JC. Glycemic control and nutrition. JPEN. Journal of Parenteral and Enteral. Nutrition. 2011;35:671–2.

    Google Scholar 

  19. Valero MA, Leon-Sanz M, Escobar I, et al. Evaluation of nonglucose carbohydrates in parenteral nutrition for diabetic patients. Eur J Clin Nutr. 2001;55:1111–6.

    Article  PubMed  CAS  Google Scholar 

  20. Furnary AP, Zerr KJ, Grunkemeier GL, Starr A. Continuous intravenous insulin infusion reduces the incidence of deep sternal wound infection in diabetic patients after cardiac surgical procedures. Ann Thorac Surg. 1999;67:352–60. discussion 360–352.

    Article  PubMed  CAS  Google Scholar 

  21. van den Berghe G, Wouters P, Weekers F, et al. Intensive insulin therapy in critically ill patients. N Engl J Med. 2001;345:1359–67.

    Article  PubMed  Google Scholar 

  22. Umpierrez GE, Smiley D, Jacobs S, et al. Randomized study of basal-bolus insulin therapy in the inpatient management of patients with type 2 diabetes undergoing general surgery (RABBIT 2 surgery). Diabetes Care. 2011;34:256–61.

    Article  PubMed  CAS  Google Scholar 

  23. Cheung NW, Napier B, Zaccaria C, Fletcher JP. Hyperglycemia is associated with adverse outcomes in patients receiving total parenteral nutrition. Diabetes Care. 2005;28:2367–71.

    Article  PubMed  Google Scholar 

  24. Clement S, Braithwaite SS, Magee MF, et al. Management of diabetes and hyperglycemia in hospitals. Diabetes Care. 2004;27:553–91.

    Article  PubMed  Google Scholar 

  25. •• Korytkowski MT, Salata RJ, Koerbel GL, et al. Insulin therapy and glycemic control in hospitalized patients with diabetes during enteral nutrition therapy: a randomized controlled clinical trial. Diabetes Care. 2009;32:594–6. The only randomized controlled trial comparing different insulin regimens in managing hyperglycemia in patients receiving enteral nutrition therapy.

    Article  PubMed  CAS  Google Scholar 

  26. • Ziegler TR. Parenteral nutrition in the critically ill patient. N Engl J Med. 2009;361:1088–97. State-of-the-art review article describing current evidence for the use of TPN in the hospitalized patients.

    Article  PubMed  CAS  Google Scholar 

  27. Pasquel FJ, Spiegelman R, McCauley M, et al. Hyperglycemia during total parenteral nutrition: an important marker of poor outcome and mortality in hospitalized patients. Diabetes Care. 2010;33:739–41.

    Article  PubMed  Google Scholar 

  28. Moghissi ES, Korytkowski MT, DiNardo M, et al. American Association of Clinical Endocrinologists and American Diabetes Association consensus statement on inpatient glycemic control. Endocr Pract. 2009;15:353–69.

    Article  PubMed  Google Scholar 

  29. Mesotten D, Van den Berghe G. Glycemic targets and approaches to management of the patient with critical illness. Curr Diab Rep. 2012;12:101–7.

    Article  PubMed  Google Scholar 

  30. • Marik PE, Preiser JC. Toward understanding tight glycemic control in the ICU: a systematic review and metaanalysis. Chest. 2010;137:544–51. This meta-analysis suggests that glycemic targets for the patients in ICU receiving parenteral nutrition can be lower than in other crictically ill patients.

    Article  PubMed  CAS  Google Scholar 

  31. Sarkisian S, Fenton TR, Shaheen AA. Raman M [Parenteral nutrition-associated hyperglycemia in noncritically ill inpatients is associated with higher mortality. Canadian journal of gastroenterology]. Journal Canadien de Gastroenterologie. 2010;24:453–7.

    PubMed  Google Scholar 

  32. Lin LY, Lin HC, Lee PC, et al. Hyperglycemia correlates with outcomes in patients receiving total parenteral nutrition. Am J Med Sci. 2007;333:261–5.

    Article  PubMed  Google Scholar 

  33. Van den Berghe G, Wilmer A, Milants I, et al. Intensive insulin therapy in mixed medical/surgical intensive care units: benefit vs harm. Diabetes. 2006;55:3151–9.

    Article  PubMed  Google Scholar 

  34. Cresci G. Targeting the use of specialized nutritional formulas in surgery and critical care. JPEN; J Parenter Enteral Nutr. 2005;29:S92–5.

    Article  PubMed  Google Scholar 

  35. McMahon MM, Rizza RA. Nutrition support in hospitalized patients with diabetes mellitus. Mayo Clin Proc. 1996;71:587–94.

    Article  PubMed  CAS  Google Scholar 

  36. Bantle JP, Wylie-Rosett J, Albright AL, et al. Nutrition recommendations and interventions for diabetes: a position statement of the American Diabetes Association. Diabetes Care. 2008;31 Suppl 1:S61–78.

    PubMed  CAS  Google Scholar 

  37. McClave SA, Martindale RG, Vanek VW, et al. Guidelines for the Provision and Assessment of Nutrition Support Therapy in the Adult Critically Ill Patient: Society of Critical Care Medicine (SCCM) and American Society for Parenteral and Enteral Nutrition (A.S.P.E.N.). JPEN; J Parenter Enteral Nutr. 2009;33:277–316.

    Article  PubMed  Google Scholar 

  38. Anderson AD, Palmer D, MacFie J. Peripheral parenteral nutrition. Br J Surg. 2003;90:1048–54.

    Article  PubMed  CAS  Google Scholar 

  39. Heyland DK, Montalvo M, MacDonald S, et al. Total parenteral nutrition in the surgical patient: a meta-analysis. Can J Surg. 2001;44:102–11.

    PubMed  CAS  Google Scholar 

  40. Bellantone R, Doglietto GB, Bossola M, et al. Preoperative parenteral nutrition in the high risk surgical patient. JPEN; J Parenter Enteral Nutr. 1988;12:195–7.

    Article  PubMed  CAS  Google Scholar 

  41. Kreymann KG, Berger MM, Deutz NE, et al. ESPEN Guidelines on enteral nutrition: intensive care. Clin Nutr. 2006;25:210–23.

    Article  PubMed  CAS  Google Scholar 

  42. Florian JP, Pawelczyk JA. Non-esterified fatty acids increase arterial pressure via central sympathetic activation in humans. Clin Sci. 2010;118:61–9.

    Article  CAS  Google Scholar 

  43. Craig LD, Nicholson S, Silverstone FA, Kennedy RD. Use of a reduced-carbohydrate, modified-fat enteral formula for improving metabolic control and clinical outcomes in long-term care residents with type 2 diabetes: results of a pilot trial. Nutrition. 1998;14:529–34.

    Article  PubMed  CAS  Google Scholar 

  44. Leon-Sanz M, Garcia-Luna PP, Sanz-Paris A, et al. Glycemic and lipid control in hospitalized type 2 diabetic patients: evaluation of 2 enteral nutrition formulas (low carbohydrate-high monounsaturated fat vs high carbohydrate). JPEN; J Parenter Enteral Nutr. 2005;29:21–9.

    Article  PubMed  Google Scholar 

  45. Elia M, Ceriello A, Laube H, et al. Enteral nutritional support and use of diabetes-specific formulas for patients with diabetes: a systematic review and meta-analysis. Diabetes Care. 2005;28:2267–79.

    Article  PubMed  Google Scholar 

  46. Alish CJ, Garvey WT, Maki KC, et al. A diabetes-specific enteral formula improves glycemic variability in patients with type 2 diabetes. Diabetes Technol Ther. 2010;12:419–25.

    Article  PubMed  CAS  Google Scholar 

  47. Vaisman N, Lansink M, Rouws CH, et al. Tube feeding with a diabetes-specific feed for 12 weeks improves glycaemic control in type 2 diabetes patients. Clin Nutr. 2009;28:549–55.

    Article  PubMed  Google Scholar 

  48. Pohl M, Mayr P, Mertl-Roetzer M, et al. Glycemic control in patients with type 2 diabetes mellitus with a disease-specific enteral formula: stage II of a randomized, controlled multicenter trial. JPEN; J Parenter Enteral Nutr. 2009;33:37–49.

    Article  PubMed  CAS  Google Scholar 

  49. Pohl M, Mayr P, Mertl-Roetzer M, et al. Glycaemic control in type II diabetic tube-fed patients with a new enteral formula low in carbohydrates and high in monounsaturated fatty acids: a randomised controlled trial. Eur J Clin Nutr. 2005;59:1221–32.

    Article  PubMed  CAS  Google Scholar 

  50. Yokoyama J, Someya Y, Yoshihara R, Ishii H. Effects of high-monounsaturated fatty acid enteral formula vs high-carbohydrate enteral formula on plasma glucose concentration and insulin secretion in healthy individuals and diabetic patients. J Int Med Res. 2008;36:137–46.

    PubMed  CAS  Google Scholar 

  51. Charney P, Hertzler SR. Management of blood glucose and diabetes in the critically ill patient receiving enteral feeding. Nutr Clin Pract. 2004;19:129–36.

    Article  PubMed  Google Scholar 

  52. Umpierrez GE. Basal vs sliding-scale regular insulin in hospitalized patients with hyperglycemia during enteral nutrition therapy. Diabetes Care. 2009;32:751–3.

    Article  PubMed  Google Scholar 

  53. Fatati G, Mirri E, Del Tosto S, et al. Use of insulin glargine in patients with hyperglycaemia receiving artificial nutrition. Acta Diabetol. 2005;42:182–6.

    Article  PubMed  CAS  Google Scholar 

  54. Cook A, Burkitt D, McDonald L, Sublett L. Evaluation of glycemic control using NPH insulin sliding scale vs insulin aspart sliding scale in continuously tube-fed patients. Nutrition in Clinical Practice: official publication of the American Society for Parenteral and Enteral Nutrition. 2009;24:718–22.

    Article  Google Scholar 

  55. Hsia E, Seggelke SA, Gibbs J, et al. Comparison of 70/30 biphasic insulin with glargine/lispro regimen in non-critically ill diabetic patients on continuous enteral nutrition therapy. Nutrition in Clinical Practice: official publication of the American Society for Parenteral and Enteral Nutrition. 2011;26:714–7.

    Article  Google Scholar 

  56. Umpierrez GE, Jones S, Smiley D, et al. Insulin analogs vs human insulin in the treatment of patients with diabetic ketoacidosis: a randomized controlled trial. Diabetes Care. 2009;32:1164–9.

    Article  PubMed  CAS  Google Scholar 

  57. Detsky AS, Baker JP, O’Rourke K, Goel V. Perioperative parenteral nutrition: a meta-analysis. Ann Intern Med. 1987;107:195–203.

    PubMed  CAS  Google Scholar 

  58. Muller JM, Brenner U, Dienst C, Pichlmaier H. Preoperative parenteral feeding in patients with gastrointestinal carcinoma. Lancet. 1982;1:68–71.

    Article  PubMed  CAS  Google Scholar 

  59. Quigley EM, Marsh MN, Shaffer JL, Markin RS. Hepatobiliary complications of total parenteral nutrition. Gastroenterology. 1993;104:286–301.

    PubMed  CAS  Google Scholar 

  60. Schutz Y, Thiebaud D, Acheson KJ, et al. Thermogenesis induced by five different intravenous glucose/insulin infusions in healthy young men. Clin Nutr. 1983;2:93–6.

    Article  PubMed  CAS  Google Scholar 

  61. Askanazi J, Weissman C, Rosenbaum SH, et al. Nutrition and the respiratory system. Crit Care Med. 1982;10:163–72.

    Article  PubMed  CAS  Google Scholar 

  62. Singer P, Berger MM, Van den Berghe G, et al. ESPEN Guidelines on Parenteral Nutrition: intensive care. Clin Nutr. 2009;28:387–400.

    Article  PubMed  Google Scholar 

  63. Via MA, Mechanick JI. Inpatient enteral and parental nutrition for patients with diabetes. Curr Diab Rep. 2011;11:99–105.

    Article  PubMed  CAS  Google Scholar 

  64. Ahrens CL, Barletta JF, Kanji S, et al. Effect of low-calorie parenteral nutrition on the incidence and severity of hyperglycemia in surgical patients: a randomized, controlled trial. Crit Care Med. 2005;33:2507–12.

    Article  PubMed  CAS  Google Scholar 

  65. Lee H, Koh SO, Park MS. Higher dextrose delivery via TPN related to the development of hyperglycemia in nondiabetic critically ill patients. Nutr Res Pract. 2011;5:450–4.

    Article  PubMed  CAS  Google Scholar 

  66. •• Casaer MP, Mesotten D, Hermans G, et al. Early vs late parenteral nutrition in critically ill adults. N Engl J Med. 2011;365:506–17. The results of this prospective randomized trial demonstrate new standards of nutrition initiation in hospitalized patients requiring parenteral nutrition.

    Article  PubMed  CAS  Google Scholar 

  67. Lidder P, Flanagan D, Fleming S, et al. Combining enteral with parenteral nutrition to improve postoperative glucose control. Br J Nutr. 2010;103:1635–41.

    Article  PubMed  CAS  Google Scholar 

  68. Yaqoob P. Lipids and the immune response. Curr Opin Clin Nutr Metab Care. 1998;1:153–61.

    Article  PubMed  CAS  Google Scholar 

  69. Yaqoob P. Monounsaturated fatty acids in parenteral nutrition; evaluation of risks and benefits. Br J Nutr. 2005;94:867–8.

    Article  PubMed  CAS  Google Scholar 

  70. Buenestado A, Cortijo J, Sanz MJ, et al. Olive oil-based lipid emulsion’s neutral effects on neutrophil functions and leukocyte-endothelial cell interactions. JPEN; J Parenter Enteral Nutr. 2006;30:286–96.

    Article  PubMed  CAS  Google Scholar 

  71. Garcia-de-Lorenzo A, Denia R, Atlan P, et al. Parenteral nutrition providing a restricted amount of linoleic acid in severely burned patients: a randomized double-blind study of an olive oil-based lipid emulsion vs medium/long-chain triacylglycerols. Br J Nutr. 2005;94:221–30.

    Article  PubMed  CAS  Google Scholar 

  72. Yaqoob P. Monounsaturated fats and immune function. Proc Nutr Soc. 1998;57:511–20.

    Article  PubMed  CAS  Google Scholar 

  73. Siqueira J, Smiley D, Newton C, et al. Substitution of standard soybean oil with olive oil-based lipid emulsion in parenteral nutrition: comparison of vascular, metabolic, and inflammatory effects. J Clin Endocrinol Metab. 2011;96:3207–16.

    Article  PubMed  CAS  Google Scholar 

  74. •• Umpierrez GE, Spiegelman R, Zhao V, et al. A double-blind, randomized clinical trial comparing soybean oil-based vs olive oil-based lipid emulsions in adult medical-surgical intensive care unit patients requiring parenteral nutrition. Crit Care Med. 2012;40:1792–8. This is the only trial that compared clinical outcomes betwenn ICU patients receiving soybean oil-based and olive oil-based parenteral nutrition.

    Article  PubMed  CAS  Google Scholar 

  75. Opara EC, Petro A, Tevrizian A, et al. L-glutamine supplementation of a high fat diet reduces body weight and attenuates hyperglycemia and hyperinsulinemia in C57BL/6J mice. J Nutr. 1996;126:273–9.

    PubMed  CAS  Google Scholar 

  76. Grau T, Bonet A, Minambres E, et al. The effect of L-alanyl-L-glutamine dipeptide supplemented total parenteral nutrition on infectious morbidity and insulin sensitivity in critically ill patients. Crit Care Med. 2011;39:1263–8.

    Article  PubMed  CAS  Google Scholar 

  77. McMahon MM. Management of parenteral nutrition in acutely ill patients with hyperglycemia. Nutr Clin Pract. 2004;19:120–8.

    Article  PubMed  Google Scholar 

  78. Sajbel TA, Dutro MP, Radway PR. Use of separate insulin infusions with total parenteral nutrition. JPEN; J Parenter Enteral Nutr. 1987;11:97–9.

    Article  PubMed  CAS  Google Scholar 

  79. Hongsermeier T, Bistrian BR. Evaluation of a practical technique for determining insulin requirements in diabetic patients receiving total parenteral nutrition. JPEN; J Parenter Enteral Nutr. 1993;17:16–9.

    Article  PubMed  CAS  Google Scholar 

  80. Jakoby MG, Nannapaneni N. An insulin protocol for management of hyperglycemia in patients receiving parenteral nutrition is superior to ad hoc management. JPEN; J Parenter Enteral Nutr. 2012;36:183–8.

    Article  PubMed  CAS  Google Scholar 

  81. Bankhead R, Boullata J, Brantley S, et al. Enteral nutrition practice recommendations. JPEN; J Parenter Enteral Nutr. 2009;33:122–67.

    Article  PubMed  Google Scholar 

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Gosmanov, A.R., Umpierrez, G.E. Management of Hyperglycemia During Enteral and Parenteral Nutrition Therapy. Curr Diab Rep 13, 155–162 (2013). https://doi.org/10.1007/s11892-012-0335-y

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