Increased hypoglycemia associated with renal failure during continuous intravenous insulin infusion and specialized nutritional support

ESPEN practical guideline on clinical nutrition in hospitalized patients with acute or chronic kidney disease

BACKGROUND AND AIMS

Hospitalized patients often have acute kidney disease (AKD) or chronic kidney disease (CKD), with important metabolic and nutritional consequences. Moreover, in case kidney replacement therapy (KRT) is started, the possible impact on nutritional requirements cannot be neglected. On this regard, the present guideline aims to provide evidence-based recommendations for clinical nutrition in hospitalized patients with KD.

METHODS

The standard operating procedure for ESPEN guidelines was used. Clinical questions were defined in both the PICO format, and organized in subtopics when needed, and in non-PICO questions for the more general topics. The literature search was from January 1st, 1999 until January 1st, 2020. Each question led to one or more recommendation/statement and related commentaries. Existing evidence was graded, as well as recommendations and statements were developed and agreed upon in a multistage consensus process.

RESULTS

The present guideline provides 32 evidence-based recommendations and 8 statements, defining how to assess nutritional status, how to define patients at risk, how to choose the route of feeding, and how to integrate nutrition with KRT. In the final online voting, a strong consensus was reached in 84% at least of recommendations and 100% of statements.

CONCLUSION

The presence of KD in hospitalized patients identifies a highly heterogeneous group of subjects with widely varying nutrient needs and intakes. Considering the high nutritional risk related with this clinical condition, an individualized approach consisting of nutritional status evaluation and monitoring, frequent evaluation of nutritional requirements, and careful integration with KRT should be planned to avoid both underfeeding and overfeeding. Practical recommendations and statements were developed, aiming at defining suggestions for everyday clinical practice in the individualization of nutritional support in this patient setting. Literature areas with scarce or without evidence were also identified, thus requiring further basic or clinical research.

Molecular mechanisms of hematological and biochemical alterations in malaria: A review

Malaria is a dangerous disease that contributes to millions of hospital visits and hundreds of thousands of deaths, especially in children residing in sub-Saharan Africa. Although several interventions such as vector control, case detection, and treatment are already in place, there is no substantive reduction in the disease burden. Several studies in the past have reported the emergence of resistant strains of malaria parasites (MPs) and mosquitoes, and poor adherence and inaccessibility to effective antimalarial drugs as the major factors for this persistent menace of malaria infections. Moreover, victory against MP infections for many years has been hampered by an incomplete understanding of the complex nature of malaria pathogenesis. Very recent studies have identified different complex interactions and hematological alterations induced by malaria parasites. However, no studies have hybridized these alterations for a better understanding of Malaria pathogenesis. Hence, this review thoroughly discusses the molecular mechanisms of all reported hematological and biochemical alterations induced by MPs infections. Specifically, the mechanisms in which MP-infection induces anemia, thrombocytopenia, leukopenia, dyslipidemia, hypoglycemia, oxidative stress, and liver and kidney malfunctions were presented. The study also discussed how MPs evade the host's immune response and suggested strategies to limit evasion of the host's immune response to combat malaria and its complications.

Diabetic Ketoacidosis in Patients with End-stage Kidney Disease: A Review

Diabetes mellitus is a highly prevalent disease. Chronic kidney disease is one of its chronic complications, and diabetic ketoacidosis is one of the most dreaded acute complications. The increasing prevalence of diabetes mellitus and renal failure has resulted in physicians increasingly encountering diabetic ketoacidosis in this complicated subgroup of patients. This review discusses the pathophysiologic understanding of diabetic ketoacidosis in patients with renal failure, its varying clinical presentation, and management and prevention. We have also highlighted the role of patient weight and proximity to dialysis as tools to assess and manage fluid status in this challenging group of patients.

ESPEN guideline on clinical nutrition in hospitalized patients with acute or chronic kidney disease

Acute kidney disease (AKD) - which includes acute kidney injury (AKI) - and chronic kidney disease (CKD) are highly prevalent among hospitalized patients, including those in nephrology and medicine wards, surgical wards, and intensive care units (ICU), and they have important metabolic and nutritional consequences. Moreover, in case kidney replacement therapy (KRT) is started, whatever is the modality used, the possible impact on nutritional profiles, substrate balance, and nutritional treatment processes cannot be neglected. The present guideline is aimed at providing evidence-based recommendations for clinical nutrition in hospitalized patients with AKD and CKD. Due to the significant heterogeneity of this patient population as well as the paucity of high-quality evidence data, the present guideline is to be intended as a basic framework of both evidence and - in most cases - expert opinions, aggregated in a structured consensus process, in order to update the two previous ESPEN Guidelines on Enteral (2006) and Parenteral (2009) Nutrition in Adult Renal Failure. Nutritional care for patients with stable CKD (i.e., controlled protein content diets/low protein diets with or without amino acid/ketoanalogue integration in outpatients up to CKD stages four and five), nutrition in kidney transplantation, and pediatric kidney disease will not be addressed in the present guideline.

Exploring pancreatic pathology in Plasmodium falciparum malaria patients

Hypoglycaemia is an important complication of Plasmodium falciparum malaria infection, which can be lethal if not treated. A decrease in blood sugar (BS) level has been correlated with disease severity, parasitaemia and the use of certain antimalarial drugs. This study explored the relationship between pancreatic pathology, including the expressions of insulin and glucagon in the islets of Langerhans, and the BS levels in P. falciparum malaria patients. Pancreatic tissues from malaria patients were divided into three groups, namely those with BS < 40 mg/dl, BS = 40–120 mg/dl, and BS > 120 mg/dl. In P. falciparum malaria, pancreatic tissues showed numerous parasitised red blood cells (PRBCs) in the capillaries, oedema, acinar necrosis and the presence of inflammatory cells. The islet size and the expression of insulin were significantly increased in P. falciparum malaria patients with hypoglycaemia. In addition, insulin expression was positively correlated with islet size and negatively correlated with BS levels. This pioneer study documents an increase in insulin expression and an increase in islet size in hypoglycaemic patients with P. falciparum malaria. This could contribute to the pathogenesis of hypoglycaemia and provides evidence for the potential need to effectively manage the hypoglycaemia seen in malaria infection.

Incidence of Hypoglycemia in Burn Patients: A Focus for Process Improvement

Background: Glycemic control in burn patients is critical for reducing infection and mortality. Objective: This study was conducted to assess the incidence and outcomes of hypoglycemia during continuous insulin infusions (CII). Methods: This institutional review board-approved study was a retrospective, single burn center, electronic chart review. Patients admitted between January 1, 2013, and October 31, 2014, who received a CII were included. Patients with incomplete data or who received <24 hours of CII were excluded. Results: Thirty-eight patients met inclusion criteria; 6 were excluded. The average patient was a 52-year-old Caucasian male with a 33% total body surface area burn and an acute physiology and chronic health evaluation (APACHE) II score of 20.Hypoglycemia was present for 87 of 6540 hours of CII therapy (1.1%). Two-thirds experienced a serum glucose <70 mg/dL and half <60 mg/dL. The most commonly assessed reasons for the hypoglycemic episodes were protocol violations (47%) and glucose variability (30%). After multivariable logistic regression, only history of diabetes remained a statistically significant risk factor with an odds ratio of 15.4 (95% confidence interval: 2.5-95.1). Four different CII protocols were prescribed. All protocols had a high glucose variability, as assessed by hours / day within goal range (13.1 ± 2.5, 14.1 ± 3.1, 14.3 ± 2.4, 9.8; P = .282). Conclusion: The amount of different protocols likely contributed to protocol violations and glucose variability. Our data demonstrate the need to create and consolidate usage to a single protocol in attempts to improve glycemic control.

End-Stage Renal Disease Increases Rates of Adverse Glucose Events When Treating Diabetic Ketoacidosis or Hyperosmolar Hyperglycemic State

IN BRIEF Treatment guidelines for diabetic emergencies are well described in patients with normal to moderately impaired kidney function. However, management of patients with end-stage renal disease (ESRD) is an ongoing challenge. This article describes a retrospective study comparing the rates of adverse glucose events (defined as hypoglycemia or a decrease in glucose >200 mg/dL/h) between patients with ESRD and those with normal kidney function who were admitted with diabetic ketoacidosis (DKA) or hyperosmolar hyperglycemic state (HHS). These results indicate that current treatment approaches to DKA or HHS in patients with ESRD are suboptimal and require further evaluation.

Haemodialysis, nutritional disorders and hypoglycaemia in critical care

This study aimed to determine hypoglycemia incidence and associated factors in critically ill patients. It looked at a retrospective cohort with 106 critically ill adult patients with 48 hours of glycaemic control and 72 hours of follow up. The dependent variable, hypoglycaemia (≤70 mg/dl), was assessed with respect to independent variables: age, diet, insulin, catecholamines, haemodialysis, nursing workload and the Simplified Acute Physiology Score. Statistical analysis was performed using Student's t-test, Fisher's exact test and logistic regression at 5% significance level. Incidence of hypoglycaemia was 14.2%. Hypoglycaemia was higher in the group of patients on catecholamines (p=0.040), with higher glycaemic variability (p<0.001) and death in the intensive care unit (p=0.008). Risk factors were identified as absence of oral diet (OR 5.11; 95% CI 1.04-25.10) and haemodialysis (OR 4.28; 95% CI 1.16-15.76). Patients on haemodialysis and with no oral diet should have their glycaemic control intensified in order to prevent and/or manage hypoglycaemic episodes.

Prevention of acute kidney injury and protection of renal function in the intensive care unit: update 2017 : Expert opinion of the Working Group on Prevention, AKI section, European Society of Intensive Care Medicine

BACKGROUND

Acute kidney injury (AKI) in the intensive care unit is associated with significant mortality and morbidity.

OBJECTIVES

To determine and update previous recommendations for the prevention of AKI, specifically the role of fluids, diuretics, inotropes, vasopressors/vasodilators, hormonal and nutritional interventions, sedatives, statins, remote ischaemic preconditioning and care bundles.

METHOD

A systematic search of the literature was performed for studies published between 1966 and March 2017 using these potential protective strategies in adult patients at risk of AKI. The following clinical conditions were considered: major surgery, critical illness, sepsis, shock, exposure to potentially nephrotoxic drugs and radiocontrast. Clinical endpoints included incidence or grade of AKI, the need for renal replacement therapy and mortality. Studies were graded according to the international GRADE system.

RESULTS

We formulated 12 recommendations, 13 suggestions and seven best practice statements. The few strong recommendations with high-level evidence are mostly against the intervention in question (starches, low-dose dopamine, statins in cardiac surgery). Strong recommendations with lower-level evidence include controlled fluid resuscitation with crystalloids, avoiding fluid overload, titration of norepinephrine to a target MAP of 65-70 mmHg (unless chronic hypertension) and not using diuretics or levosimendan for kidney protection solely.

CONCLUSION

The results of recent randomised controlled trials have allowed the formulation of new recommendations and/or increase the strength of previous recommendations. On the other hand, in many domains the available evidence remains insufficient, resulting from the limited quality of the clinical trials and the poor reporting of kidney outcomes.

Hyper/hypoglycemia and acute kidney injury in critically ill patients

BACKGROUND & AIMS

Abnormalities of blood glucose (BG) concentration (hyper- and hypoglycemia), now referred to with the cumulative term of dysglycemia, are frequently observed in critically ill patients, and significantly affect their clinical outcome. Acute kidney injury (AKI) may further complicate glycemic control in the same clinical setting. This narrative review was aimed at describing the pathogenesis of hyper- and hypoglycemia in the intensive care unit (ICU), with special regard to patients with AKI. Moreover, the complex relationship between AKI, glycemic control, hypoglycemic risk, and outcomes was analyzed.

METHODS

An extensive literature search was performed, in order to identify the relevant studies describing the epidemiology, pathogenesis, treatment and outcome of hypo- and hyperglycemia in critically ill patients with AKI.

RESULTS AND CONCLUSION

Patients with AKI are at increased risk of both hyper-and hypoglycemia. The available evidence does not support a protective effect on the kidney by glycemic control protocols employing Intensive Insulin Treatment (IIT), i.e. those aimed at maintaining normal BG concentrations (80-110 mg/dl). Recent guidelines taking into account the high risk for hypoglycemia associated with IIT protocols in critically ill patients, now suggest higher BG concentration targets (<180 mg/dl or 140-180 mg/dl) than those previously recommended (80-110 mg/dl). Notwithstanding the limited evidence available, it seems reasonable to extend these indications also to ICU patients with AKI.

Hypocaloric Enteral Nutrition Protects against Hypoglycemia Associated with Intensive Insulin Therapy Better than Intravenous Dextrose

Intensive insulin therapy treats hyperglycemia but increases the risk of hypoglycemia. Typically, intravenous dextrose is given to prevent hypoglycemia; however, enteral nutrition is preferred. We hypothesized that the provision of hypocaloric enteral nutrition would protect against hypoglycemia. A retrospective analysis was performed evaluating patients treated with intensive insulin therapy comparing the use of enteral nutrition versus a dextrose-only intravenous solution. Nutrition in the 2 hours before each blood glucose test was assessed, and the association with hypoglycemia (50 mg/dL or less) evaluated. Risk of hypoglycemia as a function of nutrition type and rate was estimated by multivariable regression. A total of 26,140 blood glucose tests were collected on 1289 patients. Hypoglycemia occurred in 6.4 per cent of patients. In regression models, enteral nutrition was the strongest protective factor against hypoglycemia ( P < 0.001) with the largest risk reduction (steepest portion of the curve) occurring at 60 per cent goal. Hypocaloric enteral nutrition showed a greater risk reduction than a peripheral dextrose-only intravenous solution alone. In the setting of intensive insulin therapy, the provision of enteral nutrition, even if hypocaloric, is sufficient to protect against hypoglycemia. Future prospective studies should evaluate the efficacy of enteral nutrition in reducing the risk of hypoglycemia and whether lower rates of hypoglycemia correspond to improved outcomes.

Hypoglycemia in noncritically ill patients receiving total parenteral nutrition: a multicenter study. (Study group on the problem of hyperglycemia in parenteral nutrition; Nutrition area of the Spanish Society of Endocrinology and Nutrition)

OBJECTIVE

Hypoglycemia is a common problem among hospitalized patients. Treatment of hyperglycemia with insulin is potentially associated with an increased risk for hypoglycemia. The aim of this study was to determine the prevalence and predictors of hypoglycemia (capillary blood glucose <70 mg/dL) in hospitalized patients receiving total parenteral nutrition (TPN).

METHODS

This prospective multicenter study involved 19 Spanish hospitals. Noncritically ill adults who were prescribed TPN were included, thus enabling us to collect data on capillary blood glucose and insulin dosage.

RESULTS

The study included 605 patients of whom 6.8% (n = 41) had at least one capillary blood glucose <70 mg/dL and 2.6% (n = 16) had symptomatic hypoglycemia. The total number of hypoglycemic episodes per 100 d of TPN was 0.82. In univariate analysis, hypoglycemia was significantly associated with the presence of diabetes, a lower body mass index (BMI), and treatment with intravenous (IV) insulin. Patients with hypoglycemia also had a significantly longer hospital length of stay, PN duration, higher blood glucose variability, and a higher insulin dose. Multiple logistic regression analysis showed that a lower BMI, high blood glucose variability, and TPN duration were risk factors for hypoglycemia. Use of IV insulin and blood glucose variability were predictors of symptomatic hypoglycemia.

CONCLUSIONS

The occurrence of hypoglycemia in noncritically ill patients receiving PN is low. A lower BMI and a greater blood glucose variability and TPN duration are factors associated with the risk for hypoglycemia. IV insulin and glucose variability were predictors of symptomatic hypoglycemia.

Increasing awareness of hypoglycaemia in patients with type 2 diabetes treated with oral agents

Hypoglycaemia is the most common acute complication of type 2 diabetes and can limit therapeutic efforts to improve glycaemic control in order to protect against long-term complications. It is a potential side effect of the drugs used to treat diabetes, specifically exogenous insulin or insulin secretagogues. As many people are prescribed these agents, hypoglycaemia is frequent in clinical practice, although patients commonly do not inform their healthcare professional of the problems spontaneously. The impact of hypoglycaemia on the patient and to the healthcare system is significant through reduced treatment satisfaction and adherence, reduced quality of life and serious health consequences. This has financial implications and costs for the patient, the public and the economy at large. The single most important risk factor for hypoglycaemia is previous hypoglycaemia. Prevention depends on appropriate education regarding diabetes management and selfcare, self-monitoring of blood glucose, awareness of factors that may precipitate hypoglycaemia, and an individualized approach to therapy and glycaemic control targets. The purpose of this review is to increase understanding of the impact and consequences of hypoglycaemia, in particular that associated with sulphonylurea therapy, and to highlight areas requiring more attention in order to improve the overall management of people with type 2 diabetes.

Improved safety with intravenous insulin therapy for critically ill patients with renal failure

OBJECTIVE

The aim of this study was to evaluate the safety and efficacy of a new intravenous (IV) regular human insulin infusion (RHI) algorithm for glycemic control in critically ill patients with renal failure.

METHODS

Adult trauma patients with renal failure who received a new RHI algorithm were compared with those who received the discontinued RHI algorithm (historical control). Target blood glucose (BG) concentration was 70 to 149 mg/dL (3.9-8.3 mmol/L). Patients were evaluated for 7 d while receiving the RHI infusion and continuous enteral or parenteral nutrition.

RESULTS

Mean BG was higher for the new RHI algorithm group (n = 25) compared with control (n = 21): 145 ± 10 mg/dL or 8.1 ± 0.6 mmol/L versus 133 ± 14 mg/dL or 7.4 ± 0.8 mmol/L (P = 0.001). The new RHI algorithm resulted in less time within the target BG range (11.9 ± 2.5 h/d versus 16.1 ± 3.3 h/d; P = 0.001); however, BGs were within 70 to 179 mg/dL (or 3.9-10 mmol/L) for 16.3 ± 2.6 h/d. The proportion of patients who experienced an episode of moderate hypoglycemia (BG 40-60 mg/dL or 2.2-3.3 mmol/L) or severe hypoglycemia (BG < 40 mg/dL or 2.2 mmol/L) was decreased (32% versus 76%; P = 0.001) and eliminated (0% versus 29%, P = 0.006), respectively.

CONCLUSIONS

The new RHI algorithm improved patient safety by decreasing the prevalence of moderate hypoglycemia and eliminating severe hypoglycemia. The duration of glycemic control within the target BG range was decreased, but acceptable within a higher target BG ceiling.

Fasting glucose level is associated with nocturnal hypoglycemia in elderly male patients with type 2 diabetes

BACKGROUND

Nocturnal hypoglycemia was a common and serious problem among patients with type 2 diabetes (T2DM), especially in the elderly. This study investigated whether fasting glucose was an indicator of nocturnal hypoglycemia in elderly male patients with T2DM.

METHODS

A total of 291 elderly male type 2 diabetic patients who received continuous glucose monitoring (CGM) between January 2007 and January 2011 were enrolled in the study. The association of fasting glucose and nocturnal hypoglycemia based on CGM data was analyzed, comparing with bedtime glucose.

RESULTS

Based on CGM data, patients with nocturnal hypoglycemia had significantly lower fasting glucose (5.88 ± 1.29 versus 6.92 ± 1.32 mmol/L) and bedtime glucose (7.33 ± 1.70 versus 8.01 ± 1.95 mmol/L) than patients without nocturnal hypoglycemia (both p < 0.01). Compared with the highest quartile, the lowest quartile of fasting glucose had a significantly increased risk of nocturnal hypoglycemia after the multiple adjustments (pfor trend < 0.001). However, this association did not appear in bedtime glucose. When the prediction of nocturnal hypoglycemia either by fasting glucose or bedtime glucose using the area under receiver operating characteristic (ROC) curve, fasting glucose but not bedtime glucose, was an indicator of nocturnal hypoglycemia, with an area under the ROC curve (AUC) of 0.714 (95% CI: 0.653 ∼ 0.774, p < 0.001). On the ROC curve, the Youden index was maximal when fasting glucose was 6.1 mmol/L.

CONCLUSIONS

Fasting glucose may be a convenient and clinically useful indicator of nocturnal hypoglycemia in elderly male patients with T2DM. Risk of nocturnal hypoglycemia significantly increased when fasting glucose was less than 6.1 mmol/L.

Transitional NPH insulin therapy for critically ill patients receiving continuous enteral nutrition and intravenous regular human insulin

BACKGROUND

The intent of this study was to evaluate the efficacy and safety of transitioning from a continuous intravenous (IV) regular human insulin (RHI) or intermittent IV RHI therapy to subcutaneous neutral protamine Hagedorn (NPH) insulin with intermittent corrective IV RHI for critically ill patients receiving continuous enteral nutrition (EN).

METHODS

Data were obtained from critically ill trauma patients receiving continuous EN during transitional NPH insulin therapy. Target blood glucose concentration (BG) range was 70-149 mg/dL. BG was determined every 1-4 hours.

RESULTS

Thirty-two patients were transitioned from a continuous IV RHI infusion (CIT) to NPH with intermittent corrective IV RHI therapy. Thirty-four patients had NPH added to their preexisting supplemental intermittent IV RHI therapy (SIT). BG concentrations were maintained in the target range for 18 ± 3 and 15 ± 4 h/d for the CIT and SIT groups, respectively (P < .05). Thirty-eight percent of patients experienced a BG <60 mg/dL, and 9% had a BG <40 mg/dL. Hypoglycemia was more prevalent for those who were older (P < .01) or exhibited greater daily BG variability (P < .01) or worse HgbA1C (p < 0.05).

CONCLUSION

Transitional NPH therapy with intermittent corrective IV RHI was effective for achieving BG concentrations within 70-149 mg/dL for the majority of the day. NPH therapy should be implemented with caution for those who are older, have erratic daily BG control, or have poor preadmission glycemic control.

Evaluation of nursing adherence to a paper-based graduated continuous intravenous regular human insulin infusion algorithm

OBJECTIVE

The use of continuous intravenous regular human insulin (RHI) infusion is often necessary to achieve glycemic control in critically ill patients. Because insulin is a high-risk medication owing to the potential for severe hypoglycemia, it is imperative that insulin infusion algorithms are designed to be safe, effective, and instructionally clear. The safety and efficacy of our intravenous RHI infusion algorithm protocol has been previously established (Nutrition 2008;24:536-45); however, the protocol violations by nursing personnel were not examined. The objective of this study was to assess nursing adherence to our RHI infusion algorithm.

METHODS

Continuous RHI infusion algorithm violations were retrospectively evaluated in adult patients admitted to a trauma intensive care unit who received concurrent continuous enteral and/or parenteral nutrition therapy and our algorithm for at least 3 d. Blood glucose (BG) monitoring was done every 1 to 2 h with the target BG at 70 to 149 mg/dL (3.9 to 8.3 mmol/L). Nursing adherence to the RHI infusion protocol was evaluated for each patient by comparing the adjustments in insulin infusion rates documented by the nursing personnel with the prescribed adjustments per our graduated continuous intravenous RHI infusion algorithm.

RESULTS

A total of 4150 BG measurements necessitating the determination of the appropriate RHI dosage rate by nursing personnel in 40 patients occurred during the observational period. The target BG was achieved for a mean of 20 h/d and none of the patients had an episode of severe hypoglycemia (BG <40 mg/dL or 2.2 mmol/L). The overall rate of algorithm violations was 12.1%. The algorithm violations accounted for a single episode of mild to moderate hypoglycemia (BG 40 to 60 mg/dL or 2.2 to 3.3 mmol/L) in 4 patients and 65 total episodes of hyperglycemia (BG ≥150 mg/dL or 8.3 mmol/L) in 18 patients.

CONCLUSION

An adherence rate of nearly 90% is indicative of excellent nursing adherence compared with other published paper-based algorithms that examined protocol adherence. These data, combined with our previously published glycemic control data, indicate that this RHI infusion algorithm is an effective one for hyperglycemic trauma patients receiving continuous enteral and/or parenteral nutritional therapy.

Provision of balanced nutrition protects against hypoglycemia in the critically ill surgical patient

BACKGROUND

Intensive insulin therapy lowers blood glucose and improves outcomes but increases the risk of hypoglycemia. Typically, insulin protocols require a dextrose solution to prevent hypoglycemia. The authors hypothesized that the provision of balanced nutrition (enteral nutrition [EN] or parenteral nutrition [PN]) would be more protective against hypoglycemia (≤50 mg/dL) than carbohydrate alone.

METHODS

A retrospective analysis was performed of patients treated with intensive insulin therapy and surviving ≥24 hours. The computer-based insulin protocol requires infusion of D10W at 30 mL/h if EN or PN is not provided. Nutrition provision was assessed in 2-hour increments, comparing periods of blood glucose control with and without balanced nutrition. The risk of hypoglycemia for each blood glucose measurement was estimated by multivariable regression.

RESULTS

In total, 66,592 glucose measurements were collected on 1392 patients. Hypoglycemic events occurred in 5.8/1000 glucose tests after 2 hours without balanced nutrition compared to 2.2/1000 tests when balanced nutrition was given in the preceding 2 hours. In multivariable regression models, balanced nutrition was the strongest protective factor against hypoglycemia. Patients who did not receive balanced nutrition in the preceding 2 hours had a 3 times increase in the odds of a hypoglycemic event at their next glucose check (odds ratio = 3.6, P < .001). Providing carbohydrate alone was not protective.

CONCLUSIONS

Balanced nutrition is associated with reduced risk of hypoglycemia. These results suggest that balanced nutrition should be given when insulin therapy is initiated. Future studies should evaluate the efficacy of EN vs PN in preventing hypoglycemia.

Increasing blood glucose variability heralds hypoglycemia in the critically ill

BACKGROUND

Control of hyperglycemia improves outcomes, but increases the risk of hypoglycemia. Recent evidence suggests that blood glucose variability (BGV) is more closely associated with mortality than either isolated or mean BG. We hypothesized that differences in BGV over time are associated with hypoglycemia and can be utilized to estimate risk of hypoglycemia (<50 mg/dL).

MATERIALS AND METHODS

Patients treated with intravenous insulin in the Surgical Intensive Care Unit of a tertiary care center formed the retrospective cohort. Exclusion criteria included death within 24 h of admission. We describe BGV in patients over time and its temporal relationship to hypoglycemic events. The risk of hypoglycemia for each BG measurement was estimated in a multivariable regression model. Predictors were measures of BGV, infusions of dextrose and vasopressors, patient demographics, illness severity, and BG measurements.

RESULTS

A total of 66,592 BG measurements were collected on 1392 patients. Hypoglycemia occurred in 154 patients (11.1%). Patient BGV fluctuated over time, and increased in the 24 h preceding a hypoglycemic event. In crude and adjusted analyses, higher BGV was positively associated with a hypoglycemia (OR 1.41, P < 0.001). Previous hypoglycemic events and time since previous BG measurement were also positively associated with hypoglycemic events. Severity of illness, vasopressor use, and diabetes were not independently associated with hypoglycemia.

CONCLUSIONS

BGV increases in the 24 h preceding hypoglycemia, and patients are at increased risk during periods of elevated BG variability. Prospective measurement of variability may identify periods of increased risk for hypoglycemia, and provide an opportunity to mitigate this risk.