Clinical management of hyperglycaemic patients receiving total parenteral nutrition

Prevalence and Risk Factors of Total Parenteral Nutrition Induced Hyperglycemia at a Single Institution: Retrospective Study

Background: Total parenteral nutrition (TPN) provides full nutrition support to critically ill patients with an impaired digestive tract. Patients who receive TPN support are at higher risk for complications such as hyperglycemia. In our study, we aim to assess the prevalence of hyperglycemia induced by TPN and identify its risk factors in hospitalized adult patients. Methods: Patients who received TPN between January 2012 and December 2017 at University of Pittsburgh Medical Center-St. Margaret hospital were retrospectively screened. TPN-induced hyperglycemia was confirmed whether blood glucose was ≥180 mg/dL at any point, from the time of TPN initiation until 1-day post TPN termination. Characteristics of the hyperglycemia and the nonhyperglycemia groups were analyzed to predict potential risk factors. Results: A total of 197 patients were screened, 55 were excluded (1 died, 37 diabetic, and 17 had elevated blood glucose before TPN), and 142 patients were included, 42 of them (29.6%) developed hyperglycemia following TPN administration. Duration of TPN, surgical indications, and obesity were significantly higher in the hyperglycemia group. Additionally, age and steroids use were independent predictors of hyperglycemia in TPN patients after applying multivariable logistic regression model on our sample. Conclusions: Hyperglycemia is common after TPN. Risk factors assessment may help optimizing glycemic control in higher risk individuals to improve their outcomes. These include patients with obesity, surgical indication of TPN, and longer duration of TPN.

Differences in Glycemic Control in Diabetic and Non-diabetic Patients with Parenteral Nutrition Using a Basal plus Correction Insulin Regimen: An Observational, Retrospective Study

INTRODUCTION

Hyperglycemia is a frequent complication of parenteral nutrition (PN) in patients both with and without diabetes mellitis (DM). The aim of this study was to evaluate the quality of glucose control achieved with basal plus-correction insulin in surgical patients with and without a history of DM receiving PN.

METHODS

Retrospective evaluation of a protocol applied during the period of January 2013-December 2015. The insulin dose was started at 0.4 and 0.3 IU/kg/day in patients with previous DM and without a history of DM, respectively, and the target blood glucose (BG) was < 180 mg/dl. Mean BG levels, insulin total daily dose (TDD) and hypoglycemic (< 70 mg/dl) events on different days of PN were also evaluated.

RESULTS

Forty-one patients with previous type 2 DM and 39 without DM were evaluated. Glycemic control in both groups was as follows: during the first 48 h (230.4 ± 67 vs. 189.4 ± 38 mg/dl, p = 0.002); at the midpoint (224.6 ± 58 vs. 181.3 ± 27 mg/dl, p = 0.003); 48 h before ending TPN (196.4 ± 43 vs. 169.8 ± 40 mg/dl, p = 0.004). Insulin TDD was 0.5 ± 0.3 U/kg/day in patients with DM and 0.37 ± 0.3 units/kg/day in those without DM (p < 0.05). A total of 18 patients experienced hypoglycemic events, without differences between the groups.

CONCLUSION

A basal-correction insulin regimen is an alternative method for managing hyperglycemia in non-critically ill surgical patients on PN.

Addition of Insulin to Parenteral Nutrition for Control of Hyperglycemia

Administration of parenteral nutrition (PN) may result in hyperglycemia in patients with preexisting diabetes or disease-related insulin resistance, and it can be associated with increased rates of complications. Treatment requires insulin therapy. Insulin can be administered subcutaneously, intravenously via a variable rate sliding scale, or by adding it directly to the PN. The last method is a potentially attractive technique for a number of reasons-it could deliver the insulin intravenously at a steady rate alongside carbohydrates, and in malnourished patients with little subcutaneous tissue, it may prevent the need for frequent insulin injections. Despite such potential advantages, the addition of insulin to PN remains controversial, largely with respect to the bioavailability of insulin in PN and resultant concerns of the risk of hypoglycemia. There is a paucity of long-term quality controlled studies to address this question. The available literature suggests that, at least in the short term, insulin addition to PN can achieve reasonable glycemic control with low rates of hypoglycemia, and the technique compares favorably with the use of long-acting insulin preparations. This literature review finds a wide range of values reported for insulin availability via PN, ranging from 44% to 95% depending on the type of PN container material used and the presence of added vitamins and trace elements. Few studies looking at glycemic control among patients receiving home PN were found, and larger prospective trials are needed to assess the efficacy and safety of this technique in this patient group.

Glargine Insulin Use Versus Continuous Regular Insulin in Diabetic Surgical Noncritically Ill Patients Receiving Parenteral Nutrition: Randomized Controlled Study

BACKGROUND

Hyperglycemia is a major complication of parenteral nutrition (PN). Guidelines for hyperglycemia management in noncritically ill patients cite basal insulin administration but do not recommend a regimen. The GLUCOSE-in-PN study aimed to compare the efficacy of glargine insulin versus continuously infused regular insulin in PN (RI-in-PN) to achieve glycemic control in noncritically ill surgical patients with diabetes who were receiving PN.

METHODS

This prospective randomized open-label study was conducted at King Faisal Specialist Hospital and Research Centre. Noncritically ill surgical patients with diabetes who were receiving PN were randomized to receive basal glargine insulin or RI-in-PN on day 4 of PN support. Mean blood glucose levels were compared on study days 5-9. The percentages of blood glucose measurements at goal were compared between groups.

RESULTS

Sixty-seven PN treatment episodes were analyzed. There were no statistically significant differences in mean glucose levels between groups on any study day ( P > .1). Overall glycemic control rates were 52.24% (glargine insulin) and 47.76% (RI-in-PN; P = .06). A significantly higher percentage of hyperglycemia was observed on day 5 for glargine insulin versus RI-in-PN (22.39% vs 5.97%, P = .0059). Blood glucose measurements indicated 6 hypoglycemic events: 2 for glargine insulin (5.7%) and 4 for RI-in-PN (11.4%; P > .1).

CONCLUSION

Both glargine insulin and RI-in-PN are effective basal insulin modalities for blood glucose control in noncritically ill surgical patients with diabetes who are receiving PN. Uncontrolled hyperglycemic events occurred more frequently with glargine insulin, and the rate of hypoglycemia was acceptable for both regimens.

Prevalence of diabetes, prediabetes, and stress hyperglycemia: insulin therapy and metabolic control in patients on total parenteral nutrition (prospective multicenter study)

OBJECTIVE

The prevalence of carbohydrate metabolism disorders in patients who receive total parenteral nutrition (TPN) is not well known. These disorders can affect the treatment, metabolic control, and prognosis of affected patients. The aims of this study were to determine the prevalence in noncritically ill patients on TPN of diabetes, prediabetes, and stress hyperglycemia; the factors affecting hyperglycemia during TPN; and the insulin therapy provided and the metabolic control achieved.

METHODS

We undertook a prospective multicenter study involving 19 Spanish hospitals. Noncritically ill patients who were prescribed TPN were included, and data were collected on demographic, clinical, and laboratory variables (glycated hemoglobin, C-reactive protein [CRP], capillary blood glucose) as well as insulin treatment.

RESULTS

The study included 605 patients. Before initiation of TPN, the prevalence of known diabetes was 17.4%, unknown diabetes 4.3%, stress hyperglycemia 7.1%, and prediabetes 27.8%. During TPN therapy, 50.9% of patients had at least one capillary blood glucose of >180 mg/dL. Predisposing factors were age, levels of CRP and glycated hemoglobin, the presence of diabetes, infectious complications, the number of grams of carbohydrates infused, and the administration of glucose-elevating drugs. Most (71.6%) patients were treated with insulin. The mean capillary blood glucose levels during TPN were: known diabetes (178.6 ± 46.5 mg/dL), unknown diabetes (173.9 ± 51.9), prediabetes (136.0 ± 25.4), stress hyperglycemia (146.0 ± 29.3), and normal (123.2 ± 19.9) (P<.001).

CONCLUSION

The prevalence of carbohydrate metabolism disorders is very high in noncritically ill patients on TPN. These disorders affect insulin treatment and the degree of metabolic control achieved.

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.

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.

Hyperglycemia during total parenteral nutrition: an important marker of poor outcome and mortality in hospitalized patients

OBJECTIVE

To determine the effect of total parenteral nutrition (TPN)-induced hyperglycemia on hospital outcome.

RESEARCH DESIGN AND METHODS

The study determined whether blood glucose values before, within 24 h, and during days 2-10 of TPN are predictive of hospital complications and mortality.

RESULTS

Subjects included a total of 276 patients receiving TPN for a mean duration of 15 +/- 24 days (+/-SD). In multiple regression models adjusted for age, sex, and diabetes status, mortality was independently predicted by pre-TPN blood glucose of 121-150 mg/dl (odds ratio [OR] 2.2, 95% CI 1.1-4.4, P = 0.030), 151-180 mg/dl (3.41, 1.3-8.7, P = 0.01), and >180 mg/dl (2.2, 0.9-5.2, P = 0.077) and by blood glucose within 24 h of >180 mg/dl (2.8, 1.2-6.8, P = 0.020). A blood glucose within 24 h of >180 mg/dl was associated with increased risk of pneumonia (OR 3.1, 95% CI 1.4-7.1) and acute renal failure (2.3, 1.1-5.0).

CONCLUSIONS

Hyperglycemia is associated with increased hospital complications and mortality in patients receiving TPN.

[Multicenter study on the prevalence of hyperglycemia among hospitalized patients with parenteral nutrition]

OBJECTIVE

The aim of this cross-sectional national multicentric study was to determine the prevalence of hyperglycemia in patients with parenteral nutrition and to assess other clinical factors associated with this complication.

METHOD

All Spanish hospital pharmacy services were invited to participate in the study.

RESULTS

Twenty eight (28) pharmacy services agreed to participate. The study included 442 patients. The prevalence of hyperglycemia (plasma levels > 200 mg/dL) was 26.7%. Eighty four point two per cent of the patients received less than 3.5 mg/kg/minute of glucose, this infusion rate being considered as the safe threshold. In most patients, follow-up of glycemia was based on capillary blood determination with reactive strips and in 27.6% of the cases in which insulin was prescribed, it was added to the parenteral nutrition bag, in full or in part. No significant correlations were found between glycemia and the clinical factors studied (disorders, fever, medication), except for insulin.

CONCLUSIONS

This national multicentric study of the prevalence of hyperglycemia among patients with parenteral nutrition, leaded by hospital pharmacists, was a joint effort aimed to better understand this metabolic complication. Findings are consistent with those reported by other authors and have allowed us to describe the current situation.

Evaluation of nonglucose carbohydrates in parenteral nutrition for diabetic patients

OBJECTIVE

There is little information on the advantages of nonglucose carbohydrates in total parenteral nutrition (TPN) for diabetic patients. The aim of this study is to evaluate glycemic control and insulin requirements in diabetic patients who received TPN with different sources of carbohydrates, and to determine whether insulin requirements are different when septic and non-septic diabetic patients are studied.

MATERIALS AND METHODS

One-hundred and thirty-eight patients were randomly divided into two groups receiving either glucose (G), n=71, or glucose-fructose-xylitol 2:1:1 (GFX), n=67. There were no differences between the demographic or anthropometric characteristics of the groups, nor between the patients with diabetes mellitus type 1 and type 2, nor the initial TPN composition. Acceptable glycemic control was considered when glycemia reached <200 mg/dl.

RESULTS

Glycemic control was attained in 79.7% of patients (74.6 vs 85.1%), in the same period of treatment. At the end of treatment, insulin requirements were not different (45+/-19 vs 45+/-26 UI/day) in both groups, while similar amounts of carbohydrates (191+/-36 vs 187+/-45 g/day) were infused. The ratio insulin/body weight and insulin/carbohydrates were equal in both groups. In the GFX group nonseptic and septic patients needed less and more insulin, respectively, than their counterparts in the G group. No major adverse events related to carbohydrate infusions were observed.

CONCLUSIONS

Either G or GFX could be used in TPN for diabetic patients, providing glycemic control in most cases with similar insulin requirements. GFX mixtures were slightly more beneficial to attain glycemic control in nonseptic patients, but septic diabetic patients had higher insulin needs in this group.