Glycemic Management of Hospitalized Patients Receiving Nutrition Support

Continuous Feeding Insulin Injection (CFII): A New Simple Method to Stabilize Severe Glucose Variability and Nutrition Delivery in Critically Ill Patients

This report describes a new, simple, and systematic approach, Continuous Feeding Insulin Injection (CFII), designed to stabilize severe glucose variability and optimize nutritional delivery in critically ill patients when intensive insulin therapy (IIT) alone proves insufficient. Septic patients frequently develop inflammation-induced insulin resistance, resulting in recurrent episodes of hyperglycemia and hypoglycemia. Fever, systemic inflammation, and appetite loss further disrupt glucose homeostasis, complicating nutritional management. CFII integrates two key components: continuous enteral nutrition (CEN) delivered at a fixed rate over 24 hours, based on the patient's metabolic needs, and continuous insulin infusion dynamically adjusted according to frequent or continuous blood glucose monitoring. This approach stabilizes both blood glucose levels and nutritional intake. We present a case of a 65-year-old woman with type 2 diabetes (BMI 21.2 kg/m²) who developed sepsis secondary to pyelonephritis. Despite receiving intensive insulin therapy (IIT), she experienced severe glycemic fluctuations (38-361 mg/dL; mean±SD: 218.6±110.0 mg/dL) and recurrent hypoglycemia, rendering oral intake nearly impossible. CFII was initiated with enteral feeding starting at 1000 kcal/day and gradually increased to 1400 kcal/day, while insulin infusion was dynamically adjusted every three hours. This strategy successfully stabilized severe glucose variability (164.5±35.9 mg/dL), eliminated hypoglycemic episodes, and achieved controlled nutrition delivery. Clinically, similar approaches are presumed to have been used in patients receiving CEN; however, this is the first report to the best of our knowledge to systematically describe CFII as a structured method for glucose and nutritional management in critically ill patients, to propose the term "CFII" and to demonstrate its effectiveness in a patient for whom IIT alone was insufficient. CFII enables nutritional delivery to be tailored to the course of treatment while maintaining stable glycemic control. Its simplicity, practicality, and compatibility with existing hospital systems make CFII an accessible method for broader clinical application. CFII has the potential to improve metabolic outcomes and enhance survival rates in this vulnerable patient population. Further research, including systematic evaluations and randomized controlled trials, is necessary to confirm its efficacy, safety, and applicability across diverse clinical settings.

Management of Hyperglycemia in Hospitalized Patients

People with diabetes account for 25% of hospitalizations, or 8 million admissions annually. Poor glycemic control in the hospital is associated with increased morbidity, mortality, length of stay, and readmissions. Key considerations of inpatient diabetes management include initiation of appropriate insulin or medication regimens and frequent dose adjustments based on patient-specific factors. Inpatient diabetes management teams and new technologies are increasingly prevalent and can assist in achieving glycemic targets in the hospital. At discharge, standardized checklists should be used to ensure successful transitions of care.

Managing blood glucose levels with a hybrid closed-loop system in a patient with type 1 diabetes mellitus on enteral nutrition: A case report

The achievement of glycemic management is challenging in patients with diabetes on enteral nutrition, limited literature exists on hybrid closed-loop systems' efficacy in such a situation. We described the case of a patient with type 1 diabetes treated by advanced hybrid closed loop on enteral nutrition with satisfactory glycemic management.

Evaluation of the Effect of Thickeners in Enteral Formulas on the Gastric Emptying Rate of Proteins and Carbohydrates Using a Semi-Dynamic Gastric Model

The emptying rate of specific nutrients in enteral formulas is poorly understood, despite the importance of controlling the emptying rate in tube-fed patients. Because of their viscosity, thickened formulas are widely used to avoid gastric reflux and reduce the burden on caregivers. This study examined how thickeners in enteral formulas affected the gastric emptying rates of proteins and carbohydrates. A semi-dynamic gastric model was used to prepare and digest test enteral formulas that contained either no thickeners or agar (0.2%). The amounts of protein and carbohydrates in each emptied aliquot were determined, and the emptying rate was calculated. We found that agar accelerated protein emptying, and an exploratory experiment with agar (0.5%) suggested the possibility of concentration dependence. Additionally, experiments using gellan gum (0.08%), guar gum (0.2%), or carrageenan (0.08%, 0.2%) suggested that protein emptying could vary depending on the thickener type and that carrageenan might slow it. These results could help with the appropriate selection of thickeners added to liquid foods based on the patient's metabolic profile to manage nutrition, not only for tube-fed patients but also for those with oropharyngeal dysphagia or diabetes.

Safety and Efficacy of Insulins in Critically Ill Patients Receiving Continuous Enteral Nutrition

OBJECTIVE

There is a relative lack of consensus regarding the optimal management of hyperglycemia in patients receiving continuous enteral nutrition (EN), with or without a diagnosis of diabetes.

METHODS

This retrospective study examined 475 patients (303 with known diabetes) hospitalized in critical care setting units in 2019 in a single center who received continuous EN. Rates of hypoglycemia, hyperglycemia, and glucose levels within the target range (70-180 mg/dL) were compared between patients with and without diabetes, and among patients treated with intermediate-acting (IA) biphasic neutral protamine Hagedorn 70/30, long-acting (LA) insulin, or rapid-acting insulin only.

RESULTS

Among those with type 2 diabetes mellitus, IA and LA insulin regimens were associated with a significantly higher proportion of patient-days in the target glucose range and fewer hyperglycemic days. Level 1 (<70 mg/dL) and level 2 (<54 mg/dL) hypoglycemia occurred rarely, and there were no significant differences in level 2 hypoglycemia frequency across the different insulin regimens.

CONCLUSION

Administration of IA and LA insulin can be safe and effective for those receiving insulin doses for EN-related hyperglycemia.