Parenteral Nutrition Strategies for Achieving Glycemic Control in the Critical Care Setting

Soo An Choi

doi:10.4093/jkd.2015.16.1.25

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Choi: Parenteral Nutrition Strategies for Achieving Glycemic Control in the Critical Care Setting

Focused Issue

J Korean Diabetes 2015;16(1):25-32.

Published online: 20 January 2015

DOI: https://doi.org/10.4093/jkd.2015.16.1.25

Parenteral Nutrition Strategies for Achieving Glycemic Control in the Critical Care Setting

Soo An Choi

Department of Clinical Pharmacy, College of Pharmacy, Seoul National University, Seoul, Korea

Corresponding author: Soo An Choi Department of Clinical Pharmacy, College of Pharmacy, Seoul National University, 103 Daehak-ro, Jongno-gu, Seoul 110-799, Korea, E-mail: taijino2@snu.ac.kr

This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/by-nc/3.0) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.

Abstract

Hyperglycemia commonly occurs in acutely ill patients who receive nutritional support, even those without a history of diabetes. A number of observational studies have identified hyperglycemia as a factor independently associated with poor outcome in various critically ill populations. Thus, glycemic control is an important component of metabolic management of the critically ill patient. Avoiding excessive calorie provision, especially carbohydrate calories, is one of the most obvious considerations for nutrition support regimens in terms of glucose control. In adult patients, carbohydrate provision is nearly always less than 4–5 mg/kg/minute. Also, providing lipid calories with parenteral nutrition (PN) helps to avoid excessive amounts of dextrose. There is evidence that, if the rate of lipid infusion remains low (less than 0.11 g/kg/hour), there is minimal risk of immunosuppressive effects. While avoidance of excessive total calories may be the most important aspect of managing nutrition during stress hyperglycemia, there may be some further advantage to hypocaloric feeding in some patients. Determining when to prescribe insulin is a key strategy in preventing hyperglycemia among patients receiving PN. Protocol-directed insulin dosing closely linking insulin to carbohydrate leads to better control of PN-induced hyperglycemia than ad hoc insulin dosing strategies that rely heavily on supplemental insulin.

Keywords: Critical illness, Hyperglycemia, Hypoglycemia, Insulin, Parenteral nutrition

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Table 1.

Intravenous regular human insulinsliding scale coverage for patients with hyperglycemia

Blood glucose (mg/dL)	Intervention
< 40	50% dextrose 25 g IV
40∼70	50% dextrose 12.5 g IV
71∼125	No change (0 units RHI)
126∼150	3 units RHI
151∼175	6 units RHI
176∼200	9 units RHI
201∼225	12 units RHI
226∼250	15 units RHI
251–275	18 units RHI
276∼300	21 units RHI
> 300	24 units RHI

IV, intravenously; RHI, regular human insulin.

Table 2.

Insulin dosing protocol: PN-inducedhyperglycemia

Initial insulin^a
Prandial	1 U/20 g CHO
Daily insulin adjustment by BG, mg/dL
< 70	Decrease 20%
70∼79	Decrease 10%
80∼140	No change
141∼200	1 U/15 g CHO day 2, then increase 10%
> 200	1 U/15 g CHO day 2, then increase 20%

PN, parenteral nutrition; CHO, carbohydrate; BG, blood glucose.

^a Administered two-thirds regular insulin in PN preparation and one-third subcutaneous Neutral Protamine Hagedorn (NPH) insulin in 3 or 4 equal doses. Insulin dose < 14 U/d was provided entirely as NPH insulin in 3 or 4 equal doses administered divided at 6- or 8-hour intervals.

Table 3.

Continuous IV insulin infusion algorithms with a target BG range of 70 to 149 mg/dL forcritically ill trauma patients at the regional medical center in Memphis

IV insulin infusion algorithm for patients with normal renal function		IV insulin infusion algorithm for patients with renal failure
BG (mg/dL)	Intervention	BG (mg/dL)	Intervention
< 40^a	50% dextrose 25 g IV, stop RHI	< 40^b	50% dextrose 25 g IV, stop RHI
40∼70^a	50% dextrose 12.5 g IV, stop RHI	40∼70^b	50% dextrose 12.5 g IV, stoop RHI
71∼100	Decrease RHI by 50%	71∼125	Decrease RHI by 50%
101∼125	No change	126∼150	No change
126∼175	Increase RHI by 1 unit/h	151∼200	Increase RHI by 1 unit/h
176∼200	Increase RHI by 2 unit/h	201∼250	Increase RHI by 2 unit/h
201∼225	Increase RHI by 3 unit/h	251∼300	Increase RHI by 3 unit/h
226∼250	Increase RHI by 4 unit/h	> 300	Increase RHI by 4 unit/h
251∼275	Increase RHI by 5 unit/h
> 300	Increase RHI by 6 unit/h

IV, intravenous; BG, blood glucose; RHI, regular human insulin.

^a When BG > 100 mg/dL, restart RHI infusion at 1/2 the last infusion rate. BG may be repeated 30 minutes following administration of rescue IV glucose.

^b When BG > 125 mg/dL, restart RHI infusion at 1/2 the last infusion rate. BG may be repeated 30 minutes following administration of rescue IV glucose.

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