Management of Hyperglycemia and Enteral Nutrition in the Hospitalized Patient

Abstract

There has been increased attention on the importance of identifying and distinguishing the differences between stress-induced hyperglycemia (SH), newly diagnosed hyperglycemia (NDH), and hyperglycemia in persons with established diabetes mellitus (DM). Inpatient blood glucose control is now being recognized as not only a cost issue for hospitals but also a concern for patient safety and care. The reasons for the increased incidence of hyperglycemia in hospitalized patients include preexisting DM, undiagnosed DM or prediabetes, SH, and medication-induced hyperglycemia with resulting transient blood glucose variability. It is clear that identifying and documenting hyperglycemia in hospitalized patients with and without a previous diagnosis of DM and initiating prompt insulin treatment are important. Agreement on the optimum treatment goals for hyperglycemia remains quite controversial, and the benefits of intensive glucose management may be lost at the cost of hypoglycemia in intensive care unit patients. Nutrition support in the form of enteral nutrition (EN) increases the risk of hyperglycemia in both critical and non-critically ill hospitalized patients. Reasons for beginning a tube feeding are the same whether a person has NDH or DM. What differs is how to incorporate EN into the established insulin management protocols. The risk for hyperglycemia with the addition of EN is even higher in those without a previous diagnosis of DM. This review discusses the incidence of hyperglycemia, the pathogenesis of hyperglycemia, factors contributing to hyperglycemia in the hospitalized patient, glycemic management goals, current glycemic management recommendations, and considerations for EN formula selection, administration, and treatment.

Dietary Management of Blood Glucose in Medical Critically Ill Overweight and Obese Patients: An Open‐Label Randomized Trial

“…Hyperglycemia is almost universally observed in critically ill patients contributing to poor clinical outcomes. EN formulas worsen hyperglycemia and may hinder efforts at controlling glucose . Increasing awareness of the problems associated with standard nutrition has prompted investigators to explore alternative options, including the substitution of high‐glycemic to low‐glycemic carbohydrates, addition of lipids as an energy source, or allowing an energy deficit through hypocaloric nutrition or permissive underfeeding …”

Management of hospitalized type 2 diabetes mellitus patients

“…Before beginning enteral nutrition, it is important to know the metabolic status, previous control of diabetes, and insulin requirements. [29] Continuous enteral nutrition has an effect, not totally known, in secretion and action on incretin hormones and can contribute to hyperglycemia. Hospitalization produces insulin resistance and together with delivery of glucose and gluconeogenic substrates via enteral contribute to hyperglycemia.…”

“…Although some institutions do not have recommendations about this, [31] diabetic-specific formulas have been suggested in patients with persistent hyperglycemia. [29] Retrospective studies with different insulin regimens have demonstrated effectiveness to manage hyperglycemia with a variable degree of control. These studies use basal insulin glargine once daily, NPH every 4 or 6 hours, or 70/30 biphasic insulin twice or 3 times a day.…”

Avaliação da terapia nutricional enteral em pacientes críticos de uma Unidade de Terapia Intensiva

“…Uma menor oferta calórica em pacientes internados em UTI está associada ao aumento nos episódios de hipoglicemia (28)(29)(30) , infecções severas (31) , maior tempo de internação (32) , maiores gastos com a saúde desses indivíduos (33) e aumento nas taxas de mortalidade (31,34) . O consenso canadense para terapia nutricional em paciente crítico preconiza que o acompanhamento diário e o rígido controle do protocolo de nutrição enteral da UTI por parte da EMTN deve facilitar um maior recebimento da dieta prescrita (35) .…”