Advertisement

Risk Factors for Predicting Hypoglycemia in Patients Receiving Concomitant Parenteral Nutrition and Insulin Therapy

Published:January 23, 2013DOI:https://doi.org/10.1016/j.jand.2012.11.007

      Abstract

      The occurrence of hypoglycemia in patients receiving parenteral nutrition (PN) is low, yet its consequences can be detrimental. Treatment of hyperglycemia with insulin to achieve optimal blood glucose control is challenging and potentially associated with increased risk of the development of hypoglycemia. The objective of this study was to determine the association of patient characteristics on the risk of hypoglycemia among patients receiving concomitant PN and insulin therapy. This retrospective cohort study was conducted from January 1, 2008, to December 31, 2011, and included 1,657 patients who received PN. There was a significant decrease in the occurrence of hypoglycemia observed over time: 9.1% (43 of 475) in 2008, 6.4% (30 of 468) in 2009, 5.8% (20 of 347) in 2010, and 3.5% (13 of 367) in 2011 (P=0.013). Patients in whom hypoglycemia developed had a significantly longer duration on PN (18.0 vs 8.1 days, P<0.0001) as well as more days requiring insulin in the PN (16.1 vs 2.7 days, P<0.0001). The strongest predictors of hypoglycemia were: receiving PN in the ICU (OR 1.86, 95% CI 1.16 to 3.01), history of diabetes (OR 2.10, 95% CI 1.26 to 3.51), days on PN (OR 0.93, 95% CI 0.91 to 0.95), and an insulin drip (OR 3.14, 95% CI 1.81 to 5.42). With the identification of patient factors that contribute to an increase in hypoglycemia, existing protocols can be modified to treat hyperglycemia and prevent hypoglycemia.

      Keywords

      To read this article in full you will need to make a payment

      Purchase one-time access:

      Academic & Personal: 24 hour online accessCorporate R&D Professionals: 24 hour online access
      One-time access price info
      • For academic or personal research use, select 'Academic and Personal'
      • For corporate R&D use, select 'Corporate R&D Professionals'

      Subscribe:

      Subscribe to Journal of the Academy of Nutrition and Dietetics
      Already a print subscriber? Claim online access
      Already an online subscriber? Sign in
      Institutional Access: Sign in to ScienceDirect

      References

        • Ziegler T.R.
        Parenteral nutrition in the critically ill patient.
        N Engl J Med. 2009; 36: 1088-1097
        • Meadows N.
        Monitoring and complications of parenteral nutrition.
        Nutrition. 1998; 14: 806-808
        • Van den Berghe G.
        • Wouters P.
        • Weekers F.
        • et al.
        Intensive insulin therapy in critically ill patients.
        N Engl J Med. 2001; 345: 1359-1367
        • Cheung N.W.
        • Napier B.
        • Zaccaria C.
        • Fletcher J.P.
        Hyperglycemia is associated with adverse outcomes in patients receiving total parenteral nutrition.
        Diabetes Care. 2005; 28: 2367-2371
        • Sheean P.
        • Freels S.A.
        • Helton W.S.
        • Braunschweig C.A.
        Adverse clinical consequences of hyperglycemia from total parenteral nutrition exposure during hematopoietic stem cell transplantation.
        Biol Blood Marrow Transplant. 2006; 12: 656-664
        • Van der Voort P.H.
        • Feenstra R.A.
        • Bakker A.J.
        • De Heide L.
        • Boerma E.D.
        • Van der Horst I.C.
        Intravenous glucose intake independently related to intensive care unit and hospital mortality: An argument for glucose toxicity in critically ill patients.
        Clin Endocrinol. 2006; 64: 141-145
        • Schloerb P.R.
        Glucose in parenteral nutrition: A survey of US medical centers.
        J Parenter Enteral Nutr. 2004; 28: 447-452
        • Pasquel F.J.
        • Spiegelman R.
        • McCauley M.
        • et al.
        Hyperglycemia during total parenteral nutrition: An important marker of poor outcome and mortality in hospitalized patients.
        Diabetes Care. 2010; 33: 739-741
        • Marik P.E.
        • Preiser J.C.
        Toward understanding tight glycemic control in the ICU: A systematic review and meta-analysis.
        Chest. 2010; 137: 544-551
        • The Diabetes Control and Complications Trial Research Group
        The effect of intensive treatment of diabetes on the development and progression of long-term complications and insulin-dependent diabetes mellitus.
        N Engl J Med. 1993; 329: 977-986
        • The ADVANCE Collaborative Group
        Intensive blood glucose control and vascular outcomes in patients with type 2 diabetes.
        N Engl J Med. 2008; 358: 2560-2572
        • Donnelly L.A.
        • Morris A.D.
        • Frier B.M.
        • et al.
        Frequency and predictors of hypoglycemia in type 1 and insulin-treated type 2 diabetes: A population-based study.
        Diabet Med. 2005; 22: 749-755
        • Shilo S.
        • Berezovsky S.
        • Friedlander Y.
        • Sonnenblick M.
        Hypoglycemia in hospitalized nondiabetic older patients.
        J Am Geriatr Soc. 1998; 46: 978-982
        • Wolfe R.R.
        • O'Donnell T.F.
        • Stone M.D.
        • Richmand D.A.
        • Burke J.F.
        Investigation of factors determining the optimal glucose infusion rate in total parenteral nutrition.
        Metabolism. 1980; 29: 892-900
        • Rosmarin D.K.
        • Wardlwa G.M.
        • Mirtallo J.
        Hyperglycemia associated with high, continuous infusion rates of total parenteral nutrition dextrose.
        Nutr Clin Pract. 1996; 11: 151-156
        • McMahon M.
        Management of parenteral nutrition in acutely ill patients with hyperglycemia.
        Nutr Clin Pract. 2004; 19: 120-128
        • American Diabetes Association
        Diagnosis and Classification of Diabetes Mellitus.
        Diabetes Care. 2007; 30: S42-S47
        • Pleva M.
        • Mirtallo J.M.
        • Steinberg S.M.
        Hyperglycemic events in non-intensive care unit patients receiving parenteral nutrition.
        Nutr Clin Pract. 2009; 24 (636-634)
        • Jakoby M.D.
        • Nannapeneni N.
        An insulin protocol for management of hyperglycemia in patients receiving parenteral nutrition is superior to ad hoc management.
        J Parenter Enteral Nutr. 2012; 36: 183-188
        • NICE-SUGAR Study Investigators
        Intensive versus conventional glucose control in critically ill patients.
        N Engl J Med. 2009; 360: 1283-1297
        • Van den Berghe G.
        • Wilmer A.
        • Hermans G.
        • et al.
        Intensive insulin therapy in the medical ICU.
        N Engl J Med. 2006; 354: 449-461

      Biography

      K. F. Kinnare is a nutrition support dietitian, Walgreens Infusion Services, Wood Dale, IL; at the time of the study, she was a clinical dietitian at Rush University Medical Center, Chicago, IL.

      Biography

      C. A. Bacon is a clinical dietitian, Rush University Medical Center, Chicago, IL.

      Biography

      Y. Chen is a clinical dietitian, Rush University Medical Center, Chicago, IL.

      Biography

      S. J. Peterson is a clinical dietitian, Rush University Medical Center, Chicago, IL.

      Biography

      D. C. Sowa is clinical nutrition manager/internship director, Rush University Medical Center, Chicago, IL.