Computer‐Assisted Glucose Regulation During Rapid Step‐Wise Increases of Parenteral Nutrition in Critically Ill Patients

Abstract

Background: Early delivery of calories is important in critically ill patients, and the administration of parenteral nutrition (PN) is sometimes required to achieve this goal. However, PN can induce acute hyperglycemia, which is associated with adverse outcome. We hypothesized that initiation of PN using a rapid “step‐up” approach, coupled with a computerized insulin‐dosing protocol, would result in a desirable caloric intake within 24 hours without causing hyperglycemia. Methods: In our surgical intensive care unit (ICU), glucose is regulated by a nurse‐centered computerized glucose regulation program. When adequate enteral feeding was not possible, PN was initiated according to a simple step‐up rule at an infusion rate of 10 mL/h (approximately 10 kcal/h) and subsequently increased by steps of 10 mL/h every 4 hours, provided glucose was <10 mmol/L, until the target caloric intake (1 kcal/kg/h) was reached. All glucose levels and insulin doses were collected during the step‐up period and for 24 hours after achieving target feeding. Results: In all 23 consecutive patients requiring PN, mean intake was 1 kcal/kg/h within 24 hours. Of the 280 glucose samples during the 48‐hour study period, mean ± standard deviation glucose level was 7.4 ± 1.4 mmol/L. Only 4.5% of glucose measurements during the step‐up period were transiently ≥10 mmol/L. After initiating PN, the insulin requirement rose from 1.1 ± 1.5 units/h to 2.9 ± 2.5 units/h (P < .001). Conclusions: This proof of concept study shows that rapid initiation of PN using a step‐up approach coupled with computerized glucose control resulted in adequate caloric intake within 24 hours while maintaining adequate glycemic control.

Fatores de risco associados í glicemia instável em pacientes crí­ticos: revisão integrativa da literatura

“…A nutrição dos pacientes críticos também influencia na variação glicêmica [18,21]. A nutrição enteral é a preferida quando não há contraindicações (como obstrução intestinal, íleo grave ou hipoperfusão do trato gastrointestinal), por ser mais fisiológica, associada a menos complicações infecciosas e a uma elevação dos níveis de glicose do sangue menos dramática do que a nutrição parenteral [2].…”

Yoğun Bakim Hastalarinin Monitorizasyonunda Gelişmeler

“…Buna ilave olarak bilgisayarlı sistemler hemşire ve doktorların iş zamanını, hedef glisemiye ulaşma zamanını ve hipo ve hiperglisemi başlama zamanını azaltmaya olanak sağlar (33). Örneğin, bir pilot çalışma daha önceden belirlenmiş bir protokole göre PB'nin kademeli olarak arttırılması sırasında hemşire-merkezli bilgisayar-destekli glisemi düzenlenme-sinin 24 saat içinde yeterli kalori alımı ile birlikte yeterli glisemik kontrol sağlayacağını öne sürmüştür (34). Son dönemdeki makaleler yoğun insülin tedavisi ve sıkı glisemik kontrol için fizyolojik ve pratik matematik modelleri geliştirmiştir (10,35).…”

Monitoring in the Intensive Care

“…In addition, computerized systems allow reducing nurses and physicians work time, time to reach the targeted glycaemia and the onset of hypo- and hyperglycaemia [172, 181]. For example, a pilot study suggests that nurse-centered computer-assisted glycemia regulation during stepwise increases of PN according to a predefined protocol resulted in adequate caloric intake within 24 hours together with an adequate glycaemic control [182]. Recent articles develop physiological and practical mathematical models for intensive insulin therapy and tight glycaemic control [183, 184].…”