Nutrition and Hyperglycemia Management in the Inpatient Setting (Meals on Demand, Parenteral, or Enteral Nutrition)

Abstract

Patients with and without diabetes mellitus commonly develop hyperglycemia while receiving EN or PN support, placing them at increased risk of adverse outcomes, including in-hospital mortality. Very little new evidence is available in the form of randomized controlled trials (RCT) to guide the glycemic management of these patients. Reduction in the dextrose concentration within parenteral nutrition as well as selection of an enteral formula that diminishes the carbohydrate exposure to a patient receiving enteral nutrition are common strategies utilized in practice. No specific insulin regimen has been shown to be superior in the management of patients receiving EN or PN nutrition support. For those receiving oral nutrition, new challenges have been introduced with the most recent practice allowing patients to eat meals on demand, leading to extreme variability in carbohydrate exposure and risk of hypo and hyperglycemia. Synchronization of nutrition delivery with the astute use of intravenous or subcutaneous insulin therapy to match the physiologic action of insulin in patients receiving nutritional support should be implemented to improve glycemic control in hospitalized patients. Further RCTs are needed to evaluate glycemic and other clinical outcomes of patients receiving nutritional support. For patients eating meals on demand, development of hospital guidelines and policies are needed, ensuring optimization and coordination of meal insulin delivery in order to facilitate patient safety.

Influence of Hyperglycemia Associated with Enteral Nutrition on Mortality in Patients with Stroke

“…Several factors may influence it as the increase in hepatic glucose production and the decrease in peripheral consumption caused by stress and the high levels of cytokines and stress hormones (glucagon, cortisol, and catecholamines). These patients also have an increase in the glycaemic load associated with artificial nutrition [22]. In the patient with enteral nutrition up to 34.5% develop hyperglycaemia [13].…”

Glycemic Control During Enteral Tube Feeding in Patients with Diabetes Mellitus

“…The diabetes-specific formulas had less carbohydrate content but more fat and fiber content compared to the standard formulas and, therefore, produced slower gastric emptying, slower nutrient assimilation, and less glucose rise [9]. Six years after the JBDS guidelines, several studies are still being performed to assess the optimal feed constituents and optimal insulin regimen to aid glycemic control during ETF [10-12]. These and ongoing studies substantiate the fact that glycemic control is difficult to achieve in patients with diabetes during ETF.…”

15. Diabetes Care in the Hospital: Standards of Medical Care in Diabetes—2021

“…For patients receiving continuous peripheral or central parenteral nutrition, human regular insulin may be added to the solution, particularly if .20 units of correctional insulin have been required in the past 24 h. A starting dose of 1 unit of human regular insulin for every 10 g dextrose has been recommended (84) and should be adjusted daily in the solution. Adding insulin to the parenteral nutrition bag is the safest way to prevent hypoglycemia if the parenteral nutrition is stopped or interrupted.…”