Computer-assisted glucose regulation during rapid step-wise increases of parenteral nutrition in critically ill patients: a proof of concept study.
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.
Hoekstra
Miriam
M
Department of Anesthesiology, University Medical Center Groningen, University of Groningen, Groningen, the Netherlands. m.hoekstra@thorax.umcg.nl
Schoorl
Michiel A
MA
van der Horst
Iwan C C
IC
Vogelzang
Mathijs
M
Wietasch
J K Götz
JK
Zijlstra
Felix
F
Nijsten
Maarten W N
MW
D000328:Adult; D000368:Aged; D001786:Blood Glucose / Q000378:metabolism*; D003422:Critical Care / Q000379:methods; D016638:Critical Illness / Q000628:therapy*; D004360:Drug Therapy, Computer-Assisted; D002149:Energy Intake; D005260:Female; D005947:Glucose / Q000008:administration & dosage*; D006801:Humans; D006943:Hyperglycemia / Q000209:etiology / Q000517:prevention & control*; D007328:Insulin / Q000627:therapeutic use*; D008297:Male; D008875:Middle Aged; D010288:Parenteral Nutrition / Q000379:methods*; D036301:Qualitative Research
D001786:Blood Glucose; D007328:Insulin; D005947:Glucose