title: Computer-assisted glucose regulation during rapid step-wise increases of parenteral nutrition in critically ill patients: a proof of concept study.
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.
authors.affiliation: Department of Anesthesiology, University Medical Center Groningen, University of Groningen, Groningen, the Netherlands. m.hoekstra@thorax.umcg.nl
authors.forename: Miriam
authors.initials: M
authors.lastname: Hoekstra
authors.forename: Michiel A
authors.initials: MA
authors.lastname: Schoorl
authors.forename: Iwan C C
authors.initials: IC
authors.lastname: van der Horst
authors.forename: Mathijs
authors.initials: M
authors.lastname: Vogelzang
authors.forename: J K Götz
authors.initials: JK
authors.lastname: Wietasch
authors.forename: Felix
authors.initials: F
authors.lastname: Zijlstra
authors.forename: Maarten W N
authors.initials: MW
authors.lastname: Nijsten
mesh_terms: 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
chemical_list: D001786:Blood Glucose; D007328:Insulin; D005947:Glucose