title: Provision of balanced nutrition protects against hypoglycemia in the critically ill surgical patient.
abstract: BACKGROUND
  Intensive insulin therapy lowers blood glucose and improves outcomes but increases the risk of hypoglycemia. Typically, insulin protocols require a dextrose solution to prevent hypoglycemia. The authors hypothesized that the provision of balanced nutrition (enteral nutrition [EN] or parenteral nutrition [PN]) would be more protective against hypoglycemia (≤50 mg/dL) than carbohydrate alone.
  
  
  METHODS
  A retrospective analysis was performed of patients treated with intensive insulin therapy and surviving ≥24 hours. The computer-based insulin protocol requires infusion of D10W at 30 mL/h if EN or PN is not provided. Nutrition provision was assessed in 2-hour increments, comparing periods of blood glucose control with and without balanced nutrition. The risk of hypoglycemia for each blood glucose measurement was estimated by multivariable regression.
  
  
  RESULTS
  In total, 66,592 glucose measurements were collected on 1392 patients. Hypoglycemic events occurred in 5.8/1000 glucose tests after 2 hours without balanced nutrition compared to 2.2/1000 tests when balanced nutrition was given in the preceding 2 hours. In multivariable regression models, balanced nutrition was the strongest protective factor against hypoglycemia. Patients who did not receive balanced nutrition in the preceding 2 hours had a 3 times increase in the odds of a hypoglycemic event at their next glucose check (odds ratio = 3.6, P < .001). Providing carbohydrate alone was not protective.
  
  
  CONCLUSIONS
  Balanced nutrition is associated with reduced risk of hypoglycemia. These results suggest that balanced nutrition should be given when insulin therapy is initiated. Future studies should evaluate the efficacy of EN vs PN in preventing hypoglycemia.
authors.affiliation: Division of Trauma and Surgical Critical Care, Department of Surgery, Vanderbilt University Medical Center, Nashville, Tennessee 37212, USA. rondi.kauffmann@vanderbilt.edu
authors.forename: Rondi M
authors.initials: RM
authors.lastname: Kauffmann
authors.forename: Rachel M
authors.initials: RM
authors.lastname: Hayes
authors.forename: Judith M
authors.initials: JM
authors.lastname: Jenkins
authors.forename: Patrick R
authors.initials: PR
authors.lastname: Norris
authors.forename: Jose J
authors.initials: JJ
authors.lastname: Diaz
authors.forename: Addison K
authors.initials: AK
authors.lastname: May
authors.forename: Bryan R
authors.initials: BR
authors.lastname: Collier
mesh_terms: D000328:Adult; D000368:Aged; D001786:Blood Glucose / Q000378:metabolism*; D016638:Critical Illness / Q000628:therapy*; D004032:Diet; D004040:Dietary Carbohydrates / Q000494:pharmacology; D005260:Female; D006801:Humans; D007003:Hypoglycemia / Q000139:chemically induced / Q000517:prevention & control*; D007328:Insulin / Q000009:adverse effects* / Q000627:therapeutic use; D008297:Male; D008875:Middle Aged; D015999:Multivariate Analysis; D009752:Nutritional Status; D018529:Nutritional Support; D010288:Parenteral Nutrition; D012189:Retrospective Studies
chemical_list: D001786:Blood Glucose; D004040:Dietary Carbohydrates; D007328:Insulin