J Korean Diabetes.  2015 Mar;16(1):25-32. 10.4093/jkd.2015.16.1.25.

Parenteral Nutrition Strategies for Achieving Glycemic Control in the Critical Care Setting

  • 1Department of Clinical Pharmacy, College of Pharmacy, Seoul National University, Seoul, Korea. taijino2@snu.ac.kr


Hyperglycemia commonly occurs in acutely ill patients who receive nutritional support, even those without a history of diabetes. A number of observational studies have identified hyperglycemia as a factor independently associated with poor outcome in various critically ill populations. Thus, glycemic control is an important component of metabolic management of the critically ill patient. Avoiding excessive calorie provision, especially carbohydrate calories, is one of the most obvious considerations for nutrition support regimens in terms of glucose control. In adult patients, carbohydrate provision is nearly always less than 4-5 mg/kg/minute. Also, providing lipid calories with parenteral nutrition (PN) helps to avoid excessive amounts of dextrose. There is evidence that, if the rate of lipid infusion remains low (less than 0.11 g/kg/hour), there is minimal risk of immunosuppressive effects. While avoidance of excessive total calories may be the most important aspect of managing nutrition during stress hyperglycemia, there may be some further advantage to hypocaloric feeding in some patients. Determining when to prescribe insulin is a key strategy in preventing hyperglycemia among patients receiving PN. Protocol-directed insulin dosing closely linking insulin to carbohydrate leads to better control of PN-induced hyperglycemia than ad hoc insulin dosing strategies that rely heavily on supplemental insulin.


Critical illness; Hyperglycemia; Hypoglycemia; Insulin; Parenteral nutrition

MeSH Terms

Critical Care*
Critical Illness
Nutritional Support
Parenteral Nutrition*



1. Pasquel FJ, Spiegelman R, McCauley M, Smiley D, Umpierrez D, Johnson R, Rhee M, Gatcliffe C, Lin E, Umpierrez E, Peng L, Umpierrez GE. Hyperglycemia during total parenteral nutrition: an important marker of poor outcome and mortality in hospitalized patients. Diabetes Care. 2010; 33:739–41.
2. Lewis KS, Kane-Gill SL, Bobek MB, Dasta JF. Intensive insulin therapy for critically ill patients. Ann Pharmacother. 2004; 38:1243–51.
3. Van den Berghe G, Wouters P, Weekers F, Verwaest C, Bruyninckx F, Schetz M, Vlasselaers D, Ferdinande P, Lauwers P, Bouillon R. Intensive insulin therapy in critically ill patients. N Engl J Med. 2001; 345:1359–67.
4. Marik PE, Preiser JC. Toward understanding tight glycemic control in the ICU: a systematic review and metaanalysis. Chest. 2010; 137:544–51.
5. Qaseem A, Humphrey LL, Chou R, Snow V, Shekelle P. Clinical Guidelines Committee of the American College of Physicians. Use of intensive insulin therapy for the management of glycemic control in hospitalized patients: a clinical practice guideline from the American College of Physicians. Ann Intern Med. 2011; 154:260–7.
6. McMahon MM, Nystrom E, Braunschweig C, Miles J, Compher C. American Society for Parenteral and Enteral Nutrition (A.S.P.E.N.) Board of Directors; American Society for Parenteral and Enteral Nutrition. A.S.P.E.N. clinical guidelines: nutrition support of adult patients with hyperglycemia. JPEN J Parenter Enteral Nutr. 2013; 37:23–36.
7. Singer P, Berger MM, Van den Berghe G, Biolo G, Calder P, Forbes A, Griffiths R, Kreyman G, Leverve X, Pichard C, ESPEN . ESPEN Guidelines on Parenteral Nutrition: intensive care. Clin Nutr. 2009; 28:387–400.
8. Mechanick JI. Metabolic mechanisms of stress hyperglycemia. JPEN J Parenter Enteral Nutr. 2006; 30:157–63.
9. Ling Pei-Ra. McCowen KC. Carbohydrates. Gottschlich MM, editor. A.S.P.E.N. Nutrition Support Core Curriculum. Sliver Spring: American Society for Parenteral and Enteral Nutrition;2007. p. p33–47.
10. Bier DM, Brosnan JT, Flatt JP, Hanson RW, Heird W, Hellerstein MK, Jéquier E, Kalhan S, Koletzko B, Macdonald I, Owen O, Uauy R. Report of the IDECG Working Group on lower and upper limits of carbohydrate and fat intake. International Dietary Energy Consultative Group. Eur J Clin Nutr. 1999; 53(Suppl 1):S177–8.
11. Rosmarin DK, Wardlaw GM, Mirtallo J. Hyperglycemia associated with high, continuous infusion rates of total parenteral nutrition dextrose. Nutr Clin Pract. 1996; 11:151–6.
12. Wirtitsch M, Wessner B, Spittler A, Roth E, Volk T, Bachmann L, Hiesmayr M. Effect of different lipid emulsions on the immunological function in humans: a systematic review with metaanalysis. Clin Nutr. 2007; 26:302–13.
13. Mesotten D, Swinnen JV, Vanderhoydonc F, Wouters PJ, Van den Berghe G. Contribution of circulating lipids to the improved outcome of critical illness by glycemic control with intensive insulin therapy. J Clin Endocrinol Metab. 2004; 89:219–26.
14. Wichmann MW, Thul P, Czarnetzki HD, Morlion BJ, Kemen M, Jauch KW. Evaluation of clinical safety and beneficial effects of a fish oil containing lipid emulsion (Lipoplus, MLF541): data from a prospective, randomized, multicenter trial. Crit Care Med. 2007; 35:700–6.
15. Waitzberg DL, Torrinhas RS, Jacintho TM. New parenteral lipid emulsions for clinical use. JPEN J Parenter Enteral Nutr. 2006; 30:351–67.
16. Heller AR, Rössler S, Litz RJ, Stehr SN, Heller SC, Koch R, Koch T. Omega-3 fatty acids improve the diagnosis-related clinical outcome. Crit Care Med. 2006; 34:972–9.
17. Korean Diabetes Association. Treatment guideline for diabetes. 4th ed.Seoul: Gold'Planning and Development;2011. p. p52–7.
18. Grau T, Bonet A, Rubio M, Mateo D, Farré M, Acosta JA, Blesa A, Montejo JC, de Lorenzo AG, Mesejo A. Working Group on Nutrition and Metabolism of the Spanish Society of Critical Care. Liver dysfunction associated with artificial nutrition in critically ill patients. Crit Care. 2007; 11:R10.
19. Hopkins LL Jr, Ransome-Kuti O, Majaj AS. Improvement of impaired carbohydrate metabolism by chromium 3 in manourished infants. Am J Clin Nutr. 1968; 21:203–11.
20. Anderson RA, Polansky MM, Bryden NA, Canary JJ. Supplemental-chromium effects on glucose, insulin, glucagon, and urinary chromium losses in subjects consuming controlled low-chromium diets. Am J Clin Nutr. 1991; 54:909–16.
21. Moukarzel A. Chromium in parenteral nutrition: too little or too much? Gastroenterology. 2009; 137(5 Suppl):S18–28.
22. Vanek VW, Borum P, Buchman A, Fessler TA, Howard L, Jeejeebhoy K, Kochevar M, Shenkin A, Valentine CJ. Novel Nutrient Task Force, Parenteral Multi-Vitamin and Multi–Trace Element Working Group; American Society for Parenteral and Enteral Nutrition (A.S.P.E.N.) Board of Directors. A.S.P.E.N. position paper: recommendations for changes in commercially available parenteral multivitamin and multi-trace element products. Nutr Clin Pract. 2012; 27:440–91.
23. Krenitsky J. Glucose control in the intensive care unit: a nutrition support perspective. Nutr Clin Pract. 2011; 26:31–43.
24. Ahrens CL, Barletta JF, Kanji S, Tyburski JG, Wilson RF, Janisse JJ, Devlin JW. Effect of low-calorie parenteral nutrition on the incidence and severity of hyperglycemia in surgical patients: a randomized, controlled trial. Crit Care Med. 2005; 33:2507–12.
25. Frankenfield DC, Smith JS, Cooney RN. Accelerated nitrogen loss after traumatic injury is not attenuated by achievement of energy balance. JPEN J Parenter Enteral Nutr. 1997; 21:324–9.
26. Heyland DK, Dhaliwal R, Drover JW, Gramlich L, Dodek P. Canadian Critical Care Clinical Practice Guidelines Committee. Canadian clinical practice guidelines for nutrition support in mechanically ventilated, critically ill adult patients. JPEN J Parenter Enteral Nutr. 2003; 27:355–73.
27. Dhaliwal R, Cahill N, Lemieux M, Heyland DK. The Canadian critical care nutrition guidelines in 2013: an update on current recommendations and implementation strategies. Nutr Clin Pract. 2014; 29:29–43.
28. NICE-SUGAR Study Investigators. Finfer S, Chittock DR, Su SY, Blair D, Foster D, Dhingra V, Bellomo R, Cook D, Dodek P, Henderson WR, Hébert PC, Heritier S, Heyland DK, McArthur C, McDonald E, Mitchell I, Myburgh JA, Norton R, Potter J, Robinson BG, Ronco JJ. Intensive versus conventional glucose control in critically ill patients. N Engl J Med. 2009; 360:1283–97.
29. Jacobi J, Bircher N, Krinsley J, Agus M, Braithwaite SS, Deutschman C, Freire AX, Geehan D, Kohl B, Nasraway SA, Rigby M, Sands K, Schallom L, Taylor B, Umpierrez G, Mazuski J, Schunemann H. Guidelines for the use of an insulin infusion for the management of hyperglycemia in critically ill patients. Crit Care Med. 2012; 40:3251–76.
30. Dickerson RN, Maish GO 3rd, Minard G, Brown RO. Nutrition Support Team-Led Glycemic Control Program for Critically Ill Patients. Nutr Clin Pract. 2014; 29:534–41.
31. McDonnell ME, Aprovian CM. Diabetes Mellitus. Gottschlich MM, editor. A.S.P.E.N. Nutrition Support Core Curriculum. Sliver Spring: American Society for Parenteral and Enteral Nutrition;2007. p. p676–94.
32. Jakoby MG, Nannapaneni N. An insulin protocol for management of hyperglycemia in patients receiving parenteral nutrition is superior to ad hoc management. JPEN J Parenter Enteral Nutr. 2012; 36:183–8.
33. Roehl KA, Lach K, Coltman AE, Bacon CA, Singh S, Peterson SJ, Sowa DC. Predictors of insulin requirements among hospitalized adults receiving parenteral nutrition. JPEN J Parenter Enteral Nutr. 2013; 37:755–62.
34. Moghissi ES, Korytkowski MT, DiNardo M, Einhorn D, Hellman R, Hirsch IB, Inzucchi SE, Ismail-Beigi F, Kirkman MS, Umpierrez GE. American Association of Clinical Endocrinologists; American Diabetes Association. American Association of Clinical Endocrinologists and American Diabetes Association consensus statement on inpatient glycemic control. Diabetes Care. 2009; 32:1119–31.
35. Vriesendorp TM, van Santen S, DeVries JH, de Jonge E, Rosendaal FR, Schultz MJ, Hoekstra JB. Predisposing factors for hypoglycemia in the intensive care unit. Crit Care Med. 2006; 34:96–101.
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