Nutr Res Pract.  2011 Oct;5(5):450-454.

Higher dextrose delivery via TPN related to the development of hyperglycemia in non-diabetic critically ill patients

• Lee H
• Koh SO
• Park MS

Abstract

The beneficial effects of total parenteral nutrition (TPN) in improving the nutritional status of malnourished patients during hospital stays have been well established. However, recent randomized trials and meta-analyses have reported an increased rate of TPN-associated complications and mortality in critically ill patients. The increased risk of complications during TPN therapy has been linked to the development of hyperglycemia, especially during the first few days of TPN therapy. This retrospective study was conducted to determine whether the amount of dextrose from TPN in the 1st week in the intensive care unit (ICU) was related to the development of hyperglycemia and the clinical outcome. We included 88 non-diabetic critically ill patients who stayed in the medical ICU for more than two days. The subjects were 65 +/- 16 years old, and the mean APACHE (Acute Physiology and Chronic Health Evaluation) II score upon admission was 20.9 +/- 7.1. The subjects received 2.3 +/- 1.4 g/kg/day of dextrose intravenously. We divided the subjects into two groups according to the mean blood glucose (BG) level during the 1st week of ICU stay: < 140 mg/dl vs > or = 140 mg/dl. Baseline BG and the amount of dextrose delivered via TPN were significantly higher in the hyperglycemia group than those in the normoglycemia group. Mortality was higher in the hyperglycemia group than in the normoglycemia group (42.4% vs 12.8%, P = 0.008). The amount of dextrose from TPN was the only significant variable in the multiple linear regression analysis, which included age, APACHE II score, baseline blood glucose concentration and dextrose delivery via TPN as independent variables. We concluded that the amount of dextrose delivered via TPN might be associated with the development of hyperglycemia in critically ill patients without a history of diabetes mellitus. The amount of dextrose in TPN should be decided and adapted carefully to maintain blood glucose within the target range.

Keyword

Hyperglycemia; dextrose; parenteral nutrition; critically ill; non-diabetic

MeSH Terms

APACHE
Blood Glucose
Critical Illness
Diabetes Mellitus
Glucose
Humans
Hyperglycemia
Intensive Care Units
Length of Stay
Linear Models
Nutritional Status
Parenteral Nutrition
Parenteral Nutrition, Total
Retrospective Studies
Blood Glucose
Glucose

Figure

• 

  Fig. 1 Amount of carbohydrate delivery via TPN and EN. We divided the subjects into two groups according to the mean blood glucose level during the first week of ICU care: < 140 mg/dl, normoglycemia group vs ≥ 140 mg/dl, hyperglycemia group. TPN, total parenteral nutrition; EN, enteral nutrition

Reference

1. Heyland DK, Montalvo M, MacDonald S, Keefe L, Su XY, Drover JW. Total parenteral nutrition in the surgical patient: a meta-analysis. Can J Surg. 2001. 44:102–111.

2. der Voort PH, Feenstra RA, Bakker AJ, Heide L, Boerma EC, van der Horst IC. Intravenous glucose intake independently related to intensive care unit and hospital mortality: an argument for glucose toxicity in critically ill patients. Clin Endocrinol (Oxf). 2006. 64:141–145.

3. McClave SA, Martindale RG, Vanek VW, McCarthy M, Roberts P, Taylor B, Ochoa JB, Napolitano L, Cresci G. A.S.P.E.N. Board of Directors. American College of Critical Care Medicine. Society of Critical Care Medicine. Guidelines for the Provision and Assessment of Nutrition Support Therapy in the Adult Critically Ill Patient: Society of Critical Care Medicine (SCCM) and American Society for Parenteral and Enteral Nutrition (A.S.P.E.N.). JPEN J Parenter Enteral Nutr. 2009. 33:277–316.

4. 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.

5. Cheung NW, Napier B, Zaccaria C, Fletcher JP. Hyperglycemia is associated with adverse outcomes in patients receiving total parenteral nutrition. Diabetes Care. 2005. 28:2367–2371.

6. Heuer JG, Sharma GR, Zhang T, Ding C, Bailey DL, Stephens EJ, Holmes KC, Grubbs RL, Fynboe KA, Chen YF, Jakubowski JA. Effects of hyperglycemia and insulin therapy on outcome in a hyperglycemic septic model of critical illness. J Trauma. 2006. 60:865–872.

7. Rosmarin DK, Wardlaw GM, Mirtallo J. Hyperglycemia associated with high, continuous infusion rates of total parenteral nutrition dextrose. Nutr Clin Pract. 1996. 11:151–156.

8. Lin LY, Lin HC, Lee PC, Ma WY, Lin HD. Hyperglycemia correlates with outcomes in patients receiving total parenteral nutrition. Am J Med Sci. 2007. 333:261–265.

9. 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. 33:739–741.

10. 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 the critically ill patients. N Engl J Med. 2001. 345:1359–1367.

11. Van den Berghe G, Wilmer A, Hermans G, Meersseman W, Wouters PJ, Milants I, Van Wijngaerden E, Bobbaers H, Bouillon R. Intensive insulin therapy in the medical ICU. N Engl J Med. 2006. 354:449–461.

12. Van den Berghe G, Schetz M, Vlasselaers D, Hermans G, Wilmer A, Bouillon R, Mesotten D. Clinical review: Intensive insulin therapy in critically ill patients: NICE-SUGAR or Leuven blood glucose target? J Clin Endocrinol Metab. 2009. 94:3163–3170.

13. Sacks G, Mayhew S, Johnson D. Merrit R, editor. Parenteral nutrition implementation and management. The A.S.P.E.N. Nutrition Support Practice Manual. 2005. 2nd ed. Sliver Spring: American Society for Parenteral and Enteral Nutrition;108–117.

14. McMahon M, Manji N, Driscoll DF, Bistrian BR. Parenteral nutrition in patients with diabetes mellitus: theoretical and practical considerations. JPEN J Parenter Enteral Nutr. 1989. 13:545–553.

15. Trujillo EB, Young LS, Chertow GM, Randall S, Clemons T, Jacobs DO, Robinson MK. Metabolic and monetary costs of avoidable parenteral nutrition use. JPEN J Parenter Enteral Nutr. 1999. 23:109–113.

16. Saalwachter AR, Evans HL, Willcutts KF, O'Donnell KB, Radigan AE, McElearney ST, Smith RL, Chong TW, Schirmer BD, Pruett TL, Sawyer RG. A nutrition support team led by general surgeons decreases inappropriate use of total parenteral nutrition on a surgical service. Am Surg. 2004. 70:1107–1111.

17. Dissanaike S, Shelton M, Warner K, O'Keefe GE. The risk for bloodstream infections is associated with increased parenteral caloric intake in patients receiving parenteral nutrition. Crit Care. 2007. 11:R114.

18. Sheean PM, Freels SA, Helton WS, Braunschweig CA. Adverse clinical consequences of hyperglycemia from total parenteral nutrition exposure during hematopoietic stem cell transplantation. Biol Blood Marrow Transplant. 2006. 12:656–664.

19. Vincent JL, Moreno R. Clinical review: scoring systems in the critically ill. Crit Care. 2010. 14:207.

20. Shin Y, Park S, Choue R. Comparison of time course changes in blood glucose, insulin and lipids between high carbohydrate and high fat meals in healthy young women. Nutr Res Pract. 2009. 3:128–133.

21. Yokoyama J, Someya Y, Yoshihara R, Ishii H. Effects of high-monounsaturated fatty acid enteral formula versus high-carbohydrate enteral formula on plasma glucose concentration and insulin secretion in healthy individuals and diabetic patients. J Int Med Res. 2008. 36:137–146.

22. Pohl M, Mayr P, Mertl-Roetzer M, Lauster F, Lerch M, Eriksen J, Haslbeck M, Rahlfs VW. Glycaemic control in type II diabetic tube-fed patients with a new enteral formula low in carbohydrates and high in monounsaturated fatty acids: a randomised controlled trial. Eur J Clin Nutr. 2005. 59:1221–1232.