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Management of blood glucose and diabetes in critically ill patient receiving enteral feeding. Pamela Charney, et al. Nutrition in Clinical practice 19:129-136, April 2004. 報告者 : 賴美足 93.10.21. Management of blood glucose and diabetes in critically ill patient receiving enteral feeding.

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93 10 21

Management of blood glucose and diabetes in critically ill patient receiving enteral feeding.Pamela Charney, et al. Nutrition in Clinical practice 19:129-136, April 2004.

報告者:賴美足

93.10.21

management of blood glucose and diabetes in critically ill patient receiving enteral feeding
Management of blood glucose and diabetes in critically ill patient receiving enteral feeding.

ˇ1.Mechanics of glucose regulation

2.Evaluation of energy source

3.Selection of enteral formulas and

infusion routes

4.Glycemic control in patients receiving

tube feeding

insulin
Insulin
  • The β-cells secrete 40 to 50 units of insulin daily.
  • Endocrine sensors located in the GI tract signal the pancreas.
  • Parenteral nutrition dose not stimulate the early insulin secretion. (∵dextrose bypasses the GI tract)
glucagon
Glucagon
  • The liver is the main site of glucagon action.
  • In the fasting, blood glucose is maintained via hepatic gluconeogenesis and glycogenolysis.
  • Lipolysis and ketogenesis are also stimulated by glucagon.
catecholamines epinephrine and norepinephrine
Catecholamines epinephrine and norepinephrine
  • Catecholamines epinephrine and norepinephrine act in the periphery to stimulate muscle glycogenolysis.
during stress or illness hyperglycemia may cause by
During stress or illness, hyperglycemia may cause by:

Stress、illness

Cytokines、Inflammatory mediators

Increased gluconeogenesis、

Insulin resistance

hyperglycemia

management of blood glucose and diabetes in critically ill patient receiving enteral feeding8
Management of blood glucose and diabetes in critically ill patient receiving enteral feeding.

1.Mechanics of glucose regulation

ˇ2.Evaluation of energy source

3.Selection of enteral formulas and

infusion routes

4.Glycemic control in patients receiving

tube feeding

diet and diabetes the energy substrate controversy
Diet and diabetes: the energy substrate controversy
  • Monounsaturated fatty acids
  • Alternate carbohydrate sources
monounsaturated fatty acids
Monounsaturated fatty acids
  • 30% of total calories as MUFA have improvement in lipoprotein and glycemic control in DM patients.
  • High MUFA diet and low GI diet had similar impact on PC glucose in IGT patients.
alternate carbohydrate sources
Alternate carbohydrate sources
  • Fructose
  • Modifying starch
  • Fructooligosaccharides (FOS)
  • Induced-viscosity complexes
  • Natural glucose-lowering agents
fructose gi of fructose 19
Fructose (GI of fructose=19)
  • Small dose (5~10g) : eg, a piece of fruit

beneficial for reducing the acute. postprandial glycemic response. (fig 1.)

  • Large dose (50g) :

increase serum TG.

malabsorptive diarrhea and intolerance.

only small dose had the effect of lower glucose level.

slide13

Figure 1. The effect of fructose on the release of glucokinase from its regulatory protein in the hepatocyte. GKRP, glucokinase regulatory protein.

Glucose

Fructose

Fructokinase

Fructose-1-phosphate

Glucose-6-phosphate

Glucose

Inactive glucokinase

Activeglucokinase

Fructose-6-phosphate

Fructose-6-phosphate

GKRP

GKRP

Nucleus

Glycolysis

Cytosol

modifying starch
Modifying starch
  • Slowly digested
  • Raw corn starch: cannot be added to liquid formulas. (∵high temp. gelatinization, increase digestibility)
  • OSA-esrerified starch (1-octenyl succinic anhydride-esterified starch): reduced PC glucose. (heat stable, slowly digested)
fos fructooligosaccharides
FOS (Fructooligosaccharides)
  • Not absorbed from the small intestine no increase in PC glucose.
  • As a prebiotic for healthy bacteria in the large intestine.
induced viscosity complexes
Induced-viscosity complexes
  • Lower glycemia similar to soluble dietary fibers.
  • Outside the body: free-flowing, low-viscosity solution
  • In the GI tract: increase viscosity. (∵acid and amylase)
  • Can reduce the tube clogging that occurs with fiber-containing formulas.
natural glucose lowering agents
Natural glucose-lowering agents
  • American ginseng
  • Organic acid (lactic and acetic acids)
  • Fenugreek seeds
  • Clausena anisata extract
management of blood glucose and diabetes in critically ill patient receiving enteral feeding18
Management of blood glucose and diabetes in critically ill patient receiving enteral feeding.

1.Mechanics of glucose regulation

2.Evaluation of energy source

ˇ3.Selection of enteral formulas and

infusion routes

4.Glycemic control in patients receiving

tube feeding

enteral formula selection
Enteral formula selection
  • Most “standard” polymeric formulas can be used.
  • For critically ill patients, total calorie may be more importance.
  • Overfeeding should be avoid. (↑insulin requirement)
  • Special formulas specific for DM patients. (↑MUFA, ↓CHO)
  • Most formulas do not contain >15g fiber per liter. (viscosity↑)
enteral formula infusion continuous vs intermittent feeding
Enteral formula infusion: continuous vs intermittent feeding
  • Continuous feeding allows for improved blood glucose control.
  • Postpyloric feeding be used in patient who have a history of gastroparesis or are at risk for developing delayed gastric emptying.
  • Postpyloric feedings should be initiated on a continuous basis.
management of blood glucose and diabetes in critically ill patient receiving enteral feeding22
Management of blood glucose and diabetes in critically ill patient receiving enteral feeding.

1.Mechanics of glucose regulation

2.Evaluation of energy source

3.Selection of enteral formulas and

infusion routes

ˇ4.Glycemic control in patients receiving

tube feeding

goals for glycemic control during enteral feeding
Goals for glycemic control during enteral feeding
  • As close to normal as possible.
  • Hyperglycemia ↑risk of infection.
  • A prospective, randomized, controlled trial comparing standard care vs tight blood glucose control in surgical ICU patients showed that morbidity and mortality were significantly reduced if blood glucose goals were set at 110 mg/dL or lower.
  • Avoidance of hypoglycemia is important.
serum glucose goals
Serum glucose goals
  • Critically ill patients : 80~120 mg/dl
  • Non-critically ill patients: 100~150 mg/dl
effects of hypoglycemia 60mg dl
Effects of hypoglycemia(≦60mg/dl)
  • Adrenergic:

sweating, palpitations, anxiety, tachycardia, hunger.

  • Neuroglycopenic:

headache, visual change, seizures, confusion.

slide26
Treatment of hypoglycemia in hospitalized adult patients treated with insulin or oral diabetic agents

I. Presumed symptomatic hypoglycemia should be treated without waiting to check plasma or blood glucose level.

A. if the patient is able to swallow safely, administer ~15g of

CHO in one of the following forms:

1. 5 sugar packets dissolved in 4 ounces (1/2cup) of water.

2. 4 ounces (1/2cup) of fruit juice.

3. glucose oral gel (glucose 15) 15g orally must be used for

those receiving Acarbose (Precose) or Miglitol (Glyset).

B. if the patient has a functioning feeding tube, administer one

of the following by feeding tube:

1. 4 ounces (1/2cup) of fruit juice. (not orange juice or

other pulp-containing juice)

2. 5 sugar packets dissolved in 4 ounces (1/2cup) of water.

slide27
Treatment of hypoglycemia in hospitalized adult patients treated with insulin or oral diabetic agents (續)

C. if the patient is not able to take oral feeding or is NPO:

1. if IV access is available, administer D50W 25ml (12.5g).

2. if no IV access is present, administer Glucagon 1mg by

subcutaneous injection. After glucogen treatment, for

those patients who are not NPO, provide a snack in

order to prevent subsequent hypoglycemia.

D. contact either the primary service or the diabetes consulting service, whichever is responsible for the patient’s diabetes management.

slide28
Treatment of hypoglycemia in hospitalized adult patients treated with insulin or oral diabetic agents (續)

II. For treatment of asympomatic hypoglycemia (glucose ≦60mg/dl), follow steps A through C above.

III. Glucose monitoring after treatment:

measure reflectance meter glucose in 15 minutes. If glucose level is not >80mg/dl, repeat the treatment outlined above. Recheck the glucose level in 15 minutes. Repeat further treatment (and glucose checks at 15 minutes intervals) until the glucose level is >80mg/dl.

hyperglycemia and hypoglycemia common causes
hyperglycemia and hypoglycemia: common causes
  • Hyperglycemia:

Illness/infection, Overfeeding, Medications, Insufficient insulin, Volume depletion

  • Hypoglycemia:

excess insulin dose, severe stress, renal dysfunction, severe hepatitis, sepsis, diabetic gastroparesis

glycemic management during enteral feeding
Glycemic management during enteral feeding
  • Type 1 DM patient: Basal insulin should be provided with CHO, even during periods of no oral intake.
  • Renal dysfunction patients: OHA may be contraindicated in critical.
  • 50% of preillness insulin requirements during initiation of feeding.
  • “Sliding scale” + basal insulin
conclusion
Conclusion
  • Special formulas for DM have not shown improved outcomes when compared with standard formulas.
  • Close monitoring and judicious use of insulin are keys to maintaining control and avoiding complications.
reference
Reference

M. Molly McMahon.

Management of parenteral nutrition in acutely ill patients with hyperglycemia.

Nutrition in Clinical practice 19:120-128, April 2004.