Management of Hospitalized Hyperglycemic Patients – Medical Nutrition Therapy

Chair:
Karmeen Kulkarni, MS, RD, BC-ADM, CDE

Panel:
M Patricia Fuhrman, MS, RD, BC-ADM, CDE
Pam Charney, MS, RD, CDE
Betsy Bohannon, MS, RD, CDE, BC-ADM

Considerations for the management of hyperglycemia in the hospital were addressed in this session. Specific concerns related to parenteral, enteral, and oral nutrition were discussed. The overall goals of medical nutrition therapy is a hospital setting include providing adequate nutrition, supporting metabolic processes, reducing and/or preventing complications, promoting wound healing, and promoting recovery.

In terms of parenteral nutrition, there are a variety of complicating factors, including infections, fluids and electrolytes, GI issues, and hyperglycemia. There are many potential causes of hyperglycemia, including overfeeding, use of clear liquids, medications, aging, infection, obesity, diabetes mellitus, metabolic stress, pancreatitis, and numerous others. Hyperglycemia, in turn, is associated with numerous other negative effects, including oxidative stress, challenges with hydration, immune dysfunction, impaired wound healing, and, insulin resistance. Although it is clearly important to manage hyperglycemia in hospitalized patients, no hard and fast guidelines exist. Clinical research has demonstrated that control of hyperglycemia is associated with less mortality and morbidity and improved wound healing. ADA guidelines recommend a goal of < 110 mg/dL. Although tight glycemic control may raise concerns regarding hypoglycemia, several major studies including the DIGAMI study have demonswtrated no serious hypoglycemia with tight control in a hospital setting. Use of insulin infusion is also optimal in this setting.

When managing enteral nutrition, important factors to consider include patient selection, most appropriate route of access, most appropriate formula, and whether goals are being met. GI function should be evaluated to inform decisions regarding route, and risk of aspiration should also be assessed. If feeding into the stomach, high fat and fiber formulas should be avoided due to slower emptying speed. Formula choice should be individualized within specific medical parameters. Prior to initiating feeding, good control should be established (150 mg/dL or less). Insulin should be adjusted as feeding increases, and plans should be made for dealing with unscheduled feeding interruptions. Feeding initiatiation should be at a rate of 50-70 ml/hr, slower if glucose levels are erratic. When making the transition from insulin infusion to subcutaneous insulin administration, insulin needs can be estimated from insulin required on the previous day, with approximately 50% of insulin being given as basal and 50% used to cover feedings.

When managing the transition from enteral nutrition to feeding by mouth, it is important to consider all forms of carbohydrates. Glycemic goals should be < 110 mg/dL for preprandial and < 180 for peak postprandial. Medical nutrition therapy in a hospital setting must be flexible and involve good record keeping. Patients should be encouraged to count carbohydrates, and if they do not know how, they should receive adequate education on this topic. The old “ADA diet" is no longer used, and diets that restrict sugar are not encouraged. The emphasis should be on consistent carbohydrate content, not carbohydrate source or caloric intake. Three to five carbohydrate servings of 15 grams each is recommended, which generally amounts to 1500 to 2000 calories. Finally, continued self management training should be arranged for the patient upon discharge.