Predictors of insulin requirements among hospitalized adults receiving parenteral nutrition.

OBJECTIVE: The objective of this quality improvement project was to determine factors predictive of parenteral nutrition (PN) insulin therapy. METHODS: Patients receiving PN at a tertiary care academic medical center between January 1, 2009, and December 1, 2012, 18 years or older were included. Variables collected included demographics, medical information, and PN-specific data. χ(2) and Student t tests were used to determine differences between patients who did and did not require PN insulin. Odds ratios (ORs) with 95% confidence intervals (CIs) were used to determine associations between characteristics. Stepwise forward logistic regression was used determine the best predictors of PN insulin. RESULTS: A total of 1388 patients were started on PN. After adjusting for potential confounders, strong associations existed between PN insulin requirements and diabetes mellitus (DM) diagnosis (OR, 8.90; 95% CI, 4.98-15.90, P < .001), overweight/obese status (body mass index ≥25.0 kg/m(2)) (OR, 2.12; 95% CI, 1.04-4.30, P = .04), intensive care unit (ICU) admission (OR, 1.79; 95% CI, 1.03-3.11, P = .04), blood glucose (BG) on day of PN start >120 mg/dL (OR, 2.32; 95% CI, 1.32-4.05, P = .003), mean BG >180 mg/dL while receiving PN (OR, 6.10; 95% CI, 2.18-17.04, P = .001), and hemoglobin A1c (A1c) ≥5.7% (OR, 3.18; 95% CI, 1.84-5.50, P < .001). Among variables available at PN initiation, DM diagnosis (P < .001), A1c ≥5.7% (P < .001), BG >120 mg/dL on PN start day (P < .001), and ICU admission (P < .001) predicted the need for PN insulin.

Risk factors for predicting hypoglycemia in patients receiving concomitant parenteral nutrition and insulin therapy.

The occurrence of hypoglycemia in patients receiving parenteral nutrition (PN) is low, yet its consequences can be detrimental. Treatment of hyperglycemia with insulin to achieve optimal blood glucose control is challenging and potentially associated with increased risk of the development of hypoglycemia. The objective of this study was to determine the association of patient characteristics on the risk of hypoglycemia among patients receiving concomitant PN and insulin therapy. This retrospective cohort study was conducted from January 1, 2008, to December 31, 2011, and included 1,657 patients who received PN. There was a significant decrease in the occurrence of hypoglycemia observed over time: 9.1% (43 of 475) in 2008, 6.4% (30 of 468) in 2009, 5.8% (20 of 347) in 2010, and 3.5% (13 of 367) in 2011 (P=0.013). Patients in whom hypoglycemia developed had a significantly longer duration on PN (18.0 vs 8.1 days, P<0.0001) as well as more days requiring insulin in the PN (16.1 vs 2.7 days, P<0.0001). The strongest predictors of hypoglycemia were: receiving PN in the ICU (OR 1.86, 95% CI 1.16 to 3.01), history of diabetes (OR 2.10, 95% CI 1.26 to 3.51), days on PN (OR 0.93, 95% CI 0.91 to 0.95), and an insulin drip (OR 3.14, 95% CI 1.81 to 5.42). With the identification of patient factors that contribute to an increase in hypoglycemia, existing protocols can be modified to treat hyperglycemia and prevent hypoglycemia.

Assessing the influence of registered dietitian order-writing privileges on parenteral nutrition use.

Previous studies have examined the influence of a nutrition support team on parenteral nutrition (PN) use; however, the influence of registered dietitian (RD) order-writing privileges on appropriate PN use has yet to be reported. A retrospective cohort was conducted at a single tertiary care urban academic medical center to compare adult PN use before RD order-writing privileges (January 1, 2003 to December 31, 2004, pre-privileges) to after RD order-writing privileges (January 1, 2006 to December 31, 2007, post-privileges). RD order-writing privileges were obtained June 2005; PN patients during the washout period (January 1, 2005 to December 31, 2005) were not included. Descriptive statistics were conducted (N=1,965 patients). Although total hospital admissions increased from the pre-privileges to post-privileges periods (P<0.0001), overall PN use decreased from 1,080 patients during the pre-privileges period to 885 patients during the post-privileges period (P<0.0001). Inappropriate PN use decreased from 482 (45%) to 240 (27%) patients (P<0.0001) during the pre- and post-privileges periods, respectively. Among inappropriate PN use, there was a decrease in PN administration for patients with poor oral intake (130 to 41 patients), pancreatitis (78 to 26 patients), intractable nausea and vomiting (68 to 23 patients), and mucositis (56 to 18 patients; all Ps<0.0003), reflecting a 20% cost savings for PN. No significant differences were found in hospital length of stay, admissions to intensive care units, or other infectious complications between the two periods. RDs with order-writing privileges can decrease inappropriate PN use and costs in a hospital setting. Future studies should continue to highlight the influence of RDs in these advanced practice roles, as well as other members of the nutrition support team, especially with regard to nutrition support delivery and patient outcomes.

Adequacy of oral intake in critically ill patients 1 week after extubation.

Hospital malnutrition is associated with increased morbidity and mortality, particularly among patients admitted to intensive care units (ICUs). The purpose of this observational study (August to November 2007) was to examine the adequacy of oral intake and to identify predictors of oral intake after ICU patients were removed from invasive mechanical ventilation. Patients aged > or = 18 years who required mechanical ventilation for at least 24 hours, advanced to an oral diet postextubation, and did not require supplemental enteral or parenteral nutrition were included. The first 7 days of oral intake after extubation were assessed via modified multiple-pass 24-hour recall and the numbers of days on therapeutic diets and reasons for decreased intake were collected. Oral intake <75% of daily requirements was considered inadequate. Descriptive statistics, chi2, Student t tests, and logistic regression analyses were conducted. Of the 64 patients who met eligibility criteria, 50 were included. Of these 50 patients, 54% were women and intubated for 5.2 days, with a mean age of 59.1 years, body mass index of 28.7, and Acute Physiology and Chronic Health Evaluation II score of 21.9. Subjective Global Assessment determined 44% were malnourished upon admission to the ICU. The average daily energy and protein intake failed to exceed 50% of daily requirements on all 7 days for the entire population. The majority of patients who consumed <75% of daily requirements were prescribed a therapeutic diet and/or identified "no appetite" and nausea/vomiting as the barriers to eating. Although more research is needed, these data call into question the use of restrictive oral diets and suggest that alternative medical nutrition therapies are needed to optimize nutrient intake in this unique patient population.