Citation Information :
Mithal A, P Kulkarni A, Reddy BR, Sharma J, Sivakumar M, Bathina H, Chakravarti S, Joshi A. Practice Guidelines for Enteral Nutrition Management in Dysglycemic Critically Ill Patients: A Relook for Indian Scenario. Indian J Crit Care Med 2019; 23 (12):594-603.
Background and aim: Intensive-care practices and settings differ for India in comparison to other countries. While guidelines are available to direct the use of enteral nutrition (EN), there are no recommendations specific to nutritional management of EN in dysglycemic patients, specific to patients in Indian critical care settings. Advisory board meetings were arranged to develop the practice guidelines specific to the Indian context, for the use of EN in dysglycemic critically ill patients and to overcome challenges in this field.
Materials and methods: Two advisory board meetings were organized to review various existing guidelines, meta-analyses, randomized controlled trials (RCTs), controlled trials and review articles, for their contextual relevance and strength. Three rounds of Delphi voting were done to arrive at consensus on certain recommendations. A systematic grading of practice guidelines by the advisory board was done based on strength of the consensus voting and reviewed supporting evidences.
Results: Based on the literature review, the recommendations for developing the practice guidelines were made as per the grading criteria agreed upon by the advisory board. The recommendations were to address challenges regarding prediction and assessment of dysglycemia (DG), acceptable glycemic targets in such settings, general nutritional aspects pertaining to DG nutrition, and nutrition in various superspecialty cases in critical care settings, where DG is commonly encountered.
Conclusion: This paper summarizes the optimum EN practices for managing DG in critically ill patients. The practical solutions to overcome the challenges in this field are presented as practice guidelines at the end of each section. These guidelines are expected to provide guidance for EN management in dysglycemic critically ill patients. These guidelines also outline the model glycemic control task force and its roles in nutrition care as well as an intensive care unit DG nutrition protocol.
Mehta Y, Sunavala JD, Zirpe K, Tyagi N, Garg S, Sinha S, et al. Practice guidelines for nutrition in critically ill patients: a relook for Indian scenario. Indian J Crit Care Med 2018;22(4):263–273. DOI: 10.4103/ijccm.IJCCM_3_18.
Janssen PG, Gorter KJ, Stolk RP, Rutten GE. Low yield of population-based screening for type 2 diabetes in the Netherlands: the ADDITION Netherlands study. Fam Pract 2007;24(6):555–561. DOI: 10.1093/fampra/cmm052.
Malcolm JC, Kocourek J, Keely E, Feibel RJ, Brez S, Forster AJ, et al. Implementation of a screening program to detect previously undiagnosed dysglycemia in hospitalized patients. Can J Diabetes 2014;38(2):79–84. DOI: 10.1016/j.jcjd.2014.02.005.
Tekumit H, Cenal AR, Polat A, Uzun K, Tataroglu C, Akinci E. Diagnostic value of hemoglobin A1c and fasting plasma glucose levels in coronary artery bypass grafting patients with undiagnosed diabetes mellitus. Ann Thorac Surg 2010;89(5):1482–1487. DOI: 10.1016/j.athoracsur.2009.11.033.
Moghissi ES, Korytkowski MT, DiNardo M, Einhorn D, Hellman R, Hirsch IB, et al. American Association of Clinical Endocrinologists and American Diabetes Association Consensus Statement on Inpatient Glycaemic Control. Diabetes Care 2009;32(6):1119–1131. DOI: 10.2337/dc09-9029.
Dhatariya K, Levy N, Kilvert A, Watson B, Cousins D, Flanagan D, et al. NHS diabetes guideline for the perioperative management of the adult patient with diabetes. Diabet Med 2012;29(4):420–433. DOI: 10.1111/j.1464-5491.2012.03582.x.
Panikar V, Sosale A, Agarwal S, Unnikrishnan A, Kalra S, Bhattacharya A, et al. RSSDI clinical practice recommendations for management of in-hospital hyperglycaemia—2016. Int J Diabetes Dev Ctries 2016;36(Suppl 1):S1–S21. DOI: 10.1007/s13410-016-0528-z.
Jehan F, Khan M, Sakran JV, Khreiss M, O'Keeffe T, Chi A, et al. Perioperative glycemic control and postoperative complications in patients undergoing emergency general surgery: what is the role of Plasma Hemoglobin A1c? J Trauma Acute Care Surg 2018;84(1):112–117. DOI: 10.1097/TA.0000000000001724.
Finkielman JD, Oyen LJ, Afessa B. Agreement between bedside blood and plasma glucose measurement in the ICU setting. Chest 2005;127(5):1749–1751. DOI: 10.1378/chest.127.5.1749.
Monnier L, Mas E, Ginet C, Michel F, Villon L, Cristol JP, et al. Activation of oxidative stress by acute glucose fluctuations compared with sustained chronic hyperglycaemia in patients with type 2 diabetes. JAMA 2006;295(14):1681–1687. DOI: 10.1001/jama.295.14.1681.
Monnier L, Colette C, Owens DR. Glycemic variability: the third component of the dysglycemia in diabetes. Is it important? How to measure it? J Diabetes Sci Technol 2008;2(6):1094–1100. DOI: 10.1177/193229680800200618.
Braithwaite SS. Glycemic variability in hospitalized patients: choosing metrics while awaiting the evidence. Curr Diab Rep 2013;13(1): 138–154. DOI: 10.1007/s11892-012-0345-9.
Eslami S, Taherzadeh Z, Schultz MJ, Abu-Hanna A. Glucose variability measures and their effect on mortality: a systematic review. Intensive Care Med 2011;37(4):583–593. DOI: 10.1007/s00134-010-2129-5.
Krinsley JS, Preiser JC. Time in blood glucose range 70 to 140 mg/dl >80% is strongly associated with increased survival in non-diabetic critically ill adults. Crit Care 2015;19:179. DOI: 10.1186/s13054-015-0908-7.
Sim MA, Liu W, Chew STH, Ti LK. Wider perioperative glycaemic fluctuations increase risk of postoperative atrial fibrillation and ICU length of stay. PLoS One 2018;13(6):e0198533. DOI: 10.1371/journal.pone.0198533.
Rao PV, Makkar BM, Kumar A, Das AK, Singh AK, Mithal A, et al. RSSDI consensus on self-monitoring of blood glucose in types 1 and 2 diabetes mellitus in India. Int J Diabetes Dev Countries 2018;38(3):260–279. DOI: 10.1007/s13410-018-0677-3.
Rodbard HW, Blonde L, Braithwaite SS, Brett EM, Cobin RH, Handelsman Y, et al. American Association of Clinical Endocrinologists medical guidelines for clinical practice for the management of diabetes mellitus. Endocr Pract 2007;13(Suppl 1):1–68. DOI: 10.4158/EP.13.S1.1.
Van den Berghe G, Schetz M, Vlasselaers D, Hermans G, Wilmer A, Bouillon R, et al. Clinical review: intensive insulin therapy in critically ill patients: NICE-SUGAR or Leuven blood glucose target? J Clin Endocrinol Metab 2009;94(9):3163–3170. DOI: 10.1210/jc.2009- 0663.
Van den Berghe G. How does blood glucose control with insulin save lives in intensive care? J Clin Invest 2004;114(9):1187–1195. DOI: 10.1172/JCI23506.
Van den Berghe G, Wilmer A, Hermans G, Meersseman W, Wouters PJ, Milants I, et al. Intensive insulin therapy in the medical ICU. N Engl J Med 2006;354(5):449–461. DOI: 10.1056/NEJMoa052521.
NICE-SUGAR Study Investigators, Finfer S, Chittock DR, Su SY, Blair D, Foster D, et al. Intensive versus conventional glucose control in critically ill patients. N Engl J Med 2009;360(13):1283–1297. DOI: 10.1056/NEJMoa0810625.
Sathya B, Davis R, Taveira T, Whitlatch H, Wu W-C. Intensity of peri-operative glycemic control and postoperative outcomes in patients with diabetes: a meta-analysis. Diabetes Res Clin Pract 2013;102(1): 8–15. DOI: 10.1016/j.diabres.2013.05.003.
American Diabetes Association. Diabetes Care in the Hospital: Standards of Medical Care in Diabetes-2019. Diabetes Care 2019;42(Suppl 1):S173–S181. DOI: 10.2337/dc19-S015.
Kozier B, Eeb G, Berman A, Burkc K. Fundamentals of Nursing-Concepts, Process and Practice, 6th ed., New York, Upper Saddle River: Prentice-Hall; 2000.
Stefanogiannis N, Lawes CM, Turley M, Tobias M, Hoorn SV, Mhurchu CN, et al. Nutrition and the burden of disease in New Zealand: 1997–2011. Public Health Nutr J 2005;8(4):395–401. DOI: 10.1079/PHN2004694.
Heyland DK, Schroter-Noppe D, Drover J, Jain M, Keefe L, Dhalwal R, et al. Nutrition support in the critical care setting: current practice in Canadian ICUs–opportunities for improvement? JPEN J Parenter Enteral Nutr 2003;27(1):74–83. DOI: 10.1177/014860710302700174.
Rolandelli RH. Clinical Nutrition: Enteral and tube feeding, 4th ed., Philadelphia: Elseviers Sanders; 2005; p. 244.
Duggan CH, Watkins J, Walkers W. Nutrition in pediatrics basic science. Clinical Application, 4th ed. Hamilton, Ontario: BC Decker Inc.; 2008.
Shahriari M, Rezaei E, Bakht LA, Abbasi S. Comparison of the effects of enteral feeding through the bolus and continuous methods on blood sugar and prealbumin levels in ICU inpatients. J Educ Health Promot 2015;4:95. DOI: 10.4103/2277-9531.171809.
Jenkins DJA, Wolever TMS, Taylor RH, Barker H, Fielden H, Baldwin JM, et al. Glycaemic index of foods: a physiological basis for carbohydrate exchange. Am J Clin Nutr 1981;34(3):362–366. DOI: 10.1093/ajcn/34.3.362.
Brand-Miller J, Hayne S, Petocz P, Colagiuri S. Low-glycemic index diets in the management of diabetes. Diabetes Care 2003;26(8): 2261–2267. DOI: 10.2337/diacare.26.8.2261.
Levitan EB, Cook NR, Stampfer MJ, Ridker PM, Rexrode KM, Buring JE, et al. Dietary glycaemic index, dietary glycaemic load, blood lipids, and C-reactive protein. Metabolism 2008;57(3):437–443. DOI: 10.1016/j.metabol.2007.11.002.
American Diabetes Association. Nutrition principles and recommendations in diabetes. Diabetes Care 2008;31(Suppl 1): S61–S78. DOI: 10.2337/dc08-S061.
Jenkins DJA, Kendall CW, Augustin LS, Franceschi S, Hamidi M, Marchie A, et al. Glycemic index: overview of implications in health and disease. Am J Clin Nutr 2002;76(1):266S–273S. DOI: 10.1093/ajcn/76.1.266S.
Sieri S, Brighenti F, Agnoli C, Grioni S, Masala G, Bendinelli B, et al. Dietary glycemic load and glycemic index and risk of cerebrovascular disease in the EPICOR cohort. PLoS One 2013;8(5):e62625. DOI: 10.1371/journal.pone.0062625.
https://www.gisymbol.com/about-glycemic-index/, accessed on 19-08-2019.
Sieri S, Krogh V, Berrino F, Evangelista A, Agnoli C, Brighenti F, et al. Dietary glycaemic load and index and risk of coronary heart disease in a large Italian cohort: the EPICOR study. Arch Intern Med 2010;170(7):640–647. DOI: 10.1001/archinternmed.2010.15.
Farvid MS, Homayouni F, Shokoohi M, Fallah A, Farvid MS. Glycemic index, glycemic load and their association with glycemic control among patients with type 2 diabetes. Eur J Clin Nutr 2014;68(4):459–463. DOI: 10.1038/ejcn.2013.288.
Alish CJ, Garvey WT, Maki KC, Sacks GS, Hustead DS, Hegazi RA, et al. A diabetes-specific enteral formula improves glycemic variability in patients with type 2 diabetes. Diabetes Technol Ther 2010;12(6):419–425. DOI: 10.1089/dia.2009.0185.
Visek J, Lacigova S, Cechurova D, Rusavy Z. Comparison of a low-glycaemic index vs standard diabetic diet. Biomed Pap Med Fac Univ Palacky Olomouc Czech Repub 2014;158(1):112–116. DOI: 10.5507/bp.2012.103.
Ojo O, Ojo OO, Adebowale F, Wang XH. The effect of dietary glycaemic index on glycaemia in patients with type 2 diabetes: a systematic review and meta-analysis of randomized controlled trials. Nutrients 2018;10(3):E373. DOI: 10.3390/nu10030373.
Devitt AA, Oliver JS, Hegazi RA, Mustad VA. Glycemia targeted specialized nutrition (GTSN) improves postprandial glycemia and GLP-1 with similar appetitive responses compared to a healthful whole food breakfast in persons with type 2 diabetes: a randomized, controlled trial. J Diabetes Res Clin Metab 2012;1:20. DOI: 10.7243/2050-0866-1-20.
Brazeu AS, Mircescu H, Desjardins K, Leroux C, Strychar I, Ekoé JM, et al. Carbohydrate counting accuracy and blood glucose variability in adults with type 1 diabetes. Diabetes Res Clin Pract 2013;99(1):19–23. DOI: 10.1016/j.diabres.2012.10.024.
Mottalib A, Mohd-Yusof BN, Shehabeldin M, Pober DM, Mitri J, Hamdy O. Impact of diabetes-specific nutritional formulas versus oatmeal on postprandial glucose, insulin, GLP-1 and postprandial lipidemia. Nutrients 2016;8(7):E443. DOI: 10.3390/nu8070443.
Vaisman N, Lansink M, Rouws CH, van Laere KM, Segal R, Niv E, et al. Tube feeding with a diabetes-specific feed for 12 weeks improves glycaemic control in type 2 diabetes patients. Clin Nutr 2009;28(5):549–555. DOI: 10.1016/j.clnu.2009.05.004.
Pietraszek A, Gregersen S, Pedersen SB, Holst JJ, Hermansen K. Acute effects of monounsaturated fat on postprandial lipemia and gene expression in first-degree relatives of subjects with type 2 diabetes. Eur J Clin Nutr 2014;68(9):1022–1028. DOI: 10.1038/ejcn.2014.64.
Mesejo A, Montejo-Gonźalez JC, Vaquerizo-Alonso C, Lobo-Tamer G, Zabarte-Martinez M, Herrero-Meseguer JI, et al. Diabetes-specific enteral nutrition formula in hyperglycemic, mechanically ventilated, critically ill patients: a prospective, open-label, blind-randomized, multicenter study. Crit Care 2015;19:390. DOI: 10.1186/s13054-015-1108-1.
Shao Y, Heng W, Li S, Xu Y, Hu G. Tube feeding with a diabetes-specific enteral formula improves glycemic control in severe acute ischemic stroke patients. JPEN J Parenter Enteral Nutr 2018;42(5):926–932. DOI: 10.1002/jpen.1035.
van Steen SC, Rijkenberg S, Sechterberger MK, DeVries JH, van der Voort PHJ. Glycemic effects of a low-carbohydrate enteral formula compared with an enteral formula of standard composition in critically Ill patients: an open-label randomized controlled clinical trial. JPEN J Parenter Enteral Nutr 2017;42(6):1035–1045. DOI: 10.1002/jpen.1045.
Plauth M, Bernal W, Dasarathy S, Merli M, Plank LD, Schütz T, et al. ESPEN guideline on clinical nutrition in liver disease. Clin Nutr 2019;38(2):485–521. DOI: 10.1016/j.clnu.2018.12.022.
KDOQI. KDOQI clinical practice guidelines and clinical practice recommendations for diabetes and chronic kidney disease. Am J Kidney Dis 2007;49(2 Suppl 2):S12–S154. DOI: 10.1053/j.ajkd.2006.12.005.
Voss AC, Maki KC, Garvey WT, Hustead DS, Alish C, Fix B, et al. Effect of two carbohydrate-modified tube-feeding formulas on metabolic responses in patients with type 2 diabetes. Nutrition 2008;24(10): 990–997. DOI: 10.1016/j.nut.2008.06.009.
Fekete ÁA, Givens DI, Lovegrove JA. Can milk proteins be a useful tool in the management of cardiometabolic health? An updated review of human intervention trials. Proc Nutr Soc 2016;75(3):328–341. DOI: 10.1017/S0029665116000264.
Mansour A, Hosseini S, Larijani B, Pajouhi M, Mohajeri-Tehrani MR. Nutrients related to GLP1 secretory responses. Nutrition 2013;29(6):813–820. DOI: 10.1016/j.nut.2012.11.015.
Tolhurst G, Heffron H, Lam YS, Parker HE, Habib AM, Diakogiannaki E, et al. Short-chain fatty acids stimulate glucagon-like peptide-1 secretion via the G-protein-coupled receptor FFAR2. Diabetes 2012;61(2):364–371. DOI: 10.2337/db11-1019.
The Diabetes Control and Complications Trial Research Group, Nathan DM, Genuth S, Lachin J, Cleary P, Crofford O, et al. The effect of intensive treatment of diabetes on the development and progression of long-term complications in insulin-dependent diabetes mellitus. N Engl J Med 1993;329(14):977–986. DOI: 10.1056/NEJM199309303291401.
Cakmak M, Cakmak N, Cetemen S, Tanriverdi H, Enc Y, Teskin O, et al. The value of admission glycosylated haemoglobin level in patients with acute myocardial infarction. Can J Cardiol 2008;24(5):375–378. DOI: 10.1016/s0828-282x(08)70600-7.
Stranders I, Diamant M, van Gelder RE, Spruijt HJ, Twisk JW, Heine RJ, et al. Admission blood glucose level as risk indicator of death after myocardial infarction in patients with and without diabetes mellitus. Arch Intern Med 2004;164(9):982–988. DOI: 10.1001/archinte.164.9.982.
Su G, Mi SH, Li Z, Tao H, Yang HX, Zheng H. Prognostic value of early in-hospital glycemic excursion in elderly patients with acute myocardial infarction. Cardiovasc Diabetol 2013;12:33. DOI: 10.1186/1475-2840-12-33.
Nam K, Jeon Y, Kim WH, Jung DE, Kwon SM, Kang P, et al. Intraoperative glucose variability, but not average glucose concentration, may be a risk factor for acute kidney injury after cardiac surgery: a retrospective study. Can J Anesth 2019;66(8):921–933. DOI: 10.1007/s12630-019-01349-0.
Moriyama N, Ishihara M, Noguchi T, Nakanishi M, Arakawa T, Asaumi Y, et al. Admission hyperglycaemia is an independent predictor of acute kidney injury in patients with acute myocardial infarction. Circ J 2014;78(6):1475–1480. DOI: 10.1253/circj.cj-14-0117.
de Azevedo JR, de Araujo LO, da Silva WS, de Azevedo RP. A carbohydrate-restrictive strategy is safer and as efficient as intensive insulin therapy in critically ill patients. J Crit Care 20010;25(1):84–89. DOI: 10.1016/j.jcrc.2008.10.011.
Ely EW, Shintani A, Truman B, Speroff T, Gordon SM, Harrell Jr FE, et al. Delirium as a predictor of mortality in mechanically ventilated patients in the intensive care unit. JAMA 2004;291(14):1753–1762. DOI: 10.1001/jama.291.14.1753.
Sharshar T, Gray F, Lorin de la Grandmaison G, Hopkinson NS, Ross E, Dorandeu A, et al. Apoptosis of neurons in cardiovascular autonomic centres triggered by inducible nitric oxide synthase after death from septic shock. Lancet 2003;362(9398):1799–1805. DOI: 10.1016/s0140-6736(03)14899-4.
Ntaios G, Egli M, Faouzi M, Michel P. J-shaped association between serum glucose and functional outcome in acute ischemic stroke. Stroke 2010;41(10):2366–2370. DOI: 10.1161/STROKEAHA.110.592170.
Khwaja A. KDIGO clinical practice guidelines for acute kidney injury. Nephron Clin Pract 2012;120(4):c179–c184. DOI: 10.1159/000339789.
Song JW, Shim JK, Yoo KJ, Oh SY, Kwak YL. Impact of intraoperative hyperglycaemia on renal dysfunction after off-pump coronary artery bypass. Interact Cardiovasc Thorac Surg 2013;17(3):473–478. DOI: 10.1093/icvts/ivt209.
Ikizler TA, Pupim LB, Brouillette JR, Levenhagen DK, Farmer K, Hakim RM, et al. Haemodialysis stimulates muscle and whole-body protein loss and alters substrate oxidation. Am J Physiol Endocrinol Metab 2002;282(1):E107–E116. DOI: 10.1152/ajpendo.2002.282.1.E107.
Marezi G, Cosentino N, Milazzo V, De Metrio M, Rubino M, Campodonico J, et al. Acute kidney injury in diabetic patients with acute myocardial infarction: role of acute and chronic glycemia. J Am Heart Assoc 2018;7(8):e008122. DOI: 10.1161/JAHA.117.008122.
Mangano CM, Diamondstone LS, Ramsay JG, Aggarwal A, Herskowitz A, Mangano DT. Renal dysfunction after myocardial revascularization: risk factors, adverse outcomes, and hospital resource utilization. the multicentre study of perioperative ischemia research group. Ann Intern Med 1998;128(3):194–203. DOI: 10.7326/0003-4819-128-3-199802010-00005.
Halkos ME, Lattouf OM, Puskas JD, Kilgo P, Cooper WA, Morris CD, et al. Elevated preoperative hemoglobin A1c level is associated with reduced long-term survival after coronary artery bypass surgery. Ann Thorac Surg 2008;86(5):1431–1437. DOI: 10.1016/j.athoracsur.2008.06.078.
Ginde AA, Savaser DJ, Camargo Jr CA. Limited communication and management of emergency department hyperglycaemia in hospitalized patients. J Hosp Med 2009;4(1):45–49. DOI: 10.1002/jhm.400.
Tonks KT, Jones GR, McGeechan K, Campbell LV. Hyperglycaemia in hospital inpatients: still a sticky situation. Intern Med J 2010;40(7): 521–526. DOI: 10.1111/j.1445-5994.2010.02197.x.
Amrith BP, Sethi P, Soneja M, Vikram N, Kumar A, Aggarwal P, et al. Effect of implementation of ADA/AACE guidelines on the management of hospitalized hyperglycaemic patients through training of residents: a tertiary care centre study. Indian J Endocr Metab 2018;22(5):616–620. DOI: 10.4103/ijem.IJEM_698_17.