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.