Transitional NPH insulin therapy for critically ill patients receiving continuous enteral nutrition and intravenous regular human insulin.

BACKGROUND: The intent of this study was to evaluate the efficacy and safety of transitioning from a continuous intravenous (IV) regular human insulin (RHI) or intermittent IV RHI therapy to subcutaneous neutral protamine Hagedorn (NPH) insulin with intermittent corrective IV RHI for critically ill patients receiving continuous enteral nutrition (EN). METHODS: Data were obtained from critically ill trauma patients receiving continuous EN during transitional NPH insulin therapy. Target blood glucose concentration (BG) range was 70-149 mg/dL. BG was determined every 1-4 hours. RESULTS: Thirty-two patients were transitioned from a continuous IV RHI infusion (CIT) to NPH with intermittent corrective IV RHI therapy. Thirty-four patients had NPH added to their preexisting supplemental intermittent IV RHI therapy (SIT). BG concentrations were maintained in the target range for 18 ± 3 and 15 ± 4 h/d for the CIT and SIT groups, respectively (P < .05). Thirty-eight percent of patients experienced a BG <60 mg/dL, and 9% had a BG <40 mg/dL. Hypoglycemia was more prevalent for those who were older (P < .01) or exhibited greater daily BG variability (P < .01) or worse HgbA1C (p < 0.05). CONCLUSION: Transitional NPH therapy with intermittent corrective IV RHI was effective for achieving BG concentrations within 70-149 mg/dL for the majority of the day. NPH therapy should be implemented with caution for those who are older, have erratic daily BG control, or have poor preadmission glycemic control.

Hypocaloric, high-protein nutrition therapy in older vs younger critically ill patients with obesity.

BACKGROUND: Older patients require more protein than younger patients to achieve anabolism, but age-associated renal dysfunction may limit the amount of protein that can be safely provided. This study examined whether older, critically ill trauma patients with obesity can safely achieve nitrogen equilibrium and have positive clinical outcomes similar to younger obese patients during hypocaloric, high-protein nutrition therapy. METHODS: Adult patients with traumatic injury and obesity (body mass index [BMI] >30 kg/m(2)), admitted to the Presley Trauma Center from January 2009 to April 2011, were evaluated. Patients were targeted to receive hypocaloric, high-protein nutrition therapy (<25 kcal/kg ideal body weight [IBW]/d and >2 g/kg IBW/d of protein) for >10 days. Patients were stratified as older (≥60 years) or younger (18-59 years). RESULTS: Seventy-four patients (33 older, 41 younger) were studied. Older and younger patients were similar in BMI and injury severity. When given isonitrogenous regimens (2.3 ± 0.2 g/kg IBW/d), nitrogen balance was similar between older and younger patients (-3.2 ± 5.7 g/d vs -4.9 ± 9.0 g/d; P = .363). Older patients experienced a greater mean serum urea nitrogen concentration than younger patients (30 ± 14 mg/dL vs 20 ± 9 mg/dL; P = .001) during nutrition therapy. Clinical outcomes were not different between groups. CONCLUSIONS: Older critically ill trauma patients exhibited an equivalent net protein response as younger patients during hypocaloric, high-protein nutrition therapy. Older patients are at greater risk for developing azotemia. Close monitoring is warranted.

Influence of traumatic brain injury on potassium and phosphorus homeostasis in critically ill multiple trauma patients.

OBJECTIVE: The intent of this study was to ascertain whether multiple trauma patients with traumatic brain injury (TBI) had lower serum concentrations of potassium and phosphorus and required more aggressive supplementation than multiple trauma patients without TBI. METHODS: Ventilator-dependent adult patients without renal impairment who were admitted to the trauma intensive care unit or neurosurgical intensive care unit and who received enteral nutrition were evaluated for the first 14 d after hospital admission. Patients were grouped according to the presence or absence of TBI. Target serum concentrations for potassium and phosphorus were 4 mEq/L and 4 mg/dL, respectively. Electrolyte repletion therapy was given according to the nutritional support service guidelines. RESULTS: Fifty trauma patients (25 with and without TBI) were studied. Daily serum potassium concentrations were consistently lower for those with TBI (P < or = 0.001), whereas the mean net potassium intake was greater (1.3 +/- 0.5 versus 0.7 +/- 0.3 mEq x kg(-1) x d(-1), respectively, P < or = 0.001). Serial serum phosphorus concentrations were similar between groups (P = NS) except for a significantly lower serum phosphorus concentration for trauma patients with TBI on day 3 after hospital admission (2.5 +/- 0.5 versus 2.9 +/- 0.7 mg/dL, respectively, P < or = 0.05). However, the mean net phosphorus intake was significantly greater for trauma patients with TBI (0.65 +/- 0.25 versus 0.45 +/- 0.17 mmol x kg(-1) x d(-1), P < or = 0.001). CONCLUSION: Potassium and phosphorus requirements are greater for multiple trauma patients with TBI compared with those without TBI.

Safety and efficacy of a graduated intravenous insulin infusion protocol in critically ill trauma patients receiving specialized nutritional support.

OBJECTIVE: The intent of this study was to evaluate the safety and efficacy of our protocol for providing continuous intravenous regular human insulin (RHI) infusion to hyperglycemic critically ill trauma patients receiving specialized nutritional support. METHODS: Capillary blood glucose (BG) concentrations were determined every 1-2 h. Glucose control was defined as a BG concentration in the target range of 70-149 mg/dL (3.9-8.3 mmol/L). Data were recorded for 1 d before the RHI infusion and for a maximum of 8 d thereafter while receiving the RHI infusion. RESULTS: Forty adult critically ill trauma patients received 102 +/- 62 units of RHI daily for 10 +/- 6 d. BG control was achieved within 5 +/- 3 h. BG decreased from 194 +/- 55 mg/dL (10.8 +/- 3.1 mmol/L) to 134 +/- 19 mg/dL (7.4 +/- 1.1 mmol/L) after 1 d of RHI infusion (P < 0.001). Average daily BG ranged from 119 to 124 mg/dL and the target range was maintained for 19.6 +/- 4.7 h/d. None of the patients experienced severe hypoglycemia (<40 mg/dL); 14 patients had asymptomatic hypoglycemia (<60 mg/dL or <3.3 mmol/L) for a total of 23 episodes out of 4140 measurements (0.56%). Estimated creatinine clearance for those with hypoglycemia was 69 +/- 32 mL/min compared with 117 +/- 58 mL/min for the others (P < 0.01). CONCLUSION: Our protocol was safe and effective for the management of hyperglycemia in critically ill trauma patients receiving specialized nutritional support but should be used with caution in patients with renal insufficiency.

Vitamin K-independent warfarin resistance after concurrent administration of warfarin and continuous enteral nutrition.

STUDY OBJECTIVE: To assess the influence of withholding continuous enteral nutrition for 1 hour before and after warfarin administration compared with the coadministration of warfarin with continuous enteral nutrition on changes in international normalized ratios (INRs). DESIGN: Retrospective, crossover case series. SETTING: Intensive care units of a university-affiliated medical center. PATIENTS: Six adults who required nutritional support for at least the first 10 consecutive days of warfarin therapy; during that 10-day period, they had a period of at least 3 consecutive days during which the enteral feeding was withheld for 1 hour before and after warfarin administration, and had a period of at least 3 consecutive days when feedings were not withheld during warfarin administration. Patients with advanced liver disease and those who received therapies, during the observation period, that significantly alter warfarin metabolism were omitted from the study. MEASUREMENTS AND MAIN RESULTS: The change in INR during the 3-day observation period when feedings were withheld for 1 hour before and after warfarin administration was significantly different versus the change in INR during coadministration of warfarin with continuous feeding (mean +/- SD 0.74 +/- 0.66 vs -0.13 +/- 0.81, p < or = 0.05). This difference in INR response occurred despite the administration of similar dosages of warfarin (5.6 +/- 2.1 vs 5.7 +/- 2.1 mg/day, p>0.05). Also noted was a clinically irrelevant, but statistically significant, difference in vitamin K intake between treatment periods (77 +/- 36 mug/day when feedings were withheld vs 102 +/- 28 microg/day when feedings were not withheld, p < or = 0.05). CONCLUSION: Continuous enteral nutrition should be withheld for 1 hour before and after warfarin administration to prevent enteral nutrition-associated warfarin resistance.

Dose-dependent characteristics of intravenous calcium therapy for hypocalcemic critically ill trauma patients receiving specialized nutritional support.

OBJECTIVE: The purpose of this investigation was to evaluate the dose-dependent characteristics of intravenous calcium gluconate therapy for hypocalcemic critically ill patients. METHODS: The dose-dependent characteristics of 2 g versus 4 g of intravenous calcium gluconate therapy were evaluated in 25 critically ill, adult multiple trauma patients with hypocalcemia. The calcium gluconate was infused at a rate of 1 g/h for both groups. Patients weighed within 90% to 120% of ideal body weight, had normal renal function, did not receive diuretic therapy, and did not have anasarca. RESULTS: Fifteen patients with mild hypocalcemia (serum ionized calcium concentration [iCa] 1-1.12 mmol/L) were given 2 g of calcium gluconate. Ten patients with moderate to severe hypocalcemia (iCa <1 mmol/L) were given 4 g. Each dosage group had a significant (P < or = 0.001) increase in iCa (from 1.07 +/- 0.05 to 1.17 +/- 0.05 mmol/L and from 0.92 +/- 0.08 to 1.16 +/- 0.11 mmol/L, respectively). Each dosage group retained about half of the dose in the exchangeable calcium space (P = NS between groups), but the higher dosage group retained significantly more elemental calcium overall (81 +/- 38 versus 201 +/- 50 mg, respectively, P < or = 001). Serum ionized calcium concentrations achieved a plateau without a further decline in iCa by 10 h after completion of the infusion for each dosage. CONCLUSION: About half of the administered elemental calcium dose was retained for each dosage group, with the higher dose (4 g) resulting in significantly more elemental calcium retention in the exchangeable calcium space. An iCa determination performed about > or =10 h after the completion of the calcium gluconate infusion should be sufficient time to ensure equilibration of iCa to assess the efficacy of the therapy. This mode of calcium therapy serves as an effective means for providing calcium to the acutely hypocalcemic, critically ill, multiple trauma patient.

A new graduated dosing regimen for phosphorus replacement in patients receiving nutrition support.

BACKGROUND: Hypophosphatemia is a common metabolic complication in patients receiving specialized nutrition support. We changed our previously reported dosing algorithm because the low dose no longer appeared to be effective at increasing serum phosphorus concentrations. The purpose of this study was to evaluate the safety and efficacy of a revised weight-based phosphorus-dosing algorithm in critically ill trauma patients receiving specialized nutrition support. METHODS: Seventy-nine adult trauma patients with hypophosphatemia (serum phosphorus concentration < or = 0.96 mmol/L) receiving nutrition support received an IV dose of phosphorus on day 1 according to the serum concentration of phosphorus: 0.73-0.96 mmol/L (0.32 mmol/kg, low dose), 0.51-0.72 mmol/L (0.64 mmol/kg, moderate dose), and < or = 0.5 mmol/L (1 mmol/kg, high dose). The IV phosphorus bolus dose was administered at 7.5 mmol/hour. Generally, patients with a serum potassium concentration <4 mmol/L received potassium phosphate and patients with a serum potassium concentration > or = 4 mmol/L received sodium phosphate. Patients who still had hypophosphatemia on day 2 were dosed using the new dosing algorithm by the nutrition support service according to that day's serum concentration of phosphorus, or empirically by the trauma service. RESULTS: Of the 79 patients studied, 57 were male and 22 were female with a mean age of 44.8 +/- 20.6 years. Mean Injury Severity Scores and APACHE-II scores were 27.1 +/- 11.6 and 15.2 +/- 6.8, respectively. There was no difference in baseline characteristics among the 3 dosing groups. Of the 79 patients, 34 received the low dose, 30 received the moderate dose, and 15 received the high dose of phosphorous. Mean serum phosphorous concentrations on day 2 were significantly increased in the moderate-dosed group (0.64 +/- 0.06 to 0.77 +/- 0.22 mmol/L, p < .05) and high-dosed group (0.38 +/- 0.06 to 0.93 +/- 0.32 mmol/L, p < .01), respectively, when compared with day 1. Mean serum phosphorus concentrations were normal in all 3 groups on day 3. Serum concentrations of magnesium, sodium, and potassium, as well as arterial pH, were stable across the study. Mean concentrations of ionized calcium were not significantly different in any of the 3 dosing groups across the study period. CONCLUSIONS: This weight-based phosphorus-dosing algorithm is safe for use in critically ill patients receiving nutrition support. The moderate and severe-dose regimens effectively increase serum phosphorus concentrations.