Drincic Andjela T, Knezevich Jon T, Akkireddy Padmaja
Department of Internal Medicine: Diabetes, Endocrinology and Metabolism, University of Nebraska Medical Center, 984120 Nebraska Medical Center, Omaha, NE, 68198-4120, USA.
Department of Pharmaceutical and Nutrition Care, University of Nebraska Medical Center, 984120 Nebraska Medical Center, Omaha, NE, 68198-4120, USA.
Curr Diab Rep. 2017 Aug;17(8):59. doi: 10.1007/s11892-017-0882-3.
The goal of this paper is to provide the latest evidence and expert recommendations for management of hospitalized patients with diabetes or hyperglycemia receiving enteral (EN), parenteral (PN) nutrition support or, those with unrestricted oral diet, consuming meals on demand.
Patients with and without diabetes mellitus commonly develop hyperglycemia while receiving EN or PN support, placing them at increased risk of adverse outcomes, including in-hospital mortality. Very little new evidence is available in the form of randomized controlled trials (RCT) to guide the glycemic management of these patients. Reduction in the dextrose concentration within parenteral nutrition as well as selection of an enteral formula that diminishes the carbohydrate exposure to a patient receiving enteral nutrition are common strategies utilized in practice. No specific insulin regimen has been shown to be superior in the management of patients receiving EN or PN nutrition support. For those receiving oral nutrition, new challenges have been introduced with the most recent practice allowing patients to eat meals on demand, leading to extreme variability in carbohydrate exposure and risk of hypo and hyperglycemia. Synchronization of nutrition delivery with the astute use of intravenous or subcutaneous insulin therapy to match the physiologic action of insulin in patients receiving nutritional support should be implemented to improve glycemic control in hospitalized patients. Further RCTs are needed to evaluate glycemic and other clinical outcomes of patients receiving nutritional support. For patients eating meals on demand, development of hospital guidelines and policies are needed, ensuring optimization and coordination of meal insulin delivery in order to facilitate patient safety.
本文旨在为接受肠内营养（EN）、肠外营养（PN）支持的糖尿病或高血糖住院患者，或那些口服饮食不受限制、按需进食的患者的管理提供最新证据和专家建议。
无论有无糖尿病，患者在接受EN或PN支持时通常会出现高血糖，这使他们面临包括院内死亡在内的不良结局风险增加。目前几乎没有以随机对照试验（RCT）形式提供的新证据来指导这些患者的血糖管理。降低肠外营养中的葡萄糖浓度以及选择能减少接受肠内营养患者碳水化合物摄入量的肠内营养配方是实践中常用的策略。尚无特定胰岛素方案在接受EN或PN营养支持患者的管理中显示出优越性。对于那些接受口服营养的患者，最近允许患者按需进食的做法带来了新的挑战，导致碳水化合物摄入量极度可变，增加了低血糖和高血糖风险。应通过巧妙使用静脉或皮下胰岛素治疗使营养供给与胰岛素的生理作用相匹配，以改善住院患者的血糖控制。需要进一步的RCT来评估接受营养支持患者的血糖及其他临床结局。对于按需进食的患者，需要制定医院指南和政策，确保进餐胰岛素给药的优化与协调，以促进患者安全。
