Both good glyco-metabolic control and adequate nutritional support are able to influence the prognosis of hospitalized patients. Supporting malnourished individuals using enteral or parenteral nutrition accentuates the risk of hyperglycaemia particularly in diabetics. Hyperglycaemia can be prevented by using low-carbohydrate enteral nutrition mixtures (Table 2) or by limiting the concentration of glucose in the parenteral nutrition bags. In the hospital reality, most people do not receive adequate nutritional support to cover needs, both to prevent and to cure energy protein malnutrition (PEM). One of the reasons for inadequate treatment is precisely the fear of worsening hyperglycemia: in this perspective, hyperglycemia is considered the greatest obstacle to the practice of proper nutritional support.
On the other hand, the use of artificial nutrition, without adequate insulin therapy, can cause serious metabolic decompensation and negatively affects mortality even in non-critical patients; the use of targeted insulin treatment protocols together with an early and appropriate nutritional support allows excellent glycemic control and avoids a negative energy balance. Artificial nutrition should only be started when the blood sugar is at values below 180 mg / dl in the absence of dehydration and hyperosmolarity. The calculation of energy and fluid requirements is similar to the non-diabetic subject (1).
On the other hand, the use of artificial nutrition, without adequate insulin therapy, can cause serious metabolic decompensation and negatively affects mortality even in non-critical patients; the use of targeted insulin treatment protocols together with an early and appropriate nutritional support allows excellent glycemic control and avoids a negative energy balance. Artificial nutrition should only be started when the blood sugar is at values below 180 mg / dl in the absence of dehydration and hyperosmolarity. The calculation of energy and fluid requirements is similar to the non-diabetic subject (1).
On the other hand, the use of artificial nutrition, without adequate insulin therapy, can cause serious metabolic decompensation and negatively affects mortality even in non-critical patients; the use of targeted insulin treatment protocols together with an early and appropriate nutritional support allows excellent glycemic control and avoids a negative energy balance. Artificial nutrition should only be started when the blood sugar is at values below 180 mg / dl in the absence of dehydration and hyperosmolarity. The calculation of energy and fluid requirements is similar to the non-diabetic subject (1).
the use of targeted insulin treatment protocols together with an early and appropriate nutritional support allows excellent glycemic control and avoids a negative energy balance. Artificial nutrition should only be started when the blood sugar is at values below 180 mg / dl in the absence of dehydration and hyperosmolarity. The calculation of energy and fluid requirements is similar to the non-diabetic subject (1). the use of targeted insulin treatment protocols together with an early and appropriate nutritional support allows excellent glycemic control and avoids a negative energy balance. Artificial nutrition should only be started when the blood sugar is at values below 180 mg / dl in the absence of dehydration and hyperosmolarity. The calculation of energy and fluid requirements is similar to the non-diabetic subject (1).
Normally, NA should only be initiated when the blood sugar is ≤ 180 mg / dl in the absence of ketonuria or complications such as dehydration or hyperosmolarity.
Enteral nutrition
Diabetes-specific diets are characterized by low carbohydrate content with a low glycemic index and high in MUFA or those in which the carbohydrate level is similar to that of standard formulas, but malt dextrins are replaced by modified tapioca. These formulas also contain high amounts of water-soluble fibers (partially hydrolysed guar gum) in order to slow down the absorption of the carbohydrates themselves. In most patients it is advisable to use the formula with a lower carbohydrate content that has shown less influence on glycemic control (Table 2) (32.34).
There are no clinical trials examining the different strategies of insulin treatment in people with hyperglycaemia in NE. In the initial phase of NE, induction, IV insulin can be used with continuous infusion, as described in parenteral nutrition or boluses of similar rapid subcutaneous tissue up to the achievement of blood sugar levels below 180 mg / dl. The insulin treatment is then evaluated in relation to the modalities with which the NE is performed; in all cases, avoidance of insulin sliding scale need to be avoided.
Continuous enteral nutrition
It provides for the administration of the prescribed volume of mixture at a constant rate during a period of 20-24 hours and is the most advantageous and effective modality, since it reduces the speed of gastric filling and decreases the gastrointestinal side effects. When nutrition is administered continuously, carbohydrate intake per hour of infusion remains constant. The subcutaneous insulin patterns evaluated in the studies are: intermediate insulin 2-3 times a day, glargine once a day with possible boluses of fast analogue every 4 hours or regular insulin every 6 hours, insulin 70/30 three times a day and insulin adjust 4 times a day.
Since there are no direct comparison studies between the different therapeutic regimens theoretically all can be used. The pattern that appears to be more effective and with lower risk of hypoglycaemia is that with a long-acting basal analogue once a day with additional boluses of rapid analogue every 4 hours or regular insulin every 6 hours. Any correction boluses added may be computed to formulate the slow analogue dosage in the following days. Daily insulin requirements will vary based on patient characteristics, associated diseases, stress hyperglycemia or previous diabetes, type of previous hypoglycaemic treatment. In patients already on insulin therapy, the dose should be adjusted on the basis of previous needs and current clinical conditions.
The initial dose of insulin, in the patient previously treated with insulin and stabilized, it can be calculated by taking the average insulin dosage of the two previous days and starting with 50-70% of the insulin dose. In patients treated with oral antidiabetics, a total initial dose of 0.3-0.5 IU / kg body weight is recommended which includes the basal and nutritional insulin needs to be supplemented with the correction boluses with rapid analogs or regular insulin. It is then possible to calculate the insulin requirement to cover the nutritional needs considering 1 unit every 10-15 gr of carbohydrates administered continuously in 24 hours. It is sufficient to use a peristaltic pump for the administration of nutrition that minimizes the risks of hypoglycemia and careful glycemic monitoring, when deciding on the suspension of the NE, to avoid possible problems. The need to wash the SNG with 20-30 ml of water every 8-12 hours, as commonly advised to avoid lumen occlusion, is not considered an obstacle to the use of a long-acting analogue. During enteral nutrition the blood sugar should be checked every two to four hours until the desired target is reached and then every 8 hours (45-51).