Objective: To evaluate glycemic control for critically ill, hyperglycemic trauma patients with renal failure who received concurrent intensive insulin therapy and continuous enteral (EN) or parenteral nutrition (PN).
Methods: Adult trauma patients with renal failure, who were given EN or PN concurrently with continuous graduated intravenous regular human insulin (RHI) infusion for at least 3 days were evaluated. Our conventional RHI algorithm was modified for those with renal failure by allowing greater changes in blood glucose concentrations (BG) before the infusion rate was escalated. BG was determined every 1-2 hours while receiving the insulin infusion. BG control was evaluated on the day prior to RHI infusion and for a maximum of 7 days while receiving RHI. Target BG during the RHI infusion was 70 to 149 mg/dL (3.9 to 8.3 mmol/L). Glycemic control and incidence of hypoglycemia for those with renal failure were compared to a historical cohort of critically ill, hyperglycemic trauma patients without renal failure given our conventional RHI algorithm.
Results: Twenty-one patients with renal failure who received the modified RHI algorithm were evaluated and compared to forty patients without renal failure given our conventional RHI algorithm. Average BG was significantly greater for those with renal failure (133 + 14 mg/dL or 7.3 + 0.7 mmol/L) compared to those without renal failure (122 + 15 mg/dL or 6.8 + 0.8 mmol/L), respectively (p < 0.01). Patients with renal failure experienced worsened glycemic variability with 16.1 + 3.3 hours/day within the target BG range, 6.9 + 3.2 hours/day above the target BG range, and 1.4 + 1.1 hours below the target BG range compared to 19.6 + 4.7 hours/day (p < 0.001), 3.4 + 3.0 hours/day (p < 0.001), and 0.7 + 0.8 hours/day (p < 0.01) for those without renal failure, respectively. Moderate hypoglycemia (< 60 mg/dL or < 3.3 mmol/L) occurred in 76% of patients with renal failure compared to 35% without renal failure (p < 0.005). Severe hypoglycemia (BG < 40 mg/dL or < 2.2 mmol/L) occurred in 29% of patients with renal failure compared to none of those without renal failure (p < 0.001).
Conclusion: Despite receiving a modified RHI infusion, critically ill trauma patients with renal failure are at higher risk for developing hypoglycemia and experience more glycemic variability than patients without renal failure.
Dickerson, Roland N.; Hamilton, Leslie A.; Connor, Kathryn A.; Maish, George O.; Croce, Martin A.; Minard, Gayle; and Brown, Rex O. (2011). "Increased hypoglycemia associated with renal failure during continuous intravenous insulin infusion and specialized nutritional support." Nutrition 27.7-8, 766-772.
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