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CHAPTER 21: Glycemic Control 141

data that suggest that PN supplemented with glutamine is associated • Heyland D, Muscedere J, Wischmeyer PE, et al. A randomized
with increased survival in seriously ill hospitalized patients. It is trial of glutamine and antioxidants in critically ill patients. N Engl
20
difficult to provide high-dose free glutamine intravenously to criti- J Med. 2013;368(16):1489-1497.
cally ill patients due to problems with limited solubility and stability,
especially in critically ill patients with volume-restricted conditions. • Heyland DK, Dhaliwal R, Jiang X, Day A. Identifying critically ill
However, recent advances in parenteral glutamine delivery have over- patients who benefit the most from nutrition therapy: the devel-
come some of these challenges, making the provision of bioavailable opment and initial validation of a novel risk assessment tool. Crit
glutamine practical, even at higher doses. The treatment effect is Care. November 15, 2011;15(6):R268.
140
likely greatest when high-dose (>0.28 g/kg per day) glutamine • Jensen GL, Mirtallo J, Compher C, et al. Adult starvation and
is given parenterally. A lack of treatment effect is observed when low disease-related malnutrition: a proposal for etiology-based diag-
dose for short durations of time are used in critically ill patients. nosis in the clinical practice setting from the International
141
Whether parenteral glutamine has a beneficial effect on patients Consensus Guideline Committee. JPEN J ParenterEnteral Nutr.
receiving enteral nutrition is unknown. March-April 2010;34(2):156-159.
Use of Enteral Nutrition in Patients on Parenteral Nutrition: The adverse • McClave SA, Heyland DK. The physiologic response and associ-
effect of PN may be related to the absence of nutrients in the bowel. ated clinical benefits from provision of early enteral nutrition.
The gastrointestinal mucosa is metabolically very active and the lack Nutr Clin Pract. 2009;24(3):305-315.
of enteral nutrients (as in the case of PN) would result in mucosal • McClave SA, Martindale RG, Vanek VW, et al. A.S.P.E.N. Board
atrophy, increased permeability, bacterial overgrowth, transloca- of Directors; American College of Critical Care Medicine; Society
tion of bacteria and/or gut-derived factors that activate the immune of Critical Care Medicine. Guidelines for the Provision and
system, atrophy of the GALT, and increased production of proinflam- Assessment of Nutrition Support Therapy in the Adult Critically Ill
matory cytokines. Patient: Society of Critical Care Medicine (SCCM) and American
An observational study suggested that low-volume EN is associated Society for Parenteral and Enteral Nutrition (A.S.P.E.N.). JPEN J
with less toxicity compared to PN alone. Clearly our recommenda- Parenter Enteral Nutr. May-June 2009;33(3):277-316.
142
tion is that EN is used preferentially to PN, but in the patient who is not • NICE-SUGAR Study Investigators, Finfer S, Chittock DR, et al.
tolerating adequate amounts of EN over a prolonged period of time, if Intensive versus conventional glucose control in critically ill
PN is going to be used, we suggest that attempts to provide EN be con- patients. N Engl J Med. March 26, 2009;360(13):1283-1297.
tinued until EN is successful and the PN can be discontinued.
• Singer P, Berger MM, Van den Berghe G, et al. ESPEN Guidelines
on Parenteral Nutrition: intensive care. Clin Nutr. August
SUMMARY AND CONCLUSIONS
2009;28(4):387-400.
An opportunity exists for aggressive enteral nutritional therapy to favor-
ably alter a patient’s course through critical illness. The window of time
to start enteral feeding and/or key nutrients to resuscitate the metaboli-
cally active gastrointestinal tract is variable in duration depending on REFERENCES
the specific disease process; the opportunity may involve a time frame Complete references available online at www.mhprofessional.com/hall
as limited as several hours or as long as 2 to 3 days. During this period,
provision of enteral nutrients in a way that maximizes the benefits and
minimizes the risks (see Table 20-1) has the capability to maintain
gut integrity, minimize permeability, reduce oxidative stress and mac-
rophage activation, and ultimately improve patient outcome through CHAPTER Glycemic Control
reduced infectious morbidity, organ failure, length of hospitalization,
and even mortality. There is a limited role for PN, and when it is used 21 Jean-Charles Preiser
it should similarly be used in a way that maximizes the benefits and Carole Ichai
minimizes the risks (see Table 20-1).

KEY REFERENCES KEY POINTS
• Alberda C, Gramlich L, Jones NE, et al. The relationship between • The physiological regulation of blood glucose involves hormonal
nutritional intake and clinical outcomes in critically ill patients: and neural mechanisms, resulting in a control of glucose flux
results of an international multicenter observation study. Intensive across cell membranes.
Care Med. 2009;35(10):1728-1737. • High glucose concentrations are associated with cellular toxicity.
• Boelens PG, Heesakkers FF, Luyer MD, et al. Reduction of post- • Stress hyperglycemia is a marker of severity of illness.
operative ileus by early enteral nutrition in patients undergoing
major rectal surgery: prospective, randomized, controlled trial. • Intensive insulin therapy used to tightly control blood sugar was
Ann Surg. 2014;259(4):649-655. found beneficial in one single-center study, but not in seven inde-
• Casaer MP, Van den Berghe G. Nutrition in the acute phase of pendent other prospective trials.
critical illness. N Engl J Med. 2014;370(13):1227-1236. • Current recommendations advocate a moderate glucose control
• Critical Care Nutrition. Clinical Practice Guidelines. http://www. by insulin therapy.
criticalcarenutrition.com/index.php?option=com_content&view=
article&id=18&Itemid=10. Accessed March 23, 2011.
• Doig GS, Simpson F, Sweetman EA, et al. Early parenteral nutri- INTRODUCTION
tion in critically ill patients with short-term relative contraindi-
cations to early enteral nutrition: a randomized controlled trial. Critical illness is typically associated with a so-called stress-induced
JAMA. 2013;309(20):2130-2138. hyperglycemia, defined as a transient hyperglycemia during illness in
1
patients without previous evidence of diabetes. The relationship between

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