Nutritional priorities: complications
Approximately 15% of hospital in-patients are diagnosed with diabetes alongside their admitting complication. This prevalance is expected to rise due to the increased rates of obesity, over the next decade increasing the prevalence of diabetes is expected to increase by over 50%. Patients who have diabetes tend to have longer length of stay, more frequent re-admission and tend to be sicker during their hospital admission than the non-diabetic population. The majority of these patients are admitted for treatment of a medical condition that is independent of their diabetes. It is therefore crucial that their diabetes is managed correctly during their admission. Common complications within the hospital setting arise due to mistreatment of hypoglycaemia and patients being prevented from self-managing their diabetes.
The National Diabetes Inpatient Audit, May 2012, showed that the key problems that arose were Diabetic Ketoacidosis (DKA), Hypoglycaemia, minimal involvement of patient self-management, medicine mismanagement and inadequate food provision and inappropriate timing of food and medication. These are all aspects of hospital care which can be easily resolved via improved knowledge and awareness. In response to this Diabetes UK released a position statement in June 2013, in regards to the ‘inpatient care for people with diabetes’.
This chapter aims to address the areas where blood glucose control needs to be particularly focused upon and what complications may occur.
Diabetes management in the surgical patient
Currently over 10% of patients admitted for surgery are also diagnosed with diabetes. Glycaemic control has a significant impact on the risk of post-operative infection across the surgical specialities . Tighter blood glucose control can improve deep wound healing and reduce the incidence of infection. The occurrence of hypoglycaemic events during an in-patient stay is associated with increased mortality and diabetic ketoacidosis (DKA) although avoidable still occurs on the hospital ward and can result in post-operative death.
Elective operations: Pre-operative patients are routinely starved prior to anaesthetic thus requiring an adjustment of diabetes management. It is important at this stage to refer to your local trust policy in pre-operative management of diabetes. The key principles to monitor are;
- Insulin should never be stopped in patients with type 1 diabetes due to DKA
- Patients with diabetes should be given an infusion of insulin and glucose approximately 180g/day during a prolonged starvation period.
- If the starvation period is brief e.g. only one meal missed the patient does not normally require an infusion.
The day of the operation:
- On the day of surgery a preoperative blood glucose level should be checked and documented.
- A level of 4–12 mmol/L is acceptable although, ideally, it should be between
- If the patient’s blood sugar is above 12 mmol/L, the anaesthetist or the surgical team should be informed so that further management (eg, a glucose/potassium/insulin infusion) can be considered
- Patients with diabetes should be operated first on the list (whether in the morning or afternoon) so that there is minimal disruption of their diet and medication.
- Insulin requirements are increased during post-operative periods following prolonged surgery. The patient’s normal insulin doses may not be suitable and this needs to be managed by the specialist diabetes care team – refer to your local Diabetes Specialist Nurse (DSN) for guidance.
- Care should be taken to avoid hypoglycaemia post operatively due to increased production of counter-regulatory hormones which exacerbates the catabolic state.
- As patients are most likely in a catabolic state post-operatively it is significantly important to ensure adequate nutritional intake. Refer to your local Dietitian as these patients will have higher nutritional requirements during this period.
- If patients are hyperglycaemic post-operative it is crucial nutritional intake is not withheld and blood sugars are managed using medications as appropriate.
After the procedure:
- Oral antidiabetic medicines can be taken after the operation once the patient has had their first meal (ie, the morning dose should be taken after lunch).
- Long-acting insulin’s should be continued as normal.
- Blood glucose should be checked every 2 hours. If it is less than 4mmol/L, treat as hypoglycaemia with clear, oral fluid drinks containing glucose (discuss with the anaesthetist).
- If the procedure is delayed beyond midday, consider starting a GKI infusion
- Best managed with: - continuous insulin infusion & dextrose as in the management of diabetic ketoacidosis.
- Separate IV fluids
- If in good metabolic control and with normal electrolytes, make up an Insulin Solution,
- Check capillary blood glucose hourly before, during, and after procedure.
- Test capillary blood glucose more frequently if clinically concerned (e.g. hypoglycaemic).
- Do not stop insulin infusion completely unless there are problems with persisting hypoglycaemia.
- The insulin infusion should only be stopped for a short period, until restarting fluids with an increased dextrose concentration
Diabetes Management and Nutrition Support
Standard protocols for nutrition support should be followed and adjustments to diabetes medication should be prioritised over dietary restriction,
ESPEN Congress Nice, 2010, Suggestive blood glucose targets:
- Surgical ICU and major surgery strict targets before and during artificial nutrition of 4.5-6.1mmol/l
- For general patients < 9.0 mmol/l
- Strict targets if delayed would healing, pressure ulcer, neuropathy , 7.2 mmol/l
- Elderly patients or if life expectancy is short or if risk of hypoglycaemia is high: fasting 5.3-8.3 mmol/l postprandial < 13.9 mmol/l.
Oral Nutritional Supplementation
- Nutrition support should be provided as a priority, then diabetes medication adjusted accordingly to control glycaemia.
- The nutritional needs of the patient should be maintained using a combination of meals, snacks and suitable nutritional supplements.
- Milk based supplements are more suitable for patients with diabetes than juice based supplements however both should be used with caution. Your local Dietitian should be involved in prescribing nutritional supplements.
- To minimise the fluctuation in blood glucose levels it is key to distribute carbohydrate intake evenly throughout the day particularly if patients are on twice daily insulin doses.
- Enteral feeding has been shown to produce a rapid rise in blood glucose levels compared to an equivalent meal. However as most feeds are delivered via a pump at a relatively slow rate so carbohydrate delivery is spread over a number of hours.
- Continuous feeding is set over 24hours with no rest period this helps blood sugar control due to continuous delivery of carbohydrate. The level of carbohydrate intake per hour remains unchanged. 24 hour feeding is most commonly used on intensive care or high dependency units to maintain good blood sugar control. It can also be used at ward level when feeding via a tube going into the jejunum. A gastric feeding tube however requires a 20hour feeding tube to enable stomach pH to return to normal (acidic) to enable the correct position of the NG to be confirmed with a aspirate pH of <5.5. See local guidelines for further information on tube feeding)
- Type 1 diabetes patient need to continue their normal insulin at all times – whether receiving insulin via the subcutaneous or intravenous route
- Insulin should not be omitted.
- Continue subcutaneous basal analogue insulin (Glargine or Detemir) if the patient is normally on this
- Target Blood glucose levels during enteral feeding are 6-12mmol/l.
- Early referral to the Dietitian to determine an appropriate feed regimen is key.
- Aim to minimise use of intravenous insulin infusions
- Aim to establish the patient on subcutaneous insulin or glucose-lowering agents that can be administered via the feeding tube.
- Speak with your local Pharmacy department in regards to which tablets can be converted into tube suitable preparations e.g. metformin powder administered via NGT may be useful as a sole treatment, or adjunct, for people with type 2 diabetes.
- Crushing of oral tablet medications for administration via feeding tube is not recommended.
- Monitor blood glucose pre-feed and then 4-6 hourly when feed running or hourly if feed is omitted.
- Involve Diabetes Specialist Nurse immediately in event of recurrent hyperglycaemia or hypoglycaemia.
- Ensure the feed is started at the correct prescribed times as this will have been prescribed by the Dietitian and Diabetes Specialist Nurse to co-inside with the doses and timings of insulin/oral-hypoglycaemic agents.
NB: Please see flow chart on Page 9 in the Glycaemic management during the inpatient enteral feeding of stroke patients with diabetes, joint British Diabetes Societies for inpatient care June 2012
Parenteral Nutrition (PN)
- Patients should be treated with your local standard protocols for prescription of PN. The feed should be covered with adequate insulin to maintain suitable glycaemia levels (see above).
- For patients already on insulin prior to PN commencing they will generally have increased insulin requirements during feeding.
- Two approaches are used to maintain adequate glycaemia control:
- Intravenous infusion, rate adjustment according to blood glucose levels
- Multiple insulin injections, doses dependant on blood glucose levels.
Pump Therapy during Enteral feeding
- Increasing numbers of patients are being treated with insulin pump therapy (Continuous subcutaneous insulin infusion CSII).
- There are no studies available on the use of insulin pumps and nutrition support.
- Patients on insulin pumps should be proficient at carbohydrate counting and able to self-manage oral intake, bolus feeding and doses of insulin. The boluses can be given as a normal bolus or an extended bolus where the dose is delivered over a set period of time.
- Enterally fed patients have the option to match insulin by using an increased temporary basal rate or if bolus feeding to co-inside these with boluses of insulin.
- Liaison with the diabetes specialist nurse is key in these patients.
Diabetes Management and Renal disease
Approximately a third of patients with diabetes present with Chronic Kidney Disease (CKD). Those who are at increased risk are:
- Patients over 65
- High blood pressure
- Family history of CKD
- Ethnicity - African American, Hispanic American, Asian, Pacific Islander or American Indian.
Renal Disease and the Diet:
- Diet plays a key role in maintaining renal function:
- Reducing the amount of sodium (salt) in your diet can aid to reduce blood pressure and prevent further kidney damage. The most common salt intake arises through the use of table salt. A no added salt diet would be beneficial to these patients. In the later stages of renal disease when fluid restrictions are in place it may help in the management of thirst.
- Maintain a low cholesterol level as this can cause blood vessels to become blocked and increased blood pressure. A healthy balanced diet with low fat levels is appropriate. Refer the patient to your local Diabetes Specialist Dietitian for dietary advice.
- Protein intake; protein is a key part of our diet that should be maintained at a healthy level even during CKD however excess protein is damaging to the kidneys due to the pressure. Refer to your local Dietitian for accurate protein intake levels.
Diabetes medications during CKD:
- Some medications are not suitable in patients with CKD or may require reduced doses. Speak with your local pharmacist in regards to this.
^ Frisch A, Chandra P, Smiley D, Peng L, Rizzo M, Gatcliffe C et al. Prevalence and clinical outcome of hyperglycemia in the perioperative period in noncardiac surgery. Diabetes Care 2010;33:1783-8.
^ Hamblin PS, Topliss DJ, Chosich N, Lording DW, Stockigt JR. Deaths associated with diabetic ketoacidosis and hyperosmolar coma. 1973-1988. Med.J.Aust. 1989;151:441-2.
^ Joint British Diabetes Societies (JBDS) for in patient care. June 2012, Glycaemic management during the inpatient enteral feeding of stroke patients with diabetes. NHS Diabetes, Leeds UK
^ Diabetes UK Nutrtion Working Group. Evidence- based nutrition guidelines for the prevention and management of diabetes. London, UK Diabetes UK. May 2011.
^ Elia, M, CerielloAlaube H, Sinclair AJ et al. Enteral nutrition support and use of diabetes-specific formulas for patients with diabetes a systemic review and meta-analysis. Diabetes Care 2005; 28 (9): 2267-2279
^ Megaji V, Johnston JM. Inpatient management of hyperglycaemia and diabetes. Clinical Diabetes 2011; 29 (1): 3-9.
^ Via Ma, Mechanick JI. Inpatient enteral and parenteral (corrected) nutrition for patients with diabetes. Current Diabetes Reports 2011; 11 (2):99-105.
^ Clinical Resource Efficiency Support Team (CREST) Safe and effective use of insulin in secondary care: Recommendations for treating hyperglycaemia in adults. Belfast, UK: CREST; 2006.
^ Mesotten D, Van den Berghe G. Clinical potential of insulin therapy in critically ill patients. Drugs 2003; 63 (7) 625-636.
^ Levla RR, Inzucchi SE. Hospital management og hyperglycaemia. Current Opinion in Endocrinology, Diabetes and Obesity. 2011;18 (2): 110-118.
^ Fajtova VT, Anthony SG, McGurk S, McCarthy R, Homer D Griffin l, Rawn, J. A diabetes management service to improve inpatient glycaemia control. Journal of Clinical Outcome Management 2007; 14(5):249-258.
^ Raucoules-Aime. Feeding the malnourished diabetic. Conference proceedings, 2010 ESPEN congress Nice,
^ McMahon MM, Rissa RA. Nutrtion support in hospitalized patients with Diabetes mellitus. Mayo Clin Proc 1996; 71:587-594.
^ Pohl M, Mayr P, Mertl-Roetzer M et al. Glycaemic control in patients with type 2 diabetes mellitus with a diseas-specific enteral formula: Stage II of a randomized, controlled multicenter trial, Journal of Parenteral and Enteral Nutrtion. 2009; (1) 37-49.
^ Preiser JC. Stress and nutrition-induced hyperglycaemia. Conference proceedings, 2010 ESPEN Congress Nice.
^ Dhatariya, K. Flanagan, D, Hilton L., Kilvert, A. Levy N, Rayman G, Watson B. Management of adults with diabetes undergoing surgery and elective procedures: improving standards. April 2011.
^ National Kidney Foundation, 2007. Diabetes and Chronic Kidney Disease. New York, 11-10-0209
^ Diabetes UK 2013, Inpatient care for people with diabetes in England, Position Statement.