Clinical Nutrition ESPEN 41 (2021) 275e280

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Clinical Nutrition ESPEN

journal homepage: http://www.clinicalnutritionespen.com

Original article

Parenteral nutrition-associated hyperglycemia: Prevalence, predictors

and management
Muhamad Aizuddin Roszali a, b, Adlin Nadia Zakaria c, Nurul Ain Mohd Tahir a, *
a
Faculty of Pharmacy, Universiti Kebangsaan Malaysia, Kuala Lumpur, Malaysia
b
Pharmacy Department, Hospital Pakar Sultanah Fatimah, Ministry of Health, Johor, Malaysia
c
Pharmacy Department, Hospital Selayang, Ministry of Health, Selangor, Malaysia

a r t i c l e i n f o s u m m a r y

Article history: Background & aims: Hyperglycemia is among the common complications of parenteral nutrition (PN)
Received 22 July 2020 and is often associated with increased mortality despite being treatable. Studies of parenteral nutrition
Accepted 17 November 2020 causing hyperglycemia are limited and even available studies lack methodological conduct. This study
aimed to evaluate the prevalence, predictors and management of PN-associated hyperglycemia (PN-AH).
Keywords: Methods: A retrospective study was conducted at a tertiary hospital. Patients
18 years old who
Parenteral nutrition
received parenteral nutrition from 2015 to 2018 were conveniently selected. The demographic data,
Hyperglycemia
diagnosis, clinically relevant data, blood glucose readings and management of hyperglycemia were
Risk factors
Metabolic complication
gathered from electronic medical records.
Asian Results: Among 300 patients included in the study, 140 (46.7%) reported the PN-AH events. Multivariate
logistic regression analysis showed female sex, Malay ethnicity, underlying type 2 diabetes mellitus, liver
impairment, elevated pre-PN glucose level > 180 mg/dL and ICU admission were independently asso-
ciated with hyperglycemia (p < 0.05 for all variables). Furthermore, factors such as ICU admission, un-
derlying diabetes mellitus and hyperglycemia before starting PN, cause earlier development of PN-AH.
More frequent monitoring of PN was observed in the ICU, guided by a protocol, as compared to the non-
ICU setting.
Conclusion: The prevalence of PN-AH is a significant complication to require medical attention. The
predictors such as female gender, Malay ethnicity, underlying Diabetes Mellitus, liver impairment, hy-
perglycemia before starting PN, and ICU admission should be applied in clinical settings to improve the
detection of PN-AH. A guideline outlining the risk factors, monitoring strategies and treatment plans
should be developed to improve the detection and management of PN-AH.
© 2020 European Society for Clinical Nutrition and Metabolism. Published by Elsevier Ltd. All rights
reserved.

1. Introduction hyperglycemia in adult patients receiving PN is defined as having a

Hyperglycemia is a common metabolic complication of paren-
teral nutrition (PN) and may occur in patients with or without a
prior history of diabetes [1,2]. The prevalence of parenteral
nutrition-associated hyperglycemia (PN-AH) in adult patients
ranges from 17.0 to 50.9% [2e7]. According to the American Society
for Parenteral and Enteral Nutrition (ASPEN) 2013 guideline,
Abbreviations: ASPEN, American Society for Parenteral and Enteral Nutrition;
BMI, body mass index; CRP, C-Reactive protein; HbA1c, Hemoglobin A1c; ICU,
intensive care unit; IQR, interquartile range; PN, parenteral nutrition; PN-AH,
parenteral nutrition-associated hyperglycemia; RBS, random blood sugar; T2DM,
type 2 diabetes mellitus.
* Corresponding author. Faculty of Pharmacy, Universiti Kebangsaan Malaysia,
Jalan Raja Muda Abdul Aziz, 50300, Kuala Lumpur, Malaysia. Fax: þ603 26983271.
E-mail address: nurulainmt@ukm.edu.my (N.A. Mohd Tahir).
blood glucose level above 180 mg/dL (10 mmol/L) [8].
PN-AH has been shown to increase the mortality rate and also is
the risk factor for the development of infections, cardiac compli-
cations, and acute renal failure [9]. PN-AH is multifactorial, mainly
influenced by the nutrition support given and also the disease
factors such as underlying disease, the severity of illness and organ
functions [10]. Predictors found to be significantly associated with
PN-AH includes pre-PN CRP level > 116 mg/L, grams of carbohy-
drates infused, age > 65 years, HbA1c concentration of >5.7%, un-
derlying diabetes, presence of infection and concomitant use of
glucose-elevating drugs [7]. Appropriate monitoring of blood
glucose, especially focusing on these predictors would help for
better detection of PN-AH cases leading to the achievement of its
therapeutic target.

https://doi.org/10.1016/j.clnesp.2020.11.023
2405-4577/© 2020 European Society for Clinical Nutrition and Metabolism. Published by Elsevier Ltd. All rights reserved.
M.A. Roszali, A.N. Zakaria and N.A. Mohd Tahir
Most of the studies on the prevalence, predictors and manage-
ment of PN-AH were largely conducted among the Caucasian. The
Asian population has a different genetic composition and is pre-
disposed to a higher risk of diabetes mellitus [11] but the preva-
lence and risk factors for PN-AH have not been investigated and
under-represented on this topic. Regardless, the available studies
evaluating the predictors of PN-AH are based on a small sample size
[2e4,6], involved various definitions of hyperglycemia [4], and
based on various methodological conducts [2,5,6] which explain
the inconclusive findings of the study.
The purposes of this study were to evaluate the predictors of PN-
AH and identifying different strategies of PN-AH management. This
will lead to the integration of knowledge for better identification of
risk of PN-AH leading to optimal care. The goal is to achieve optimal
care for the patient receiving PN support and to illuminate the gaps
in knowledge to provide priorities for future clinical research.
2. Methods
This longitudinal, observational and retrospective study was
based on the electronic medical records data retrieved among pa-
tients aged >18 years old who received PN in a tertiary hospital
from the year 2015e2018. This study solely included patients
receiving PN which indicated when the oral or enteral route of
nutrition cannot be established or is insufficient for the mainte-
nance of the patient's nutritional requirements in relation to their
clinical status [14,15]. Nutrition supplementation either solely from
the PN or in combination with oral or enteral intake were included.
Pregnant women were excluded from the study. For the purpose of
this study, hyperglycemia was defined as at least one blood glucose
level exceeding 10 mmol/L (180 mg/dL).
A data collection form was developed comprising of the pa-
tients’ demographic characteristics (ethnicity, sex, age, body
weight, and body mass index), clinical data (diagnosis, medical
histories, estimated glomerular filtration rate, liver enzyme level,
HbA1c level, CRP level, blood glucose levels and concomitant use of
glucose-elevating medications such as corticosteroids, somato-
statin, tacrolimus and cyclosporine), PN order details and man-
agement of hyperglycemia. The data were reviewed from the start
date of PN administration until the day PN was off, to look out for
hyperglycemia events during the whole course of PN prescription.
This study has received ethical approval from the Medical
Research and Ethics Committee, Ministry of Health (NMRR-18-
3358-45186) and also from the University Research Ethics Com-
mittee (UKM PPI/111/8/JEP-2019-073).
2.1. Statistical analysis
Data were statistically analyzed using the IBM SPSS Statistics for
Windows version 24.0 software [17]. Descriptive statistics were
used to analyze demographic data, clinical data, details on PN usage
and management of PN-AH. Categorical data were presented as
frequency and percentage while continuous data were presented as
the median and interquartile range (IQR) as they were not normally
distributed when tested using the KolmogoroveSmirnov equation.
The relationship between potential predictors with PN-AH was
analyzed using simple logistic regression and all factors with a p-
value of less than 0.25 were further analyzed using the Backward LR
model of multiple logistic regression. A higher range of p-value of
<0.25 was used to ensure that all necessary factors were included
for further analyses. The predictors found to be statistically signif-
icant from the multiple logistic regression were then analyzed us-
ing the ManneWhitney equation to test for association between
the predictors with days until PN-AH occurs. This is because the
duration until PN-AH occur was also found to be not normally
276
Clinical Nutrition ESPEN 41 (2021) 275e280
distributed. All statistical tests with p-values of <0.05 denote sta-
tistical significance and a confidence interval of 95% was utilized for
logistic regression.
3. Results
Three hundred patients were selected as participants after
excluding 8 patients less than 18 years old and another 16 patients
with incomplete medical records. The characteristics of the 300
patients enrolled and the PN infused are as shown in Table 1 [Place
Table 1 here or close to here]. Among patients on PN, the majority of
them were Chinese (N ¼ 130, 43.3%) followed by the Malay (N ¼ 46,
32.9%), male (N ¼ 193, 64.3%), less than 65 years old (N ¼ 190,
63.3%) and a BMI of less than 25 kg/m2 (N ¼ 222, 74.0%). Although
100 patients (33.3%) had episodes of hyperglycemia before the PN
was started, only 41 patients were monitored for the HbA1c level.
The prevalence of PN-AH in the adult population was reported at
46.7% (n ¼ 140).
The results of the regression indicated the factors of the female
sex, Malay ethnicity, presence of underlying type 2 diabetes mel-
litus (T2DM), liver impairment (referred as elevated ALT level two
times the upper normal limit), hyperglycemia before starting PN
(glucose level more than 10 mmol/L), and ICU admission were
significant predictors for PN-AH (p < 0.05) (refer Table 2) [Place
Table 2 here or close to here]. Although some patients develop PN-
AH after receiving PN for up to 26 days, most patients develop PN-
AH at a much faster rate within a few days (median ¼ 1 day,
IQR ¼ 2). Factors to cause earlier development of PN-AH were ICU
admission, underlying T2DM and hyperglycemia before starting PN
(refer Table 3) [Place Table 3 here or close to here].
A different pattern of blood glucose monitoring was observed in
the ICU compared to the non-ICU wards as shown in Table 4 [Place
Table 4 here or close to here]. The majority of patients who received
PN in the ICU (N ¼ 91, 95.8%) were on blood glucose level moni-
toring at least four times daily compared to 63.4% (N ¼ 130) in non-
ICU wards.
Table 5 shows the treatment given for PN-AH in this institution.
It was noted that some of the patients who had hyperglycemia
while on PN were not started on any insulin or oral hypoglycemic
agents (OHA) (28.8% in ICU and 51.9% in non-ICU) [Place Table 5
here or close to here]. Focusing on treatment for PN-AH, insulin
was the most used therapy in both the ICU (N ¼ 42, 71.19%) and
non-ICU setting (N ¼ 34, 41.98%), with intravenous infusion was
frequently administered in both settings (N ¼ 59, 42.14%).
4. Discussion
The prevalence of hyperglycemia in adult patients on PN was
found to be significant at 46.7% in our study but it is slightly lower
compared to the 50.9% prevalence reported by a previous study [7].
The high prevalence rate in both of these studies showed that hy-
perglycemia is a commonly occurring complication of PN. The dif-
ferences in ethnicities and settings between our study and the
previous study were the main reason for the variation in the
prevalence rate [7]. The current study involved 3 main Asian eth-
nicities (Malays, Chinese and Indians) while the previous study
only involved the Caucasian population [7]. Previous studies had
shown that ethnicity is one of the factors affecting insulin sensi-
tivity and its secretion [18,19], thus it may also have an effect on
hyperglycemia in patients on PN. This study further reported the
Chinese ethnicity to have a higher prevalence in the development
of PN-AH, although the previous study reported that the Malay
ethnicity was associated with higher postprandial glycemic excur-
sion [19]. This is most probably because the rate of PN infusion
observed in our study was very low (restricted), <4 mg/kg/min, to
M.A. Roszali, A.N. Zakaria and N.A. Mohd Tahir Clinical Nutrition ESPEN 41 (2021) 275e280

Table 1
Association of demographic, clinical and PN factors with the development of PN-associated hyperglycemia.

Demographic, Clinical and PN Factors Develop PN-AH p-valuea

Yes, n ¼ 140 No, n ¼ 160

n (%) n (%)

Ethnicities Malay 46 (32.9) 72 (45.0) 0.032f

Chinese 64 (45.7) 66 (41.3) 0.436g
Indians 25 (17.9) 15 (9.4) 0.034h
Others 5 (3.6) 7 (4.4) 0.724i
Sex Male 82 (58.6) 111 (69.4) 0.052
Female 58 (41.4) 49 (30.6)
Age Median ¼ 61.0, IQR ¼ 21.0 <65 years 87 (62.1) 103 (64.4) 0.689

65 years 53 (37.9) 57 (35.6)
BMI Median ¼ 22.5, IQR ¼ 6.3 <25 kg/m2 94 (67.1) 128 (80.0) 0.012

25 kg/m2 46 (32.9) 32 (20.0)
ICU admission ICU 59 (42.1) 36 (22.5) <0.001
Non-ICU 81 (57.9) 124 (77.5)
Infection Yes 126 (90.0) 139 (86.9) 0.402
No 14 (10.0) 21 (13.1)
Post-Surgery within 7 days Yes 76 (54.3) 80 (50.0) 0.459
No 64 (45.7) 80 (50.0)
Pancreatitis Yes 7 (5.0) 2 (1.2) 0.079
No 133 (65.0) 158 (98.8)
Cancer Yes 58 (41.4) 76 (47.5) 0.292
No 82 (58.6) 84 (52.5)
Diabetes Mellitus Yes 67 (47.9) 19 (11.9) <0.001
No 73 (52.1) 141 (88.1)
b
Renal Impairment Yes 44 (31.4) 35 (21.9) 0.062
No 96 (68.6) 125 (78.1)
Liver Impairmentc Yes 16 (11.4) 8 (5.0) 0.046
No 124 (88.6) 152 (95.0)
Pre-PN HbA1cd 5.7% 1 (36.9) 5 (38.5) 0.015
>5.7% 27 (96.4) 8 (65.1)
e
Pre-PN CRP 116 mg/L 15 (32.6) 20 (39.2) 0.499
>116 mg/L 31 (67.4) 31 (60.8)
Pre-PN Blood Glucose Level 10 mmol/L 60 (42.9) 140 (87.5) <0.001
>10 mmol/L 80 (57.1) 20 (12.5)
Use of Glucose-elevating Drugs Yes 34 (24.3) 22 (13.8) 0.021
No 106 (75.7) 138 (86.3)
Administration PN Continuous PN 132 (94.3) 143 (89.4) 0.130
Cyclical PN 8 (5.7) 17 (10.6)
Total Calorie/day 30 kcal/kg/day 132 (94.3) 152 (95.0) 0.784
>30 kcal/kg/day 8 (5.7) 8 (5.0)
Glucose Infusion Rate 4 mg/kg/min 137 (97.9) 156 (97.5) 0.838
>4 mg/kg/min 3 (2.1) 4 (2.5)
a
Simple logistic regression.
b
Renal impairment was defined as creatinine clearance lower than 60 mL/min.
c
Liver impairment was defined as elevated transaminases level 2  Upper limit of the normal range.
d
HbA1c total n ¼ 41.
e
Pre-PN CRP total n ¼ 97.
f
Malay ethnicity vs Non-Malay ethnicity.
g
Chinese ethnicity vs Non-Chinese ethnicity.
h
Indian ethnicity vs Non-Indian ethnicity.
i
Others ethnicity vs Non-others ethnicity.

be a match for the low insulin secretory capacity among the Malay
ethnicity. Furthermore, the Malay ethnicity was also reported as
one of the predictors for PN-AH. This finding proves ethnicity does
affect the hyperglycemia episodes in patients on PN and more
studies are necessary to explain the exact mechanism of how
ethnicity affects glucose metabolism. However, our findings of non-
significance associations of age factors to the development of PN-
AH differs from outcomes by Olviera et al. (2014) [7]. This might
be because of the large range of age groups (18e89 years old) in our
study as compared to the previous study [7].
Our findings also report that patients with underlying T2DM,
hyperglycemia before starting PN and ICU admission were associ-
ated with higher risks of developing PN-AH and potentially develop
PN-AH within a short period after starting PN. Similar to the pre-
vious study, underlying T2DM and hyperglycemia before starting
PN were predictors to increase the risk of PN-AH [7]. Hyperglyce-
mia is a clinical presentation of diabetes that might lead to the
277
disorders of carbohydrate metabolism. The development of hy-
perglycemia in critically ill patients without diabetes are associated
with the amount of dextrose administered via TPN [20]. Hyper-
glycemia is common in critically ill patients due to the actions of
stress hormones which then led to increased hepatic gluconeo-
genesis, glycogenolysis and peripheral insulin resistance [21]. Thus,
it was expected that these factors would further increase the risk of
hyperglycemia. Furthermore, this study also observed findings of
liver impairment as one of the predictive factors in the develop-
ment of PN-AH. The liver is involved in glucose metabolism [21]
and liver impairment would disturb the glucose metabolism pro-
cess. Administration of a marked amount of glucose can also lead to
liver function abnormalities [22].
The practice of monitoring blood glucose levels is of paramount
importance to optimize the detection and treatment of PN-AH,
considering the reported findings of its predictors [23]. A protocol
adopted the recommendations from the ESPEN guideline is
M.A. Roszali, A.N. Zakaria and N.A. Mohd Tahir Clinical Nutrition ESPEN 41 (2021) 275e280

Table 2
Simple and multiple logistic regression analysis: adjusted risk of presenting capillary blood glucose higher than 180 mg/dL during PN infusion.

Characteristics Simple Logistic Regression Multiple Logistic Regression (Backward-LR model)

P-value Crude OR (95% CI) B P-value Adjusted OR (95% CI)

Sex
Female 0.052 1.60 (1.00e2.58) 0.61 0.049 1.84 (1.00e3.38)
Male Reference
Malay Ethnicity
Malay 0.032 0.60 (0.37e0.96) 1.01 0.002 0.36 (0.19e0.69)
Non-Malay Reference
ICU admission
ICU <0.001 2.51 (1.52e4.14) 1.21 <0.001 3.35 (1.74e6.45)
Non-ICU Reference
Pancreatitis
Yes 0.079 4.16 (0.85e20.36) 1.76 0.078 5.82 (0.82e41.36)
No Reference
Underlying T2DM
Yes <0.001 6.81 (3.80e12.20) 1.71 <0.001 5.54 (2.66e11.52)
No Reference
Liver impairment
Yes 0.046 2.45 (1.02e5.92) 1.10 0.040 3.00 (1.05e8.55)
No Reference
Pre-PN BG level
>10 mmol/L <0.001 9.33 (5.25e16.60) 1.80 <0.001 6.07 (3.05e12.08)
10 mmol/L Reference
Use of Glucose-elevating drug
Yes 0.021 2.01 (1.11e3.64) 0.74 0.058 2.09 (0.98e4.46)
No Reference

Parameters included in the model but without statistical significance: Renal impairment, cyclical administration of parenteral nutrition, elevated BMI (
25 kg/m2); T2DM:
type 2 diabetes mellitus.

Table 3
Association between patient factors with the onset to develop PN-associated hyperglycemia.

Factors Days to develop PN-AH, Median (IQR) Z statistics (ManneWhitney test) p-value

Sex Male 1.0 (1.0) 0.791 0.429

Female 1.0 (2.0)
Malay Ethnicity Malay 1.0 (1.0) 0.693 0.488
Non-Malay 1.0 (2.0)
ICU admission ICU 1.0 (0.0) 2.724 0.006
Non-ICU 1.0 (2.0)
Underlying type 2 Diabetes Mellitus Yes 1.0 (0.0) 3.420 0.001
No 2.0 (3.0)
Liver impairment Yes 1.0 (0.0) 1.388 0.165
No 1.0 (2.0)
Pre-PN RBS 10 mmol/L 2.0 (4.0) 4.396 <0.001
>10 mmol/L 1.0 (0.0)

Table 4
Blood glucose monitoring frequency for patients on parenteral nutrition and for patients who developed PN-associated hyperglycemia in ICU and Non-ICU wards.

Blood glucose monitoring for PN patient Blood glucose monitoring for PN patient post PN-AH

Frequency of Blood glucose monitoring n (%) Frequency of Blood glucose monitoring n (%)

ICU Non-ICU ICU Non-ICU

1x/day 1 (1.1) 51 (24.9) 1x/day 0 (0.0) 7 (8.6)

2x/day 2 (2.1) 12 (5.9) 2x/day 1 (1.7) 4 (4.9)
3x/day 1 (1.1) 12 (5.9) 3x/day 1 (1.7) 3 (3.7)
4x/day 83 (87.4) 124 (60.5) 4x/day 45 (76.3) 55 (67.9)
More than 4x/day 8 (8.4) 6 (2.9) More than 4x/day 12 (20.3) 12 (14.8)
Total 95 (100.0) 205 (100.0) Total 59 (100.0) 81 (100.0)

available in the ICU to guide the healthcare providers in the PN
management [16]. The guideline includes recommendations on the
initiation of treatment following 2 consecutive blood glucose
readings of more than 10 mmol/L and should be followed by blood
glucose monitoring of 2e4 times a day for patients who developed
PN-AH until the glucose level stabilized [22,24]. Generally, it was
observed that the monitoring of blood glucose levels among pa-
tients in ICU wards is more frequent as compared to those staying
in the non-ICU setting. Furthermore, our study followed the
278
recommendation to use insulin therapy for the management of PN-
AH where insulin therapy was the most utilized treatment in our
institution. Besides, continuous intravenous insulin infusion (either
sliding scale protocol or fixed-rate infusion) was the most used
insulin regimen, especially in the ICU setting. This regimen is
considered the safest and most effective way to achieve glycemic
control and it can be titrated to respond rapidly to changing clinical
conditions [1,25e27]. In non-ICU wards, it has also been shown
to produce superior glycemic control without an increased rate
M.A. Roszali, A.N. Zakaria and N.A. Mohd Tahir
Table 5
Treatment for PN-Associated hyperglycemia in ICU and Non-ICU.
Treatment for PN-Associated Hyperglycemia
No treatment
Intravenous infusion insulin (sliding scale)
Intravenous infusion insulin (fixed rate)
Corrective subcutaneous insulin
Basal bolus insulin
Non-insulin
of hypoglycemia compared to subcutaneous basal-correction
insulin [28].
On the other hand, factors such as concomitant use of glucose
elevating drugs and elevated pre-PN CRP levels were not signifi-
cantly associated with the development of PN-AH. The low
numbers of patient on concomitant use of glucose elevating drugs
did not significantly predict the association. The other reason could
be because these drugs are most commonly administered in ICU
and complications and severity of illness associated with ICU
admission may disguise the effects. The CRP level was not often
monitored in PN cases and was only utilized to monitor the prog-
ress of patients with severe infections or inflammatory disorders.
This explained the skewness of CRP level distribution the right with
the median of 140.0 mg/L, much higher than the mean of 94.3 mg/L
reported in a previous study [7].
The results of this study were limited by the retrospective na-
ture of data collection. Data from medical records that are not
specifically meant for research purposes have challenged the
researcher to extract and interpret the data. However, efforts had
been made to minimize the impact of this limitation in reporting
the result by crosschecking the medical records with other docu-
ments (nurses' records, medication administration records and
pharmacists’ records) to get a better view of the patient conditions
at the particular time. Additionally, good documentation through
the use of electronic medical records and the documentation by the
Nutrition Support Pharmacists has been carried out with scrupu-
lous attention to the PN detail may improve the reliability and
validity of the study results.
This study highlighted ethnicity is one of the predictors for PN-
AH, thus the management of PN-AH should be tailored according to
the ethnicity of the patients. Furthermore, PN-AH is a highly
prevalent problem requiring attention from healthcare pro-
fessionals to reduce its risk of complication and mortality. The
predictors associated with metabolic disturbance such as under-
lying T2DM, pre-elevated glucose level, ICU admission and liver
impairment are clinically relevant for guiding healthcare pro-
fessionals to improve the detection and management of PN-AH.
Multicenter studies involving a wide range of ethnicities should
be conducted to discover the mechanisms of how these factors
affect hyperglycemia. Furthermore, the development of guidelines
should take into consideration these risks to improve the detection,
monitoring and treatment of PN-AH. All these combined can lead to
improved outcomes (lower complications and mortality rate) if PN-
AH is anticipated, detected early and controlled promptly.
5. Conclusion
The prevalence of PN-AH is high in adult patients regardless of
the population difference. Predictors of PN-AH such as female sex,
Malay ethnicity, underlying T2DM, liver impairment, hyperglyce-
mia before starting PN and ICU admission should be anticipated to
increase the risk of PN-AH. The mechanism of ethnicity factors
affecting glucose metabolism had not been established and further
studies are warranted to explore the mechanisms. A guideline
279
Clinical Nutrition ESPEN 41 (2021) 275e280
ICU, n ¼ 59 (%) Non-ICU, n ¼ 81 (%)
17 (28.8) 42 (51.9)
39 (66.1) 17 (21.0)
2 (3.4) 1 (1.2)
1 (1.7) 3 (3.7)
0 (0.0) 13 (16.0)
0 (0.0) 5 (6.2)
outlining the risk factors, monitoring strategies and treatment
plans should be developed to improve the detection and manage-
ment of PN-AH.
Funding
This research did not receive any specific grant from funding
agencies in the public, commercial, or not-for-profit sectors.
Declaration of competing interest
The authors have no conflict of interest with regard to the
content of this article. The views expressed in the submitted article
are the authors' own opinions and do not express the views of their
official position of the institution.
Acknowledgements
We would like to thank the Director General of Health Malaysia
for his permission to publish this article.
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