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TPN-associated hyperglycaemia in surgical patients: improving management through ward-based practice

Published online by Cambridge University Press:  22 June 2010

L. Wainwright ,
L. French ,
L. Vokes ,
D. Meeking  and
T. Trebble
L. Wainwright
Affiliation:
Blood Sciences, Queen Alexandra Hospital, Southwick Hill Road, PortsmouthPO6 3LY
L. French
Affiliation:
Biochemistry, Nottingham University Hospitals NHS Trust, Hucknall Road, NottinghamNG5 1PB
L. Vokes
Affiliation:
Dietetics, Queen Alexandra Hospital, Southwick Hill Road, PortsmouthPO6 3LY
D. Meeking
Affiliation:
Endocrine Unit, Queen Alexandra Hospital, Southwick Hill Road, PortsmouthPO6 3LY
T. Trebble
Affiliation:
Gastroenterology, Queen Alexandra Hospital, Southwick Hill Road, PortsmouthPO6 3LY
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Abstract

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Proceedings of the Nutrition Society , Volume 69 , Issue OCE2: Malnutrition Matters, Joint BAPEN and Nutrition Society Meeting, 13–14 October 2009, Cardiff , 2010 , E223
Copyright
Copyright © The Authors 2009

TPN-associated glycaemic instability and hyperglycaemia are linked to an increased risk of sepsis and cardiac and renal complications(Reference Cheung, Napier, Zaccaria and Fletcher1). Tight glycaemic management in critically ill patients is associated with improved outcome(Reference Lin, Lin, Lee, Ma and Lin2). The risks of sepsis are particularly high in immediate post-surgical patients who account for a high proportion of in-hospital TPN in our Trust. We undertook an initial audit of monitoring and management of hyperglycaemia in this patient group(Reference French and Trebble3), followed by the introduction of a number of simple and inexpensive measures within ward-based practice. We present the results of our subsequent experience and re-audit.

Medical records relating to all post-surgical patients (first 5 days) receiving TPN between January and July 2007 were examined. Our standards included: twice daily bedside glucose measurements and introduction of insulin following more than one reading of blood glucose >8.0 mmol/l.

The following measures were introduced following our initial audit:

  • • Yellow stickers advising of monitoring and management were placed on the observation charts of all patients receiving TPN by the dieticians.

  • • Junior doctors from the patient's primary team were asked to attend the nutrition ward rounds where diabetes management was discussed.

  • • Nursing education was undertaken with a dedicated ward information board, in association with the senior ward sisters.

  • • Increased scrutiny by the nutrition team of glycaemic monitoring in TPN patients. This was followed by re-audit of 28 patients on TPN to assess the impact of the changes. The results of the re-audit demonstrated a marked increase in identification, surveillance and management of hyperglycaemia amongst this patient group.

We have found that, with the implementation of several simple and inexpensive measures, glycaemic monitoring of patients on TPN can be significantly improved. These interventions have also resulted in almost twice as many hyperglycaemic patients receiving treatment. Further work may be needed to determine the effect of improving patient monitoring in this group.

References

1.Cheung, NW, Napier, B, Zaccaria, C & Fletcher, JP (2005) Diabetes Care 28, 2367–2371.CrossRefGoogle Scholar
2.Lin, LY, Lin, HC, Lee, PC, Ma, WY & Lin, HD (2007) Am J Med Sci 333, 261–265.CrossRefGoogle Scholar
3.French, L & Trebble, T (2008) Biomed Scientist 52, 578–579.Google Scholar