In-hospital Management of Diabetes

Canadian Diabetes Association Clinical Practice Guidelines Expert Committee

Robyn Houlden MD, FRCPC Sara Capes MD, FRCPC Maureen Clement MD, CCFP David Miller MD, FRCPC

  • Key Messages
  • Recommendations
  • Figures
  • Highlights
  • Full Text
  • References

Key Messages

  • Hyperglycemia is common in hospitalized patients, even in those without a previous history of diabetes, and is associated with increased in-hospital complications, length of hospital stay and mortality.
  • Insulin is the most appropriate agent for effectively controlling glycemia in-hospital. A proactive approach to management using scheduled basal, bolus and correction (supplemental) insulin is the preferred method. The use of sliding-scale insulin (SSI), which treats hyperglycemia after it has occurred, should be discouraged.
  • For the majority of noncritically ill patients treated with insulin, preprandial blood glucose (BG) targets should be 5.0 to 8.0 mmol/L, in conjunction with random BG values <10.0 mmol/L, as long as these targets can be safely achieved. For critically ill patients, BG levels should be maintained between 8.0 and 10.0 mmol/L.

Highlights of Revisions

  • Preprandial blood glucose (BG) targets of 5.0 to 8.0 mmol/L with random BG values <10.0 mmol/L are suggested for the majority of noncritically ill patients.
  • Glucose levels of 8.0 to 10.0 mmol/L are suggested for most medical/surgical critically ill patients with hyperglycemia using a continuous intravenous insulin infusion.
  • The perioperative glycemic targets have been simplified to 5.0 to 10.0 mmol/L for most surgical situations.
  • There are now details within the chapter regarding glycemic management in special situations (enteral or parenteral feeds, corticosteroid use, insulin pump therapy, transition from intravenous to subcutaneous insulin).

Recommendations

  1. 1.Provided that their medical conditions, dietary intake and glycemic control are acceptable, people with diabetes should be maintained on their prehospitalization oral antihyperglycemic agents or insulin regimens [Grade D, Consensus].
  2. 2.For hospitalized patients with diabetes treated with insulin, a proactive approach that includes basal, bolus and correction (supplemental) insulin, along with pattern management, should be used to reduce adverse events and improve glycemic control, instead of the reactive sliding-scale insulin approach that uses only short- or rapid-acting insulin [Grade B, Level 2 (1,2)].
  3. 3.For the majority of noncritically ill patients treated with insulin, preprandial BG targets should be 5.0 to 8.0 mmol/L in conjunction with random BG values <10.0 mmol/L, as long as these targets can be safely achieved [Grade D, Consensus].
  4. 4.For most medical/surgical critically ill patients with hyperglycemia, a continuous IV insulin infusion should be used to maintain glucose levels between 8 and 10 mmol/L [Grade D, Consensus].
  5. 5.To maintain intraoperative glycemic levels between 5.5 and 10.0 mmol/L for patients with diabetes undergoing CABG, a continuous IV insulin infusion protocol administered by trained staff [Grade C, Level 3 (3–5)] should be used.
  6. 6.Perioperative glycemic levels should be maintained between 5.0 and 10.0 mmol/L for most other surgical situations, with an appropriate protocol and trained staff to ensure the safe and effective implementation of therapy and to minimize the likelihood of hypoglycemia [Grade D, Consensus].
  7. 7.In hospitalized patients, hypoglycemia should be avoided.
    • Protocols for hypoglycemia avoidance, recognition and management should be implemented with nurse-initiated treatment, including glucagon for severe hypoglycemia when IV access is not readily available [Grade D, Consensus].
    • Patients at risk of hypoglycemia should have ready access to an appropriate source of glucose (oral or IV) at all times, particularly when NPO or during diagnostic procedures [Grade D, Consensus].
  8. 8.Healthcare professional education, insulin protocols and order sets may be used to improve adherence to optimal insulin use and glycemic control [Grade C, Level 3 (6)].
  9. 9.Measures to assess, monitor and improve glycemic control within the inpatient setting should be implemented, as well as diabetes-specific discharge planning [Grade D, Consensus].

Abbreviations:
BG, blood glucose; CABG, coronary artery bypass grafting; IV, intravenous; NPO, nothing by mouth.

References

  1. Umpierrez GE, Smiley D, Zisman A, et al. Randomized study of basal-bolus insulin therapy in the inpatient management of patients with type 2 diabetes (RABBIT 2 trial). Diabetes Care 2007;30. 2181-2161.
  2. Umpierrez GE, Smiley D, Jacobs S, et al. Randomized study of basal-bolus insulin therapy in the inpatient management of patients with type 2 diabetes undergoing general surgery (RABBIT 2 surgery). Diabetes Care 2011;34:256-61.
  3. Furnary AP, Zerr KJ, Grunkemeier GL, et al. Continuous intravenous insulin infusion reduces the incidence of deep sternal wound infection in diabetic patients after cardiac surgical procedures. Ann Thorac Surg 1999;67:352-60.>
  4. Furnary AP, Gao G, Grunkemeier GL, et al. Continuous insulin infusion reduces mortality in patients with diabetes undergoing coronary artery bypass grafting. J Thorac Cardiovasc Surg 2003;125:1007-21.
  5. Haga KK, McClymont KL, Clarke S, et al. The effect of tight glycaemic control, during and after cardiac surgery, on patient mortality and morbidity: a systematic review and meta-analysis. J Cardiothorac Surg 2011;6:3.
  6. Maynard G, Lee J, Phillips G. Improved inpatient use of basal insulin reduced hypoglycemia and improved glycemic control: effect of structured subcutaneous insulin order sets and an insulin management algorithm. J Hosp Med 2009;4:3-15.

 

Reproduced with permission from Canadian Journal of Diabetes © 2013 Canadian Diabetes Association. To cite this article, please refer to For citation.

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