A. Diabetes care in the hospital
* All patients with diabetes admitted to the hospital should be identified in the medical record as having diabetes. (E)
* All patients with diabetes should have an order for blood glucose monitoring, with results available to all members of the health care team. (E)
* Goals for blood glucose levels:
Critically ill patients: blood glucose levels should be kept as close to 110 mg/dl (6.1 mmol/l) as possible and generally <180 mg/dl (10 mmol/l). These patients will usually require intravenous insulin. (B)
Due to concerns regarding the risk of hypoglycemia, some institutions may consider these blood glucose levels to be overly aggressive for initial targets. Through quality improvement, glycemic goals should systematically be reduced to the recommended levels. (E)
* Scheduled prandial insulin doses should be given in relation to meals and should be adjusted according to point of care glucose levels. The traditional sliding-scale insulin regimens are ineffective and are not recommended. (C)
* A plan for treating hypoglycemia should be established for each patient. Episodes of hypoglycemia in the hospital should be tracked. (E)
* All patients with diabetes admitted to the hospital should have an A1C obtained for discharge planning if the result of testing in the previous 2??s topic, and the recommendations from this meeting were also carefully reviewed and discussed in the formulation of the guidelines that follow. The management of diabetes in the hospital is generally considered secondary in importance compared with the condition that prompted admission.
Patients with hyperglycemia fall into three categories:
* Medical history of diabetes: diabetes has been previously diagnosed and acknowledged by the patient??ing the A1C test may be a valuable case-finding tool for identifying diabetes in hospitalized patients.
A rapidly growing body of literature supports targeted glucose control in the hospital setting with potential for improved mortality, morbidity, and health care economic outcomes. Hyperglycemia in the hospital may result from stress, decompensation of type 1 diabetes, type 2 diabetes, or other forms of diabetes and/or may be iatrogenic due to administration or withholding of pharmacologic agents, including glucocorticoids, vasopressors, etc. Distinction between decompensated diabetes and stress hyperglycemia is often not made.
1. Blood glucose targets
a. General medicine and surgery.
Observational studies suggest an association between hyperglycemia and increased mortality. General medical and surgical patients with a blood glucose value(s) >220 mg/dl (12.2 mmol/l) have higher infection rates.
When admissions on general medicine and surgery units were studied, patients with new hyperglycemia had significantly increased inhospital mortality, as did patients with known diabetes. In addition, length of stay was higher for the new hyperglycemic group, and both the patients with new hyperglycemia and those with known diabetes were more likely to require intensive care unit (ICU) care and transitional or nursing home care. Better outcomes were demonstrated in patients with fasting and admission blood glucose <126 mg/dl (7 mmol/l) and all random blood glucose levels <200 mg/dl (11.1 mmol/l).
b. CVD and critical care.
The relationship of blood glucose levels and mortality in the setting of acute myocatdial infarction (AMI) has been reported. A meta-analysis of 15 previously published studies compared in-hospital mortality and CHF in both hyper- and normoglycemic patients with and without diabetes. In subjects without known diabetes whose admission blood glucose was 109.8 mg/dl (6.1 mmol/l), the relative risk for in-hospital mortality was increased significantly. When diabetes was present and admission glucose 180 mg/dl (10 mmol/l), risk of death was moderately increased compared with patients who had diabetes but no hyperglycemia on admission. In another study, admission blood glucose values were analyzed in consecutive patients with AMI. Analysis revealed an independent association of admission blood glucose and mortality. The 1-year mortality rate was significantly lower in subjects with admission plasma glucose <100.8 mg/dl (5.6 mmol/l) than in those with plasma glucose 199.8 mg/dl (11 mmol/l).
Finally, in the first Diabetes and Insulin-Glucose Infusion in Acute Myocardial Infarction (DIGAMI) study, insulin-glucose infusion followed by subcutaneous insulin treatment in diabetic patients with AMI was examined. Intensive subcutaneous insulin therapy for 3 months improved long-term survival. Mean blood glucose in the intensive insulin intervention arm was 172.8 mg/dl (9.6 mmol/l) (compared with 210.6 mg/dl [11.7 mmol/l] in the “conventional” group). The broad range of blood glucose levels within each arm limits the ability to define specific blood glucose target thresholds.
c. Cardiac surgery.
Attainment of targeted glucose control in the setting of cardiac surgery is associated with reduced mortality and risk of deep sternal wound infections in cardiac surgery patients with diabetes and supports the concept that perioperative hyperglycemia is an independent predictor of infection in patients with diabetes , with the lowest mortality in patients with blood glucose <150 mg/dl (8.3 mmol/l).
d. Critical care.
A mixed group of patients with and without diabetes admitted to a surgical ICU were randomized to receive intensive insulin therapy (target blood glucose 80?? mmol/l).
e. Acute neurological disorders.
Hyperglycemia is associated with worsened outcomes in patients with acute stroke and head injury, as evidenced by the large number of observational studies in the literature. A meta-analysis identified an admission blood glucose >110 mg/dl (6.1 mmol/l) for increased mortality for acute stroke.
AMERICAN DIABETES ASSOCIATION
DIABETES CARE, VOLUME 27, SUPPLEMENT 1, JANUARY 2004
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