In-hospital Management of Diabetes

1. In-hospital Management of Diabetes Key Messages • Diabetes increases the risk for disorders that predispose individuals to hospitalization, including cardiovascular diseases, nephropathy, infection and lower-extremity amputations. • Use of “sliding scale” insulin therapy, although common, treats hyperglycemia after it has occurred. A proactive approach to management with the use of basal, bolus and correction insulin is preferred.

2. In-hospital Management of Diabetes Key Messages • Hypoglycemia remains a major impediment to achieving optimal glycemic control in hospitalized patients. Healthcare institutions should have standardized treatment protocols that address mild, moderate and severe hypoglycemia.

3. In-hospital Management of Diabetes 2008 CPG Recommendations • Provided that their medical conditions, dietary intake and glycemic control are acceptable, patients with diabetes should be maintained on their prehospitalization oral antihyperglycemic agents or insulin regimens [Grade D, Consensus].

4. In-hospital Management of Diabetes 2008 CPG Recommendations • For hospitalized patients with diabetes treated with insulin, a proactive approach that may include basal, prandial and correction-dose insulin, along with pattern management, is preferred over the “sliding scale” reactive approach using only short- or rapid-acting insulin [Grade D, Consensus].

5. In-hospital Management of Diabetes 2008 CPG Recommendations • To maintain intraoperative glycemic levels between 5.5 and 10.0 mmol/L for patients with diabetes undergoing coronary artery bypass surgery, a continuous IV insulin infusion alone [Grade C, Level 3 (38,39)] or with the addition of glucose and potassium [Grade B, Level 2 (40)], with an appropriate protocol and trained staff to ensure the safe and effective implementation of this therapy and to minimize the likelihood of hypoglycemia, should be used.

6. In-hospital Management of Diabetes 2008 CPG Recommendations • A continuous IV insulin infusion should be used to achieve glycemic levels of 4.5 to 6.0 mmol/L in postoperative ICU patients with hyperglycemia (random PG >6.1 mmol/L) requiring mechanical ventilation to reduce morbidity and mortality [Grade A, Level 1A (15)], and in medical ICU patients with hyperglycemia (random PG >6.1 mmol/L) to reduce morbidity [Grade B, Level 2 (18)].

7. In-hospital Management of Diabetes 2008 CPG Recommendations • Perioperative glycemic levels should be maintained between 5.0 and 11.0 mmol/L for most other surgical situations, with an appropriate protocol and trained staff to ensure the safe and effective implementation of this therapy and minimize the likelihood of hypoglycemia [Grade D, Consensus].

8. In-hospital Management of Diabetes 2008 CPG Recommendations • In hospitalized patients, efforts must be made to ensure that patients using insulin or insulin secretagogues have ready access to an appropriate form of glucose at all times, particularly when NPO or during diagnostic procedures [Grade D, Consensus].

9. In-hospital Management of Diabetes 2008 CPG Recommendations • Measures to assess, monitor and improve glycemic control within the inpatient setting should be implemented, and include hypoglycemia management protocols and diabetes-specific discharge planning [Grade D, Consensus]. Glucagon should be available for any patient at risk for severe hypoglycemia when IV access is not readily available [Grade D, Consensus].