NEWSLETTER
MANAGEMENT OF INPATIENT HYPERGLYCEMIA
Professor Abdul Jabbbar, AKU
Intensive management of diabetes or hyperglycemia during hospitalization is now key to Quality-care and this is evidence based as morbidity and mortalityoutcome in both medical and surgical patients is significantly affected by their glycemic control. The medical literature given below supports the notion that a dedicated team to look after all diabetic inpatients is going to help providing quality care to our patients and is also going to improve the outcomes of Surgical, coronary and other procedures done in the hospital.
Although the endocrine consult service is working
everyday, It has been noted that patients are usually
managed on sliding scale and a consult is asked on
the day of discharge. Based on the details given
below, we propose a dedicated team to look after
all such patients in the hospital. The team should
comprise an endocrinologist, a SMO, two diabetes
nurses and a full time dietitian. This team should
see all patients with diabetes or hyperglycemia
admitted and give advice and plan for their diabetes
management.
MEDICAL LITERATURE
Diabetes increases the risk for disorders that predispose individuals to hospitalization, including coronary artery, erebrovascular and peripheral vascular disease, nephropathy, infection, and lowerextremity amputations. The management of diabetes in the hospital is generally considered secondary in importance compared with the condition that prompted admission. Recent studies have focused attention to the possibility that hyperglycemia in the hospital is not necessarily a benign condition and that aggressive treatment of diabetes and hyperglycemia results in reduced mortality and morbidity.
In addition to having a medical history of diabetes, patients presenting to hospitals may have unrecognized diabetes or hospital-related hyperglycemia. Umpierrez et al. reported a 26% prevalence of known diabetes in hospitalized patients in a community teaching hospital. An additional 12% of patients had unrecognized diabetes or hospital-related hyperglycemiaas defined above.
From the patient’s perspective, 24% of adult patients with known diabetes surveyed in 1989 reported being hospitalized at least once in the previous year. The risk for hospitalization increased with age, duration of diabetes, and number of diabetes complications. Persons with diabetes reported being hospitalized in the previous year three times more frequently compared with persons without diabetes. In summary, the prevalence of diabetes in hospitalized adults is conservatively estimated at 12.4–25%, depending on the thoroughness used in identifying patients.
Intensive insulin therapy also reduced overall in hospital mortality by 34%. The rate of sepsis was 46 percent lower, acute renal failure requiring dialysis or hemofiltration was 41% lower, and the transfusion rate was 50% lower among patient receiving intensive insulin therapy. (21). Intensive insulin therapy to maintain blood glucose at or below 110 mg/dL proved to be critical in reducing morbidity and morbidity among critically ill patients regardless of whether they had a previous diagnosis of diabetes.
The design and implementation of protocols for
maintaining glucose control in the hospital may
provide useful guidance to the treating physician.
Diabetes management may be offered effectively
by primary care physicians or hospitalists, but
involvement of appropriately trained specialists or
specialty teams may reduce length of stay, improve
glycemic control, and improve outcomes.
Patient safety, quality of care, variability of practice,
and medical error have been the subjects of increasing
national concern. Quality assessment programs that
strive to promote a "culture of safety" commonly
focus on diabetes. It has been reported that 11%
of medication errors result from insulin
misadministration, both hypoglycemia and
hyperglycemia are patient safety issues appropriate
for continuous quality improvement (CQI) analysis.
Type 1 DM or Insulin requiring type 2Patient Receiving Nothing by mouth |
||
Basal Insulin ½ NPH Home dose
|
Plus Correction Insulin for Blood Glucose Regular Insulin every 6 hourly |
Adjust dose after 24 Hour |
| Patient Eating | ||
| Glucose well controlled Glucose Poorly controlled |
Plus Prandial Insulin Advance from home dose |
Plus Correction Insulin for blood glucose > 150mg/dl |
Patients with Type 2 DM on oral agents |
||
| Patient receiving nothing by mouth | ||
| Discontinue Oral agents | Begin Correction Insulin
for blood glucose >150 mg/dl • Regular Insulin 6 Hourly Not Controlled • Add Basal Insulin • 0.2-0.3 U/Kg of body weight/day • NPH 12 Hourly • Glargine 24 Hour |
Correction Insulin Scale based on bedside monitoring 150-200 +2u |
| Patient Eating | ||
| Continue Oral agents if No Contraindications and Blood glucose well controlled | ||
| Glucose Poorly Controlled Discontinue oral agents Add Basal Insulin 0.2-0.3 U/Kg of body weight/day NPH 12 hourly Glargine 24 hour OR 70/30 0.5-1 U/kg |
Plus Prandial Insulin |
Plus Correction Insulin for blood glucose > 150mg/dl Correction / Supplemetal Insulin based on bedside monitoring 150-200 +2u |
Suggested protocol for Management of inpatient hyperglycemia:
Glucose Monitoring
Beside blood glucose monitoring should be performed four times per day in all patients (before meals and at bedtime if eating; every 6 hours if not eating) for at least the first 48 hours.
If the patient is medically stable, under good glycemic control, and receiving oral agents or one insulin injection per day, the frequency of monitoring can be decreased to twice daily.
Adjust bedtime NPH / glargine according to FBS > 120 by +2 units. Correction insulin should also be revised frequently (i.e. every 1 to 2 days) based on the results of glucose monitoring.
A conservative initial insulin infusion rate would be 3 u/h with the following algorithm.
<70 mg/dl discontinue,
give 15-20 ml of 50% dextrose and re measure.
70-120 decrease rate by 1 u/h
121-180 no change
181-240 increase by 0.5 u/h
241-300 increase by 1 u/h
300- hi increase by 2u/h