Guidelines for the use of an insulin infusion for the management of hyperglycemia in critically ill patients. Crit Care Med. Stress hyperglycemia: an essential survival response!

Crit Care. Inpatient glycemic control: best practice advice from the Clinical Guidelines Committee of the American College of Physicians. Am J Med Qual. Dysglycaemia in the critically ill and the interaction of chronic and acute glycaemia with mortality.

Intensive Care Med. Liberal Glycemic Control in Critically Ill Patients With Type 2 Diabetes: An Exploratory Study. Hospital-acquired complications in intensive care unit patients with diabetes: A before-and-after study of a conventional versus liberal glucose control protocol.

Acta Anaesthesiol Scand. Is it time to abandon glucose control in critically ill adult patients? Curr Opin Crit Care. Study protocol and statistical analysis plan for the Liberal Glucose Control in Critically Ill Patients with Pre-existing Type 2 Diabetes LUCID trial.

Crit Care Resusc. Glycemic control in the critically ill: Less is more. Cleve Clin J Med. The Effect of a Liberal Approach to Glucose Control in Critically Ill Patients with Type 2 Diabetes: A Multicenter, Parallel-Group, Open-Label Randomized Clinical Trial.

Am J Respir Crit Care Med. Update on glucose control during and after critical illness. On the basis of this data we suggest that the HbA1c be checked on admission to the ICU in all diabetics with blood glucose therapeutic targets as provided in Table 1.

Plummer MP, Bellomo R, Cousins CE, Annink CE, Sundararajan K, Reddi BA, Raj JP, Chapman MJ, Horowitz M, Deane AM Dysglycaemia in the critically ill and the interaction of chronic and acute glycaemia with mortality.

Intensive Care Med. doi: PubMed Google Scholar. Badawi O, Waite MD, Fuhrman SA, Zuckerman IH Association between intensive care unit-acquired dysglycemia and in-hospital mortality. Crit Care Med — Article PubMed Google Scholar.

van den Berghe G, Wouters P, Weekers F, Verwaest C, Bruyninckx F, Schetz M, Vlasselaers D, Ferdinande P, Lauwers P, Bouillon R Intensive insulin therapy in critically ill patients. N Engl J Med — The NICE-Sugar Study Investigators Intensive versus conventional glucose control in critically ill patients.

Marik PE, Bellomo R Stress hyperglycemia: an essential survival response! Crit Care Article PubMed Central PubMed Google Scholar. Qaseem A, Humphrey LL, Chou R, Snow V, Shekelle P Use of intensive insulin therapy for the management of glycemic control in hospitalized patients: a clinical practice guideline from the American College of Physicians.

Ann Intern Med — Agus MS, Steil GM, Wypij D, Costello JM, Laussen PC, Langer M, Alexander JL Tight glycemic control versus standard care after pediatric cardiac surgery. Article CAS PubMed Central PubMed Google Scholar. Minakata K, Sakata R Perioperative control of blood glucose level in cardiac surgery.

General Thorac Cardiovasc Surg — Article Google Scholar. Diabetes Care 37 Suppl 1 :S5— Olson DE, Rhee MK, Herrick K, Ziemer DC, Twombly JG, Phillips LS Screening for diabetes and pre-diabetes with proposed A1C-based diagnostic criteria.

Diabetes Care — Egi M, Bellomo R, Stachowski E, French CJ, Hart GK, Hegarty C, Bailey M Blood glucose concentration and outcome of critical illness: the impact of diabetes. Article CAS PubMed Google Scholar. Krinsley JS, Egi M, KIss A, Devendra AM, Schuetz P, Maurer P, Schultz MJ, van Hooijdonk RT, Kiyoshi M, Mackenzie IM, Annane D, Stow P, Nasraway SA, Holewinski S, Holzinger U, Preiser JC, Vincent JL, Bellomo R Diabetes status and the relation of the three domains of glycemic contril to mortality in critically ill patients: an international multicenter cohort study.

Crit Care R Egi M, Bellomo R, Stachowski E, French CJ, Hart G Variability of blood glucose concentration and short-term mortality in critically ill patients.

Anesthesiol — Article CAS Google Scholar. Monnier L, Mas E, Ginet C, Michel F, Villon L, Cristol JP, Colette C Activation of oxidative stress by acute glucose fluctuations compared with sustained chronic hyperglycemia in patients with type 2 diabetes. JAMA — Egi M, Bellomo R, Stachowski E, French CJ, Hart GK, Taori G, Hegarty C, Bailey M The interaction of chronic and acute glycemia with mortality in critically ill patients with diabetes.

Download references. Division of Pulmonary and Critical Care Medicine, Eastern Virginia Medical School, Fairfax Av, Suite , Norfolk, VA, , USA. Diabetes has been reported to be the fourth most common comorbid condition listed on all hospital discharges 2.

Acute illness results in a number of physiological changes e. increases in circulating concentrations of stress hormones or therapeutic choices e. glucocorticoid use that can exacerbate hyperglycemia. Hyperglycemia, in turn, causes physiological changes that can exacerbate acute illness, such as decreased immune function and increased oxidative stress.

These lead to a complex cycle of worsening illness and poor glucose control 3. Although a growing body of literature supports the need for targeted glycemic control in the hospital setting, blood glucose BG continues to be poorly controlled and is frequently overlooked in general medicine and surgery services.

This is largely explained by the fact that the majority of hospitalizations for patients with diabetes are not directly related to their metabolic state, thus diabetes management is rarely the primary focus of care.

Therefore, glycemic control and other diabetes care issues are often not specifically addressed 4. A history of diabetes should be elicited in all patients admitted to hospital and, if present, should be clearly identified on the medical record.

In view of the high prevalence of inpatient hyperglycemia with associated poor outcomes, an admission BG measurement of all patients would help identify people with diabetes, even in the absence of a prior diagnosis 1,5.

For hospitalized people with known diabetes, the glycated hemoglobin A1C identifies people who may benefit from efforts to improve glycemic control and tailor therapy upon discharge 6,7.

In hospitalized people with newly recognized hyperglycemia, an A1C among those with diabetes risk factors or associated comorbidities e. cardiovascular disease [CVD] 8,9 may help differentiate people with previously undiagnosed diabetes and dysglycemia from those with stress-induced hyperglycemia and provides an opportunity to diagnose and initiate diabetes therapies 10— Among people admitted to an intensive care unit ICU , an A1C drawn at admission allows identification of people with previously unknown diabetes, people at risk of glycemic management challenges and people at an increased risk of mortality 14, A1C has been found to be specific for diagnosis of diabetes in the hospital setting, although not as sensitive as in the outpatient setting 13, Currently, there are no studies that have examined the effect of the frequency of bedside BG monitoring on the incidence of hyper- or hypoglycemia in the hospital setting.

The frequency and timing of bedside BG monitoring can be individualized; however, monitoring is typically performed before meals and at bedtime in people who are eating; every 4 to 6 hours in people who are NPO nothing by mouth or receiving continuous enteral feeding; and every 1 to 2 hours for people on continuous intravenous insulin or those who are critically ill.

Some bedside BG monitoring is indicated in individuals without known diabetes but receiving treatments known to be associated with hyperglycemia e. glucocorticoids, octreotide, parenteral nutrition and enteral nutrition The implementation and maintenance of quality control programs by health-care institutions helps to ensure the accuracy of bedside BG monitoring 19, The use of glucose meters with bar coding capability has been shown to reduce data entry errors in medical records Data management programs that transfer bedside BG monitoring results into electronic records allow evaluation of hospital-wide glycemic control Capillary blood glucose CBG point of care testing POCT should be interpreted with caution in the critically ill patient population.

Poor perfusion indices may yield conflicting capillary, arterial and whole BG values using POCT glucose meters 23— Venous or arterial samples are preferred when using a POCT meter for this patient population.

Clinical decision support system software integrating CBG POCT can aid in trend analysis, medication dosing, reduce prescription error and reduce length of stay Electronic glucose metric data and web-based reporting systems may pose utility for monitoring glycemic management performance within an organization and enhance opportunities for external benchmarking A number of studies have demonstrated that inpatient hyperglycemia is associated with increased morbidity and mortality in noncritically ill hospitalized people 1,28, Current recommendations are based mostly on retrospective studies, clinical experience and judgement.

Glycemic targets for hospitalized people with diabetes are modestly higher than those routinely advised for outpatients with diabetes given that the hospital setting presents unique challenges for the management of hyperglycemia, such as variations in patient nutritional status and the presence of acute illness.

For the majority of noncritically ill hospitalized people, recommended preprandial BG targets are 5. Lower targets may be considered in clinically stable hospitalized people with a prior history of successful tight glycemic control in the outpatient setting, while higher targets may be acceptable in terminally ill people or in those with severe comorbidities.

a missed meal 18, Acute hyperglycemia in the intensive care setting is not unusual and results from a number of factors, including stress-induced counter-regulatory hormone secretion and the effects of medications administered in the ICU Glycemic targets for people with pre-existing diabetes who are in the critical care setting have not been firmly established.

Early trials showed that achieving normoglycemia 4. However, subsequent trials in mixed populations of critically ill patients did not show a benefit of targeting BG levels of 4. A meta-analysis of trials of intensive insulin therapy in the ICU setting suggested benefit of intensive insulin therapy in surgical patients, but not in medical patients Conversely, the Normoglycemia in Intensive Care Evaluation—Survival Using Glucose Algorithm Regulation NICE-SUGAR study, the largest trial to date of intensive glucose control in critically ill medical and surgical patients, found an increase in day all-cause mortality hazard ratio [HR] 1.

Furthermore, intensive insulin therapy has been associated with an increased risk of hypoglycemia in the ICU setting The use of insulin infusion protocols with proven efficacy and safety minimizes the risk of hypoglycemia 35— There are few occasions when intravenous insulin is required, as most people with type 1 or type 2 diabetes admitted to general medical wards can be treated with subcutaneous insulin.

Intravenous insulin, however, may be appropriate for people who are critically ill with appropriate BG targets , people who are not eating and in those with hyperglycemia and metabolic decompensation e. diabetic ketoacidosis [DKA] and hyperosmolar hyperglycemic state [HHS] see Hyperglycemic Emergencies in Adults chapter, p.

The evidence to date suggests there is no benefit to intravenous insulin over subcutaneous insulin post-acute stroke 3, Health-care staff education is a critical component of the implementation of an intravenous insulin infusion protocol.

Intravenous insulin protocols should take into account the patient's current and previous BG levels as well as the rate of change in BG , and the patient's usual insulin dose. Several published insulin infusion protocols appear to be both safe and effective, with low rates of hypoglycemia; however, most of these protocols have only been validated in the ICU setting, where the nurse-to-patient ratio is higher than on medical and surgical wards 3, BG determinations can be performed every 1 to 2 hours until BG has stabilized.

With the exception of the treatment of hyperglycemic emergencies e. DKA and HHS , consideration should be given to concurrently providing people receiving intravenous insulin with some form of glucose e. intravenous glucose or through parenteral or enteral feeding.

Hospitalized people with type 1 and type 2 diabetes may be transitioned to scheduled subcutaneous insulin therapy from intravenous insulin. Short- or rapid- or fast-acting insulin can be administered 1 to 2 hours before discontinuation of the intravenous insulin to maintain effective blood levels of insulin.

If intermediate- or long-acting insulin is used, it can be given 2 to 3 hours prior to intravenous insulin discontinuation. People without a history of diabetes, who have hyperglycemia requiring more than 2 units of intravenous insulin per hour, likely require insulin therapy and can be considered for transition to scheduled subcutaneous insulin therapy.

The initial dose and distribution of subcutaneous insulin at the time of transition can be determined by extrapolating the intravenous insulin requirement over the preceding 6- to 8-hour period to a hour period.

Dividing the total daily dose as a combination of basal and bolus insulin has been demonstrated to be safe and efficacious in medically ill patients 40, The management of individuals with diabetes at the time of surgery poses a number of challenges. Acute hyperglycemia is common secondary to the physiological stress associated with surgery.

Pre-existing diabetes-related complications and comorbidities may also influence clinical outcomes. Acute hyperglycemia has been shown to adversely affect immune function 42 and wound healing 43 in animal models. Observational studies have shown that hyperglycemia increases the risk of postoperative infections 44,45 , renal allograft rejection 46 , and is associated with increased health-care resource utilization In people undergoing coronary artery bypass grafting CABG , a pre-existing diagnosis of diabetes has been identified as a risk factor for postoperative sternal wound infections, delirium, renal dysfunction, respiratory insufficiency and prolonged hospital stays 48— Intraoperative hyperglycemia during cardiopulmonary bypass has been associated with increased morbidity and mortality rates in individuals with and without diabetes 51— A systematic review of randomized controlled trials supports the use of intravenous insulin infusion targeting a blood glucose of 5.

This was demonstrated by a marked reduction in surgical site infections odds ratio 0. The perioperative glycemic targets for minor or moderate surgeries are less clear. Older studies comparing different methods of achieving glycemic control during minor and moderate surgeries did not demonstrate any adverse effects of maintaining perioperative BG levels between 5.

Attention has been placed on the relationship between postoperative hyperglycemia and surgical site infections. While the association was well documented, the impact and risks of intensive management was less clear. The risk of hypoglycemia was increased but there was no increased risk of stroke or death.

The included studies looked at the intraoperative and immediate postoperative period and used intravenous insulin to achieve intensive targets. The included studies were mostly cardiac and gastrointestinal and were found to have a moderate risk of bias Rapid institution of perioperative glucose control must be carefully considered in patients with poorly controlled type 2 diabetes undergoing monocular phacoemulsification cataract surgery with moderate to severe nonproliferative diabetic retinopathy because of the possible increased risk of postoperative progression of retinopathy and maculopathy The outcome of vitrectomy, however, does not appear to be influenced by perioperative control Given the data supporting tighter perioperative glycemic control during major surgeries and the compelling data showing the adverse effects of hyperglycemia, it is reasonable to target glycemic levels between 5.

The best way to achieve these targets in the postoperative patient is with a basal bolus insulin regimen 61, This approach has been shown to reduce postoperative complications, including wound infections. Despite this knowledge, surgical patients are often treated with correction supplemental rapid-acting insulin alone 63 which may not adequately control BG.

The benefits of improved perioperative glycemic control must be weighed against the risk of perioperative hypoglycemia.

Anesthetic agents and postoperative analgesia may alter the patient's level of consciousness and awareness of hypoglycemia. The risk of hypoglycemia can be reduced by frequent BG monitoring and carefully designed management protocols.

In general, insulin is the preferred treatment for hyperglycemia in hospitalized people with diabetes People with type 1 diabetes must be maintained on insulin therapy at all times to prevent DKA.

Scheduled subcutaneous insulin administration that consists of basal, bolus prandial and correction supplemental insulin components is the preferred method for achieving and maintaining glucose control in noncritically ill hospitalized people with diabetes or stress hyperglycemia who are eating 35, Bolus insulin can be withheld or reduced in people who are not eating regularly; however, basal insulin should not be withheld.

Stable people can usually be maintained on their home insulin regimen with adjustments made to accommodate for differences in meals and activity levels, the effects of illness and the effects of other medications.

In the hospital setting, rapid-acting insulin analogues are the preferred subcutaneous bolus and correction insulins Insulin programs that only react to, or correct for, hyperglycemia have been demonstrated to be associated with higher rates of hyperglycemia 61,66— Insulin is often required temporarily in hospital, even in people with type 2 diabetes not previously treated with insulin.

In these insulin-naive people, there is evidence demonstrating the superiority of basal-bolus-correction insulin regimens 61, A number of protocols have been published as part of studies 61,66,69— These studies have typically started insulin-naive people on 0.

breakfast, lunch and dinner ; correction doses of the bolus insulin are provided if BG values are above target. Daily review of the person's BG measurements and modification of insulin doses, as required, facilitates the achievement of target blood glucose measurements.

When comparing effective protocols, the following was observed. One study compared basal-bolus plus correction insulin with glargine and glulisine vs. Average BG levels were not different, but rates of hypoglycemia were.

Another study 74 found no difference in BG levels or rates of hypoglycemia when comparing insulin glargine vs. detemir, when used as the basal insulin in a basal-bolus program.

Yet another study 71 found that using a weight-based algorithm to titrate insulin glargine resulted in obtaining target BG levels faster than a glucose-based algorithm, with no difference in the rates of hypoglycemia.

More recently, a study compared a basal-bolus plus correction insulin regimen with a program that was basal plus correction The basal-bolus group had slightly lower BG through the day, which was not statistically significant, with no difference in FBG or in rates of hypoglycemia.

Taken together with the earlier studies from this group 61,66 , it would appear that successful management of in-hospital diabetes requires early and aggressive administration of basal insulin combined with bolus insulin, typically in the form of rapid-acting insulin analogue, similar to the approach used in the outpatient setting.

To date, no large studies have investigated the use of non-insulin antihyperglycemic agents on outcomes in hospitalized people with diabetes. Stable hospitalized people with diabetes without these contraindications can often have their home antihyperglycemic medications continued while in the hospital.

However, if contraindications develop or if glycemic control is inadequate, these drugs should be discontinued and consideration given to starting the patient on a basal-bolus-supplemental insulin regimen.

The advantages and disadvantages of various noninsulin antihyperglycemic therapies in hospital are discussed in detail in a recent review article A recent randomized but unblinded study compared sitagliptin plus basal and correctional insulin with a more traditional basal-bolus-correctional insulin program in hospitalized people with diabetes The glycemic outcomes were similar between the 2 groups; however, the basal-bolus-correctional group had a higher mean glucose than similarly insulin-treated subjects in other studies 61, This less-aggressive treatment may explain the lack of difference between the sitagliptin and the bolus insulin groups.

Medical nutrition therapy including nutritional assessment and individualized meal planning is an essential component of inpatient glycemic management programs. A consistent carbohydrate meal planning system may facilitate glycemic control in hospitalized people and facilitate matching prandial insulin doses to the amount of carbohydrate consumed 61,66,75,78— In hospitalized people with diabetes receiving parenteral nutrition, insulin can be administered in the following ways: as scheduled regular insulin dosing added directly to the parenteral solution; or as scheduled intermediate- or long-acting subcutaneous insulin doses A separate intravenous infusion of regular insulin may be an alternative method to achieve glycemic control in critical care For scheduled subcutaneous insulin dosing or regular insulin added directly to parenteral solutions, the selected starting insulin dose may be based on the current estimated TDD of insulin, the composition of the parenteral nutrition solution and the patient's weight Considering the patient's individual clinical situation is important when determining insulin dosing.

Subcutaneous correction supplemental insulin may be used in addition to scheduled insulin dosing and dose adjustments made to scheduled insulin should be adjusted based on the BG pattern. For hospitalized people with diabetes on enteral feeding regimens, there are few prospective studies examining insulin management.

In 1 randomized controlled trial, low-dose basal glargine insulin with regular insulin correction dosing was compared against regular insulin correction supplemental insulin dosing with the addition of NPH in the presence of persistent hyperglycemia and demonstrated similar efficacy for glycemic control The type of feed solution and duration of feed cyclical vs.

continuous should be considered. People with diabetes receiving bolus enteral feeds may be treated in the same manner as people who are eating meals. Correction supplemental insulin can be administered, as needed; added to the same bolus insulin.

An insulin with a shorter half-life, such as NPH, may be preferred for intermediate duration feeding schedules i. overnight , while regular or rapid-acting insulin may be more appropriate to manage hyperglycemia induced by bolus feeding schedules.

In the event that the parenteral or enteral nutrition is unexpectedly interrupted, intravenous dextrose may be required to prevent hypoglycemia depending on the last dose and type of insulin administered.

When parenteral or enteral feeding schedules are adjusted in terms of carbohydrate content or duration, the insulin type and dose will need to be re-assessed. Although the optimal management of hyperglycemia in people receiving high-dose oral corticosteroids has not been clearly defined, glycemic monitoring for 48 hours after initiation of steroids may be considered for people with or without a history of diabetes 35, For management of hyperglycemia, treatment with a basal-bolus with correction insulin regimen was more effective and safer than a correction supplemental insulin-only regimen 85 , although addition of NPH dosed variably from once a day at time of glucocorticoid administration to every 6 hours depending on glucocorticoid used was not demonstrated to improve glycemic outcomes 86, Although data for self-management in the hospitalized setting is limited, self-management in hospital may be appropriate for people who are mentally competent and desire more autonomy over their diabetes.

The majority of evidence pertains to continuous subcutaneous insulin infusion CSII therapy, where continuation of patient-managed insulin delivery has been associated with reduced episodes of severe hyperglycemia and hypoglycemia 88 and high levels of patient satisfaction In general, any person requiring insulin therapy who is self-managing diabetes in the hospital setting should be able to physically self-administer insulin and perform self-monitoring of blood glucose SMBG independently, be familiar with the recommended insulin routine, understand sick-day management guidelines and utilize a flowsheet to facilitate communication of BG results and insulin dosing between the patient and health-care providers.

The person with diabetes and the health-care provider, in consultation with nursing staff, must agree that patient self-management is an appropriate strategy while hospitalized.

Hospitals should have policies and procedures for the assessment of suitability for self-management. Although the data are limited, it appears that CSII can be safely continued in the hospital setting under certain circumstances People maintained on CSII may have decreased length of stay 90 ; however, this may reflect the severity of illness rather than a glycemic control advantage.

People maintained on CSII may have less hypoglycemia than those managed by the admitting clinician. People on CSII are encouraged to continue this form of therapy whenever safe and feasible in hospital.

Successful published inpatient protocols include assessment of pump specific self-management skills i. how to adjust their basal rate, administer a bolus dose, insert an infusion set, fill a reservoir, suspend the pump and correct a CBG result outside their target range , pre-printed orders, flow sheets and patient consents 88,91, If appropriate supports are not available, CSII may be discontinued and a basal-bolus-subcutaneous insulin regimen or intravenous insulin infusion may be initiated.

An increasing number of people are being maintained on CSII during short elective surgical procedures without any reported adverse events 93 , necessitating close collaboration between anesthesia and diabetes management teams.

Different pump manufacturers will recommend discontinuing pumps for certain hospital-based procedures e. radiology, cautery, external beam radiation.

To promote a collaborative relationship between the hospital staff and the patient, and to ensure patient safety, hospitals must have clear policies and procedures in place to guide the use of CSII in the inpatient setting Documents that stipulate contraindications for continued CSII, procedures to guide medical management of CSII and a consent form outlining the inpatient terms of use 92 support the safe use of CSII use in hospital.

Specific algorithms and order sets for management of CSII peri-operatively and during labour and delivery have been published 93, Institution-wide programs to improve glycemic control in the inpatient setting include the formation of a multidisciplinary steering committee, professional development programs focused on inpatient diabetes management 95,96 , policies to assess and monitor the quality of glycemic management, interprofessional team-based care including comprehensive patient education and discharge planning as well as standardized order sets, protocols and algorithms for diabetes care within the institution.

Implementation of such a program can result in improvements in in-hospital glycemic control 97, Computerized and mobile decision support systems that provide suggestions for insulin dosing have also been used and have been associated with lower mean BG levels 26,— ; hypoglycemia can be an unintended consequence of tighter glycemic control 70, The timely consultation of glycemic management teams has also been found to improve the quality of care provided, reduce the length of hospital stay and lower costs , , although differences in glycemic control were minimal Deployment of nurses , , nurse practitioners and physician assistants with specialty training has been associated with greater use of basal-bolus insulin therapy and lower mean BG levels.

A provincial survey of over 2, people with diabetes admitted to hospital found that people were more likely to be satisfied with their diabetes care in hospital if they had confidence that the team was knowledgeable about diabetes, presented a consistent message and acknowledged them in their diabetes care Programs that include self-management education, such as assessment of barriers and goal setting, have also been associated with improvements in glycemic control 97, Institutional implementation of hospital glycemic management programs require metrics to monitor progress, assess safety, length of stay and identify opportunities for improvement Implementation of inpatient hyperglycemia quality improvement programs evaluated with real-time metrics have been shown to improve glycemic control and safety of insulin ordering 97, To date, metrics for monitoring glycemic control programs in hospitals have not been established This lack of standardization limits the ability for benchmarking and comparison of different quality-improvement programs and protocols.

Further study into the development and implementation of appropriate standardized metrics for hospital glycemic management programs is warranted. Interventions that ensure continuity of care, such as arranging continuation of care after discharge 97 , telephone follow up and communication with primary providers at discharge , have been associated with a post-discharge reduction in A1C Providing people with diabetes and their family or caregivers with written and oral instructions regarding their diabetes management at the time of hospital discharge will facilitate transition to community care.

Comprehensive instructions may include recommendations for timing and frequency of home glucose monitoring; identification and management of hypoglycemia; a reconciled medication list, including insulin and other antihyperglycemic medications; and identification and contact information for health-care providers responsible for ongoing diabetes care and adjustment of glucose-lowering medications.

Communication of the need for potential adjustments in insulin therapy that may accompany adjustments of other medications prescribed at the time of discharge, such as corticosteroids or octreotide, to people with diabetes and their primary care providers is important.

Hypoglycemia remains a major barrier to achieving optimal glycemic control in hospitalized people with diabetes. Standardized treatment protocols that address mild, moderate and severe hypoglycemia may help mitigate this risk. Education of healthcare workers about factors that increase the risk of hypoglycemia, such as sudden reduction in oral intake, discontinuation of parenteral or enteral nutrition, unexpected transfer from the nursing unit after rapid-acting insulin administration or a reduction in corticosteroid dose 78 are important steps to reduce the risk of hypoglycemia.

Insulin is considered a high-alert medication and can be associated with risk of harm and severe adverse events. BG, blood glucose; CBG , capillary blood glucose; CABG , coronary artery bypass grafting; CSII , continuous subcutaneous insulin infusion; ICU , intensive care unit; NPH , neutral protamine Hagedorn; POC , point of care; TDD , total daily dose.

Chapter Glycemic Management in Adults With Type 1 Diabetes. Pharmacologic Glycemic Management of Type 2 Diabetes in Adults. Treatment of Diabetes in People With Heart Failure. Literature Review Flow Diagram for Chapter In-Hospital Management of Diabetes.

From: Moher D, Liberati A, Tetzlaff J, Altman DG, The PRISMA Group Preferred Reporting Items for Systematic Reviews and Meta-Analyses: The PRISMA Statement.

PLoS Med 6 6 : e pmed For more information, visit www. Halperin reports personal fees from Dexcom, Novo Nordisk, and QHR technologies, outside the submitted work.

Miller reports personal fees from Eli Lilly, Novo Nordisk, Sanofi, and AstraZeneca; and grants and personal fees from Boehringer Ingelheim, Janssen, Merck, outside the submitted work. Sarah Moore reports personal fees from Diabetes Care Alliance Boehringer Ingelheim Eli Lilly Alliance , and Merck Canada, outside the submitted work.

No other authors have anything to disclose. All content on guidelines. ca, CPG Apps and in our online store remains exactly the same. For questions, contact communications diabetes.

Stress hyperglycemia is regarded as an evolutionary adaptive response which allows the host to survive during periods of severe stress [ 5 ]. The neuroendocrine response to stress is characterized by excessive gluconeogenesis, glycogenolysis, and insulin resistance, with increased hepatic output of glucose gluconeogenesis being the major cause of stress hyperglycemia.

Insects, worms, and all verterbrates including fish develop stress hyperglycemia when exposed to stress [ 5 ]. Stress hyperglycemia provides a source of fuel for the immune system and brain at a time of stress. While mild to moderate stress hyperglycemia is protective it is likely that severe stress hyperglycemia may be deleterious.

However, the blood glucose threshold above which stress hyperglycemia becomes harmful is unknown. Furthermore, we suggest that both the duration and the degree of hyperglycemia are important in determining whether hyperglycemia is protective or harmful [ 5 ]. It seems most unlikely that a few days of hyperglycemia would be harmful; indeed attempts at rapid correction of blood glucose in these patients may be harmful.

This recommendation is based largely on uncontrolled retrospective studies. Agus et al. In this study none of the outcome measures differed between groups. Current criteria used for the diagnosis of diabetes mellitus are i HbA1c level above 6.

Although diagnostic criteria based on HbA1c may be insensitive and not uniformly applicable to all patients [ 10 ], HbA1c level measured at admission to ICU is probably still the most useful test for undiagnosed diabetes, because glucose concentrations in critically ill patients increase even in the absence of diabetes.

International guidelines recommend the use of a protocolized approach to avoid acute hyperglycemia irrespective of the presence of diabetes mellitus [ 9 ]. Recent studies have shown that the relationship between hyperglycemia and outcomes is altered by the presence of diabetes mellitus [ 11 , 12 ].

Lowering the blood glucose levels in critically ill patients with chronic hyperglycemia will result in drastic and rapid changes of glucose concentrations. The degree of blood glucose change glycemic variability has been demonstrated to be an independent predictor of poor outcome in critically ill patients [ 13 ].

In patients with type II diabetes, glycemic variability has been demonstrated to increase oxidative stress [ 14 ]. Increased oxidative stress can result in endothelial dysfunction and contribute to vascular damage. It would therefore appear appropriate to have a higher glycemic treatment target in patients with preexisting diabetes and premorbid poor glycemic control to prevent large reductions in blood glucose concentration.

Biological adjustment to preexisting hyperglycemia and less glycemic variability might explain this phenomenon. These observations generate the hypothesis that glucose levels that are considered safe and desirable in other patients might be undesirable in diabetic patients with chronic hyperglycemia.

On the basis of this data we suggest that the HbA1c be checked on admission to the ICU in all diabetics with blood glucose therapeutic targets as provided in Table 1.

Plummer MP, Bellomo R, Cousins CE, Annink CE, Sundararajan K, Reddi BA, Raj JP, Chapman MJ, Horowitz M, Deane AM Dysglycaemia in the critically ill and the interaction of chronic and acute glycaemia with mortality.

Intensive Care Med. doi: PubMed Google Scholar. Badawi O, Waite MD, Fuhrman SA, Zuckerman IH Association between intensive care unit-acquired dysglycemia and in-hospital mortality. Crit Care Med — Article PubMed Google Scholar.

van den Berghe G, Wouters P, Weekers F, Verwaest C, Bruyninckx F, Schetz M, Vlasselaers D, Ferdinande P, Lauwers P, Bouillon R Intensive insulin therapy in critically ill patients. N Engl J Med — The NICE-Sugar Study Investigators Intensive versus conventional glucose control in critically ill patients.

Marik PE, Bellomo R Stress hyperglycemia: an essential survival response! Crit Care Article PubMed Central PubMed Google Scholar. Qaseem A, Humphrey LL, Chou R, Snow V, Shekelle P Use of intensive insulin therapy for the management of glycemic control in hospitalized patients: a clinical practice guideline from the American College of Physicians.

Ann Intern Med — Agus MS, Steil GM, Wypij D, Costello JM, Laussen PC, Langer M, Alexander JL Tight glycemic control versus standard care after pediatric cardiac surgery. Article CAS PubMed Central PubMed Google Scholar. Minakata K, Sakata R Perioperative control of blood glucose level in cardiac surgery.

General Thorac Cardiovasc Surg — Article Google Scholar. Diabetes Care 37 Suppl 1 :S5— Olson DE, Rhee MK, Herrick K, Ziemer DC, Twombly JG, Phillips LS Screening for diabetes and pre-diabetes with proposed A1C-based diagnostic criteria.

Diabetes Care — Egi M, Bellomo R, Stachowski E, French CJ, Hart GK, Hegarty C, Bailey M Blood glucose concentration and outcome of critical illness: the impact of diabetes. Article CAS PubMed Google Scholar. Krinsley JS, Egi M, KIss A, Devendra AM, Schuetz P, Maurer P, Schultz MJ, van Hooijdonk RT, Kiyoshi M, Mackenzie IM, Annane D, Stow P, Nasraway SA, Holewinski S, Holzinger U, Preiser JC, Vincent JL, Bellomo R Diabetes status and the relation of the three domains of glycemic contril to mortality in critically ill patients: an international multicenter cohort study.

Crit Care R Egi M, Bellomo R, Stachowski E, French CJ, Hart G Variability of blood glucose concentration and short-term mortality in critically ill patients.

Anesthesiol — Article CAS Google Scholar. Monnier L, Mas E, Ginet C, Michel F, Villon L, Cristol JP, Colette C Activation of oxidative stress by acute glucose fluctuations compared with sustained chronic hyperglycemia in patients with type 2 diabetes.

detemir, when used as the basal insulin in a basal-bolus program. Yet another study 71 found that using a weight-based algorithm to titrate insulin glargine resulted in obtaining target BG levels faster than a glucose-based algorithm, with no difference in the rates of hypoglycemia.

More recently, a study compared a basal-bolus plus correction insulin regimen with a program that was basal plus correction The basal-bolus group had slightly lower BG through the day, which was not statistically significant, with no difference in FBG or in rates of hypoglycemia.

Taken together with the earlier studies from this group 61,66 , it would appear that successful management of in-hospital diabetes requires early and aggressive administration of basal insulin combined with bolus insulin, typically in the form of rapid-acting insulin analogue, similar to the approach used in the outpatient setting.

To date, no large studies have investigated the use of non-insulin antihyperglycemic agents on outcomes in hospitalized people with diabetes. Stable hospitalized people with diabetes without these contraindications can often have their home antihyperglycemic medications continued while in the hospital.

However, if contraindications develop or if glycemic control is inadequate, these drugs should be discontinued and consideration given to starting the patient on a basal-bolus-supplemental insulin regimen.

The advantages and disadvantages of various noninsulin antihyperglycemic therapies in hospital are discussed in detail in a recent review article A recent randomized but unblinded study compared sitagliptin plus basal and correctional insulin with a more traditional basal-bolus-correctional insulin program in hospitalized people with diabetes The glycemic outcomes were similar between the 2 groups; however, the basal-bolus-correctional group had a higher mean glucose than similarly insulin-treated subjects in other studies 61, This less-aggressive treatment may explain the lack of difference between the sitagliptin and the bolus insulin groups.

Medical nutrition therapy including nutritional assessment and individualized meal planning is an essential component of inpatient glycemic management programs. A consistent carbohydrate meal planning system may facilitate glycemic control in hospitalized people and facilitate matching prandial insulin doses to the amount of carbohydrate consumed 61,66,75,78— In hospitalized people with diabetes receiving parenteral nutrition, insulin can be administered in the following ways: as scheduled regular insulin dosing added directly to the parenteral solution; or as scheduled intermediate- or long-acting subcutaneous insulin doses A separate intravenous infusion of regular insulin may be an alternative method to achieve glycemic control in critical care For scheduled subcutaneous insulin dosing or regular insulin added directly to parenteral solutions, the selected starting insulin dose may be based on the current estimated TDD of insulin, the composition of the parenteral nutrition solution and the patient's weight Considering the patient's individual clinical situation is important when determining insulin dosing.

Subcutaneous correction supplemental insulin may be used in addition to scheduled insulin dosing and dose adjustments made to scheduled insulin should be adjusted based on the BG pattern.

For hospitalized people with diabetes on enteral feeding regimens, there are few prospective studies examining insulin management. In 1 randomized controlled trial, low-dose basal glargine insulin with regular insulin correction dosing was compared against regular insulin correction supplemental insulin dosing with the addition of NPH in the presence of persistent hyperglycemia and demonstrated similar efficacy for glycemic control The type of feed solution and duration of feed cyclical vs.

continuous should be considered. People with diabetes receiving bolus enteral feeds may be treated in the same manner as people who are eating meals. Correction supplemental insulin can be administered, as needed; added to the same bolus insulin.

An insulin with a shorter half-life, such as NPH, may be preferred for intermediate duration feeding schedules i. overnight , while regular or rapid-acting insulin may be more appropriate to manage hyperglycemia induced by bolus feeding schedules. In the event that the parenteral or enteral nutrition is unexpectedly interrupted, intravenous dextrose may be required to prevent hypoglycemia depending on the last dose and type of insulin administered.

When parenteral or enteral feeding schedules are adjusted in terms of carbohydrate content or duration, the insulin type and dose will need to be re-assessed.

Although the optimal management of hyperglycemia in people receiving high-dose oral corticosteroids has not been clearly defined, glycemic monitoring for 48 hours after initiation of steroids may be considered for people with or without a history of diabetes 35, For management of hyperglycemia, treatment with a basal-bolus with correction insulin regimen was more effective and safer than a correction supplemental insulin-only regimen 85 , although addition of NPH dosed variably from once a day at time of glucocorticoid administration to every 6 hours depending on glucocorticoid used was not demonstrated to improve glycemic outcomes 86, Although data for self-management in the hospitalized setting is limited, self-management in hospital may be appropriate for people who are mentally competent and desire more autonomy over their diabetes.

The majority of evidence pertains to continuous subcutaneous insulin infusion CSII therapy, where continuation of patient-managed insulin delivery has been associated with reduced episodes of severe hyperglycemia and hypoglycemia 88 and high levels of patient satisfaction In general, any person requiring insulin therapy who is self-managing diabetes in the hospital setting should be able to physically self-administer insulin and perform self-monitoring of blood glucose SMBG independently, be familiar with the recommended insulin routine, understand sick-day management guidelines and utilize a flowsheet to facilitate communication of BG results and insulin dosing between the patient and health-care providers.

The person with diabetes and the health-care provider, in consultation with nursing staff, must agree that patient self-management is an appropriate strategy while hospitalized. Hospitals should have policies and procedures for the assessment of suitability for self-management. Although the data are limited, it appears that CSII can be safely continued in the hospital setting under certain circumstances People maintained on CSII may have decreased length of stay 90 ; however, this may reflect the severity of illness rather than a glycemic control advantage.

People maintained on CSII may have less hypoglycemia than those managed by the admitting clinician. People on CSII are encouraged to continue this form of therapy whenever safe and feasible in hospital.

Successful published inpatient protocols include assessment of pump specific self-management skills i. how to adjust their basal rate, administer a bolus dose, insert an infusion set, fill a reservoir, suspend the pump and correct a CBG result outside their target range , pre-printed orders, flow sheets and patient consents 88,91, If appropriate supports are not available, CSII may be discontinued and a basal-bolus-subcutaneous insulin regimen or intravenous insulin infusion may be initiated.

An increasing number of people are being maintained on CSII during short elective surgical procedures without any reported adverse events 93 , necessitating close collaboration between anesthesia and diabetes management teams.

Different pump manufacturers will recommend discontinuing pumps for certain hospital-based procedures e. radiology, cautery, external beam radiation. To promote a collaborative relationship between the hospital staff and the patient, and to ensure patient safety, hospitals must have clear policies and procedures in place to guide the use of CSII in the inpatient setting Documents that stipulate contraindications for continued CSII, procedures to guide medical management of CSII and a consent form outlining the inpatient terms of use 92 support the safe use of CSII use in hospital.

Specific algorithms and order sets for management of CSII peri-operatively and during labour and delivery have been published 93, Institution-wide programs to improve glycemic control in the inpatient setting include the formation of a multidisciplinary steering committee, professional development programs focused on inpatient diabetes management 95,96 , policies to assess and monitor the quality of glycemic management, interprofessional team-based care including comprehensive patient education and discharge planning as well as standardized order sets, protocols and algorithms for diabetes care within the institution.

Implementation of such a program can result in improvements in in-hospital glycemic control 97, Computerized and mobile decision support systems that provide suggestions for insulin dosing have also been used and have been associated with lower mean BG levels 26,— ; hypoglycemia can be an unintended consequence of tighter glycemic control 70, The timely consultation of glycemic management teams has also been found to improve the quality of care provided, reduce the length of hospital stay and lower costs , , although differences in glycemic control were minimal Deployment of nurses , , nurse practitioners and physician assistants with specialty training has been associated with greater use of basal-bolus insulin therapy and lower mean BG levels.

A provincial survey of over 2, people with diabetes admitted to hospital found that people were more likely to be satisfied with their diabetes care in hospital if they had confidence that the team was knowledgeable about diabetes, presented a consistent message and acknowledged them in their diabetes care Programs that include self-management education, such as assessment of barriers and goal setting, have also been associated with improvements in glycemic control 97, Institutional implementation of hospital glycemic management programs require metrics to monitor progress, assess safety, length of stay and identify opportunities for improvement Implementation of inpatient hyperglycemia quality improvement programs evaluated with real-time metrics have been shown to improve glycemic control and safety of insulin ordering 97, To date, metrics for monitoring glycemic control programs in hospitals have not been established This lack of standardization limits the ability for benchmarking and comparison of different quality-improvement programs and protocols.

Further study into the development and implementation of appropriate standardized metrics for hospital glycemic management programs is warranted. Interventions that ensure continuity of care, such as arranging continuation of care after discharge 97 , telephone follow up and communication with primary providers at discharge , have been associated with a post-discharge reduction in A1C Providing people with diabetes and their family or caregivers with written and oral instructions regarding their diabetes management at the time of hospital discharge will facilitate transition to community care.

Comprehensive instructions may include recommendations for timing and frequency of home glucose monitoring; identification and management of hypoglycemia; a reconciled medication list, including insulin and other antihyperglycemic medications; and identification and contact information for health-care providers responsible for ongoing diabetes care and adjustment of glucose-lowering medications.

Communication of the need for potential adjustments in insulin therapy that may accompany adjustments of other medications prescribed at the time of discharge, such as corticosteroids or octreotide, to people with diabetes and their primary care providers is important.

Hypoglycemia remains a major barrier to achieving optimal glycemic control in hospitalized people with diabetes. Standardized treatment protocols that address mild, moderate and severe hypoglycemia may help mitigate this risk. Education of healthcare workers about factors that increase the risk of hypoglycemia, such as sudden reduction in oral intake, discontinuation of parenteral or enteral nutrition, unexpected transfer from the nursing unit after rapid-acting insulin administration or a reduction in corticosteroid dose 78 are important steps to reduce the risk of hypoglycemia.

Insulin is considered a high-alert medication and can be associated with risk of harm and severe adverse events. BG, blood glucose; CBG , capillary blood glucose; CABG , coronary artery bypass grafting; CSII , continuous subcutaneous insulin infusion; ICU , intensive care unit; NPH , neutral protamine Hagedorn; POC , point of care; TDD , total daily dose.

Chapter Glycemic Management in Adults With Type 1 Diabetes. Pharmacologic Glycemic Management of Type 2 Diabetes in Adults. Treatment of Diabetes in People With Heart Failure. Literature Review Flow Diagram for Chapter In-Hospital Management of Diabetes. From: Moher D, Liberati A, Tetzlaff J, Altman DG, The PRISMA Group Preferred Reporting Items for Systematic Reviews and Meta-Analyses: The PRISMA Statement.

PLoS Med 6 6 : e pmed For more information, visit www. Halperin reports personal fees from Dexcom, Novo Nordisk, and QHR technologies, outside the submitted work. Miller reports personal fees from Eli Lilly, Novo Nordisk, Sanofi, and AstraZeneca; and grants and personal fees from Boehringer Ingelheim, Janssen, Merck, outside the submitted work.

Sarah Moore reports personal fees from Diabetes Care Alliance Boehringer Ingelheim Eli Lilly Alliance , and Merck Canada, outside the submitted work.

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Next Previous. Key Messages Recommendations Figures Full Text References. Chapter Headings Introduction Screening for and Diagnosis of Diabetes and Hyperglycemia in the Hospital Setting Glucose Monitoring in the Hospital Setting Glycemic Control in the Non-Critically Ill Patient Glycemic Control in the Critically Ill Patient Role of Intravenous Insulin Role of Subcutaneous Insulin Role of Noninsulin Antihyperglycemic Agents Role of Medical Nutrition Therapy Special Clinical Situations Organization of Care Safety Other Relevant Guidelines Author Disclosures.

Key Messages Hyperglycemia is common in hospitalized people, even among those without a previous history of diabetes, and is associated with increased in-hospital complications, longer length of stay and mortality.

Insulin is the most appropriate pharmacologic agent for effectively controlling glycemia in hospital. A proactive approach to glycemic management using scheduled basal, bolus and correction supplemental insulin is the preferred method. The use of correction-only supplemental insulin, which treats hyperglycemia only after it has occurred, should be discouraged as the sole modality for treating elevated blood glucose levels.

For the majority of noncritically ill hospitalized people with diabetes, preprandial blood glucose targets should be 5. For critically ill hospitalized people with diabetes, blood glucose levels should be maintained between 6.

Hypoglycemia is a major barrier to achieving targeted glycemic control in the hospital setting. Health-care institutions should develop protocols for the assessment and treatment of hypoglycemia.

Key Messages for People with Diabetes If your admission to hospital is planned, talk with your health-care providers e. surgeon, anesthetist, primary care provider, diabetes health provider, etc.

before you are admitted in order to develop an in-hospital diabetes care plan that addresses such issues as: Who will manage your diabetes in the hospital? Will you be able to self-manage your diabetes? What adjustments to your diabetes medications or insulin doses may be necessary before and after medical procedures or surgery?

If you use an insulin pump, are hospital staff familiar with pump therapy? Your blood glucose levels may be higher in hospital than your usual target range due to a variety of factors, including the stress of your illness, medications, medical procedures and infections.

Your diabetes medications may need to be changed during your hospital stay to manage the changes in blood glucose, or if medical conditions develop that make some medications no longer safe to use.

When you are discharged, make sure that you have written instructions about: Changes in your dosage of medications or insulin injections or any new medications or treatments How often to check your blood glucose Who to contact if you have difficulty managing your blood glucose levels.

Introduction Diabetes increases the risk for hospitalization for several reasons, including: cardiovascular CV disease, nephropathy, infection, cancer and lower-extremity amputations.

Screening for and Diagnosis of Diabetes and Hyperglycemia in the Hospital Setting A history of diabetes should be elicited in all patients admitted to hospital and, if present, should be clearly identified on the medical record.

Glucose Monitoring in the Hospital Setting Bedside blood glucose monitoring Currently, there are no studies that have examined the effect of the frequency of bedside BG monitoring on the incidence of hyper- or hypoglycemia in the hospital setting.

Glycemic Control in the Non-Critically Ill Patient A number of studies have demonstrated that inpatient hyperglycemia is associated with increased morbidity and mortality in noncritically ill hospitalized people 1,28, Glycemic Control in the Critically Ill Patient Acute hyperglycemia in the intensive care setting is not unusual and results from a number of factors, including stress-induced counter-regulatory hormone secretion and the effects of medications administered in the ICU Role of Intravenous Insulin There are few occasions when intravenous insulin is required, as most people with type 1 or type 2 diabetes admitted to general medical wards can be treated with subcutaneous insulin.

Transition from IV insulin to SC insulin therapy Hospitalized people with type 1 and type 2 diabetes may be transitioned to scheduled subcutaneous insulin therapy from intravenous insulin. Perioperative glycemic control The management of individuals with diabetes at the time of surgery poses a number of challenges.

Cardiovascular surgery In people undergoing coronary artery bypass grafting CABG , a pre-existing diagnosis of diabetes has been identified as a risk factor for postoperative sternal wound infections, delirium, renal dysfunction, respiratory insufficiency and prolonged hospital stays 48— Minor and moderate surgery The perioperative glycemic targets for minor or moderate surgeries are less clear.

Role of Subcutaneous Insulin In general, insulin is the preferred treatment for hyperglycemia in hospitalized people with diabetes Role of Noninsulin Antihyperglycemic Agents To date, no large studies have investigated the use of non-insulin antihyperglycemic agents on outcomes in hospitalized people with diabetes.

Role of Medical Nutrition Therapy Medical nutrition therapy including nutritional assessment and individualized meal planning is an essential component of inpatient glycemic management programs. Special Clinical Situations Hospitalized people with diabetes receiving enteral or parenteral feedings In hospitalized people with diabetes receiving parenteral nutrition, insulin can be administered in the following ways: as scheduled regular insulin dosing added directly to the parenteral solution; or as scheduled intermediate- or long-acting subcutaneous insulin doses Self-management of diabetes in hospital Although data for self-management in the hospitalized setting is limited, self-management in hospital may be appropriate for people who are mentally competent and desire more autonomy over their diabetes.

Hospitalized people with diabetes using CSII Although the data are limited, it appears that CSII can be safely continued in the hospital setting under certain circumstances Organization of Care Institution-wide programs to improve glycemic control in the inpatient setting include the formation of a multidisciplinary steering committee, professional development programs focused on inpatient diabetes management 95,96 , policies to assess and monitor the quality of glycemic management, interprofessional team-based care including comprehensive patient education and discharge planning as well as standardized order sets, protocols and algorithms for diabetes care within the institution.

Interprofessional team-based approach The timely consultation of glycemic management teams has also been found to improve the quality of care provided, reduce the length of hospital stay and lower costs , , although differences in glycemic control were minimal Comprehensive patient education Programs that include self-management education, such as assessment of barriers and goal setting, have also been associated with improvements in glycemic control 97, Metrics for evaluating inpatient glycemic management programs Institutional implementation of hospital glycemic management programs require metrics to monitor progress, assess safety, length of stay and identify opportunities for improvement Transition from hospital to home Interventions that ensure continuity of care, such as arranging continuation of care after discharge 97 , telephone follow up and communication with primary providers at discharge , have been associated with a post-discharge reduction in A1C Safety Hypoglycemia Hypoglycemia remains a major barrier to achieving optimal glycemic control in hospitalized people with diabetes.

Insulin administration errors Insulin is considered a high-alert medication and can be associated with risk of harm and severe adverse events. Recommendations An A1C should be measured if not done in the 3 months prior to admission on: All hospitalized people with a history of diabetes to identify individuals that would benefit from glycemic optimization [Grade D, Consensus] All hospitalized people with newly diagnosed hyperglycemia or those with diabetes risk factors to identify individuals at risk for ongoing dysglycemia [Grade C, Level 3 16 ] Repeat screening should be performed 6 to 8 weeks post-hospital discharge for individuals with an A1C 6.

The frequency and timing of bedside CBG monitoring should be individualized for all in-hospital people with diabetes.

Monitoring should typically be performed: Before meals and at bedtime in people who are eating [Grade D, Consensus] Every 4 to 6 hours in people who are NPO or receiving continuous enteral feeding [Grade D, Consensus] Every 1 to 2 hours for people on continuous intravenous insulin or those who are critically ill [Grade D, Consensus].

Provided that their medical conditions, dietary intake and glycemic control are stable, people with diabetes should be maintained on their pre-hospitalization noninsulin antihyperglycemic agents or insulin regimens [Grade D, Consensus].

For hospitalized people 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 only correcting high BG with short- or rapid-acting insulin [Grade A, Level 1A 61,66, ].

For the majority of noncritically ill hospitalized people with diabetes, preprandial BG targets should be 5. For people with diabetes undergoing CABG, a continuous intravenous insulin infusion protocol targeting intraoperative glycemic levels between 5.

In hospitalized people with diabetes, hypoglycemia should be minimized. Protocols for hypoglycemia avoidance, recognition and management should be implemented with nurse-initiated treatment, including glucagon for severe hypoglycemia when intravenous access is not readily available [Grade D, Consensus].

Hospitalized people with diabetes 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]. Programs consisting of the following elements should be implemented for optimal inpatient diabetes care: Interprofessional team-based approach [Grade B, Level 2 ,, ] Health-care professional development regarding in-hospital diabetes management [Grade D, Level 4 95 ] Algorithms, order sets and decision support [Grade C, Level 3 26,99, ].

Abbreviations: BG, blood glucose; CBG , capillary blood glucose; CABG , coronary artery bypass grafting; CSII , continuous subcutaneous insulin infusion; ICU , intensive care unit; NPH , neutral protamine Hagedorn; POC , point of care; TDD , total daily dose.

Other Relevant Guidelines Chapter Glycemic Management in Adults With Type 1 Diabetes Chapter Pharmacologic Glycemic Management of Type 2 Diabetes in Adults Chapter Hyperglycemic Emergencies in Adults Chapter Management of Acute Coronary Syndromes Chapter Author Disclosures Dr.

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