Inpatient glycaemic management

Hyperglycaemia and hypoglycaemia are associated with higher mortality, independent of known history of diabetes. Patients with newly discovered hyperglycaemia have significantly higher in-hospital mortality than patients with a known history of diabetes or normoglycaemic patients.

In both critical and non-critical care settings, glycaemic control should be individualised to the patient's status and to the resources available. Management is similar in medical and surgical patients, but hypoglycaemia is more frequent in medical patients, and outcomes are worse in this group; therefore, avoidance of hypoglycaemia is essential.

Effective management of hyperglycaemia is associated with a decreased length of intensive care unit and hospital stay. An intravenous insulin infusion, along with an infusion of glucose, is the preferred method of delivering insulin in critically ill patients. Tight glycaemic control in the normal range of 4.4 to 6.1 mmol/L (80-110 mg/dL) may not be necessary, however, and may in fact be harmful.

A basal-bolus insulin regimen or a basal insulin regimen may be used in patients admitted to hospital who are not critically ill. Sliding scale insulin alone should not be used in these patients.

Inpatient glycaemic management refers to identifying and treating hyperglycaemia in the setting of acute illness in hospitalised patients with either pre-existing diabetes or new-onset hyperglycaemia. This may occur in the intensive care unit or in the general ward, and evidence and guidelines differ between these settings.[1]American Diabetes Association. Standards of care in diabetes - 2024. Diabetes Care. 2024 Jan;47(suppl 1):S1-321. https://diabetesjournals.org/care/issue/47/Supplement_1 [2]Diabetes Canada (Canadian Diabetes Association). Clinical practice guidelines for the prevention and management of diabetes in Canada. 2018 [internet publication]. https://guidelines.diabetes.ca/cpg [3]Moghissi ES, Korytkowski MT, DiNardo M, et al. American Association of Clinical Endocrinologists and American Diabetes Association consensus statement on inpatient glycemic control. Endocr Pract. 2009 May-Jun;15(4):353-69. http://www.ncbi.nlm.nih.gov/pubmed/19454396?tool=bestpractice.com [4]Korytkowski MT, Muniyappa R, Antinori-Lent K, et al. Management of hyperglycemia in hospitalized adult patients in non-critical care settings: an Endocrine Society clinical practice guideline. J Clin Endocrinol Metab. 2022 Jul 14;107(8):2101-28. https://academic.oup.com/jcem/article/107/8/2101/6605637 http://www.ncbi.nlm.nih.gov/pubmed/35690958?tool=bestpractice.com ​​​ The three groups of patients to consider are the following: 1) known diabetes mellitus before admission; 2) new diagnosis of diabetes mellitus made on admission to hospital (in these cases patients are not aware they have diabetes but present with hyperglycaemia, and diabetes is diagnosed subsequently); 3) transient hyperglycaemia (this may be related to stress, drug therapy such as corticosteroids, or parenteral and enteral nutrition, and resolves when the inciting factor is removed). The development of hyperglycaemia during acute medical or surgical illness is not a physiological or benign condition but is a marker of poor clinical outcome and increased mortality.[5]Umpierrez GE, Isaacs SD, Bazargan N, et al. Hyperglycemia: an independent marker of in-hospital mortality in patients with undiagnosed diabetes. J Clin Endocrinol Metab. 2002 Mar;87(3):978-82. https://academic.oup.com/jcem/article/87/3/978/2846522 http://www.ncbi.nlm.nih.gov/pubmed/11889147?tool=bestpractice.com ​​[6]Levetan CS, Magee MF. Hospital management of diabetes. Endocrinol Metab Clin North Am. 2000 Dec;29(4):745-70. http://www.ncbi.nlm.nih.gov/pubmed/11149160?tool=bestpractice.com [7]Finney SJ, Zekveld C, Elia A, et al. Glucose control and mortality in critically ill patients. JAMA. 2003 Oct 15;290(15):2041-7. https://jamanetwork.com/journals/jama/fullarticle/197458 http://www.ncbi.nlm.nih.gov/pubmed/14559958?tool=bestpractice.com

The prevention and management of hypoglycaemia in the inpatient setting is also addressed in this topic. Diabetic ketoacidosis and non-ketotic hyperosmolar hyperglycaemia are not specifically addressed.