Canadian Diabetes Association Clinical Practice Guidelines In-Hospital Management of Diabetes

Canadian Diabetes Association Clinical Practice Guidelines

In-Hospital Management of Diabetes

Chapter 16

Robyn Houlden, Sara Capes, Maureen Clement, David Miller

guidelines.diabetes.ca | 1-800-BANTING (226-8464) | diabetes.caCopyright © 2013 Canadian Diabetes Association

CONTINUE pre-hospital diabetes regimen if

appropriate, otherwise …

USE insulin as the treatment of choice

DO NOT use sliding scale insulin alone

DO use BASAL + BOLUS + CORRECTION insulin

regimen

AVOID hypoglycemia

2013In-hospital Management Checklist


• Approximately 1/3 of in-patients have been found to have hyperglycemia

• Many have pre-existing diabetes prior to admission

Hyperglycemia

In-hospital Hyperglycemia is Common


Hyperglycemia

Decreased immune

function, wound healing,

increased oxidative stress

Acute Illness

Increased stress hormones, use of glucocorticoids,

decreased level of activity

Inzucchi SE. NEJM 2006;355;1903

Hyperglycemia and Acute Ilness


Hyperglycemia

Increases risks of postoperative infections and

delirium

Prolonged hospital stay,

resource utilization

Increased renal dysfunction and renal allograft

rejection in transplant

Adverse Effects of Hyperglycemia


Patient Type Glucose Target (mmol/L)

Therapy of choice

Non-critically ill Fasting 5-8

Random <10

Pre-hospital regimen OR basal-bolus-correction

Critically ill 8-10 IV insulin infusion

CABG intraop 5.5-10 IV insulin infusion

Other periop 5-10 As appropriate

CABG = coronary artery bypass graft; IV = intravenous; Intraop = intraoperative; periop = perioperative

In-hospital Glycemic Targets


In the absence of routine

insulin, sliding scale insulin

regimen (bolus insulin on a prn

basis) is purely reactive rather

than proactive and allows for

hyperglycemia to occur before

responding

BG (mmol/L) Bolus insulin (U)

<4 Call MD

4.1 – 10.0 0

10.1 – 13.0 2

13.1 – 16.0 4

16.1 – 19.0 6

>19.0 Call MD

Queale WS. et al. Arch Int Med 1997;157

Sliding Scale Alone is Inefficient


4.0

10.0

Breakfast Lunch Dinner Bedtime


< 4 Call MD

4.1 – 10.0 0

10.1 – 13.0 2

13.1 – 16.0 4

16.1 – 19.0 6

> 19.0 Call MD

6.0

Bolus insulin QID

14.0

6.0

16.5

3.0

Sliding Scale alone

What do you do?

What do you do?

What do you do?

What do you do?

+4 U

0 U 0 U

+6 U

QID: four times daily; SSI: sliding-scale insulin; BG: blood glucose

Sliding Scale Insulin Alone Results in Variable Glucose Control

BG (mmol/L)


Use BASAL + BOLUS + CORRECTION

In-hospital circumstances may warrant temporarily holding

other antihyperglycemic medications (eg. renal or

hepatic impairment)

Insulin = treatment of choice

BASAL + BOLUS + CORRECTION

Insu

lin

BOLUS + CORRECTION

BASAL

Breakfast Lunch Dinner


BASAL + BOLUS + CORRECTION Results in Smoother Glycemic Control

4.0

10.0

Breakfast Lunch Dinner Bedtime


< 4 Call MD

4.1 – 10.0 0

10.1 – 13.0 2

13.1 – 16.0 4

16.1 – 19.0 6

> 19.0 Call MD

6.0

12.0

6.0

Correctional Insulin AC meals

What do you do?

What do you do?

What do you do?

6+2 U

6+0 U

6U 6U

What do you do?

6+0 U

6.0

ROUTINE Bolus insulin

Basal insulin

6U

18 U

Routine Basal


*

*

ŧŧ

††

RABBIT 2 RABBIT 2 Surgery

Adapted from: Umpierrez GE, et al. Diabetes Care 2007;30:2181-86. Adapted from: Umpierrez GE, et al. Diabetes Care 2011;34:256-61.

Basal-Bolus (BBI) Regimen Achieves Better Control than Sliding Scale (SSI) Alone

Blo

od

glu

cose

(m

mo

l/L

)

¶

¶

¶

***

Admit 1 2 3 4 5 6 7 8 9 10

Duration of treatment (days)

5.6

6.7

7.8

8.9

10.0

11.1

12.2

13.3

*p < 0.01; ¶p < 0.05.

¶

SSI

BBI

1Randomi-zation

2 3 4 5 6 7 8 9

Duration of treatment (days)

6.7

7.8

8.9

10.0

11.1

13.3

*p < 0.001, ŧp = 0.02, †p = 0.01

SSI

BBI


• Protocols for hypoglycemia avoidance, recognition

and management should be implemented with

nursing-initiated treatment

• Patients at risk of hypoglycemia should have ready

access to an appropriate source of glucose at all

times

• Insulin protocols and order sets may be used to

improve adherence to optimal insulin use and

glycemic control

Avoid Hypoglycemia


1. Provided that their medical conditions, dietary

intake, and glycemic control are acceptable, people

with diabetes should be maintained on their pre-

hospitalization oral anti-hyperglycemic agents or

insulin regimens [Grade D, Consensus]

Recommendation 1


Recommendation 2

2. For hospitalized patients 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 the reactive sliding-scale

insulin approach that uses only short- or rapid-acting

insulin [Grade B, Level 2]


3. For the majority of non critically ill patients treated

with insulin, pre-meal BG targets should be 5.0 to

8.0 mmol/L in conjunction with random BG values

<10.0 mmol/L, as long as these targets can be

safely achieved [Grade D, consensus]

4. For most medical/surgical critically ill patients

with hyperglycemia, a continuous IV insulin

infusion should be used to maintain glucose levels

between 8.0-10.0 mmol/L [Grade D, consensus]

2013

2013

Recommendations 3 and 4


5. To maintain intraoperative glycemic levels between

5.5-10.0 mmol/L for patients with diabetes

undergoing CABG, a continuous IV insulin infusion

protocol administered by trained staff, [Grade C, Level 3]

should be used

6. Perioperative glycemic levels should be maintained

between 5.0-10.0 mmol/L for most other surgical

situations, with appropriate protocol and trained staff

to ensure safe and effective implementation of

therapy and to minimize the likelihood of

hypoglycemia [Grade D, Consensus]

2013

Recommendations 5 and 6


7. In hospitalized patients, hypoglycemia should be

avoided:

– Protocols for hypoglycemia avoidance, recognition

and management should be implemented with nurse

–initiated treatment, including glucagon for severe

hypoglycemia when IV access is not readily available [Grade D, consensus]

– Patients 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]

2013Recommendation 7


8. Healthcare professional education, insulin

protocols and order sets may be used to improve

adherence to optimal insulin use and glycemic

control [Grade C, Level 3]

9. Measures to assess, monitor, and improve glycemic

control within the inpatient setting should be

implemented, as well as diabetes-specific

discharge planning [Grade D, Consensus]

2013Recommendation 8 and 9


CDA Clinical Practice Guidelines

http://guidelines.diabetes.ca – for professionals

1-800-BANTING (226-8464)

http://diabetes.ca – for patients

http://guidelines.diabetes.ca/

http://diabetes.ca/

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Canadian Diabetes Association Clinical Practice Guidelines In-Hospital Management of Diabetes