Inpatient glycaemic management

Patients with newly discovered hyperglycaemia have significantly higher in-hospital mortality than patients with a known history of diabetes or normoglycaemic patients.

Increasing evidence indicates that 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 mortality.

Both hyperglycaemia and hypoglycaemia are associated with higher mortality, independent of known history of diabetes.

Effective management of hyperglycaemia is associated with a decreased length of ICU and hospital stay. Tight glycaemic control in the normal range of 4.4 mmol/L to 6.1 mmol/L (80-110 mg/dL) may not be necessary, however, and may 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, but 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 ICU or in the general ward, and evidence and guidelines differ between these settings. The three groups of patients to consider are the following:

• Known diabetes mellitus before admission.

• 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.

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