Inpatient glycaemic management

Last reviewed: January 2019

Last updated: March 2018

Summary

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.

Definition

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.

History and exam

Key diagnostic factors

presence of risk factors for hyperglycaemia
presence of risk factors for hypoglycaemia
hx of diabetes mellitus
signs of hypoglycaemia

Full details

Other diagnostic factors

hx of recent corticosteroid use
signs of diabetic retinopathy
signs of diabetic neuropathy
polyuria, polydipsia, or unintentional weight loss

Full details

Risk factors

severe illness (hyperglycaemia or hypoglycaemia)
corticosteroid use (hyperglycaemia)
poorly controlled diabetes mellitus (hyperglycaemia)
insulin administration (hypoglycaemia)
changes to corticosteroid or insulin regimen (hypoglycaemia or hyperglycaemia)
poor nutritional intake (hypoglycaemia)
older age or cognitive impairment (hypoglycaemia)

Full details

Diagnostic investigations

1st investigations to order

random plasma glucose
HbA1c
serum urea nitrogen, creatinine, and glomerular filtration rate (GFR) calculation
spot urine albumin/creatinine ratio
serum ketones

Full details

Investigations to consider

post-discharge fasting plasma glucose or HbA1c
post-discharge oral glucose tolerance test

Full details

Treatment algorithm

ACUTE

critically ill or unplanned surgery or in ICU: hyperglycaemia

stable non-critical illness: uncontrolled hyperglycaemia

stable non-critical illness: well-controlled known diabetes

hypoglycaemia

preoperative: minor elective surgery

Contributors

Authors VIEW ALL 

M. Cecilia Lansang, MD, MPH

Associate Professor of Medicine

Director

Inpatient Diabetes Service

Department of Endocrinology

Diabetes and Metabolism Cleveland Clinic

Cleveland

Disclosures

MCL declares that she has no competing interests.

Suzanne Quinn, MD, PharmD

Endocrinology Section

Orlando Veterans Administration Medical Center

Clinical Associate Professor

Department of Medicine

University of Central Florida College of Medicine

Orlando

Disclosures

SQ declares that she has no competing interests.

Acknowledgements

Dr M. Cecilia Lansang and Dr Suzanne Quinn would like to gratefully acknowledge Dr Ajay Rao and Dr Vivian Fonseca, previous contributors to this monograph. AR and VF declare that they have no competing interests.

Peer reviewers VIEW ALL 

Guillermo E. Umpierrez, MD

Professor of Medicine

Division of Endocrinology

Metabolism and Lipids

Emory University School of Medicine

Atlanta

Disclosures

GEU is an author of a number of references cited in this monograph.

Daniel Morganstein, MBBS, MA (Cantab), MRCP, PhD

Consultant Diabetologist

Beta Cell Unit

Chelsea and Westminster NHS Trust

London

Disclosures

DM declares that he has no competing interests.

Sean Dinneen, MBBCh, FRCPI, FACP

Senior Lecturer in Medicine

National University of Ireland

Consultant in Diabetes and Endocrinology

Galway University Hospitals

Galway

Ireland

Disclosures

SD declares that he has no competing interests.

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Inpatient glycaemic management

Summary

Definition

History and exam

Key diagnostic factors

Other diagnostic factors

Risk factors

Diagnostic investigations

1st investigations to order

Investigations to consider

Treatment algorithm

critically ill or unplanned surgery or in ICU: hyperglycaemia

stable non-critical illness: uncontrolled hyperglycaemia

stable non-critical illness: well-controlled known diabetes

hypoglycaemia

preoperative: minor elective surgery

Contributors

Authors VIEW ALL 

M. Cecilia Lansang, MD, MPH

Disclosures

Suzanne Quinn, MD, PharmD

Disclosures

Acknowledgements

Peer reviewers VIEW ALL 

Guillermo E. Umpierrez, MD

Disclosures

Daniel Morganstein, MBBS, MA (Cantab), MRCP, PhD

Disclosures

Sean Dinneen, MBBCh, FRCPI, FACP

Disclosures

Differentials

Guidelines

Patient leaflets

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