Patients with newly discovered hyperglycemia have significantly higher in-hospital mortality than patients with a known history of diabetes or normoglycemic patients.
Increasing evidence indicates that the development of hyperglycemia during acute medical or surgical illness is not a physiologic or benign condition, but is a marker of poor clinical outcome and mortality.
Both hyperglycemia and hypoglycemia are associated with higher mortality, independent of known history of diabetes.
Effective management of hyperglycemia is associated with a decreased length of ICU and hospital stay. Tight glycemic control in the normal range of 80 mg/dL to 110 mg/dL (4.4-6.1 mmol/L) 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 the hospital who are not critically ill, but sliding scale insulin alone should not be used in these patients.
Inpatient glycemic management refers to identifying and treating hyperglycemia in the setting of acute illness in hospitalized patients with either pre-existing diabetes or new-onset hyperglycemia. 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:
1. Known diabetes mellitus before admission.
2. New diagnosis of diabetes mellitus made on admission to the hospital: in these cases patients are not aware they have diabetes but present with hyperglycemia, and diabetes is diagnosed subsequently.
3. Transient hyperglycemia: 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 hypoglycemia in the inpatient setting is also addressed. Diabetic ketoacidosis and non-ketotic hyperosmolar hyperglycemia are not specifically addressed.
History and exam
- hx of diabetes mellitus
- severe intercurrent illness or infection (hyperglycemia)
- insulin use (hypoglycemia)
- reduced level of consciousness/coma (hypoglycemia and hyperglycemia)
- sweating (hypoglycemia)
- tachycardia (hypoglycemia)
- unusual behavior (hypoglycemia)
- severe illness (hyperglycemia or hypoglycemia)
- corticosteroid use (hyperglycemia)
- poorly controlled diabetes mellitus (hyperglycemia)
- insulin administration (hypoglycemia)
- changes to corticosteroid or insulin regimen (hypoglycemia or hyperglycemia)
- poor nutritional intake (hypoglycemia)
- older age or cognitive impairment (hypoglycemia)
Associate Professor of Medicine
Inpatient Diabetes Service
Department of Endocrinology
Diabetes and Metabolism Cleveland Clinic
MCL declares that she has no competing interests.
Orlando Veterans Administration Medical Center
Clinical Associate Professor
Department of Medicine
University of Central Florida College of Medicine
SQ declares that she has no competing interests.
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.
Professor of Medicine
Division of Endocrinology
Metabolism and Lipids
Emory University School of Medicine
GEU is an author of a number of references cited in this monograph.
Beta Cell Unit
Chelsea and Westminster NHS Trust
DM declares that he has no competing interests.
Senior Lecturer in Medicine
National University of Ireland
Consultant in Diabetes and Endocrinology
Galway University Hospitals
SD declares that he has no competing interests.
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