Inpatient glycemic management

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

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 intensive care unit and hospital stay. Tight glycemic control in the normal range of 80-110 mg/dL (4.4 to 6.1 mmol/L) 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 the hospital who are not critically ill. 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 intensive care unit 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.