Meningococcal disease

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1st line –

empiric antibiotic therapy

Presumptive treatment for neonatal meningitis should be active against meningococci and other causes of serious bacterial infection, including Listeria.[54] Antibiotic therapy should be administered as soon as feasible.

The recommended regimen is ampicillin plus cefotaxime.[54][67]

If a cephalosporin cannot be administered (e.g., patients with an allergy), an alternative regimen is ampicillin plus an aminoglycoside (e.g., gentamicin).[54]

Specialist advice should be sought for newborns.

Primary options

ampicillin: consult specialist for guidance on neonatal dose

ampicillin : consult specialist for guidance on neonatal dose

ampicillin: consult specialist for guidance on neonatal dose

and

cefotaxime: consult specialist for guidance on neonatal dose

cefotaxime : consult specialist for guidance on neonatal dose

cefotaxime: consult specialist for guidance on neonatal dose

Secondary options

ampicillin: consult specialist for guidance on neonatal dose

ampicillin : consult specialist for guidance on neonatal dose

ampicillin: consult specialist for guidance on neonatal dose

and

gentamicin: consult specialist for guidance on neonatal dose

gentamicin : consult specialist for guidance on neonatal dose

gentamicin: consult specialist for guidance on neonatal dose

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Plus –

supportive care

Treatment recommended for ALL patients in selected patient group

Patients with meningococcal infections must be monitored closely for complications such as shock, elevated intracranial pressure, seizures, and coagulopathy.

Severe meningococcal infections are frequently complicated by hypoglycemia or hyperglycemia, acidosis, and other biochemical abnormalities that require attention.

Patients with symptoms of shock (pulse rate may be persistently elevated, the skin mottled, the extremities cool due to increased systemic vascular resistance, the capillary refilling prolonged, and the urinary output decreased) or respiratory distress should receive appropriate respiratory support. This might include supplemental oxygen, or intubation and mechanical ventilation for those with severe respiratory distress, altered consciousness, or evidence of elevated intracranial pressure.[75]

Adequate oxygenation, prevention of hypoglycemia and hyponatremia, anticonvulsant therapy if needed for early control of seizures, and measures to decrease intracranial pressure and to prevent fluctuating cerebral blood flow are important in management.[75][76]

Vasopressors should be given to patients with hypotension or poor perfusion who do not respond promptly to fluid resuscitation.[75] Consult a specialist for guidance on suitable vasopressor/inotrope regimens.

If the patient is hypovolemic or in shock, additional intravenous fluids must be given. Fluids should be given cautiously to patients with evidence of elevated intracranial pressure, myocardial dysfunction, or acute respiratory distress syndrome.

Meningococcal disease is a notifiable disease in many countries, including the US; cases should be reported immediately to local and national health departments.[19]

immunocompetent: >1 month to <50 years of age

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1st line –

empiric antibiotic therapy

Presumptive treatment for bacterial meningitis should be active against meningococci and other causes of serious bacterial infection, including Streptococcus pneumoniae.[54] Antibiotic therapy should be administered as soon as feasible.

The recommended regimen is ceftriaxone or cefotaxime plus vancomycin.[54][67]

If a cephalosporin cannot be administered (e.g., patients with an allergy), a carbapenem (e.g., meropenem) plus vancomycin can be considered.[81]

Consider whether your adult patient with diabetes or chronic kidney disease also requires cover for Listeria

Before a specific causative organism has been identified, consider whether your adult patient with diabetes or chronic kidney disease (CKD) requires empiric antibiotic cover for Listeria monocytogenes infection.

Diabetes is considered to be a risk factor for Listeria and empiric antibiotic cover for this bacteria is recommended.[92][93][94][95][96]
Some guidelines also list CKD as a risk factor for Listeria.[93][94]
- The stage of CKD may affect the need for Listeria cover so consult your patient’s nephrologist or an infectious disease specialist (based on expert opinion).

Primary options

vancomycin: children: 15 mg/kg intravenously every 6 hours; adults: 15-20 mg/kg intravenously every 8-12 hours

vancomycin : children: 15 mg/kg intravenously every 6 hours; adults: 15-20 mg/kg intravenously every 8-12 hours

vancomycin: children: 15 mg/kg intravenously every 6 hours; adults: 15-20 mg/kg intravenously every 8-12 hours

-- AND --

ceftriaxone: children: 80-100 mg/kg/day intravenously given in divided doses every 12-24 hours, maximum 4 g/day; adults: 2 g intravenously every 12 hours

ceftriaxone : children: 80-100 mg/kg/day intravenously given in divided doses every 12-24 hours, maximum 4 g/day; adults: 2 g intravenously every 12 hours

ceftriaxone: children: 80-100 mg/kg/day intravenously given in divided doses every 12-24 hours, maximum 4 g/day; adults: 2 g intravenously every 12 hours

cefotaxime: children: 200-300 mg/kg/day intravenously given in divided doses every 6-8 hours, maximum 12 g/day; adults: 2 g intravenously every 4-6 hours

cefotaxime : children: 200-300 mg/kg/day intravenously given in divided doses every 6-8 hours, maximum 12 g/day; adults: 2 g intravenously every 4-6 hours

cefotaxime: children: 200-300 mg/kg/day intravenously given in divided doses every 6-8 hours, maximum 12 g/day; adults: 2 g intravenously every 4-6 hours

Secondary options

vancomycin: children: 15 mg/kg intravenously every 6 hours; adults: 15-20 mg/kg intravenously every 8-12 hours

vancomycin : children: 15 mg/kg intravenously every 6 hours; adults: 15-20 mg/kg intravenously every 8-12 hours

vancomycin: children: 15 mg/kg intravenously every 6 hours; adults: 15-20 mg/kg intravenously every 8-12 hours

and

meropenem: children ≥3 months of age and <50 kg body weight: 40 mg/kg intravenously every 8 hours, maximum 6 g/day; children ≥3 months of age and ≥50 kg body weight and adults: 2 g intravenously every 8 hours

meropenem : children ≥3 months of age and <50 kg body weight: 40 mg/kg intravenously every 8 hours, maximum 6 g/day; children ≥3 months of age and ≥50 kg body weight and adults: 2 g intravenously every 8 hours

These drug options and doses relate to a patient with no comorbidities.

Primary options

vancomycin: children: 15 mg/kg intravenously every 6 hours; adults: 15-20 mg/kg intravenously every 8-12 hours

vancomycin : children: 15 mg/kg intravenously every 6 hours; adults: 15-20 mg/kg intravenously every 8-12 hours

vancomycin: children: 15 mg/kg intravenously every 6 hours; adults: 15-20 mg/kg intravenously every 8-12 hours

-- AND --

ceftriaxone: children: 80-100 mg/kg/day intravenously given in divided doses every 12-24 hours, maximum 4 g/day; adults: 2 g intravenously every 12 hours

ceftriaxone : children: 80-100 mg/kg/day intravenously given in divided doses every 12-24 hours, maximum 4 g/day; adults: 2 g intravenously every 12 hours

ceftriaxone: children: 80-100 mg/kg/day intravenously given in divided doses every 12-24 hours, maximum 4 g/day; adults: 2 g intravenously every 12 hours

cefotaxime: children: 200-300 mg/kg/day intravenously given in divided doses every 6-8 hours, maximum 12 g/day; adults: 2 g intravenously every 4-6 hours

cefotaxime : children: 200-300 mg/kg/day intravenously given in divided doses every 6-8 hours, maximum 12 g/day; adults: 2 g intravenously every 4-6 hours

cefotaxime: children: 200-300 mg/kg/day intravenously given in divided doses every 6-8 hours, maximum 12 g/day; adults: 2 g intravenously every 4-6 hours

Secondary options

vancomycin: children: 15 mg/kg intravenously every 6 hours; adults: 15-20 mg/kg intravenously every 8-12 hours

vancomycin : children: 15 mg/kg intravenously every 6 hours; adults: 15-20 mg/kg intravenously every 8-12 hours

vancomycin: children: 15 mg/kg intravenously every 6 hours; adults: 15-20 mg/kg intravenously every 8-12 hours

and

meropenem : children ≥3 months of age and <50 kg body weight: 40 mg/kg intravenously every 8 hours, maximum 6 g/day; children ≥3 months of age and ≥50 kg body weight and adults: 2 g intravenously every 8 hours

Show drug information for a patient with no comorbidities

Drug choice, dose and interactions may be affected by the patient's comorbidities. Check your local drug formulary.

Primary options

vancomycin

For patients with CKD, please check your local drug formulary

For patients with CKD see dose in the Renal Drug HandbookFor patients with CKD see dose in the Renal Drug Handbook

-- AND --

ceftriaxone

For patients with CKD, please check your local drug formulary

For patients with CKD see dose in the Renal Drug HandbookFor patients with CKD see dose in the Renal Drug Handbook

cefotaxime

For patients with CKD, please check your local drug formulary

For patients with CKD see dose in the Renal Drug HandbookFor patients with CKD see dose in the Renal Drug Handbook

Secondary options

vancomycin

For patients with CKD, please check your local drug formulary

For patients with CKD see dose in the Renal Drug HandbookFor patients with CKD see dose in the Renal Drug Handbook

and

meropenem

For patients with CKD, please check your local drug formulary

For patients with CKD see dose in the Renal Drug HandbookFor patients with CKD see dose in the Renal Drug Handbook

Plus – check baseline kidney function and monitor closely

Back

Plus –

supportive care

Treatment recommended for ALL patients in selected patient group

Patients with meningococcal infections must be monitored closely for complications such as shock, elevated intracranial pressure, seizures, and coagulopathy.

Severe meningococcal infections are frequently complicated by hypoglycemia or hyperglycemia, acidosis, and other biochemical abnormalities that require attention.

Patients with shock (pulse rate may be persistently elevated, the skin mottled, the extremities cool due to increased systemic vascular resistance, the capillary refilling prolonged, and the urinary output decreased) or respiratory distress should receive appropriate respiratory support. This might include supplemental oxygen, or intubation and mechanical ventilation for those with severe respiratory distress, altered consciousness, or evidence of elevated intracranial pressure.[74][75]

Oxygen therapy in your patient with asthma

Measure resting oxygen saturation in all acutely ill patients.

Be aware that pulse oximetry may overestimate oxygen saturation in patients with darker skin tones.[97]
If your patient's asthma is stable, follow guideline recommendations for oxygen saturation target for the presenting acute condition.
If the acute presenting condition triggers an acute exacerbation of your patient's asthma, the Global Initiative for Asthma recommends controlled oxygen to maintain saturations between 93% and 95%.[97]
Adjust oxygen saturation targets for altitude, where appropriate.[97]
Hypercapnia in asthma is an indicator of very severe disease showing a patient is tiring and needs ventilatory support.[98][99][100]

Oxygen therapy in your patient with COPD

Measure resting oxygen saturation and be aware of additional factors to consider when prescribing oxygen therapy in a patient with COPD who is hypoxemic. Be aware that pulse oximetry may overestimate oxygen saturation in patients with darker skin tones, which can lead to increased risk of untreated occult hypoxemia.[101][102]

Obtain a blood gas measurement if your patient with COPD has oxygen saturation <90%, clinical signs of hypercapnia (e.g., altered mental status), or respiratory distress (based on expert opinion).
- An arterial blood gas (ABG) should be used to assess patients with respiratory failure and should always be obtained if hypoxemia is an issue.[103][104]
  - Peripheral venous blood gas (VBG) analysis has increasingly been used to estimate carbon dioxide, pH, and other variables.[105] It is less painful for the patient and may be associated with fewer complications than an ABG.[105]
  - One Cochrane Review found limited data of low to very low certainty evidence that VBG is sensitive for the diagnosis of respiratory failure and isolated hypercarbia.[105] However, it has poor specificity compared with ABG analysis, making it less reliable when precise data are necessary.[105]
Recheck blood gas as clinically indicated.[102]

Be aware that patients with COPD are at increased risk of hypercapnic respiratory failure, and may require careful titration of controlled oxygen therapy.[102] Patients who are particularly at risk include those with:

Chronic hypercapnia[106]
Hypercapnia on presentation
Previous history of hypercapnic respiratory failure[103]
Moderate or severe COPD, particularly if on long-term oxygen therapy[103]
Evidence of chronic hypoventilation for other reasons, e.g., obesity hypoventilation syndrome, taking sedatives or hypnotic drugs.[102][106]

Critically ill and needs high levels of oxygen

This includes patients with comorbid COPD who need high levels of oxygen due to a critical illness such as shock, sepsis, major head injury, status epilepticus, anaphylaxis, or major trauma.

In this scenario, some guidelines recommend an initial target oxygen saturation in line with the recommendation for patients without COPD.[103]

Evidence suggests that targeting an upper oxygen saturation level of 96% may be preferred compared with a higher level.[107][108]
Subsequently, you may need to adjust to controlled oxygen therapy with a target oxygen saturation range of 88% to 92% depending on the blood gas results.[103]

Acutely but not critically ill and at risk of hypercapnic respiratory failure

This includes patients with comorbid COPD who have risk factors for hypercapnic respiratory failure and an acute condition, but are not critically ill.[103]

Give controlled oxygen therapy and use an initial target oxygen saturation of 88% to 92%.[102][103]

Check blood gas and recheck after 30 to 60 minutes.[103]

Not critically ill and NOT at risk of hypercapnic respiratory failure

As an example, a patient may have stable, mild COPD with minimal symptoms.

Use an initial target oxygen saturation as recommended by guidelines for the presenting acute condition.

Evidence suggests that for most acutely ill patients, targeting an upper oxygen saturation level of 96% may be preferred compared with a higher level.[107][108]

Measure blood gas as soon as possible[103]

Subsequently, you may need to adjust to controlled oxygen therapy with a target oxygen saturation range of 88% to 92% depending on the blood gas results.[103]

High-flow nasal cannula (HFNC)

HFNC can be considered in certain patients with COPD who are acutely unwell, as a potential bridge between oxygen delivered through conventional nasal cannula and noninvasive ventilation.[109] There is currently a lack of good-quality evidence to make specific recommendations for HFNC.[102] However, some studies have shown that it may provide benefits such as:

Decreasing the work of breathing[109][110]
A theoretical provision of low-level positive end-expiratory pressure (PEEP)[109][110][111]
Facilitating secretion mobilization.[109][110]

Ventilatory support

Start noninvasive bilevel ventilation (BiPAP) if the patient has at least one of the following:[102]

Respiratory acidosis (PaCO₂ ≥45 mmHg [6 kPa] and arterial pH ≤7.35)
Severe dyspnea and/or increased work of breathing (e.g., use of respiratory muscles, paradoxical movement of the abdomen, retraction of the intercostal spaces)
Persistent hypoxemia despite supplemental oxygen.

Start invasive mechanical ventilation support if this is indicated and the patient is considered suitable. Indications for invasive mechanical ventilation include:[102]

Inability to tolerate, or failure of, noninvasive ventilation (particularly if they have life-threatening hypoxemia)
Status post respiratory or cardiac arrest
Reduced consciousness, or psychomotor agitation that is inadequately controlled by sedation
Massive aspiration or persistent vomiting
Persistent inability to remove respiratory secretions
Severe hemodynamic instability without response to fluids or vasoactive drugs
Severe ventricular or supraventricular arrhythmias.

When considering endotracheal intubation with mechanical ventilation, always take into account the patient's wishes (e.g., advance directives).[102]

Vasopressors should be given to patients with hypotension or poor perfusion who do not respond promptly to fluid resuscitation.[74][75] Consult a specialist for guidance on suitable vasopressor/inotrope regimens.

Assess fluid status and manage fluid balance particularly closely

In a patient with heart failure and/or chronic kidney disease (CKD), judicial use of fluids is crucial to preventing clinically significant volume overload.

Be aware that hypovolemia may be difficult to assess in a person with heart failure and/or CKD.

As with any patient presenting acutely, look for signs of volume depletion on physical exam, by assessing:[112]

Vital signs:
- Blood pressure, (particularly systolic blood pressure [SBP] and mean arterial pressure)
- Pulse
- Postural hypotension
Peripheral perfusion
Capillary refill time
Jugular venous distension
Passive leg raise.

Consider point of care ultrasound (POCUS), which may give further information of the etiology of heart failure and volume status. There are several protocols that may be appropriate for each clinical situation. For example, the Rapid Ultrasound for Shock and Hypotension (RUSH) exam, commonly performed by clinicians in the emergency setting, is a noninvasive method that may help determine the cause of shock.[113] Depending on the clinical circumstance, a full echocardiogram and/or other investigations may subsequently be ordered.

More info: The RUSH exam

The RUSH exam involves a three-part physiologic assessment using point of care ultrasound (POCUS):[114]

1. The pump, i.e., the cardiac status
- Evaluate cardiac status by looking for: pericardial effusions and cardiac tamponade, left ventricular contractility, and right ventricular size
2. The tank, i.e., the effective intravascular volume status
- Assess the fullness of the tank by examining the inferior vena cava (IVC) and/or internal jugular veins
- Evaluate for "leakiness" of the tank, or free fluid in the abdominal and thoracic cavities, by performing Focused Assessment of Sonography for Trauma (FAST) and thoracic ultrasound to assess for fluid in the abdominal and thoracic cavities[115][116]
- Assess compromise of the tank by assessing for pneumothorax
3. The pipes, i.e., the arterial and venous sides of the circulatory system
- Assess the aorta looking for aortic aneurysm, rupture, dissection
- Assess lower extremity and/or upper extremity veins for deep vein thrombosis.

Other variations of RUSH have been described.[113]

Practical tip

Establish your patient's baseline blood pressure as the fall from baseline and association with any symptoms (such as presyncope or syncope) is more significant than absolute systolic blood pressure (SBP).

Heart failure

Be aware that an SBP of <90 mmHg may suggest hypotension, but a patient on medication for chronic heart failure can have a baseline SBP of <90 mmHg.

Consider consultation with a cardiologist and/or intensivist.

A patient with heart failure may require fluid resuscitation. If needed, this should include close fluid balance monitoring because there is a significant risk of pulmonary edema with fluid resuscitation. Invasive monitoring can be a valuable tool in certain circumstances in patients with heart failure, particularly (based on expert opinion):

With a suspected low output or cardiogenic shock state
With massive fluid overload, when high doses of diuretic are needed or with diuretic resistance
When unable to establish volume state
When titrating inotropes.

CKD

A patient with CKD who is hypovolemic needs immediate fluid resuscitation.

Reassess your patient after initial fluid challenge and further address the cause of hypovolemia.
If they do not rapidly stabilize:
- Consider activating the rapid response team and obtaining specialist consultation
- Consider transferring your patient to an intensive care setting where hemodynamic monitoring is possible (based on expert opinion).

Continue to monitor fluid balance particularly closely

Accurate monitoring of volume status is essential in a person with heart failure and/or chronic kidney disease (CKD).[117]

There is a significant risk of pulmonary edema with fluid resuscitation in a patient with heart failure and/or CKD, so monitor closely.
Monitoring should include:
- Regular clinical assessment of volume status (pulse, BP, jugular venous distension [JVD], and check for pulmonary and peripheral edema)
- Fluid balance (input/output chart) and daily weight
- BUN and serum creatinine to monitor kidney function, at least daily.
Consider bladder catheterization if urinary output is difficult to measure, but be aware of increased risk of infection and trauma.
Patients with greater clinical complexity, such as those with heart failure and/or advanced CKD may need admission to the intensive care unit for more invasive monitoring and interventions. If noninvasive bedside assessments are not adequate for monitoring, consider a central venous pressure catheter or pulmonary artery catheter.[117][118][119]

Practical tip

Always be mindful of signs of cardiogenic shock including elevated lactate, hypotension, worsening end-organ function, and altered mental status. Early and aggressive management is key to survival and requires immediate involvement of specialists including heart failure specialists (based on expert opinion).

De-escalation

It's important to know when to de-escalate fluid therapy. In a patient with heart failure and/or CKD, judicial use of fluids is crucial to preventing clinically significant volume overload. De-escalate when:

Your patient is euvolemic
The problem requiring fluids has been successfully reversed.

Monitor volume status consistently to try to avoid volume overload.

If a patient begins to show signs of volume overload with fluid (signs include elevated pulse rate, elevated respiratory rate due to pulmonary edema, JVD with peripheral edema, and decreased oxygen saturation):

Immediately stop fluid administration
Consider consultation with specialist
Consider intravenous diuretics, and
Arrange an urgent chest x-ray if pulmonary edema is suspected (based on expert opinion).

Unless there are extenuating circumstances, diuretics and intravenous fluids are not generally given together (based on expert opinion).

Recommendations from an intensive care specialist and/or cardiologist and/or nephrologist may be needed.

Withhold antihypertensives and/or diuretics if hypotensive

Withhold antihypertensives and/or diuretics if your patient:

Is in shock, or
Has a blood pressure ≥40 mmHg lower than their baseline.

Consider withholding antihypertensives and/or diuretics if your patient:

Is hypotensive, or
Has developed orthostatic hypotension or has postural symptoms (based on expert opinion).
- Orthostatic hypotension is defined, by consensus, as a fall in systolic blood pressure ≥20 mmHg and/or a fall in diastolic blood pressure ≥10 mmHg on assuming an upright posture.[120]
- In people with classic orthostatic hypotension, the blood pressure change occurs within 3 minutes of standing.[121] In practice, take standing blood pressure after the person has been standing for at least 1 minute (based on expert opinion).

People with hypertension, coronary artery disease, heart failure, stroke, or chronic kidney disease (CKD) will typically be taking one or more of these types of drug.

Establish your patient's baseline blood pressure and assess volume status.

Patients with treated heart failure may have chronically low blood pressure (e.g., systolic BP ≤90 mmHg). If their systolic blood pressure falls by >10-15 mmHg and is associated with symptoms (such as presyncope or syncope), it may be appropriate to withhold medications that may lower blood pressure but have no or little prognostic benefit for heart failure (such as amlodipine, doxazosin).
- If clinically appropriate, consider changing the time of administration of medication that has a prognostic benefit for heart failure (e.g., sacubitril/valsartan, beta-blockers) to night time, or splitting or reducing the dose (based on expert opinion).
- Consider consultation with a cardiologist and/or intensivist.

If diuretics are withheld in a patient with heart failure and/or CKD, close monitoring is needed as fluid can quickly accumulate.

Be aware that sodium-glucose cotransporter-2 (SGLT2) inhibitors, a class of medication with a prognostic benefit for both heart failure and CKD, also have a weak diuretic effect.[122]

If antihypertensives or diuretics have been withheld during the acute illness, consider restarting them before discharge if clinically appropriate (based on expert opinion).

Restart one at a time at a lower dose and ask the primary care physician (PCP) to titrate back to normal dose.
- Most patients won't tolerate restarting all medications at the original doses simultaneously.
- If it is not clinically appropriate to restart these medicines before discharge, ensure that the patient has follow-up to decide when the medications can be reintroduced.
- Ensure you have communicated clearly to the PCP at discharge.

Meningococcal disease is a notifiable disease in many countries, including the US; cases should be reported immediately to local and national health departments.[19]

Consider – intravenous corticosteroid

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Consider –

intravenous corticosteroid

Treatment recommended for SOME patients in selected patient group

For suspected bacterial meningitis, most experts recommend that patients older than age 6 weeks receive dexamethasone, with the first dose given prior to or concurrently with the first dose of antibiotics.[48][68][71][72] [ ] [ ]

Some studies have shown that high-dose corticosteroids reduce the likelihood of neurologic sequelae, particularly in meningitis secondary to Haemophilus influenzae or Streptococcus pneumoniae. The effectiveness of adjuvant corticosteroids in meningitis caused by Neisseria meningitidis is not yet clear.[54][69][70]

Most experts advise discontinuing corticosteroids for bacterial meningitis if the causative organism is proven to be N meningitidis, although some advise that adjunctive treatment should be continued irrespective of the pathogen.[54] Corticosteroids should be discontinued if the diagnosis of bacterial meningitis is disproved.

Manage your patient's diabetes when they are taking corticosteroids

If your patient is a child, seek specialist advice. These recommendations only concern the management of adults with diabetes.

Giving corticosteroids to someone with diabetes will worsen their glycemic control, so continue to test blood glucose at least four times a day and treat hyperglycemia if it occurs (based on expert opinion).

For patients with diabetes, use the same doses of corticosteroid as for patients without diabetes, but adjust diabetes medication. Adjust dose for existing medication or start additional glucose-lowering treatments if needed.

Patients with type 1 diabetes may need their insulin regimen intensifying.
Consider commencing insulin therapy in patients with type 2 diabetes who have high blood glucose levels pre-corticosteroid treatment (based on expert opinion).

If your patient is an inpatient, use an appropriate order set for managing hyperglycemia.[124]

If insulin orders are initiated, review and adjust these daily, taking into account levels of glycemia, and anticipated changes in dose, type, and duration of corticosteroid.[124]
- NPH (neutral protamine Hagedorn) insulin is often added to the individual's basal-bolus insulin or oral glucose-lowering medication if an intermediate-acting corticosteroid (e.g., prednisone) is started. The American Diabetes Association (ADA) recommends administering NPH insulin at the same time as the corticosteroid dose, as the action peak of 4 to 6 hours coincides with peak plasma level of the intermediate corticosteroid.
- Long-acting insulin may be needed for an individual starting a long-acting corticosteroid (e.g., dexamethasone), or for those having multiple doses or continuous doses of a corticosteroid.
- Increases in correction insulin and prandial insulin (if eating) may be needed, along with basal insulin, for an individual starting a high dose of a corticosteroid.
- Be aware of the possibility of nocturnal or early morning hypoglycemia. Consider adjusting basal insulin and avoid bed-time correctional doses of rapid-acting insulin (based on expert opinion).
- If a continuous intravenous insulin infusion is being used in a critically ill patient, follow glycemic management using a validated protocol/order set to treat persistent hyperglycemia.[125]
- If your acutely ill patient has type 1 diabetes and their blood glucose stays above 200 mg/dL (11.1 mmol/L) for more than 24 hours, check blood beta-hydroxybutyrate (or blood ketone) levels (based on expert opinion).

When you taper the corticosteroid dose, glycemic control will likely improve, which may require gradual reduction of the dose of titrated diabetic medication back to the pre-corticosteroid regimen.[126]

If the diabetes medication is not appropriately weaned off, your patient will be at a high risk of developing hypoglycemia. Communicate the strategy for titration with the outpatient team on discharge.
The duration of action for a particular corticosteroid will determine the period of effect on glycemic control.
- Intravenous corticosteroids typically have shorter half-lives, which means glycemic control returns to pre-corticosteroid levels within 24 hours.
- Oral corticosteroids, especially if long acting, (e.g., dexamethasone) may take a few days.

Monitor for psychiatric complications of corticosteroids

If your patient is a child, seek specialist advice. These recommendations only concern the management of adults with depression.

Corticosteroids are indicated as an immediate treatment in certain acute conditions, as well as some chronic conditions, but it is important to be aware that corticosteroids may have adverse psychiatric effects.[127]

Although all patients should be monitored for these effects, the risk of depression, mania, panic disorder, or suicide during corticosteroid therapy has been reported to be higher in people who are already living with these conditions, but not consistently so.[128]

If the clinical situation allows:

Check previous response to corticosteroids
- Past incidence of psychiatric complications during corticosteroid therapy may increase the risk of recurrence in subsequent treatments.[128]

Monitor for psychiatric adverse effects.

These may vary in severity and include among others:[129]
- Anxiety and insomnia
- Severe mood disorders, including manic states[127]
- Cognitive impairment.
Effects seem to be dose-related and are more common with long-term regimens, long-acting formulations, and in older patients.[128] This also stands true for patients who have neuropsychiatric adverse effects related to discontinuing long-term corticosteroid therapy.[130]
Manic episodes and delirious states are the most common psychiatric adverse effects when starting corticosteroid treatment, whereas depression is most common during chronic therapy.[128][131]
Be aware of a possible withdrawal reaction, which may present with weakness, fatigue, gastrointestinal symptoms, and delirium, as well as with psychiatric complications such as depression, when discontinuing corticosteroids.[130]

If your patient develops psychiatric complications related to corticosteroids, ask for a psychiatric consult for advice on appropriate management (based on expert opinion).

This may include adjusting dose or earlier discontinuation of the corticosteroid if the clinical situation allows.[128]
If the dose of the corticosteroid cannot be adjusted or the corticosteroid cannot be discontinued, pharmacologic treatment of the psychiatric adverse effects may be necessary (based on expert opinion).

Primary options

dexamethasone sodium phosphate: children >6 weeks of age: 0.15 mg/kg intravenously every 6 hours; adults: 10 mg intravenously every 6 hours

dexamethasone sodium phosphate : children >6 weeks of age: 0.15 mg/kg intravenously every 6 hours; adults: 10 mg intravenously every 6 hours

dexamethasone sodium phosphate: children >6 weeks of age: 0.15 mg/kg intravenously every 6 hours; adults: 10 mg intravenously every 6 hours

Plus – review diabetes medication (NEVER stop insulin in a person with type 1 diabetes)

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Plus –

review diabetes medication (NEVER stop insulin in a person with type 1 diabetes)

Treatment recommended for ALL patients in selected patient group

Check your patient's blood glucose on admission. In addition, check HbA1c if no result is available from the previous 3 months.[124][132]

Exclude hypoglycemia, diabetic ketoacidosis (DKA), and hyperosmolar hyperglycemic state (HHS).
Test for blood beta-hydroxybutyrate or ketones if:[133][134]
- Your patient was taking a sodium-glucose cotransporter-2 (SGLT2) inhibitor (e.g., dapagliflozin, canagliflozin, empagliflozin) before unplanned hospitalization, and/or
- There is acidosis, an increased anion gap, nausea/vomiting, or a combination of these.
Admission HbA1c may give you an indication of your patient’s previous diabetes control and may influence your treatment at discharge.

Never stop basal insulin (long-acting/background insulin [e.g., insulin glargine or insulin degludec]) in a patient with type 1 diabetes who presents with an acute illness or injury, unless being managed by an ongoing intravenous or subcutaneous insulin infusion.[124]

Insulin deficiency (e.g., due to delayed or missed doses) will rapidly cause ketoacidosis (based on expert opinion).

Practical tip

Seek advice from a specialized inpatient diabetes team, if available, or endocrinology team if care is particularly complex (e.g., recurrent or severe hypoglycemia, persistent hyperglycemia or recurrent DKA), or your patient needs enteral feeding. The diabetes team can also advise on the most appropriate insulin regimen and dosing during the hospital stay (based on expert opinion).

Critical illness

For persistent hyperglycemia, defined as blood glucose ≥180 mg/dL (≥10.0 mmol/L) confirmed on two occasions within 24 hours, the American Diabetes Association (ADA) recommends starting or intensifying insulin therapy for most critically ill patients.[124]

Consider starting a continuous intravenous insulin infusion for your critically ill patient for achieving glycemic goals and avoiding hypoglycemia.[124][125]

Use a validated protocol/order set for the continuous intravenous insulin infusion.[124]
This allows for predefined adjustments to the insulin infusion rate according to blood glucose measurements and past and current insulin infusion rates, to avoid hypoglycemia.[124]

More info: Continuous intravenous insulin infusion management

If a continuous intravenous insulin infusion is started:

In practice, subcutaneous basal insulin is generally discontinued (based on expert opinion).
- Less often, at some institutions, subcutaneous basal insulin may be continued (provided there is no hypotension and the patient is not on vasopressors) at 75% of the patient's usual dose.
Stop the patient’s usual subcutaneous rapid-acting and mixed insulins while on an intravenous insulin infusion.[135]
Use the continuous intravenous insulin infusion for as short a time as possible.[135]

Once ready to discontinue a continuous intravenous insulin infusion:

Follow an appropriate order set/transition protocol to switch to scheduled subcutaneous insulin.[124]
- This should include calculating the total daily dose of subcutaneous insulin needed, dividing into appropriate basal and bolus doses, monitoring and adjusting dose based on glucose monitoring, and having orders in place for potential hypoglycemic episodes (based on expert opinion).
Give subcutaneous basal insulin at least 2 hours before discontinuing the intravenous infusion to minimize rebound hyperglycemia.[124]
- Emerging data suggest that early administration of subcutaneous basal insulin alongside intravenous insulin infusion does not seem to increase the risk of hypoglycemia.[136][137]

Noncritical illness

For persistent hyperglycemia, defined as blood glucose ≥180 mg/dL (≥10.0 mmol/L) confirmed on two occasions within 24 hours, the ADA recommends starting or intensifying insulin and/or other glucose-lowering therapies for most noncritically ill patients.[124]

Generally, an insulin regimen is preferred for managing hyperglycemia in individuals with diabetes receiving hospitalized care.[124]

If your patient is not eating or drinking or has poor oral intake, a subcutaneous basal insulin or basal plus bolus correction (every 4-6 hours) insulin plan is preferred.
If they are eating adequately, subcutaneous basal insulin with prandial (with each meal, up to 3-4 times a day) and correctional doses is preferred.

In a patient who is already managing their diabetes with insulin, consider whether there is any need to adjust insulin dose when they are admitted to the hospital.

If a patient with type 1 or type 2 diabetes uses insulin at home, has adequate glycemic management, and was not admitted with significant hyperglycemia, it may be appropriate to reduce their routine dose of subcutaneous basal insulin by 20%, particularly if they are eating less than usual. Another factor to keep in mind is that hospital meals generally contain less carbohydrate than meals patients would eat at home (based on expert opinion).
Conversely, patients who are acutely ill with an infection sometimes need more insulin.
Regular monitoring of blood glucose (at least four times daily) can help guide appropriate adjustments to insulin dosing.

More info: Patients using a continuous subcutaneous insulin infusion (CSII) (insulin pump) prior to hospital admission

If a patient with diabetes had been using an insulin pump prior to hospital admission:

Follow your hospital procedure, if available, and request a specialized inpatient diabetes team or endocrinology consult.
Safe continuation of an insulin pump during hospital admission has been advocated by several professional organizations.[124][138][139][140]
Key criteria for safe use include that:[124][141]
- The patient is medically stable, willing, and capable of self-management
- There are no contraindications
- The necessary supplies and resources are available
- There are hospital staff with the appropriate expertise and training, and institutional diabetes technology protocols in place
- Staff are available to perform confirmatory point-of-care (POC) glucose measurements for insulin dose decisions, hypoglycemia assessment and treatment, and at least four times a day (based on expert opinion).

Review noninsulin glucose-lowering medications if your patient had been taking any of these before admission and determine whether these are suitable to continue during admission.

For select patients with type 2 diabetes, it may be acceptable to continue noninsulin glucose-lowering medications, such as a dipeptidyl peptidase-4 (DPP-4) inhibitor.[124] Only consider this in a patient who is (based on expert opinion):
- Clinically stable with mild hyperglycemia
- Eating regularly
- Has no contraindications.
Metformin should be discontinued in patients with contraindications, including those with increased risk of lactic acidosis (e.g., those with renal impairment, shock, or hypoxia) and those with acute heart failure.[142][143] Consider restarting metformin after the acute condition has resolved (based on expert opinion).
In general, stop SGLT2 inhibitors for your patient with diabetes who is admitted to the hospital with an acute illness (based on expert opinion). This is due to the risk of euglycemic ketoacidosis.
- In particular, avoid SGLT2 inhibitors if your patient is severely ill, or if their clinical situation predisposes them to ketoacidosis (e.g., prolonged fasting due to acute illness or surgery).[124][133]
- Be aware that ketoacidosis associated with SGLT2 inhibitors may still be present despite a normal (or near normal) serum glucose level (euglycemic ketoacidosis).[134]
- If an SGLT2 inhibitor is being initiated during a hospital admission (e.g., for treatment of heart failure), this medication should be initiated after recovery from the acute illness.[124]
  - Remain aware of the risk of ketoacidosis which can occur spontaneously with SGLT2 inhibitors.[134]
  - Monitor hydration status and basic metabolic panel (BMP) daily for elevated anion gap and acidosis (based on expert opinion).
  - Check blood beta-hydroxybutyrate (or blood ketone) levels, especially if acidosis is present, or there are symptoms of ketoacidosis (e.g., nausea or vomiting) (based on expert opinion). Measure blood ketones as urinary ketone measurement may be unreliable.
  - Be aware that beta-hydroxybutyrate levels of ≥3.0 mmol/L, along with pH <7.3 or bicarbonate <18 mmol/L, indicate DKA.[134][144]
  - In this situation, stop SGLT2 inhibitor and treat DKA.[144]

Discharge

Start thinking about a discharge plan at the time of hospitalization or after stabilization (based on expert opinion). This should be structured and tailored to the individual.[124]

Provide inpatient diabetes self-management education, focusing on skills needed after discharge, and ensure follow-up and support strategies are in place.
Arrange medication reconciliation:
- Make sure this includes a strategy for switching back to the brand of insulin your patient was on at the time of hospitalization, if appropriate and approved by insurance or covered by other programs (based on expert opinion).
- Clarify regarding timing of restarting any noninsulin glucose-lowering medications that have been temporarily stopped (based on expert opinion).
Communicate promptly to the relevant outpatient healthcare professionals.

Plus – monitor comorbidities during hospital stay

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Plus –

monitor comorbidities during hospital stay

– baseline cognitive and delirium assessments with collateral history

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baseline neurologic exam

Treatment recommended for ALL patients in selected patient group

Perform a baseline neurologic exam at the earliest appropriate opportunity for any patient with a history of stroke.

A patient with an acute condition (e.g., an infection and illness-related hypotension) is at increased risk of stroke.[145][146][147] This risk is even higher in anyone with a history of stroke.
- In particular, ischemic stroke is a known complication of acute bacterial meningitis.[92][148][149]
- Less commonly, hemorrhagic stroke can also complicate bacterial meningitis.[148]
- If there is a change in neurologic status during admission, repeat the neurologic exam to evaluate for a new acute stroke.
Ensure the right level of nursing care for the patient’s condition and ensure that clear orders are written for the patient’s functional and cognitive status (e.g., fall precautions, 1:1, soft restraints, assistance with activities of daily living [ADLs]).
- A patient with a history of stroke has a higher risk of falls and injury.[150]

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baseline cognitive and delirium assessments with collateral history

Treatment recommended for ALL patients in selected patient group

Do a baseline cognitive assessment at the earliest opportunity in any patient with a history of dementia.

Take a collateral history from family, friend, or caregiver to establish whether your patient's cognitive function is stable, gradually declining, or acutely declined.[151]
Check your patient’s level of alertness and orientation to time, place, and person, and corroborate with caregivers and review your patient’s prior medical records (based on expert opinion).
If time allows, a standardized cognitive assessment score is helpful for tracking clinical progress, and determining discharge needs (based on expert opinion).
Validated scoring tools for cognitive assessment include:
- The Mini-Cog Alzheimer's Association: Mini-Cog(TM) Opens in new window
- The Montreal Cognitive Assessment (MoCA)[152]
- The Saint Louis University Mental Status Examination (SLUMS). Saint Louis University: SLUMS Opens in new window
These scores are often best interpreted alongside a functional assessment, usually performed by an occupational therapist and/or a physical therapist.
These scores may not represent the person's usual baseline for cognition due to the impact of the acute condition and its treatment, but it is still good practice to record and repeat it when the person has recovered (based on expert opinion).

Practical tip

If your patient with dementia is an older adult, consider using the "Geriatric 5Ms" as a framework to ensure core areas of care, such as baseline cognitive function, are addressed. The 5Ms are:[153][154]

Mind (mentation, dementia, depression, and delirium)
Mobility (gait, balance, and falls prevention)
Medications (polypharmacy, deprescribing, optimal prescribing, and adverse medication effects and medication burden)
Multicomplexity (multimorbidity and complex psychosocial situations)
Matters Most to Me (each individual's health outcome goals and care preferences).

Assess for delirium whenever a patient with dementia presents with acute illness.

People living with dementia are at increased risk of delirium when they are admitted to the hospital and throughout their admission.[151][155]
Delirium is not the same as dementia. It is a potentially life-threatening acute, fluctuating change in mental functioning, with inattention, disorganized thinking, and altered levels of consciousness.[156]
Use a screening tool to detect probable delirium, taking the setting into account. Commonly used tools include:
- The Delirium Triage Screen (DTS), which may be rapidly administered in an emergency department setting and assesses arousal and attention. If positive, confirm with a more specific tool, such as the brief Confusion Assessment Method (bCAM).[151][157][158]
- The Confusion Assessment Method (CAM), if your patient is not in a critical care setting.[151][159][160]
- The Confusion Assessment Method for the Intensive Care Unit (CAM-ICU) or the Intensive Care Delirium Screening Checklist (ICDSC) if your patient is in a critical care setting, or in the recovery room after surgery.[155][161][162][163]

Practical tip

Depression can mimic delirium in older adults, particularly in patients with cognitive impairment or other comorbid medical conditions.[151]

Ask if your patient has a diagnosis of depression. If not, use a very brief screening test, such as the Patient Health Questionnaire-2 or Emergency Department Depression Screening Instrument to screen older adults for depression.
A positive screen for depression should prompt further questions, e.g., on suicidal thoughts.

Consider a multicomponent intervention to reduce the risk of delirium during a hospital admission in people with dementia, such as the Hospital Elder Life Program (HELP), or other multicomponent nonpharmacologic intervention.[164][165][166] Measures to reduce the risk of delirium may include:[151][158][167]

Helping with orientation; make sure patients have their own glasses and/or hearing aids
Getting patients mobilized as soon as possible
Controlling pain adequately
Keeping patients well hydrated and helping them to eat adequately
Monitoring and maintaining regular bowel and bladder function
Using supplemental oxygen as needed
Monitoring for and treating postoperative complications as soon as possible
Reviewing the patient's medications
- Identify and avoid medications that are high-risk for precipitating delirium, such as benzodiazepines, corticosteroids, and anticholinergics.[151][168]

Foster familiarity, e.g., consider facilitating the patient's usual caregiver to stay with the patient and bring in familiar objects from home.[151][158]

Practical tip

Dementia is a risk factor for postoperative delirium.[167][169]

Evaluate baseline cognition using a brief screening tool preoperatively.
Consider the most appropriate method of analgesia to reduce the risk of postoperative delirium.
Monitor for postoperative delirium using a validated screening instrument (e.g., CAM-Short Form).[170]

Evidence: Primary prevention of delirium in hospital using nonpharmacologic interventions

There is evidence that a nonpharmacologic approach reduces the risk of delirium in non-ICU patients in hospital.

A systematic review compared nonpharmacologic interventions designed to prevent delirium with usual care or active control in adults in a non-ICU hospital setting.[171]

Interventions were multicomponent or single components, targeted at a specific risk factor, such as disorientation or dehydration.
Meta-analysis of 14 studies on multicomponent interventions found a significant reduction in incident delirium compared with usual care (RR 0.57, 95% CI 0.46 to 0.71).
There is emerging evidence that multicomponent interventions may reduce hospital length of stay (MD -1.3 days, 95% CI -2.56 to -0.04 days), but there is significant heterogeneity between the studies.
There is little information specifically on people with dementia as this group was frequently excluded from trials despite their increased risk of developing delirium.

More info: Initial investigations for a patient with delirium

If your patient has delirium, check for and treat life-threatening causes:[151][167][172]

Hypoxia
Hypoglycemia
Hypotension
Sepsis
Drug intoxication or withdrawal, including alcohol withdrawal
Acute myocardial infarction

Although every evaluation should be tailored to the individual patient, most patients should receive:[151]

Complete blood count
Comprehensive metabolic panel
Point-of-care glucose
Urinalysis with culture
ECG

Additional tests that may be needed include (based on expert opinion):

Thyroid function tests
Folate and vitamin B12
C-reactive protein
Blood cultures (if bacteremia is suspected)
Chest x-ray

Consider whether your patient requires computed tomography (CT) of the brain.[151]

CT brain should be arranged if your patient has focal neurological deficits, head trauma, reduced level of consciousness, or has a history of fall.
CT brain should also be considered if your patient takes anticoagulants.
In practice, a patient in the hospital setting who has a change in mental status will usually receive a CT brain (based on expert opinion).

Check for and treat any reversible causes of delirium:[151][158][167][172]

Pain
Infection
Poor nutrition
Constipation
Dehydration
Medications
- Ask about recently prescribed medications, especially opioid analgesics, anxiolytics, antipsychotics, corticosteroids, or anticholinergics
Immobility
Poor sleep
Sensory impairment (e.g., ear wax or loss of glasses)

More info: Management of a patient with delirium

Manage patients with delirium initially with nonpharmacologic treatment.[151][158][167]

Reduce disorientation by providing a well-lit room, with a clock and calendar visible (e.g., on the wall).
Encourage and facilitate family, friends, and caregivers to visit the patient.
Use verbal and nonverbal techniques to de-escalate conflict and distress.

Where nonpharmacologic treatments are ineffective, and the patient is in emotional distress or considered a risk to themselves or others, a short-term (often only 1-2 days is required) antipsychotic may be considered at lowest effective dose, and only as a last resort.[151][168][173]

Any new antipsychotic prescribed for this purpose must be regularly reviewed, and discontinued as soon as possible.[168][173]
Be aware that the evidence on the efficacy of antipsychotics for delirium is inconclusive, and guidance regarding choice of antipsychotic varies.[151][158][167]
Antipsychotics should be used with caution in patients with a history of dementia as there is an increased risk of mortality in these patients[151][173]
- A systematic review of antipsychotics for delirium in hospitalized adults concluded that the evidence did not support routine use of haloperidol or atypical antipsychotics for this purpose[174]
- All antipsychotics have a warning that they are not approved for dementia-related psychosis.[151]
Haloperidol is contraindicated in patients with Parkinson disease or in patients with dementia with Lewy bodies.[163] Check for all contraindications.
Consider baseline ECG before starting any antipsychotic medication (based on expert opinion).

Provide the family/caregiver with information so they understand what is happening and how they can work together with the clinical team to help the patient get back to their usual self (based on expert opinion).

Document the diagnosis of delirium clearly (based on expert opinion).

Evidence: Risks and safe withdrawal of antipsychotics in older adults

Antipsychotics are associated with increased mortality in people with dementia.

Short-term antipsychotics may sometimes be needed in people with dementia without delirium to enable safe care. However, antipsychotics have various adverse effects in older adults and are associated with an increased risk of death in people with dementia.

A Cochrane review found very low certainty evidence that typical antipsychotics such as haloperidol improve agitation, but reported that they may improve psychosis slightly in people with Alzheimer disease and vascular dementia. Atypical antipsychotics probably reduce agitation. Both types increase the risk of somnolence and extrapyramidal symptoms.[175]
A network meta-analysis found that people who take atypical antipsychotics for behavioral and psychological symptoms of dementia may have a small improvement in behavioral and psychological symptoms but have increased safety risks including for cerebrovascular adverse events, compared with those taking placebo.[176]
Contrary to popular belief, long-term antipsychotic use can be safely withdrawn in most people with dementia once behavior has settled.[177]

Consider a psychiatric consult if your patient develops severe psychosis or agitation that is not responding to multicomponent interventions and antipsychotic medications (based on expert opinion).

– establish goals of care, taking into account any advance directives

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assess your patient’s level of frailty

Treatment recommended for ALL patients in selected patient group

Assess your patient's level of frailty to:[178][179]

Establish whether management plans are consistent with goals of care, and
Identify whether further assessment and enhanced care is needed.

Practical tip

Frailty is a distinctive clinical state, characterized by reduced homeostatic reserves, and increased vulnerability for negative health-related outcomes when exposed to endogenous and/or exogenous stressors.[180][181] This is distinct from the term "failure to thrive" (FTT), which is a commonly used, less specific term representing a worsening of frailty symptoms, with further decline in cognitive and physical functioning, predisposing to full dependence and high mortality.[182][183]

Ask your patient (with input from caregivers if relevant) about their functional capability 2 weeks BEFORE this acute episode to determine baseline state.[184]
Use the Clinical Frailty Scale (CFS) if your patient is ≥65 years old.[185][186] Dalhousie University: Clinical Frailty Scale Opens in new window
- This tool is a practical aid to identify frailty, but should not be relied on in isolation.
- Do not use the CFS to assess younger patients, or those with disabilities that reflect single-system problems (e.g., spinal cord injury).[184]
- If your patient scores 5 or higher, consider arranging a comprehensive geriatric assessment, if this is feasible and clinically appropriate, at the earliest opportunity.[181]
- A higher prehospital frailty score is associated with an increased risk of adverse outcomes including risk of mortality in-hospital, at 1, 3, 6, and 12 months; all-cause readmission within 30 days; extended length of stay; discharge to a nursing home, residential care, hospital, or a high level of care; and functional decline.[187]
Look for nonspecific complaints, such as delirium and falls.
Help to implement multidisciplinary care and to tailor the management approach according to the patient's values and goals of care.[188]

Practical tip

When reviewing a medically complex older adult with frailty, consider the "Geriatric 5Ms" (Mind, Mobility, Medications, Multicomplexity, and Matters Most), and ask yourself whether your patient would benefit from collaborative care with a geriatric specialist, if available, including a comprehensive geriatric assessment.[189][153][190][191] Canadian Geriatrics Society: Public launch of the geriatric 5Ms Opens in new window

A comprehensive geriatric assessment is a multidimensional, multidisciplinary process that identifies a patient's medical, social, and functional needs, and allows the development of a coordinated treatment plan to meet those needs.[192]

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establish goals of care, taking into account any advance directives

Treatment recommended for ALL patients in selected patient group

Ask your patient if they have an advance directive (e.g., a living will, a healthcare proxy) and/or a Do Not Resuscitate (DNR) or Do Not Intubate (DNI) order.[193]

In consultation with your patient (and/or their family or caregivers if applicable), establish goals of care for their acute medical concern, as well as life-sustaining treatment options and code status as early as possible (based on expert opinion).

This applies to all patients, but may be particularly relevant to patients living with frailty and/or with certain comorbidities, such as dementia, stroke, heart failure, COPD, and late-stage CKD (based on expert opinion).
Ensure any existing advance directives align with your patient's current preferences and goals of care.[193]

Practical tip

"Goals of care" are the overarching aims of medical care for a patient, taking into account the clinical context and the patient's values and priorities. Discussions about goals of care can be used to guide decisions on the use and limitations of specific treatments.[194]

Discuss specific treatment options and health trajectory to help your patient (or surrogate decision-maker) make informed decisions about their care.[193][195][196]

This should include (based on expert opinion):
- Code status (e.g., Do Not Resuscitate [DNR] order, Do Not Intubate [DNI] order)
- Other life-sustaining treatment options (e.g., vasopressors, extracorporeal membrane oxygenation [ECMO], kidney replacement therapy, blood transfusions, parenteral/enteral nutrition).

Promote patient autonomy by establishing your patient's values and priorities, and discussing potential benefits and harms of treatments. This helps to align care decisions and avoid unwanted interventions.[196]

In some situations, a patient with dementia, other significant comorbidities, or learning disabilities (particularly if they are acutely ill) may lack the decision-making capacity to make certain care decisions.

Assess and document decision-making capacity (the ability to make a specific decision at the time that the decision needs to be made).[197][198][199]
- Attempt to improve your patient’s capacity to participate in decision-making by addressing communication barriers and alleviating exacerbating factors, such as delirium.[200]
- Be aware that an individual’s decision-making capacity can vary over time so should be reassessed periodically.[200]
If your patient lacks decision-making capacity, establish whether they have an advance directive.[195][198][199]
- This may include a living will and/or a designated proxy known as a Durable Power of Attorney for Healthcare (DPAHC). [198]
If your patient who lacks decision-making capacity has no applicable advance directive, including no designated proxy, identify a surrogate decision-maker from a priority list of individuals such as spouse, adult child, and adult sibling.[198][199]
- The hierarchy of this list, and the scope of surrogates' decision-making, varies from state to state.
- Ensure a surrogate's decisions are consistent with patient preferences and best interests.
- In the case of conflict, consider consulting your hospital's ethics committees.
If your patient is an older adult and is unrepresented (a patient without decision-making capacity for a particular medical intervention who lacks both a relevant advance directive and a surrogate decision-maker), the American Geriatrics Society recommends:[200]
- Attempting to identify a nontraditional surrogate (e.g., a close friend, live-in companion, neighbor, or other individual who knows the patient well), in the absence of a traditional surrogate (next of kin), who is willing and able to represent your patient’s wishes and values
- Avoiding unilateral decision-making in the absence of a suitable surrogate, which could carry a risk of bias. The AGS favors a structured multidisciplinary consensus approach to decision-making.

Check your relevant state law and practice accordingly. There may be no available out-of-court process to allow nontraditional surrogates in many states.
If your unrepresented patient is in an urgent or life-threatening situation:[198][199]
- Use all available information on a patient's preferences, values, and beliefs to guide treatment decisions. If preferences are not known, urgent care decisions should be made in the patient's best interests.[195][198][201]
- Consider using the Four Box Model (also known as the Four Quadrant Model) to aid ethical decision-making. This consists of four principles:[200][202]
  - Medical indications for treatment
  - Patient preferences for care
  - Quality of life
  - Contextual features (this includes being mindful of provider biases, the patient’s psychosocial context, and how the treatment and cost of care may impact the patient).
In a less urgent situation, rarely, a court-appointed guardian may be appointed to make decisions in this context.[195][198][200]

– monitor and manage blood glucose during the hospital admission

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monitor and manage blood glucose during the hospital admission

Treatment recommended for ALL patients in selected patient group

Monitor blood glucose levels at least four times a day (every 4-6 hours if your patient is not eating, and before meals if your patient is eating) in any acutely ill patient with diabetes mellitus.[124]

The risk of hypo- and hyperglycemia increases when a person with diabetes is admitted to the hospital acutely (based on expert opinion).
More frequent monitoring is needed after any episode of hyperglycemia or hypoglycemia and after any change in hypoglycemic medication (based on expert opinion). If a correction dose of insulin is given at bedtime, check blood glucose about 4 to 6 hours later (usually about 2 a.m.) (based on expert opinion).
If your patient is having surgery, the American Diabetes Association (ADA) recommends monitoring blood glucose at least every 2 to 4 hours while the individual is taking nothing by mouth (npo).[124]
Any patient on an intravenous insulin infusion needs more frequent blood glucose measurements, ranging from every 30 minutes to every 2 hours.[124]

Practical tip

Be aware that the accuracy of point-of-care glucose meter results can be affected by factors such as hypotension, shock, edema, anemia/erythrocytosis, and several medications including vasopressors.[124][125] If your patient’s clinical status does not correlate with their glucose result, confirm the glucose level by ordering a clinical laboratory test.[124]

Decide on target blood glucose levels.

There is a general consensus among different guideline organizations on target blood glucose levels for people with diabetes in the hospital.

For most critically ill patients, the ADA recommends a target range of 140 to 180 mg/dL (7.8 to 10.0 mmol/L) once treatment has been started for persistent hyperglycemia.[124]
- Stricter target ranges, such as 110 to 140 mg/dL (6.1 to 7.8 mmol/L), may be acceptable in select critically ill patients, but only if they can be achieved without significant hypoglycemia.[124]
For most noncritically ill patients, the ADA and the Endocrine Society recommend a target range of 100 to 180 mg/dL (5.6 to 10.0 mmol/L).[124][138]
- Less stringent goals are appropriate in some patients, for instance those at high risk of hypoglycemia, advanced kidney failure, and those who are terminally ill. The ADA recommends that the focus in these people should be on avoiding hypoglycemia and symptomatic hyperglycemia.[124]

Evidence: Blood glucose targets for critically ill patients with hyperglycemia

Evidence argues against very tight glucose control in critically ill patients (a mixed population with and without a history of diabetes).

Intensive care setting:
- A randomized controlled trial (RCT) of critically ill patients in a primarily surgical intensive care setting found lower patient mortality with tight glucose control, 80 to 110 mg/dL (4.4 to 6.1 mmol/L), compared with "conventional" more liberal glucose control.[203]
- However, a subsequent multicenter RCT in critically ill medical and surgical patients in other intensive care settings found increased mortality with tighter glucose control, possibly due to more frequent episodes of hypoglycemia.[204]
- In 2017, two network meta-analyses found no benefit in mortality with tight glycemic control when compared with less tight control (79.2 to <109.8 mg/dL [4.4 to <6.1 mmol/L] vs.140.4 to <219.6 mg/dL [7.8 to <12.2 mmol/L] in one report; <110 to 144 mg/dL [<6.1 to 8.0 mmol/L] vs.144 to >180 mg/dL [8.0 to >10.0 mmol/L] in the second report) but a significant increase in the risk of hypoglycemia.[205][206]

More info: Hyperglycemia during the ongoing hospital admission

Hyperglycemia in admitted patients, whether with known diabetes or not, is associated with adverse patient outcomes, including increased mortality.[142]

Act promptly to treat hyperglycemia to avoid diabetic ketoacidosis (DKA) and hyperosmolar hyperglycemic state (HHS).
For persistent hyperglycemia, defined as blood glucose ≥180 mg/dL (≥10.0 mmol/L) confirmed on two occasions within 24 hours, the ADA recommends:[124]
- Starting or intensifying insulin therapy for most critically ill patients.
- Starting or intensifying insulin and/or other glucose-lowering therapies for most noncritically ill patients.

If your patient has DKA or HHS, consider the appropriate unit for management.

Indications for management in the intensive care unit (ICU) include:[134]
- Severe DKA or severe HHS
- Critical illness as the precipitating cause (e.g., sepsis, acute myocardial infarction, gastrointestinal bleeding)
- Altered mental status
- Another concurrent indication for ICU admission.
See Diabetic ketoacidosis or Hyperosmolar hyperglycemic state.

Patients who are usually managed with sodium-glucose cotransporter-2 (SGLT2) inhibitors before unplanned hospitalization should have beta-hydroxybutyrate or blood ketone measurements to exclude euglycemic ketoacidosis (based on expert opinion).

Be aware that the following interventions may be associated with hyperglycemia and may need to be reviewed:[207]

Corticosteroids
Some second-generation antipsychotics (e.g., olanzapine, clozapine)
Fluoroquinolone antibiotics (e.g., ciprofloxacin)
Calcineurin inhibitors (e.g., tacrolimus)
Protease inhibitors (e.g., ritonavir)
Artificial nutrition (parenteral or enteral).

Ask for a specialized inpatient diabetes team consult, if available, or endocrinology consult where hyperglycemia is difficult to control.

More info: Hypoglycemia during the ongoing hospital admission

Monitor blood glucose and adjust medication in response to illness and hospital meal times, to reduce the risk of hypoglycemic episodes.

Ensure that a hypoglycemia management surveillance protocol is in place, with an individualized plan for preventing, identifying, and treating hypoglycemia.[124]
- Immediately correct level 2 hypoglycemia (blood glucose levels <54 mg/dL [<3.0 mmol/L]) and level 3 hypoglycemia (characterized by altered mental and/or physical functioning, requiring assistance for treatment of hypoglycemia from another person for recovery, with no defined glucose level).
- Promptly treat level 1 hypoglycemia (blood glucose levels <70 mg/dL [<3.9 mmol/L] and ≥54 mg/dL [≥3.0 mmol/L]) to prevent progression to more significant levels of hypoglycemia.
- Ensure hypoglycemia treatment is included in all insulin orders.
Treat hypoglycemia, which usually involves provision of 15 g of fast-acting carbohydrates (oral or enteric juice or table sugar; intravenous dextrose). Check blood glucose 15 minutes after the treatment. If the blood glucose is not in a safe range (usually considered to be >90 mg/dL [>5.0 mmol/L]), repeat the treatment. If the oral and enteric route is not available, administer intravenous dextrose. If the patient has no intravenous access, administer glucagon (based on expert opinion). See Diabetic hypoglycemia.
Be aware that hypoglycemia may be induced by treatment of hyperglycemia/diabetes.[208]
- Sliding scale insulin (correctional or supplemental insulin without basal insulin) is associated with the highest rates of hypoglycemia (based on expert opinion). Sole use of sliding scale insulin is not recommended for most individuals in a hospital inpatient setting.[124]
- Be aware of the risk of hypoglycemia in patients on intensive insulin regimens (e.g., multiple daily injections, continuous subcutaneous insulin infusion, or automated insulin delivery systems), and those on basal insulin, sulfonylureas, or meglitinides.
- A combination of insulin and sulfonylureas further increases hypoglycemia risk.
Review and adapt your patient’s treatment plan to prevent recurrent episodes of hypoglycemia.[124]
- Be aware that level 1 hypoglycemia often predicts subsequent level 3 hypoglycemia.
Document any episodes of hypoglycemia in the electronic health record.[124]

Causes of hypoglycemia include:[124]

Inappropriate insulin dose or dose adjustment
Insulin or oral hypoglycemic medication error
Wrong timing of insulin in relation to meals
Inadequate follow-up of first episode of hypoglycemia
Patients eating less but taking the same amount of diabetes medication
Reduced appetite or vomiting
Unexpected interruption of enteral or parenteral feedings
Reduced infusion rate of intravenous dextrose
Delayed or missed blood glucose checks
Sudden reduction of corticosteroid dose
Altered ability of a patient to report symptoms
Recovery from an acute illness.

Review your patient’s medication list thoroughly. Some nondiabetic medications used to treat acute or chronic conditions may cause or contribute to hypoglycemia.[209] This is especially the case in the presence of advanced kidney or liver diseases (based on expert opinion).

These medications include:
- Some antibiotics (e.g., fluoroquinolones, trimethoprim/sulfamethoxazole, chloramphenicol)[209][210]
- Other nondiabetic medications (e.g., ACE inhibitors, beta-blockers, chloroquine, disopyramide, pentamidine, salicylates)[209]
Polypharmacy of multiple hypoglycemia-causing medications also increases this risk.[208]
This list is not exhaustive. Consult your local drug information source (based on expert opinion).

Take action if blood glucose falls below 100 mg/dL (<5.6 mmol/L) (based on expert opinion). Fasting blood glucose levels <100 mg/dL (<5.6 mmol/L) are predictive of next-day hypoglycemia.[124]

Give extra carbohydrates to prevent hypoglycemia unless your patient is going to eat a meal within an hour (based on expert opinion).
Modify insulin doses to prevent glucose from going below the target for the patient.

Take steps to reduce the risk of hypoglycemia at night. Assuming your patient is not npo (nothing by mouth), they are likely to have a smaller evening meal in the hospital than at home.

In the absence of significant hyperglycemia, consider reducing the evening basal insulin by 20% on admission (based on expert opinion).
Remember that for many patients with very high insulin needs at home, the needs are often much lower in the hospital, presumably because of changes in diet.
Review the dose used during recent prior hospitalization(s) when deciding the starting dose of insulin (based on expert opinion).

More info: Self-management of diabetes in the hospital

Support your patient in self-management of their diabetes (including monitoring blood glucose and insulin dose adjustment and administration in those treated with insulin) during a hospital admission if it is safe, the patient is willing, and it conforms to hospital policies and national guidelines.[124]

The ADA recommends that suitable candidates for self-managing their diabetes in the hospital include those who:[124]

Normally perform self-management at home
Have the necessary cognitive and physical skills while in the hospital
Have adequate oral intake
Are proficient in carbohydrate estimation
Take multiple daily insulin injections or use insulin pumps
Have stable insulin requirements, and
Understand sick-day management.

The patient and hospital care team should review the decision on self-management on a daily basis.[124]

Inspect injection sites if your patient is on insulin injections at home (based on expert opinion).

Check for insulin lipodystrophy and re-educate on injection technique, if needed.

Continuous glucose monitoring

Consider continuing personal continuous glucose monitoring (CGM) for any individual who uses this wearable technology at home.[211] Consult with the inpatient diabetes team if available.[140]

Although not approved by the Food and Drug Administration (FDA), emergency use authorization was granted during the coronavirus disease 2019 (COVID-19) pandemic and several professional bodies suggest this may be useful if complying with institutional policies and safety regulations.[124][211][132][140]
Confirmatory point-of-care glucose measurements are still needed for assessment of hypoglycemia and to guide decisions on insulin dosing.[124]
Be aware that some concomitant medications, such as acetaminophen (above a certain dose), dopamine, heparin, vitamin C, and hydroxyurea, may result in inaccurate measurements by CGM devices.[211]

More info: Management of patients with diabetes who are receiving end-of-life care

If a patient with diabetes is receiving end-of-life care:

Discuss with your patient and their family/caregivers and agree on the level of intensity of care. Less stringent targets for blood glucose levels are appropriate, with the aim of avoiding hypoglycemia and symptomatic hyperglycemia.[124][132][212]
Prioritize providing comfort and reducing the burdens of strict blood glucose management.[212]
Be aware that stopping basal insulin in a person with type 1 diabetes can lead to dehydration, ketoacidosis, nausea, and associated vomiting; therefore, continuing basal insulin in such a person could be considered as a comfort care (based on expert opinion).

– ensure monitoring is in place to detect any asthma exacerbation during your patient's hospital admission

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examine your patient’s feet

Treatment recommended for ALL patients in selected patient group

Examine the feet of any adult with diabetes on their admission to the hospital and whenever they become ill.[213]

This is to detect new ulcerations or infection, which may be unnoticed by the patient and may even be the cause of their acute illness (e.g., patient presenting with sepsis, or endocarditis where the original focus of infection is the foot lesion).

Inspect the foot for lesions and examine for loss of protective sensation.

To perform a comprehensive foot examination:[214]

Inspect the skin.
Assess any foot deformities.
Do a neurologic exam, including 10-g monofilament testing or Ipswich touch test, with at least one other assessment (pinprick, temperature, or vibration).[215]
Do a vascular exam, including pulses in the legs and feet.

If your patient has reduced sensation, they are at risk for diabetic foot ulceration.[214] Provide pressure relieving devices.

Order daily heel checks for signs of pressure trauma. There is a debate about whether compression stockings should or should not be used in people with diabetes; do not use them if there is known peripheral vascular disease.

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ensure monitoring is in place to detect any asthma exacerbation during your patient's hospital admission

Treatment recommended for ALL patients in selected patient group

Acute worsening of respiratory symptoms may suggest a patient with comorbid asthma is having an acute exacerbation of their asthma.

Follow guideline recommendations on assessing severity and managing an acute exacerbation of asthma in adults.[97]
See Acute asthma exacerbation in adults.

Temporarily stop any long-acting muscarinic antagonist (LAMA) the patient may be on for maintenance therapy (e.g., tiotropium, aclidinium, glycopyrrolate, umeclidinium) if you prescribe a nebulized short-acting muscarinic antagonist (e.g., ipratropium) (based on expert opinion).

This is due to concern over possible additive anticholinergic adverse effects.
Ensure to represcribe the LAMA once the nebulizer treatment has been stopped.

Be aware that the long-term use of beta-2 agonists to manage asthma may increase the risk of cardiovascular events.

Evidence: Cardiovascular harm with beta-2 agonists

Beta-2 agonists may increase the risk of myocardial infarction and other adverse cardiovascular events.

Beta-2 agonists increase heart rate and reduce potassium levels.[216] They are absorbed into the systemic circulation and there is evidence that long-term regular use may be associated with an increased risk of myocardial infarction, unstable angina, congestive heart failure, and arrhythmias.[217][216]
However, it is not routine practice to discontinue beta-2 agonists if they are needed for comorbid asthma.

– ensure monitoring is in place to detect any COPD exacerbation during your patient's hospital admission

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ensure monitoring is in place to detect any COPD exacerbation during your patient's hospital admission

Treatment recommended for ALL patients in selected patient group

Acute worsening of respiratory symptoms may suggest a patient with comorbid COPD is having an acute exacerbation.[102]

Differentiate from other conditions, such as a pulmonary embolism, acute heart failure, and pneumonia.
Follow guideline recommendations.[102] See Acute exacerbation of COPD.

This is due to concern over possible additive anticholinergic adverse effects.
Ensure the LAMA is represcribed once the nebulizer treatment has been stopped.

Be aware that the long-term use of beta-2 agonists to manage COPD may increase the risk of cardiovascular events.

Evidence: Cardiovascular harm with beta-2 agonists

Beta-2 agonists may increase the risk of myocardial infarction and other adverse cardiovascular events.

Beta-2 agonists increase heart rate and reduce potassium levels.[216] They are absorbed into the systemic circulation and there is evidence that long-term regular use may be associated with an increased risk of myocardial infarction, unstable angina, congestive heart failure, and arrhythmias.[216][217]
However, the Global Initiative for Chronic Obstructive Lung Disease states that there has been no reported association between beta-2-agonist use and increased mortality in people with COPD.[102] It is not routine practice to discontinue beta-2 agonists if they are needed for comorbid COPD.

– continue your patient's inhalers as prescribed for asthma or COPD

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mental status exam

Treatment recommended for ALL patients in selected patient group

Perform a mental status exam as the clinical situation allows (based on expert opinion).

The mental status exam is one of the main clinical tools routinely used in psychiatric practice, aiding diagnosis and guiding further management. Mood is one of the assessed domains.

Consider assessing current symptoms of depression using the PHQ-9 questionnaire.[218][219]

The PHQ-9 questionnaire can be used as a reliable and valid measure of depression severity in patients with a known diagnosis of depression, as well as a screening tool.
This can be self-administered or administered by the clinician, and takes less than 3 minutes to complete.
Results indicate severity of depressive symptoms.

Take into account other factors that may be influencing the patient's mental status (e.g., the effect of any illicit drug use or alcohol).[219][220]

In particular, consider whether symptoms of depression could be part of the acute medical illness (based on expert opinion).

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review current treatment for depression

Treatment recommended for ALL patients in selected patient group

Review the drugs used to manage your patient’s mental health, ensuring you have an up-to-date list. Consider that antidepressants may be used in the treatment of conditions other than depression, and drugs other than antidepressants may be used to treat depression. The information here refers to antidepressants.

Continue the patient’s usual antidepressant, unless there are good reasons not to (based on expert opinion).

If antidepressants are stopped abruptly, the patient may develop antidepressant discontinuation syndrome.[221]
The severity of the symptoms of discontinuation may vary, but they may be unpleasant and may complicate the management of the acute medical condition.

When reviewing current medications, consider:

Current and previous adverse effects
Recent changes in dose
Recent medication changes from a different drug class
The specific diagnostic subtypes of depression when prescribing medications (e.g., it is likely that patients suffering from psychotic depression would be coprescribed an antipsychotic)
Augmenting strategies that may be used when treating resistant depression (e.g., lithium or quetiapine augmentation of a selective serotonin-reuptake inhibitor [SSRI]).

Consider drug-drug interactions.

Antidepressants (particularly those that inhibit the CYP450 pathway) may cause significant interactions with drugs used for other conditions.[222]

Consider psychiatric complications when prescribing nonpsychotropic drugs.

Take particular care when prescribing anticonvulsants, antiparkinsonian drugs, and corticosteroids.

Consider adverse effects, which may include the following:

Hyponatremia, caused by antidepressants, especially SSRIs, and compounded by other coprescribed drugs (e.g., diuretics).[223][224][225][226] Review your patient’s serum electrolyte results and consider antidepressants as a potential contributing factor if they have hyponatremia.
Serotonin syndrome (altered mental state, agitation, tremor, hyper-reflexia, ocular clonus or inducible clonus, muscle rigidity, diaphoresis, tachycardia, increased bowel sounds, temperature >100.4°F [>38°C]), especially with polypharmacy and/or overdose of a serotonergic agent.[227][228] See Serotonin syndrome.
- Be particularly aware of increased risk of serotonin syndrome in patients with kidney failure on SSRIs.[229][230]
Hepatotoxicity.[231] Adjust doses of antidepressants in patients with hepatic impairment as necessary.
- However, antidepressants are rarely the cause of hepatic impairment.[231]
Prolonged QTc, arrhythmias, increased heart rate, postural hypotension with tricyclic antidepressants.[232][233] Obtain an ECG, especially in people at risk of arrhythmias.[234]
Gastrointestinal bleeding. SSRIs are associated with an increased risk of gastrointestinal bleeding.[223][235][236] Risk is particularly increased when coprescribed with aspirin, nonsteroidal anti-inflammatory drugs (NSAIDs), or oral anticoagulants.[236][237][238] Monitor closely and consider gastroprotection with proton-pump inhibitors if SSRI use cannot be avoided (based on expert opinion).

This list of adverse effects is not exhaustive - consult your drug information sources or hospital pharmacist for further information, and consider a psychiatric consult for advice.

Practical tip

Be aware that tobacco smoking cessation or switching from tobacco smoking to alternatives (including nicotine replacement therapy) may result in a change in the plasma concentration of any psychotropic the patient may be taking (e.g., for depression). This is because nicotine replacement therapy does not impact hepatic enzyme activity like tobacco smoking.[239][240][241] Consider whether any dose adjustment of the psychotropic is required, and consult the hospital pharmacist if needed.

Ask your patient about nonpharmacologic treatments for their depression and check the current level of community support.

This may include other outpatient healthcare professionals, charities, and family and social networks.

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consider psychiatric consult

Treatment recommended for ALL patients in selected patient group

Consider a psychiatric consult for any patient with comorbid depression who is admitted to the hospital with an acute condition.

Consult is strongly advised in patients with severe symptoms of depression or additional symptoms such as self harm, suicidal ideation, homicidal ideation, catatonia, psychosis (based on expert opinion).
Consult may not be required if there are no concerns that depression and/or its management (e.g., medication) may be affecting the acute condition (based on expert opinion).
Accidents of unclear circumstances, self-injurious behaviors, and/or suicide attempts (including alleged "accidental" overdose of medication) should trigger clinical suspicion of comorbid mental health disorder (based on expert opinion).

Ensure your patient has adequate support with their treatment post-discharge.

Keep in mind that the psychological impact of comorbid depression may be associated with poor adherence with recommended physical health treatments, from medication to rehabilitation.[242][243][244] This may lead to worse clinical outcomes, including higher readmission risk.[245][246]
Most importantly, affective symptoms, including depression, have been linked with excess mortality, though a causal link remains to be proven.[247][248]

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manage tobacco dependence

Treatment recommended for ALL patients in selected patient group

If your patient currently uses tobacco, assess their tobacco use and provide assistance and support with tobacco cessation interventions.[249][250][251]

Offer nicotine replacement therapy (NRT) and/or other tobacco cessation pharmacotherapies for all patients with tobacco dependence if there are no contraindications.[249][250][251][252] For admitted patients, NRT should be offered on admission. This is particularly important as they may be unable to use tobacco due to both their acute illness and admission to the hospital.

Advise:

That nicotine is highly addictive and nicotine withdrawal can be extremely distressing and uncomfortable.[250]
NRT prevents rapid withdrawal.[250]
That there are a number of highly effective treatment options that offer the best chance of stopping smoking.[249][250][251]

NRT should combine long-acting formulations (e.g., transdermal patches) together with short-acting formulations (e.g., chewing gum, lozenges, nasal spray) as combination NRT is more effective than a single NRT.[249][253][254]

Ensure a sufficient dose of NRT is prescribed to adequately address withdrawal symptoms.[255]
Ask the patient how many cigarettes they smoke per day; this may determine the starting dose of NRT.
Ask about the type of tobacco product used, including e-cigarettes, water pipe use, and other smokeless tobacco products (snuff, ground, or chewing tobacco), as use of these products also results in nicotine addiction.
Check drug information sources for any contraindications or cautions, particularly if your patient has one or more comorbidity and/or is hemodynamically unstable.
Assess for symptoms of withdrawal daily (based on expert opinion).

For any patient who has an intention to quit using tobacco, consider using varenicline and NRT together as this is a highly effective combination for tobacco cessation in adults.[256] Combination therapy for tobacco dependence is more effective than use of a single agent.[254]

One Cochrane Review found high-certainty evidence that varenicline is an effective treatment for tobacco dependence.[257] The same review found that people taking varenicline likely have an increased chance of a more serious adverse effect (e.g., cardiac) that could result in hospital admission; however, these are still rare (2.7% to 4% of people on varenicline, compared with 2.7% of people not taking varenicline) and may include events that are unrelated to varenicline.[257] Check drug information sources for a full list of contraindications and cautions or seek pharmacist advice.
Mental health illness is NOT a contraindication to prescribing varenicline. However, varenicline should be used with caution in people with a pre-existing psychiatric illness as it may worsen symptoms.
Bupropion is an alternative option to varenicline for tobacco cessation but is less likely to result in successful quitting.[257] Consider the potential for drug-drug interactions.

Start tobacco cessation counseling while the patient is in hospital and continue this, along with pharmacotherapy and behavioral support, after discharge.[252] Quit rates for hospitalized patients are highest when smoking cessation counseling begins in hospital and continues for more than a month after discharge.[252]

Ensure your patient has follow-up with their primary care practitioner or addiction medicine physician to continue treatment for tobacco dependence.

Practical tip

Note that COPD is commonly underdiagnosed in patients with tobacco dependence.[258] If you have concern that your patient may have undiagnosed COPD, ensure discharge instructions include testing to complete evaluation for COPD (based on expert opinion).

See Smoking cessation for more information.

≥50 years of age or immunocompromised

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empiric antibiotic therapy

Presumptive treatment for bacterial meningitis should be active against meningococci and other causes of serious bacterial infection, including Listeria.[54] Antibiotic therapy should be administered as soon as feasible.

The recommended regimen is ampicillin plus ceftriaxone or cefotaxime plus vancomycin.[54][67] If ampicillin cannot be administered (e.g., patients with an allergy), trimethoprim/sulfamethoxazole could be considered as an alternative for some patient groups to ensure cover for Listeria monocytogenes in place of ampicillin.[67][81] Specialist advice should be sought for immunocompromised newborns.

Consider whether your adult patient with diabetes or chronic kidney disease also requires cover for Listeria

Diabetes is considered to be a risk factor for Listeria and empiric antibiotic cover for this bacteria is recommended.[92][93][94][95][96]
Some guidelines also list CKD as a risk factor for Listeria.[93][94]
- The stage of CKD may affect the need for Listeria cover so consult your patient’s nephrologist or an infectious disease specialist (based on expert opinion).

Primary options

ampicillin: neonates: consult specialist for guidance on dose; children: 200-400 mg/kg/day intravenously given in divided doses every 4-6 hours, maximum 12 g/day; adults: 1-2 g intravenously every 3-4 hours

ampicillin : neonates: consult specialist for guidance on dose; children: 200-400 mg/kg/day intravenously given in divided doses every 4-6 hours, maximum 12 g/day; adults: 1-2 g intravenously every 3-4 hours

-- AND --

vancomycin: neonates: consult specialist for guidance on dose; children: 15 mg/kg intravenously every 6 hours; adults: 15-20 mg/kg intravenously every 8-12 hours

vancomycin : neonates: consult specialist for guidance on dose; children: 15 mg/kg intravenously every 6 hours; adults: 15-20 mg/kg intravenously every 8-12 hours

vancomycin: neonates: consult specialist for guidance on dose; children: 15 mg/kg intravenously every 6 hours; adults: 15-20 mg/kg intravenously every 8-12 hours

-- AND --

ceftriaxone: neonates: consult specialist for guidance on dose; children: 80-100 mg/kg/day intravenously given in divided doses every 12-24 hours, maximum 4 g/day; adults: 2 g intravenously every 12 hours

ceftriaxone : neonates: consult specialist for guidance on dose; children: 80-100 mg/kg/day intravenously given in divided doses every 12-24 hours, maximum 4 g/day; adults: 2 g intravenously every 12 hours

cefotaxime: neonates: consult specialist for guidance on dose; children: 200-300 mg/kg/day intravenously given in divided doses every 6-8 hours, maximum 12 g/day; adults: 2 g intravenously every 4-6 hours

cefotaxime : neonates: consult specialist for guidance on dose; children: 200-300 mg/kg/day intravenously given in divided doses every 6-8 hours, maximum 12 g/day; adults: 2 g intravenously every 4-6 hours

Secondary options

sulfamethoxazole/trimethoprim: children ≥2 months of age and adults: 10-20 mg/kg/day intravenously given in divided doses every 6-12 hours

sulfamethoxazole/trimethoprim : children ≥2 months of age and adults: 10-20 mg/kg/day intravenously given in divided doses every 6-12 hours

sulfamethoxazole/trimethoprim: children ≥2 months of age and adults: 10-20 mg/kg/day intravenously given in divided doses every 6-12 hours

-- AND --

vancomycin: neonates: consult specialist for guidance on dose; children: 15 mg/kg intravenously every 6 hours; adults:15-20 mg/kg intravenously every 8-12 hours

vancomycin : neonates: consult specialist for guidance on dose; children: 15 mg/kg intravenously every 6 hours; adults:15-20 mg/kg intravenously every 8-12 hours

vancomycin: neonates: consult specialist for guidance on dose; children: 15 mg/kg intravenously every 6 hours; adults:15-20 mg/kg intravenously every 8-12 hours

-- AND --

ceftriaxone : neonates: consult specialist for guidance on dose; children: 80-100 mg/kg/day intravenously given in divided doses every 12-24 hours, maximum 4 g/day; adults: 2 g intravenously every 12 hours

cefotaxime : neonates: consult specialist for guidance on dose; children: 200-300 mg/kg/day intravenously given in divided doses every 6-8 hours, maximum 12 g/day; adults: 2 g intravenously every 4-6 hours

These drug options and doses relate to a patient with no comorbidities.

Primary options

ampicillin : neonates: consult specialist for guidance on dose; children: 200-400 mg/kg/day intravenously given in divided doses every 4-6 hours, maximum 12 g/day; adults: 1-2 g intravenously every 3-4 hours

-- AND --

vancomycin: neonates: consult specialist for guidance on dose; children: 15 mg/kg intravenously every 6 hours; adults: 15-20 mg/kg intravenously every 8-12 hours

vancomycin : neonates: consult specialist for guidance on dose; children: 15 mg/kg intravenously every 6 hours; adults: 15-20 mg/kg intravenously every 8-12 hours

vancomycin: neonates: consult specialist for guidance on dose; children: 15 mg/kg intravenously every 6 hours; adults: 15-20 mg/kg intravenously every 8-12 hours

-- AND --

ceftriaxone : neonates: consult specialist for guidance on dose; children: 80-100 mg/kg/day intravenously given in divided doses every 12-24 hours, maximum 4 g/day; adults: 2 g intravenously every 12 hours

cefotaxime : neonates: consult specialist for guidance on dose; children: 200-300 mg/kg/day intravenously given in divided doses every 6-8 hours, maximum 12 g/day; adults: 2 g intravenously every 4-6 hours

Secondary options

sulfamethoxazole/trimethoprim: children ≥2 months of age and adults: 10-20 mg/kg/day intravenously given in divided doses every 6-12 hours

sulfamethoxazole/trimethoprim : children ≥2 months of age and adults: 10-20 mg/kg/day intravenously given in divided doses every 6-12 hours

sulfamethoxazole/trimethoprim: children ≥2 months of age and adults: 10-20 mg/kg/day intravenously given in divided doses every 6-12 hours

-- AND --

vancomycin: neonates: consult specialist for guidance on dose; children: 15 mg/kg intravenously every 6 hours; adults:15-20 mg/kg intravenously every 8-12 hours

vancomycin : neonates: consult specialist for guidance on dose; children: 15 mg/kg intravenously every 6 hours; adults:15-20 mg/kg intravenously every 8-12 hours

vancomycin: neonates: consult specialist for guidance on dose; children: 15 mg/kg intravenously every 6 hours; adults:15-20 mg/kg intravenously every 8-12 hours

-- AND --

ceftriaxone : neonates: consult specialist for guidance on dose; children: 80-100 mg/kg/day intravenously given in divided doses every 12-24 hours, maximum 4 g/day; adults: 2 g intravenously every 12 hours

cefotaxime : neonates: consult specialist for guidance on dose; children: 200-300 mg/kg/day intravenously given in divided doses every 6-8 hours, maximum 12 g/day; adults: 2 g intravenously every 4-6 hours

Show drug information for a patient with no comorbidities

Drug choice, dose and interactions may be affected by the patient's comorbidities. Check your local drug formulary.

Primary options

ampicillin

For patients with CKD, please check your local drug formulary

For patients with CKD see dose in the Renal Drug HandbookFor patients with CKD see dose in the Renal Drug Handbook

-- AND --

vancomycin

For patients with CKD, please check your local drug formulary

For patients with CKD see dose in the Renal Drug HandbookFor patients with CKD see dose in the Renal Drug Handbook

-- AND --

ceftriaxone

For patients with CKD, please check your local drug formulary

For patients with CKD see dose in the Renal Drug HandbookFor patients with CKD see dose in the Renal Drug Handbook

cefotaxime

For patients with CKD, please check your local drug formulary

For patients with CKD see dose in the Renal Drug HandbookFor patients with CKD see dose in the Renal Drug Handbook

Secondary options

sulfamethoxazole/trimethoprim

For patients with CKD, please check your local drug formulary

For patients with CKD see dose in the Renal Drug HandbookFor patients with CKD see dose in the Renal Drug Handbook

-- AND --

vancomycin

For patients with CKD, please check your local drug formulary

For patients with CKD see dose in the Renal Drug HandbookFor patients with CKD see dose in the Renal Drug Handbook

-- AND --

ceftriaxone

For patients with CKD, please check your local drug formulary

For patients with CKD see dose in the Renal Drug HandbookFor patients with CKD see dose in the Renal Drug Handbook

cefotaxime

For patients with CKD, please check your local drug formulary

For patients with CKD see dose in the Renal Drug HandbookFor patients with CKD see dose in the Renal Drug Handbook

Plus – check baseline kidney function and monitor closely

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Plus –

supportive care

Treatment recommended for ALL patients in selected patient group

Patients with meningococcal infections must be monitored closely for complications such as shock, elevated intracranial pressure, seizures, and coagulopathy.

Severe meningococcal infections are frequently complicated by hypoglycemia or hyperglycemia, acidosis, and other biochemical abnormalities that require attention.

Oxygen therapy in your patient with asthma

Measure resting oxygen saturation in all acutely ill patients.

Be aware that pulse oximetry may overestimate oxygen saturation in patients with darker skin tones.[97]
If your patient's asthma is stable, follow guideline recommendations for oxygen saturation target for the presenting acute condition.
If the acute presenting condition triggers an acute exacerbation of your patient's asthma, the Global Initiative for Asthma recommends controlled oxygen to maintain saturations between 93% and 95%.[97]
Adjust oxygen saturation targets for altitude, where appropriate.[97]
Hypercapnia in asthma is an indicator of very severe disease showing a patient is tiring and needs ventilatory support.[98][99][100]

Oxygen therapy in your patient with COPD

Obtain a blood gas measurement if your patient with COPD has oxygen saturation <90%, clinical signs of hypercapnia (e.g., altered mental status), or respiratory distress (based on expert opinion).
- An arterial blood gas (ABG) should be used to assess patients with respiratory failure and should always be obtained if hypoxemia is an issue.[103][104]
  - Peripheral venous blood gas (VBG) analysis has increasingly been used to estimate carbon dioxide, pH, and other variables.[105] It is less painful for the patient and may be associated with fewer complications than an ABG.[105]
  - One Cochrane Review found limited data of low to very low certainty evidence that VBG is sensitive for the diagnosis of respiratory failure and isolated hypercarbia.[105] However, it has poor specificity compared with ABG analysis, making it less reliable when precise data are necessary.[105]
Recheck blood gas as clinically indicated.[102]

Chronic hypercapnia[106]
Hypercapnia on presentation
Previous history of hypercapnic respiratory failure[103]
Moderate or severe COPD, particularly if on long-term oxygen therapy[103]
Evidence of chronic hypoventilation for other reasons, e.g., obesity hypoventilation syndrome, taking sedatives or hypnotic drugs.[102][106]

Critically ill and needs high levels of oxygen

This includes patients with comorbid COPD who need high levels of oxygen due to a critical illness such as shock, sepsis, major head injury, status epilepticus, anaphylaxis, or major trauma.

In this scenario, some guidelines recommend an initial target oxygen saturation in line with the recommendation for patients without COPD.[103]

Evidence suggests that targeting an upper oxygen saturation level of 96% may be preferred compared with a higher level.[107][108]
Subsequently, you may need to adjust to controlled oxygen therapy with a target oxygen saturation range of 88% to 92% depending on the blood gas results.[103]

Acutely but not critically ill and at risk of hypercapnic respiratory failure

This includes patients with comorbid COPD who have risk factors for hypercapnic respiratory failure and an acute condition, but are not critically ill.[103]

Give controlled oxygen therapy and use an initial target oxygen saturation of 88% to 92%.[102][103]

Check blood gas and recheck after 30 to 60 minutes.[103]

Not critically ill and NOT at risk of hypercapnic respiratory failure

As an example, a patient may have stable, mild COPD with minimal symptoms.

Use an initial target oxygen saturation as recommended by guidelines for the presenting acute condition.

Evidence suggests that for most acutely ill patients, targeting an upper oxygen saturation level of 96% may be preferred compared with a higher level.[107][108]

Measure blood gas as soon as possible[103]

Subsequently, you may need to adjust to controlled oxygen therapy with a target oxygen saturation range of 88% to 92% depending on the blood gas results.[103]

High-flow nasal cannula (HFNC)

Decreasing the work of breathing[109][110]
A theoretical provision of low-level positive end-expiratory pressure (PEEP)[109][110][111]
Facilitating secretion mobilization.[109][110]

Ventilatory support

Start noninvasive bilevel ventilation (BiPAP) if the patient has at least one of the following:[102]

Respiratory acidosis (PaCO₂ ≥45 mmHg [6 kPa] and arterial pH ≤7.35)
Severe dyspnea and/or increased work of breathing (e.g., use of respiratory muscles, paradoxical movement of the abdomen, retraction of the intercostal spaces)
Persistent hypoxemia despite supplemental oxygen.

Start invasive mechanical ventilation support if this is indicated and the patient is considered suitable. Indications for invasive mechanical ventilation include:[102]

Inability to tolerate, or failure of, noninvasive ventilation (particularly if they have life-threatening hypoxemia)
Status post respiratory or cardiac arrest
Reduced consciousness, or psychomotor agitation that is inadequately controlled by sedation
Massive aspiration or persistent vomiting
Persistent inability to remove respiratory secretions
Severe hemodynamic instability without response to fluids or vasoactive drugs
Severe ventricular or supraventricular arrhythmias.

When considering endotracheal intubation with mechanical ventilation, always take into account the patient's wishes (e.g., advance directives).[102]

Assess fluid status and manage fluid balance particularly closely

In a patient with heart failure and/or chronic kidney disease (CKD), judicial use of fluids is crucial to preventing clinically significant volume overload.

Be aware that hypovolemia may be difficult to assess in a person with heart failure and/or CKD.

As with any patient presenting acutely, look for signs of volume depletion on physical exam, by assessing:[112]

Vital signs:
- Blood pressure, (particularly systolic blood pressure [SBP] and mean arterial pressure)
- Pulse
- Postural hypotension
Peripheral perfusion
Capillary refill time
Jugular venous distension
Passive leg raise.

More info: The RUSH exam

The RUSH exam involves a three-part physiologic assessment using point of care ultrasound (POCUS):[114]

1. The pump, i.e., the cardiac status
- Evaluate cardiac status by looking for: pericardial effusions and cardiac tamponade, left ventricular contractility, and right ventricular size
2. The tank, i.e., the effective intravascular volume status
- Assess the fullness of the tank by examining the inferior vena cava (IVC) and/or internal jugular veins
- Evaluate for "leakiness" of the tank, or free fluid in the abdominal and thoracic cavities, by performing Focused Assessment of Sonography for Trauma (FAST) and thoracic ultrasound to assess for fluid in the abdominal and thoracic cavities[115][116]
- Assess compromise of the tank by assessing for pneumothorax
3. The pipes, i.e., the arterial and venous sides of the circulatory system
- Assess the aorta looking for aortic aneurysm, rupture, dissection
- Assess lower extremity and/or upper extremity veins for deep vein thrombosis.

Other variations of RUSH have been described.[113]

Practical tip

Heart failure

Be aware that an SBP of <90 mmHg may suggest hypotension, but a patient on medication for chronic heart failure can have a baseline SBP of <90 mmHg.

Consider consultation with a cardiologist and/or intensivist.

With a suspected low output or cardiogenic shock state
With massive fluid overload, when high doses of diuretic are needed or with diuretic resistance
When unable to establish volume state
When titrating inotropes.

CKD

A patient with CKD who is hypovolemic needs immediate fluid resuscitation.

Reassess your patient after initial fluid challenge and further address the cause of hypovolemia.
If they do not rapidly stabilize:
- Consider activating the rapid response team and obtaining specialist consultation
- Consider transferring your patient to an intensive care setting where hemodynamic monitoring is possible (based on expert opinion).

Continue to monitor fluid balance particularly closely

Accurate monitoring of volume status is essential in a person with heart failure and/or chronic kidney disease (CKD).[117]

There is a significant risk of pulmonary edema with fluid resuscitation in a patient with heart failure and/or CKD, so monitor closely.
Monitoring should include:
- Regular clinical assessment of volume status (pulse, BP, jugular venous distension [JVD], and check for pulmonary and peripheral edema)
- Fluid balance (input/output chart) and daily weight
- BUN and serum creatinine to monitor kidney function, at least daily.
Consider bladder catheterization if urinary output is difficult to measure, but be aware of increased risk of infection and trauma.
Patients with greater clinical complexity, such as those with heart failure and/or advanced CKD may need admission to the intensive care unit for more invasive monitoring and interventions. If noninvasive bedside assessments are not adequate for monitoring, consider a central venous pressure catheter or pulmonary artery catheter.[117][118][119]

Practical tip

De-escalation

Your patient is euvolemic
The problem requiring fluids has been successfully reversed.

Monitor volume status consistently to try to avoid volume overload.

Immediately stop fluid administration
Consider consultation with specialist
Consider intravenous diuretics, and
Arrange an urgent chest x-ray if pulmonary edema is suspected (based on expert opinion).

Unless there are extenuating circumstances, diuretics and intravenous fluids are not generally given together (based on expert opinion).

Recommendations from an intensive care specialist and/or cardiologist and/or nephrologist may be needed.

Withhold antihypertensives and/or diuretics if hypotensive

Withhold antihypertensives and/or diuretics if your patient:

Is in shock, or
Has a blood pressure ≥40 mmHg lower than their baseline.

Consider withholding antihypertensives and/or diuretics if your patient:

Is hypotensive, or
Has developed orthostatic hypotension or has postural symptoms (based on expert opinion).
- Orthostatic hypotension is defined, by consensus, as a fall in systolic blood pressure ≥20 mmHg and/or a fall in diastolic blood pressure ≥10 mmHg on assuming an upright posture.[120]
- In people with classic orthostatic hypotension, the blood pressure change occurs within 3 minutes of standing.[121] In practice, take standing blood pressure after the person has been standing for at least 1 minute (based on expert opinion).

People with hypertension, coronary artery disease, heart failure, stroke, or chronic kidney disease (CKD) will typically be taking one or more of these types of drug.

Establish your patient's baseline blood pressure and assess volume status.

Patients with treated heart failure may have chronically low blood pressure (e.g., systolic BP ≤90 mmHg). If their systolic blood pressure falls by >10-15 mmHg and is associated with symptoms (such as presyncope or syncope), it may be appropriate to withhold medications that may lower blood pressure but have no or little prognostic benefit for heart failure (such as amlodipine, doxazosin).
- If clinically appropriate, consider changing the time of administration of medication that has a prognostic benefit for heart failure (e.g., sacubitril/valsartan, beta-blockers) to night time, or splitting or reducing the dose (based on expert opinion).
- Consider consultation with a cardiologist and/or intensivist.

If diuretics are withheld in a patient with heart failure and/or CKD, close monitoring is needed as fluid can quickly accumulate.

Be aware that sodium-glucose cotransporter-2 (SGLT2) inhibitors, a class of medication with a prognostic benefit for both heart failure and CKD, also have a weak diuretic effect.[122]

If antihypertensives or diuretics have been withheld during the acute illness, consider restarting them before discharge if clinically appropriate (based on expert opinion).

Restart one at a time at a lower dose and ask the primary care physician (PCP) to titrate back to normal dose.
- Most patients won't tolerate restarting all medications at the original doses simultaneously.
- If it is not clinically appropriate to restart these medicines before discharge, ensure that the patient has follow-up to decide when the medications can be reintroduced.
- Ensure you have communicated clearly to the PCP at discharge.

Meningococcal disease is a notifiable disease in many countries, including the US; cases should be reported immediately to local and national health departments.[19]

Consider – intravenous corticosteroid

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Consider –

intravenous corticosteroid

Treatment recommended for SOME patients in selected patient group

Manage your patient's diabetes when they are taking corticosteroids

If your patient is a child, seek specialist advice. These recommendations only concern the management of adults with diabetes.

Patients with type 1 diabetes may need their insulin regimen intensifying.
Consider commencing insulin therapy in patients with type 2 diabetes who have high blood glucose levels pre-corticosteroid treatment (based on expert opinion).

If your patient is an inpatient, use an appropriate order set for managing hyperglycemia.[124]

If insulin orders are initiated, review and adjust these daily, taking into account levels of glycemia, and anticipated changes in dose, type, and duration of corticosteroid.[124]
- NPH (neutral protamine Hagedorn) insulin is often added to the individual's basal-bolus insulin or oral glucose-lowering medication if an intermediate-acting corticosteroid (e.g., prednisone) is started. The American Diabetes Association (ADA) recommends administering NPH insulin at the same time as the corticosteroid dose, as the action peak of 4 to 6 hours coincides with peak plasma level of the intermediate corticosteroid.
- Long-acting insulin may be needed for an individual starting a long-acting corticosteroid (e.g., dexamethasone), or for those having multiple doses or continuous doses of a corticosteroid.
- Increases in correction insulin and prandial insulin (if eating) may be needed, along with basal insulin, for an individual starting a high dose of a corticosteroid.
- Be aware of the possibility of nocturnal or early morning hypoglycemia. Consider adjusting basal insulin and avoid bed-time correctional doses of rapid-acting insulin (based on expert opinion).
- If a continuous intravenous insulin infusion is being used in a critically ill patient, follow glycemic management using a validated protocol/order set to treat persistent hyperglycemia.[125]
- If your acutely ill patient has type 1 diabetes and their blood glucose stays above 200 mg/dL (11.1 mmol/L) for more than 24 hours, check blood beta-hydroxybutyrate (or blood ketone) levels (based on expert opinion).

If the diabetes medication is not appropriately weaned off, your patient will be at a high risk of developing hypoglycemia. Communicate the strategy for titration with the outpatient team on discharge.
The duration of action for a particular corticosteroid will determine the period of effect on glycemic control.
- Intravenous corticosteroids typically have shorter half-lives, which means glycemic control returns to pre-corticosteroid levels within 24 hours.
- Oral corticosteroids, especially if long acting, (e.g., dexamethasone) may take a few days.

Monitor for psychiatric complications of corticosteroids

If your patient is a child, seek specialist advice. These recommendations only concern the management of adults with depression.

Although all patients should be monitored for these effects, the risk of depression, mania, panic disorder, or suicide during corticosteroid therapy has been reported to be higher in people who are already living with these conditions, but not consistently so.[128]

If the clinical situation allows:

Check previous response to corticosteroids
- Past incidence of psychiatric complications during corticosteroid therapy may increase the risk of recurrence in subsequent treatments.[128]

Monitor for psychiatric adverse effects.

These may vary in severity and include among others:[129]
- Anxiety and insomnia
- Severe mood disorders, including manic states[127]
- Cognitive impairment.
Effects seem to be dose-related and are more common with long-term regimens, long-acting formulations, and in older patients.[128] This also stands true for patients who have neuropsychiatric adverse effects related to discontinuing long-term corticosteroid therapy.[130]
Manic episodes and delirious states are the most common psychiatric adverse effects when starting corticosteroid treatment, whereas depression is most common during chronic therapy.[128][131]
Be aware of a possible withdrawal reaction, which may present with weakness, fatigue, gastrointestinal symptoms, and delirium, as well as with psychiatric complications such as depression, when discontinuing corticosteroids.[130]

If your patient develops psychiatric complications related to corticosteroids, ask for a psychiatric consult for advice on appropriate management (based on expert opinion).

This may include adjusting dose or earlier discontinuation of the corticosteroid if the clinical situation allows.[128]
If the dose of the corticosteroid cannot be adjusted or the corticosteroid cannot be discontinued, pharmacologic treatment of the psychiatric adverse effects may be necessary (based on expert opinion).

Primary options

dexamethasone sodium phosphate: children >6 weeks of age: 0.15 mg/kg intravenously every 6 hours; adults: 10 mg intravenously every 6 hours

dexamethasone sodium phosphate : children >6 weeks of age: 0.15 mg/kg intravenously every 6 hours; adults: 10 mg intravenously every 6 hours

dexamethasone sodium phosphate: children >6 weeks of age: 0.15 mg/kg intravenously every 6 hours; adults: 10 mg intravenously every 6 hours

Plus – review diabetes medication (NEVER stop insulin in a person with type 1 diabetes)

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Plus –

review diabetes medication (NEVER stop insulin in a person with type 1 diabetes)

Treatment recommended for ALL patients in selected patient group

Check your patient's blood glucose on admission. In addition, check HbA1c if no result is available from the previous 3 months.[124][132]

Exclude hypoglycemia, diabetic ketoacidosis (DKA), and hyperosmolar hyperglycemic state (HHS).
Test for blood beta-hydroxybutyrate or ketones if:[133][134]
- Your patient was taking a sodium-glucose cotransporter-2 (SGLT2) inhibitor (e.g., dapagliflozin, canagliflozin, empagliflozin) before unplanned hospitalization, and/or
- There is acidosis, an increased anion gap, nausea/vomiting, or a combination of these.
Admission HbA1c may give you an indication of your patient’s previous diabetes control and may influence your treatment at discharge.

Insulin deficiency (e.g., due to delayed or missed doses) will rapidly cause ketoacidosis (based on expert opinion).

Practical tip

Critical illness

Consider starting a continuous intravenous insulin infusion for your critically ill patient for achieving glycemic goals and avoiding hypoglycemia.[124][125]

Use a validated protocol/order set for the continuous intravenous insulin infusion.[124]
This allows for predefined adjustments to the insulin infusion rate according to blood glucose measurements and past and current insulin infusion rates, to avoid hypoglycemia.[124]

More info: Continuous intravenous insulin infusion management

If a continuous intravenous insulin infusion is started:

In practice, subcutaneous basal insulin is generally discontinued (based on expert opinion).
- Less often, at some institutions, subcutaneous basal insulin may be continued (provided there is no hypotension and the patient is not on vasopressors) at 75% of the patient's usual dose.
Stop the patient’s usual subcutaneous rapid-acting and mixed insulins while on an intravenous insulin infusion.[135]
Use the continuous intravenous insulin infusion for as short a time as possible.[135]

Once ready to discontinue a continuous intravenous insulin infusion:

Follow an appropriate order set/transition protocol to switch to scheduled subcutaneous insulin.[124]
- This should include calculating the total daily dose of subcutaneous insulin needed, dividing into appropriate basal and bolus doses, monitoring and adjusting dose based on glucose monitoring, and having orders in place for potential hypoglycemic episodes (based on expert opinion).
Give subcutaneous basal insulin at least 2 hours before discontinuing the intravenous infusion to minimize rebound hyperglycemia.[124]
- Emerging data suggest that early administration of subcutaneous basal insulin alongside intravenous insulin infusion does not seem to increase the risk of hypoglycemia.[136][137]

Noncritical illness

Generally, an insulin regimen is preferred for managing hyperglycemia in individuals with diabetes receiving hospitalized care.[124]

If your patient is not eating or drinking or has poor oral intake, a subcutaneous basal insulin or basal plus bolus correction (every 4-6 hours) insulin plan is preferred.
If they are eating adequately, subcutaneous basal insulin with prandial (with each meal, up to 3-4 times a day) and correctional doses is preferred.

In a patient who is already managing their diabetes with insulin, consider whether there is any need to adjust insulin dose when they are admitted to the hospital.

If a patient with type 1 or type 2 diabetes uses insulin at home, has adequate glycemic management, and was not admitted with significant hyperglycemia, it may be appropriate to reduce their routine dose of subcutaneous basal insulin by 20%, particularly if they are eating less than usual. Another factor to keep in mind is that hospital meals generally contain less carbohydrate than meals patients would eat at home (based on expert opinion).
Conversely, patients who are acutely ill with an infection sometimes need more insulin.
Regular monitoring of blood glucose (at least four times daily) can help guide appropriate adjustments to insulin dosing.

More info: Patients using a continuous subcutaneous insulin infusion (CSII) (insulin pump) prior to hospital admission

If a patient with diabetes had been using an insulin pump prior to hospital admission:

Follow your hospital procedure, if available, and request a specialized inpatient diabetes team or endocrinology consult.
Safe continuation of an insulin pump during hospital admission has been advocated by several professional organizations.[124][138][139][140]
Key criteria for safe use include that:[124][141]
- The patient is medically stable, willing, and capable of self-management
- There are no contraindications
- The necessary supplies and resources are available
- There are hospital staff with the appropriate expertise and training, and institutional diabetes technology protocols in place
- Staff are available to perform confirmatory point-of-care (POC) glucose measurements for insulin dose decisions, hypoglycemia assessment and treatment, and at least four times a day (based on expert opinion).

Review noninsulin glucose-lowering medications if your patient had been taking any of these before admission and determine whether these are suitable to continue during admission.

For select patients with type 2 diabetes, it may be acceptable to continue noninsulin glucose-lowering medications, such as a dipeptidyl peptidase-4 (DPP-4) inhibitor.[124] Only consider this in a patient who is (based on expert opinion):
- Clinically stable with mild hyperglycemia
- Eating regularly
- Has no contraindications.
Metformin should be discontinued in patients with contraindications, including those with increased risk of lactic acidosis (e.g., those with renal impairment, shock, or hypoxia) and those with acute heart failure.[142][143] Consider restarting metformin after the acute condition has resolved (based on expert opinion).
In general, stop SGLT2 inhibitors for your patient with diabetes who is admitted to the hospital with an acute illness (based on expert opinion). This is due to the risk of euglycemic ketoacidosis.
- In particular, avoid SGLT2 inhibitors if your patient is severely ill, or if their clinical situation predisposes them to ketoacidosis (e.g., prolonged fasting due to acute illness or surgery).[124][133]
- Be aware that ketoacidosis associated with SGLT2 inhibitors may still be present despite a normal (or near normal) serum glucose level (euglycemic ketoacidosis).[134]
- If an SGLT2 inhibitor is being initiated during a hospital admission (e.g., for treatment of heart failure), this medication should be initiated after recovery from the acute illness.[124]
  - Remain aware of the risk of ketoacidosis which can occur spontaneously with SGLT2 inhibitors.[134]
  - Monitor hydration status and basic metabolic panel (BMP) daily for elevated anion gap and acidosis (based on expert opinion).
  - Check blood beta-hydroxybutyrate (or blood ketone) levels, especially if acidosis is present, or there are symptoms of ketoacidosis (e.g., nausea or vomiting) (based on expert opinion). Measure blood ketones as urinary ketone measurement may be unreliable.
  - Be aware that beta-hydroxybutyrate levels of ≥3.0 mmol/L, along with pH <7.3 or bicarbonate <18 mmol/L, indicate DKA.[134][144]
  - In this situation, stop SGLT2 inhibitor and treat DKA.[144]

Discharge

Start thinking about a discharge plan at the time of hospitalization or after stabilization (based on expert opinion). This should be structured and tailored to the individual.[124]

Provide inpatient diabetes self-management education, focusing on skills needed after discharge, and ensure follow-up and support strategies are in place.
Arrange medication reconciliation:
- Make sure this includes a strategy for switching back to the brand of insulin your patient was on at the time of hospitalization, if appropriate and approved by insurance or covered by other programs (based on expert opinion).
- Clarify regarding timing of restarting any noninsulin glucose-lowering medications that have been temporarily stopped (based on expert opinion).
Communicate promptly to the relevant outpatient healthcare professionals.

Plus – monitor comorbidities during hospital stay

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Plus –

monitor comorbidities during hospital stay

– baseline cognitive and delirium assessments with collateral history

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baseline neurologic exam

Treatment recommended for ALL patients in selected patient group

Perform a baseline neurologic exam at the earliest appropriate opportunity for any patient with a history of stroke.

A patient with an acute condition (e.g., an infection and illness-related hypotension) is at increased risk of stroke.[145][146][147] This risk is even higher in anyone with a history of stroke.
- In particular, ischemic stroke is a known complication of acute bacterial meningitis.[92][148][149]
- Less commonly, hemorrhagic stroke can also complicate bacterial meningitis.[148]
- If there is a change in neurologic status during admission, repeat the neurologic exam to evaluate for a new acute stroke.
Ensure the right level of nursing care for the patient’s condition and ensure that clear orders are written for the patient’s functional and cognitive status (e.g., fall precautions, 1:1, soft restraints, assistance with activities of daily living [ADLs]).
- A patient with a history of stroke has a higher risk of falls and injury.[150]

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baseline cognitive and delirium assessments with collateral history

Treatment recommended for ALL patients in selected patient group

Do a baseline cognitive assessment at the earliest opportunity in any patient with a history of dementia.

Take a collateral history from family, friend, or caregiver to establish whether your patient's cognitive function is stable, gradually declining, or acutely declined.[151]
Check your patient’s level of alertness and orientation to time, place, and person, and corroborate with caregivers and review your patient’s prior medical records (based on expert opinion).
If time allows, a standardized cognitive assessment score is helpful for tracking clinical progress, and determining discharge needs (based on expert opinion).
Validated scoring tools for cognitive assessment include:
- The Mini-Cog Alzheimer's Association: Mini-Cog(TM) Opens in new window
- The Montreal Cognitive Assessment (MoCA)[152]
- The Saint Louis University Mental Status Examination (SLUMS). Saint Louis University: SLUMS Opens in new window
These scores are often best interpreted alongside a functional assessment, usually performed by an occupational therapist and/or a physical therapist.
These scores may not represent the person's usual baseline for cognition due to the impact of the acute condition and its treatment, but it is still good practice to record and repeat it when the person has recovered (based on expert opinion).

Practical tip

Mind (mentation, dementia, depression, and delirium)
Mobility (gait, balance, and falls prevention)
Medications (polypharmacy, deprescribing, optimal prescribing, and adverse medication effects and medication burden)
Multicomplexity (multimorbidity and complex psychosocial situations)
Matters Most to Me (each individual's health outcome goals and care preferences).

Assess for delirium whenever a patient with dementia presents with acute illness.

People living with dementia are at increased risk of delirium when they are admitted to the hospital and throughout their admission.[151][155]
Delirium is not the same as dementia. It is a potentially life-threatening acute, fluctuating change in mental functioning, with inattention, disorganized thinking, and altered levels of consciousness.[156]
Use a screening tool to detect probable delirium, taking the setting into account. Commonly used tools include:
- The Delirium Triage Screen (DTS), which may be rapidly administered in an emergency department setting and assesses arousal and attention. If positive, confirm with a more specific tool, such as the brief Confusion Assessment Method (bCAM).[151][157][158]
- The Confusion Assessment Method (CAM), if your patient is not in a critical care setting.[151][159][160]
- The Confusion Assessment Method for the Intensive Care Unit (CAM-ICU) or the Intensive Care Delirium Screening Checklist (ICDSC) if your patient is in a critical care setting, or in the recovery room after surgery.[155][161][162][163]

Practical tip

Depression can mimic delirium in older adults, particularly in patients with cognitive impairment or other comorbid medical conditions.[151]

Ask if your patient has a diagnosis of depression. If not, use a very brief screening test, such as the Patient Health Questionnaire-2 or Emergency Department Depression Screening Instrument to screen older adults for depression.
A positive screen for depression should prompt further questions, e.g., on suicidal thoughts.

Helping with orientation; make sure patients have their own glasses and/or hearing aids
Getting patients mobilized as soon as possible
Controlling pain adequately
Keeping patients well hydrated and helping them to eat adequately
Monitoring and maintaining regular bowel and bladder function
Using supplemental oxygen as needed
Monitoring for and treating postoperative complications as soon as possible
Reviewing the patient's medications
- Identify and avoid medications that are high-risk for precipitating delirium, such as benzodiazepines, corticosteroids, and anticholinergics.[151][168]

Foster familiarity, e.g., consider facilitating the patient's usual caregiver to stay with the patient and bring in familiar objects from home.[151][158]

Practical tip

Dementia is a risk factor for postoperative delirium.[167][169]

Evaluate baseline cognition using a brief screening tool preoperatively.
Consider the most appropriate method of analgesia to reduce the risk of postoperative delirium.
Monitor for postoperative delirium using a validated screening instrument (e.g., CAM-Short Form).[170]

Evidence: Primary prevention of delirium in hospital using nonpharmacologic interventions

There is evidence that a nonpharmacologic approach reduces the risk of delirium in non-ICU patients in hospital.

A systematic review compared nonpharmacologic interventions designed to prevent delirium with usual care or active control in adults in a non-ICU hospital setting.[171]

Interventions were multicomponent or single components, targeted at a specific risk factor, such as disorientation or dehydration.
Meta-analysis of 14 studies on multicomponent interventions found a significant reduction in incident delirium compared with usual care (RR 0.57, 95% CI 0.46 to 0.71).
There is emerging evidence that multicomponent interventions may reduce hospital length of stay (MD -1.3 days, 95% CI -2.56 to -0.04 days), but there is significant heterogeneity between the studies.
There is little information specifically on people with dementia as this group was frequently excluded from trials despite their increased risk of developing delirium.

More info: Initial investigations for a patient with delirium

If your patient has delirium, check for and treat life-threatening causes:[151][167][172]

Hypoxia
Hypoglycemia
Hypotension
Sepsis
Drug intoxication or withdrawal, including alcohol withdrawal
Acute myocardial infarction

Although every evaluation should be tailored to the individual patient, most patients should receive:[151]

Complete blood count
Comprehensive metabolic panel
Point-of-care glucose
Urinalysis with culture
ECG

Additional tests that may be needed include (based on expert opinion):

Thyroid function tests
Folate and vitamin B12
C-reactive protein
Blood cultures (if bacteremia is suspected)
Chest x-ray

Consider whether your patient requires computed tomography (CT) of the brain.[151]

CT brain should be arranged if your patient has focal neurological deficits, head trauma, reduced level of consciousness, or has a history of fall.
CT brain should also be considered if your patient takes anticoagulants.
In practice, a patient in the hospital setting who has a change in mental status will usually receive a CT brain (based on expert opinion).

Check for and treat any reversible causes of delirium:[151][158][167][172]

Pain
Infection
Poor nutrition
Constipation
Dehydration
Medications
- Ask about recently prescribed medications, especially opioid analgesics, anxiolytics, antipsychotics, corticosteroids, or anticholinergics
Immobility
Poor sleep
Sensory impairment (e.g., ear wax or loss of glasses)

More info: Management of a patient with delirium

Manage patients with delirium initially with nonpharmacologic treatment.[151][158][167]

Reduce disorientation by providing a well-lit room, with a clock and calendar visible (e.g., on the wall).
Encourage and facilitate family, friends, and caregivers to visit the patient.
Use verbal and nonverbal techniques to de-escalate conflict and distress.

Any new antipsychotic prescribed for this purpose must be regularly reviewed, and discontinued as soon as possible.[168][173]
Be aware that the evidence on the efficacy of antipsychotics for delirium is inconclusive, and guidance regarding choice of antipsychotic varies.[151][158][167]
Antipsychotics should be used with caution in patients with a history of dementia as there is an increased risk of mortality in these patients[151][173]
- A systematic review of antipsychotics for delirium in hospitalized adults concluded that the evidence did not support routine use of haloperidol or atypical antipsychotics for this purpose[174]
- All antipsychotics have a warning that they are not approved for dementia-related psychosis.[151]
Haloperidol is contraindicated in patients with Parkinson disease or in patients with dementia with Lewy bodies.[163] Check for all contraindications.
Consider baseline ECG before starting any antipsychotic medication (based on expert opinion).

Document the diagnosis of delirium clearly (based on expert opinion).

Evidence: Risks and safe withdrawal of antipsychotics in older adults

Antipsychotics are associated with increased mortality in people with dementia.

A Cochrane review found very low certainty evidence that typical antipsychotics such as haloperidol improve agitation, but reported that they may improve psychosis slightly in people with Alzheimer disease and vascular dementia. Atypical antipsychotics probably reduce agitation. Both types increase the risk of somnolence and extrapyramidal symptoms.[175]
A network meta-analysis found that people who take atypical antipsychotics for behavioral and psychological symptoms of dementia may have a small improvement in behavioral and psychological symptoms but have increased safety risks including for cerebrovascular adverse events, compared with those taking placebo.[176]
Contrary to popular belief, long-term antipsychotic use can be safely withdrawn in most people with dementia once behavior has settled.[177]

– establish goals of care, taking into account any advance directives

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assess your patient’s level of frailty

Treatment recommended for ALL patients in selected patient group

Assess your patient's level of frailty to:[178][179]

Establish whether management plans are consistent with goals of care, and
Identify whether further assessment and enhanced care is needed.

Practical tip

Ask your patient (with input from caregivers if relevant) about their functional capability 2 weeks BEFORE this acute episode to determine baseline state.[184]
Use the Clinical Frailty Scale (CFS) if your patient is ≥65 years old.[185][186] Dalhousie University: Clinical Frailty Scale Opens in new window
- This tool is a practical aid to identify frailty, but should not be relied on in isolation.
- Do not use the CFS to assess younger patients, or those with disabilities that reflect single-system problems (e.g., spinal cord injury).[184]
- If your patient scores 5 or higher, consider arranging a comprehensive geriatric assessment, if this is feasible and clinically appropriate, at the earliest opportunity.[181]
- A higher prehospital frailty score is associated with an increased risk of adverse outcomes including risk of mortality in-hospital, at 1, 3, 6, and 12 months; all-cause readmission within 30 days; extended length of stay; discharge to a nursing home, residential care, hospital, or a high level of care; and functional decline.[187]
Look for nonspecific complaints, such as delirium and falls.
Help to implement multidisciplinary care and to tailor the management approach according to the patient's values and goals of care.[188]

Practical tip

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–

establish goals of care, taking into account any advance directives

Treatment recommended for ALL patients in selected patient group

Ask your patient if they have an advance directive (e.g., a living will, a healthcare proxy) and/or a Do Not Resuscitate (DNR) or Do Not Intubate (DNI) order.[193]

This applies to all patients, but may be particularly relevant to patients living with frailty and/or with certain comorbidities, such as dementia, stroke, heart failure, COPD, and late-stage CKD (based on expert opinion).
Ensure any existing advance directives align with your patient's current preferences and goals of care.[193]

Practical tip

Discuss specific treatment options and health trajectory to help your patient (or surrogate decision-maker) make informed decisions about their care.[193][195][196]

This should include (based on expert opinion):
- Code status (e.g., Do Not Resuscitate [DNR] order, Do Not Intubate [DNI] order)
- Other life-sustaining treatment options (e.g., vasopressors, extracorporeal membrane oxygenation [ECMO], kidney replacement therapy, blood transfusions, parenteral/enteral nutrition).

Assess and document decision-making capacity (the ability to make a specific decision at the time that the decision needs to be made).[197][198][199]
- Attempt to improve your patient’s capacity to participate in decision-making by addressing communication barriers and alleviating exacerbating factors, such as delirium.[200]
- Be aware that an individual’s decision-making capacity can vary over time so should be reassessed periodically.[200]
If your patient lacks decision-making capacity, establish whether they have an advance directive.[195][198][199]
- This may include a living will and/or a designated proxy known as a Durable Power of Attorney for Healthcare (DPAHC). [198]
If your patient who lacks decision-making capacity has no applicable advance directive, including no designated proxy, identify a surrogate decision-maker from a priority list of individuals such as spouse, adult child, and adult sibling.[198][199]
- The hierarchy of this list, and the scope of surrogates' decision-making, varies from state to state.
- Ensure a surrogate's decisions are consistent with patient preferences and best interests.
- In the case of conflict, consider consulting your hospital's ethics committees.
If your patient is an older adult and is unrepresented (a patient without decision-making capacity for a particular medical intervention who lacks both a relevant advance directive and a surrogate decision-maker), the American Geriatrics Society recommends:[200]
- Attempting to identify a nontraditional surrogate (e.g., a close friend, live-in companion, neighbor, or other individual who knows the patient well), in the absence of a traditional surrogate (next of kin), who is willing and able to represent your patient’s wishes and values
- Avoiding unilateral decision-making in the absence of a suitable surrogate, which could carry a risk of bias. The AGS favors a structured multidisciplinary consensus approach to decision-making.

Check your relevant state law and practice accordingly. There may be no available out-of-court process to allow nontraditional surrogates in many states.
If your unrepresented patient is in an urgent or life-threatening situation:[198][199]
- Use all available information on a patient's preferences, values, and beliefs to guide treatment decisions. If preferences are not known, urgent care decisions should be made in the patient's best interests.[195][198][201]
- Consider using the Four Box Model (also known as the Four Quadrant Model) to aid ethical decision-making. This consists of four principles:[200][202]
  - Medical indications for treatment
  - Patient preferences for care
  - Quality of life
  - Contextual features (this includes being mindful of provider biases, the patient’s psychosocial context, and how the treatment and cost of care may impact the patient).
In a less urgent situation, rarely, a court-appointed guardian may be appointed to make decisions in this context.[195][198][200]

– monitor and manage blood glucose during the hospital admission

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monitor and manage blood glucose during the hospital admission

Treatment recommended for ALL patients in selected patient group

The risk of hypo- and hyperglycemia increases when a person with diabetes is admitted to the hospital acutely (based on expert opinion).
More frequent monitoring is needed after any episode of hyperglycemia or hypoglycemia and after any change in hypoglycemic medication (based on expert opinion). If a correction dose of insulin is given at bedtime, check blood glucose about 4 to 6 hours later (usually about 2 a.m.) (based on expert opinion).
If your patient is having surgery, the American Diabetes Association (ADA) recommends monitoring blood glucose at least every 2 to 4 hours while the individual is taking nothing by mouth (npo).[124]
Any patient on an intravenous insulin infusion needs more frequent blood glucose measurements, ranging from every 30 minutes to every 2 hours.[124]

Practical tip

Decide on target blood glucose levels.

There is a general consensus among different guideline organizations on target blood glucose levels for people with diabetes in the hospital.

For most critically ill patients, the ADA recommends a target range of 140 to 180 mg/dL (7.8 to 10.0 mmol/L) once treatment has been started for persistent hyperglycemia.[124]
- Stricter target ranges, such as 110 to 140 mg/dL (6.1 to 7.8 mmol/L), may be acceptable in select critically ill patients, but only if they can be achieved without significant hypoglycemia.[124]
For most noncritically ill patients, the ADA and the Endocrine Society recommend a target range of 100 to 180 mg/dL (5.6 to 10.0 mmol/L).[124][138]
- Less stringent goals are appropriate in some patients, for instance those at high risk of hypoglycemia, advanced kidney failure, and those who are terminally ill. The ADA recommends that the focus in these people should be on avoiding hypoglycemia and symptomatic hyperglycemia.[124]

Evidence: Blood glucose targets for critically ill patients with hyperglycemia

Evidence argues against very tight glucose control in critically ill patients (a mixed population with and without a history of diabetes).

Intensive care setting:
- A randomized controlled trial (RCT) of critically ill patients in a primarily surgical intensive care setting found lower patient mortality with tight glucose control, 80 to 110 mg/dL (4.4 to 6.1 mmol/L), compared with "conventional" more liberal glucose control.[203]
- However, a subsequent multicenter RCT in critically ill medical and surgical patients in other intensive care settings found increased mortality with tighter glucose control, possibly due to more frequent episodes of hypoglycemia.[204]
- In 2017, two network meta-analyses found no benefit in mortality with tight glycemic control when compared with less tight control (79.2 to <109.8 mg/dL [4.4 to <6.1 mmol/L] vs.140.4 to <219.6 mg/dL [7.8 to <12.2 mmol/L] in one report; <110 to 144 mg/dL [<6.1 to 8.0 mmol/L] vs.144 to >180 mg/dL [8.0 to >10.0 mmol/L] in the second report) but a significant increase in the risk of hypoglycemia.[205][206]

More info: Hyperglycemia during the ongoing hospital admission

Hyperglycemia in admitted patients, whether with known diabetes or not, is associated with adverse patient outcomes, including increased mortality.[142]

Act promptly to treat hyperglycemia to avoid diabetic ketoacidosis (DKA) and hyperosmolar hyperglycemic state (HHS).
For persistent hyperglycemia, defined as blood glucose ≥180 mg/dL (≥10.0 mmol/L) confirmed on two occasions within 24 hours, the ADA recommends:[124]
- Starting or intensifying insulin therapy for most critically ill patients.
- Starting or intensifying insulin and/or other glucose-lowering therapies for most noncritically ill patients.

If your patient has DKA or HHS, consider the appropriate unit for management.

Indications for management in the intensive care unit (ICU) include:[134]
- Severe DKA or severe HHS
- Critical illness as the precipitating cause (e.g., sepsis, acute myocardial infarction, gastrointestinal bleeding)
- Altered mental status
- Another concurrent indication for ICU admission.
See Diabetic ketoacidosis or Hyperosmolar hyperglycemic state.

Be aware that the following interventions may be associated with hyperglycemia and may need to be reviewed:[207]

Corticosteroids
Some second-generation antipsychotics (e.g., olanzapine, clozapine)
Fluoroquinolone antibiotics (e.g., ciprofloxacin)
Calcineurin inhibitors (e.g., tacrolimus)
Protease inhibitors (e.g., ritonavir)
Artificial nutrition (parenteral or enteral).

Ask for a specialized inpatient diabetes team consult, if available, or endocrinology consult where hyperglycemia is difficult to control.

More info: Hypoglycemia during the ongoing hospital admission

Monitor blood glucose and adjust medication in response to illness and hospital meal times, to reduce the risk of hypoglycemic episodes.

Ensure that a hypoglycemia management surveillance protocol is in place, with an individualized plan for preventing, identifying, and treating hypoglycemia.[124]
- Immediately correct level 2 hypoglycemia (blood glucose levels <54 mg/dL [<3.0 mmol/L]) and level 3 hypoglycemia (characterized by altered mental and/or physical functioning, requiring assistance for treatment of hypoglycemia from another person for recovery, with no defined glucose level).
- Promptly treat level 1 hypoglycemia (blood glucose levels <70 mg/dL [<3.9 mmol/L] and ≥54 mg/dL [≥3.0 mmol/L]) to prevent progression to more significant levels of hypoglycemia.
- Ensure hypoglycemia treatment is included in all insulin orders.
Treat hypoglycemia, which usually involves provision of 15 g of fast-acting carbohydrates (oral or enteric juice or table sugar; intravenous dextrose). Check blood glucose 15 minutes after the treatment. If the blood glucose is not in a safe range (usually considered to be >90 mg/dL [>5.0 mmol/L]), repeat the treatment. If the oral and enteric route is not available, administer intravenous dextrose. If the patient has no intravenous access, administer glucagon (based on expert opinion). See Diabetic hypoglycemia.
Be aware that hypoglycemia may be induced by treatment of hyperglycemia/diabetes.[208]
- Sliding scale insulin (correctional or supplemental insulin without basal insulin) is associated with the highest rates of hypoglycemia (based on expert opinion). Sole use of sliding scale insulin is not recommended for most individuals in a hospital inpatient setting.[124]
- Be aware of the risk of hypoglycemia in patients on intensive insulin regimens (e.g., multiple daily injections, continuous subcutaneous insulin infusion, or automated insulin delivery systems), and those on basal insulin, sulfonylureas, or meglitinides.
- A combination of insulin and sulfonylureas further increases hypoglycemia risk.
Review and adapt your patient’s treatment plan to prevent recurrent episodes of hypoglycemia.[124]
- Be aware that level 1 hypoglycemia often predicts subsequent level 3 hypoglycemia.
Document any episodes of hypoglycemia in the electronic health record.[124]

Causes of hypoglycemia include:[124]

Inappropriate insulin dose or dose adjustment
Insulin or oral hypoglycemic medication error
Wrong timing of insulin in relation to meals
Inadequate follow-up of first episode of hypoglycemia
Patients eating less but taking the same amount of diabetes medication
Reduced appetite or vomiting
Unexpected interruption of enteral or parenteral feedings
Reduced infusion rate of intravenous dextrose
Delayed or missed blood glucose checks
Sudden reduction of corticosteroid dose
Altered ability of a patient to report symptoms
Recovery from an acute illness.

These medications include:
- Some antibiotics (e.g., fluoroquinolones, trimethoprim/sulfamethoxazole, chloramphenicol)[209][210]
- Other nondiabetic medications (e.g., ACE inhibitors, beta-blockers, chloroquine, disopyramide, pentamidine, salicylates)[209]
Polypharmacy of multiple hypoglycemia-causing medications also increases this risk.[208]
This list is not exhaustive. Consult your local drug information source (based on expert opinion).

Take action if blood glucose falls below 100 mg/dL (<5.6 mmol/L) (based on expert opinion). Fasting blood glucose levels <100 mg/dL (<5.6 mmol/L) are predictive of next-day hypoglycemia.[124]

Give extra carbohydrates to prevent hypoglycemia unless your patient is going to eat a meal within an hour (based on expert opinion).
Modify insulin doses to prevent glucose from going below the target for the patient.

Take steps to reduce the risk of hypoglycemia at night. Assuming your patient is not npo (nothing by mouth), they are likely to have a smaller evening meal in the hospital than at home.

In the absence of significant hyperglycemia, consider reducing the evening basal insulin by 20% on admission (based on expert opinion).
Remember that for many patients with very high insulin needs at home, the needs are often much lower in the hospital, presumably because of changes in diet.
Review the dose used during recent prior hospitalization(s) when deciding the starting dose of insulin (based on expert opinion).

More info: Self-management of diabetes in the hospital

The ADA recommends that suitable candidates for self-managing their diabetes in the hospital include those who:[124]

Normally perform self-management at home
Have the necessary cognitive and physical skills while in the hospital
Have adequate oral intake
Are proficient in carbohydrate estimation
Take multiple daily insulin injections or use insulin pumps
Have stable insulin requirements, and
Understand sick-day management.

The patient and hospital care team should review the decision on self-management on a daily basis.[124]

Inspect injection sites if your patient is on insulin injections at home (based on expert opinion).

Check for insulin lipodystrophy and re-educate on injection technique, if needed.

Continuous glucose monitoring

Consider continuing personal continuous glucose monitoring (CGM) for any individual who uses this wearable technology at home.[211] Consult with the inpatient diabetes team if available.[140]

Although not approved by the Food and Drug Administration (FDA), emergency use authorization was granted during the coronavirus disease 2019 (COVID-19) pandemic and several professional bodies suggest this may be useful if complying with institutional policies and safety regulations.[124][211][132][140]
Confirmatory point-of-care glucose measurements are still needed for assessment of hypoglycemia and to guide decisions on insulin dosing.[124]
Be aware that some concomitant medications, such as acetaminophen (above a certain dose), dopamine, heparin, vitamin C, and hydroxyurea, may result in inaccurate measurements by CGM devices.[211]

More info: Management of patients with diabetes who are receiving end-of-life care

If a patient with diabetes is receiving end-of-life care:

Discuss with your patient and their family/caregivers and agree on the level of intensity of care. Less stringent targets for blood glucose levels are appropriate, with the aim of avoiding hypoglycemia and symptomatic hyperglycemia.[124][132][212]
Prioritize providing comfort and reducing the burdens of strict blood glucose management.[212]
Be aware that stopping basal insulin in a person with type 1 diabetes can lead to dehydration, ketoacidosis, nausea, and associated vomiting; therefore, continuing basal insulin in such a person could be considered as a comfort care (based on expert opinion).

– ensure monitoring is in place to detect any asthma exacerbation during your patient's hospital admission

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examine your patient’s feet

Treatment recommended for ALL patients in selected patient group

Examine the feet of any adult with diabetes on their admission to the hospital and whenever they become ill.[213]

This is to detect new ulcerations or infection, which may be unnoticed by the patient and may even be the cause of their acute illness (e.g., patient presenting with sepsis, or endocarditis where the original focus of infection is the foot lesion).

Inspect the foot for lesions and examine for loss of protective sensation.

To perform a comprehensive foot examination:[214]

Inspect the skin.
Assess any foot deformities.
Do a neurologic exam, including 10-g monofilament testing or Ipswich touch test, with at least one other assessment (pinprick, temperature, or vibration).[215]
Do a vascular exam, including pulses in the legs and feet.

If your patient has reduced sensation, they are at risk for diabetic foot ulceration.[214] Provide pressure relieving devices.

Order daily heel checks for signs of pressure trauma. There is a debate about whether compression stockings should or should not be used in people with diabetes; do not use them if there is known peripheral vascular disease.

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ensure monitoring is in place to detect any asthma exacerbation during your patient's hospital admission

Treatment recommended for ALL patients in selected patient group

Acute worsening of respiratory symptoms may suggest a patient with comorbid asthma is having an acute exacerbation of their asthma.

Follow guideline recommendations on assessing severity and managing an acute exacerbation of asthma in adults.[97]
See Acute asthma exacerbation in adults.

This is due to concern over possible additive anticholinergic adverse effects.
Ensure to represcribe the LAMA once the nebulizer treatment has been stopped.

Be aware that the long-term use of beta-2 agonists to manage asthma may increase the risk of cardiovascular events.

Evidence: Cardiovascular harm with beta-2 agonists

Beta-2 agonists may increase the risk of myocardial infarction and other adverse cardiovascular events.

Beta-2 agonists increase heart rate and reduce potassium levels.[216] They are absorbed into the systemic circulation and there is evidence that long-term regular use may be associated with an increased risk of myocardial infarction, unstable angina, congestive heart failure, and arrhythmias.[217][216]
However, it is not routine practice to discontinue beta-2 agonists if they are needed for comorbid asthma.

– ensure monitoring is in place to detect any COPD exacerbation during your patient's hospital admission

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ensure monitoring is in place to detect any COPD exacerbation during your patient's hospital admission

Treatment recommended for ALL patients in selected patient group

Acute worsening of respiratory symptoms may suggest a patient with comorbid COPD is having an acute exacerbation.[102]

Differentiate from other conditions, such as a pulmonary embolism, acute heart failure, and pneumonia.
Follow guideline recommendations.[102] See Acute exacerbation of COPD.

This is due to concern over possible additive anticholinergic adverse effects.
Ensure the LAMA is represcribed once the nebulizer treatment has been stopped.

Be aware that the long-term use of beta-2 agonists to manage COPD may increase the risk of cardiovascular events.

Evidence: Cardiovascular harm with beta-2 agonists

Beta-2 agonists may increase the risk of myocardial infarction and other adverse cardiovascular events.

Beta-2 agonists increase heart rate and reduce potassium levels.[216] They are absorbed into the systemic circulation and there is evidence that long-term regular use may be associated with an increased risk of myocardial infarction, unstable angina, congestive heart failure, and arrhythmias.[216][217]
However, the Global Initiative for Chronic Obstructive Lung Disease states that there has been no reported association between beta-2-agonist use and increased mortality in people with COPD.[102] It is not routine practice to discontinue beta-2 agonists if they are needed for comorbid COPD.

– continue your patient's inhalers as prescribed for asthma or COPD

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mental status exam

Treatment recommended for ALL patients in selected patient group

Perform a mental status exam as the clinical situation allows (based on expert opinion).

The mental status exam is one of the main clinical tools routinely used in psychiatric practice, aiding diagnosis and guiding further management. Mood is one of the assessed domains.

Consider assessing current symptoms of depression using the PHQ-9 questionnaire.[218][219]

The PHQ-9 questionnaire can be used as a reliable and valid measure of depression severity in patients with a known diagnosis of depression, as well as a screening tool.
This can be self-administered or administered by the clinician, and takes less than 3 minutes to complete.
Results indicate severity of depressive symptoms.

Take into account other factors that may be influencing the patient's mental status (e.g., the effect of any illicit drug use or alcohol).[219][220]

In particular, consider whether symptoms of depression could be part of the acute medical illness (based on expert opinion).

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review current treatment for depression

Treatment recommended for ALL patients in selected patient group

Continue the patient’s usual antidepressant, unless there are good reasons not to (based on expert opinion).

If antidepressants are stopped abruptly, the patient may develop antidepressant discontinuation syndrome.[221]
The severity of the symptoms of discontinuation may vary, but they may be unpleasant and may complicate the management of the acute medical condition.

When reviewing current medications, consider:

Current and previous adverse effects
Recent changes in dose
Recent medication changes from a different drug class
The specific diagnostic subtypes of depression when prescribing medications (e.g., it is likely that patients suffering from psychotic depression would be coprescribed an antipsychotic)
Augmenting strategies that may be used when treating resistant depression (e.g., lithium or quetiapine augmentation of a selective serotonin-reuptake inhibitor [SSRI]).

Consider drug-drug interactions.

Antidepressants (particularly those that inhibit the CYP450 pathway) may cause significant interactions with drugs used for other conditions.[222]

Consider psychiatric complications when prescribing nonpsychotropic drugs.

Take particular care when prescribing anticonvulsants, antiparkinsonian drugs, and corticosteroids.

Consider adverse effects, which may include the following:

Hyponatremia, caused by antidepressants, especially SSRIs, and compounded by other coprescribed drugs (e.g., diuretics).[223][224][225][226] Review your patient’s serum electrolyte results and consider antidepressants as a potential contributing factor if they have hyponatremia.
Serotonin syndrome (altered mental state, agitation, tremor, hyper-reflexia, ocular clonus or inducible clonus, muscle rigidity, diaphoresis, tachycardia, increased bowel sounds, temperature >100.4°F [>38°C]), especially with polypharmacy and/or overdose of a serotonergic agent.[227][228] See Serotonin syndrome.
- Be particularly aware of increased risk of serotonin syndrome in patients with kidney failure on SSRIs.[229][230]
Hepatotoxicity.[231] Adjust doses of antidepressants in patients with hepatic impairment as necessary.
- However, antidepressants are rarely the cause of hepatic impairment.[231]
Prolonged QTc, arrhythmias, increased heart rate, postural hypotension with tricyclic antidepressants.[232][233] Obtain an ECG, especially in people at risk of arrhythmias.[234]
Gastrointestinal bleeding. SSRIs are associated with an increased risk of gastrointestinal bleeding.[223][235][236] Risk is particularly increased when coprescribed with aspirin, nonsteroidal anti-inflammatory drugs (NSAIDs), or oral anticoagulants.[236][237][238] Monitor closely and consider gastroprotection with proton-pump inhibitors if SSRI use cannot be avoided (based on expert opinion).

This list of adverse effects is not exhaustive - consult your drug information sources or hospital pharmacist for further information, and consider a psychiatric consult for advice.

Practical tip

Ask your patient about nonpharmacologic treatments for their depression and check the current level of community support.

This may include other outpatient healthcare professionals, charities, and family and social networks.

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consider psychiatric consult

Treatment recommended for ALL patients in selected patient group

Consider a psychiatric consult for any patient with comorbid depression who is admitted to the hospital with an acute condition.

Consult is strongly advised in patients with severe symptoms of depression or additional symptoms such as self harm, suicidal ideation, homicidal ideation, catatonia, psychosis (based on expert opinion).
Consult may not be required if there are no concerns that depression and/or its management (e.g., medication) may be affecting the acute condition (based on expert opinion).
Accidents of unclear circumstances, self-injurious behaviors, and/or suicide attempts (including alleged "accidental" overdose of medication) should trigger clinical suspicion of comorbid mental health disorder (based on expert opinion).

Ensure your patient has adequate support with their treatment post-discharge.

Keep in mind that the psychological impact of comorbid depression may be associated with poor adherence with recommended physical health treatments, from medication to rehabilitation.[242][243][244] This may lead to worse clinical outcomes, including higher readmission risk.[245][246]
Most importantly, affective symptoms, including depression, have been linked with excess mortality, though a causal link remains to be proven.[247][248]

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manage tobacco dependence

Treatment recommended for ALL patients in selected patient group

If your patient currently uses tobacco, assess their tobacco use and provide assistance and support with tobacco cessation interventions.[249][250][251]

Advise:

That nicotine is highly addictive and nicotine withdrawal can be extremely distressing and uncomfortable.[250]
NRT prevents rapid withdrawal.[250]
That there are a number of highly effective treatment options that offer the best chance of stopping smoking.[249][250][251]

Ensure a sufficient dose of NRT is prescribed to adequately address withdrawal symptoms.[255]
Ask the patient how many cigarettes they smoke per day; this may determine the starting dose of NRT.
Ask about the type of tobacco product used, including e-cigarettes, water pipe use, and other smokeless tobacco products (snuff, ground, or chewing tobacco), as use of these products also results in nicotine addiction.
Check drug information sources for any contraindications or cautions, particularly if your patient has one or more comorbidity and/or is hemodynamically unstable.
Assess for symptoms of withdrawal daily (based on expert opinion).

One Cochrane Review found high-certainty evidence that varenicline is an effective treatment for tobacco dependence.[257] The same review found that people taking varenicline likely have an increased chance of a more serious adverse effect (e.g., cardiac) that could result in hospital admission; however, these are still rare (2.7% to 4% of people on varenicline, compared with 2.7% of people not taking varenicline) and may include events that are unrelated to varenicline.[257] Check drug information sources for a full list of contraindications and cautions or seek pharmacist advice.
Mental health illness is NOT a contraindication to prescribing varenicline. However, varenicline should be used with caution in people with a pre-existing psychiatric illness as it may worsen symptoms.
Bupropion is an alternative option to varenicline for tobacco cessation but is less likely to result in successful quitting.[257] Consider the potential for drug-drug interactions.

Ensure your patient has follow-up with their primary care practitioner or addiction medicine physician to continue treatment for tobacco dependence.

Practical tip

See Smoking cessation for more information.

suspected meningococcal bacteremia

<1 month of age

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empiric antibiotic therapy

Presumptive treatment for suspected bacteremia should be active against meningococci and other causes of serious bacterial infection, including group B Streptococcus agalactiae, Escherichia coli, and Listeria.[54] Antibiotic therapy should be administered as soon as feasible.

Cefotaxime or ceftriaxone or ceftazidime or an aminoglycoside (e.g., gentamicin) plus ampicillin is a suitable option in these patients.[73]

Primary options

ampicillin: consult specialist for guidance on neonatal dose

ampicillin : consult specialist for guidance on neonatal dose

ampicillin: consult specialist for guidance on neonatal dose

-- AND --

ceftriaxone: consult specialist for guidance on neonatal dose

ceftriaxone : consult specialist for guidance on neonatal dose

ceftriaxone: consult specialist for guidance on neonatal dose

cefotaxime: consult specialist for guidance on neonatal dose

cefotaxime : consult specialist for guidance on neonatal dose

cefotaxime: consult specialist for guidance on neonatal dose

ceftazidime sodium: consult specialist for guidance on neonatal dose

ceftazidime sodium : consult specialist for guidance on neonatal dose

ceftazidime sodium: consult specialist for guidance on neonatal dose

gentamicin: consult specialist for guidance on neonatal dose

gentamicin : consult specialist for guidance on neonatal dose

gentamicin: consult specialist for guidance on neonatal dose

Consider – acyclovir

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supportive care

Treatment recommended for ALL patients in selected patient group

Patients with meningococcal infections must be monitored closely for complications such as shock, elevated intracranial pressure, seizures, and coagulopathy.

Severe meningococcal infections are frequently complicated by hypoglycemia or hyperglycemia, acidosis, and other biochemical abnormalities that require attention.

Meningococcal disease is a notifiable disease in many countries, including the US; cases should be reported immediately to local and national health departments.[19]

children ≥1 month of age

Show drug information for a patient with no comorbidities

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empiric antibiotic therapy

Ceftriaxone or cefotaxime or ceftriaxone or cefepime plus vancomycin is a suitable option in these patients.[73]

The management of suspected bacteremia is becoming increasingly complex and should be based on local susceptibility rates, risk factors (e.g., immunocompromised state, focal infection), and the severity of illness. Additional antibiotic cover may be required for those with relevant risk factors (e.g., for Listeria).

Primary options

vancomycin: 15 mg/kg intravenously every 6 hours

vancomycin : 15 mg/kg intravenously every 6 hours

vancomycin: 15 mg/kg intravenously every 6 hours

-- AND --

ceftriaxone: 80-100 mg/kg/day intravenously given in divided doses every 12-24 hours, maximum 4 g/day

ceftriaxone : 80-100 mg/kg/day intravenously given in divided doses every 12-24 hours, maximum 4 g/day

ceftriaxone: 80-100 mg/kg/day intravenously given in divided doses every 12-24 hours, maximum 4 g/day

cefotaxime: 200-300 mg/kg/day intravenously given in divided doses every 6-8 hours, maximum 12 g/day

cefotaxime : 200-300 mg/kg/day intravenously given in divided doses every 6-8 hours, maximum 12 g/day

cefotaxime: 200-300 mg/kg/day intravenously given in divided doses every 6-8 hours, maximum 12 g/day

cefepime: children ≥2 months of age: 150 mg/kg/day intravenously given in divided doses every 8 hours

cefepime : children ≥2 months of age: 150 mg/kg/day intravenously given in divided doses every 8 hours

cefepime: children ≥2 months of age: 150 mg/kg/day intravenously given in divided doses every 8 hours

Drug choice, dose and interactions may be affected by the patient's comorbidities. Check your local drug formulary.

Primary options

vancomycin

For patients with CKD, please check your local drug formulary

For patients with CKD see dose in the Renal Drug HandbookFor patients with CKD see dose in the Renal Drug Handbook

-- AND --

ceftriaxone

For patients with CKD, please check your local drug formulary

For patients with CKD see dose in the Renal Drug HandbookFor patients with CKD see dose in the Renal Drug Handbook

cefotaxime

For patients with CKD, please check your local drug formulary

For patients with CKD see dose in the Renal Drug HandbookFor patients with CKD see dose in the Renal Drug Handbook

cefepime

For patients with CKD, please check your local drug formulary

For patients with CKD see dose in the Renal Drug HandbookFor patients with CKD see dose in the Renal Drug Handbook

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supportive care

Treatment recommended for ALL patients in selected patient group

Patients with meningococcal infections must be monitored closely for complications such as shock, elevated intracranial pressure, seizures, and coagulopathy.

Severe meningococcal infections are frequently complicated by hypoglycemia or hyperglycemia, acidosis, and other biochemical abnormalities that require attention.

Meningococcal disease is a notifiable disease in many countries, including the US; cases should be reported immediately to local and national health departments.[19]

adults

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empiric antibiotic therapy

Presumptive treatment for suspected bacteremia should be active against meningococci and other causes of serious bacterial infection, including Streptococcus pneumoniae and Staphylococcus aureus.[54] Antibiotic therapy should be administered as soon as feasible. Therapy should include one or more broad-spectrum antibiotics active against gram-positive and gram-negative organisms.

Vancomycin plus ceftriaxone or cefotaxime or cefepime or imipenem/cilastatin or meropenem with or without an aminoglycoside (e.g., gentamicin) is a suitable option in these patients.[73]

The management of suspected bacteremia is becoming increasingly complex and should be based on local microbiology, personal risk factors (e.g., immunocompromised state, focal infection), age, and the severity of illness. Additional antibiotic cover may be required for those with relevant risk factors (e.g., for Listeria).

Consider whether your adult patient with diabetes or chronic kidney disease also requires cover for Listeria

Diabetes is considered to be a risk factor for Listeria and empiric antibiotic cover for this bacteria is recommended.[92][93][94][95][96]
Some guidelines also list CKD as a risk factor for Listeria.[93][94]
- The stage of CKD may affect the need for Listeria cover so consult your patient’s nephrologist or an infectious disease specialist (based on expert opinion).

Primary options

vancomycin: 15-20 mg/kg intravenously every 8-12 hours

vancomycin : 15-20 mg/kg intravenously every 8-12 hours

vancomycin: 15-20 mg/kg intravenously every 8-12 hours

-- AND --

ceftriaxone: 2 g intravenously every 12 hours

ceftriaxone : 2 g intravenously every 12 hours

ceftriaxone: 2 g intravenously every 12 hours

cefotaxime: 2 g intravenously every 4-6 hours

cefotaxime : 2 g intravenously every 4-6 hours

cefotaxime: 2 g intravenously every 4-6 hours

cefepime: 2 g intravenously every 8 hours

cefepime : 2 g intravenously every 8 hours

cefepime: 2 g intravenously every 8 hours

imipenem/cilastatin: 500 mg intravenously every 6 hours

imipenem/cilastatin : 500 mg intravenously every 6 hours

imipenem/cilastatin: 500 mg intravenously every 6 hours

meropenem: 2 g intravenously every 8 hours

meropenem : 2 g intravenously every 8 hours

meropenem: 2 g intravenously every 8 hours

vancomycin: 15-20 mg/kg intravenously every 8-12 hours

vancomycin : 15-20 mg/kg intravenously every 8-12 hours

vancomycin: 15-20 mg/kg intravenously every 8-12 hours

-- AND --

ceftriaxone: 2 g intravenously every 12 hours

ceftriaxone : 2 g intravenously every 12 hours

ceftriaxone: 2 g intravenously every 12 hours

cefotaxime: 2 g intravenously every 4-6 hours

cefotaxime : 2 g intravenously every 4-6 hours

cefotaxime: 2 g intravenously every 4-6 hours

cefepime: 2 g intravenously every 8 hours

cefepime : 2 g intravenously every 8 hours

cefepime: 2 g intravenously every 8 hours

imipenem/cilastatin: 500 mg intravenously every 6 hours

imipenem/cilastatin : 500 mg intravenously every 6 hours

imipenem/cilastatin: 500 mg intravenously every 6 hours

meropenem: 2 g intravenously every 8 hours

meropenem : 2 g intravenously every 8 hours

meropenem: 2 g intravenously every 8 hours

-- AND --

gentamicin: 5 mg/kg/day intravenously given in 1-3 divided doses

gentamicin : 5 mg/kg/day intravenously given in 1-3 divided doses

gentamicin: 5 mg/kg/day intravenously given in 1-3 divided doses

Plus – check baseline kidney function and monitor closely

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supportive care

Treatment recommended for ALL patients in selected patient group

Patients with meningococcal infections must be monitored closely for complications such as shock, elevated intracranial pressure, seizures, and coagulopathy.

Severe meningococcal infections are frequently complicated by hypoglycemia or hyperglycemia, acidosis, and other biochemical abnormalities that require attention.

Oxygen therapy in your patient with asthma

Measure resting oxygen saturation in all acutely ill patients.

Be aware that pulse oximetry may overestimate oxygen saturation in patients with darker skin tones.[97]
If your patient's asthma is stable, follow guideline recommendations for oxygen saturation target for the presenting acute condition.
If the acute presenting condition triggers an acute exacerbation of your patient's asthma, the Global Initiative for Asthma recommends controlled oxygen to maintain saturations between 93% and 95%.[97]
Adjust oxygen saturation targets for altitude, where appropriate.[97]
Hypercapnia in asthma is an indicator of very severe disease showing a patient is tiring and needs ventilatory support.[98][99][100]

Oxygen therapy in your patient with COPD

Obtain a blood gas measurement if your patient with COPD has oxygen saturation <90%, clinical signs of hypercapnia (e.g., altered mental status), or respiratory distress (based on expert opinion).
- An arterial blood gas (ABG) should be used to assess patients with respiratory failure and should always be obtained if hypoxemia is an issue.[103][104]
  - Peripheral venous blood gas (VBG) analysis has increasingly been used to estimate carbon dioxide, pH, and other variables.[105] It is less painful for the patient and may be associated with fewer complications than an ABG.[105]
  - One Cochrane Review found limited data of low to very low certainty evidence that VBG is sensitive for the diagnosis of respiratory failure and isolated hypercarbia.[105] However, it has poor specificity compared with ABG analysis, making it less reliable when precise data are necessary.[105]
Recheck blood gas as clinically indicated.[102]

Chronic hypercapnia[106]
Hypercapnia on presentation
Previous history of hypercapnic respiratory failure[103]
Moderate or severe COPD, particularly if on long-term oxygen therapy[103]
Evidence of chronic hypoventilation for other reasons, e.g., obesity hypoventilation syndrome, taking sedatives or hypnotic drugs.[102][106]

Critically ill and needs high levels of oxygen

This includes patients with comorbid COPD who need high levels of oxygen due to a critical illness such as shock, sepsis, major head injury, status epilepticus, anaphylaxis, or major trauma.

In this scenario, some guidelines recommend an initial target oxygen saturation in line with the recommendation for patients without COPD.[103]

Evidence suggests that targeting an upper oxygen saturation level of 96% may be preferred compared with a higher level.[107][108]
Subsequently, you may need to adjust to controlled oxygen therapy with a target oxygen saturation range of 88% to 92% depending on the blood gas results.[103]

Acutely but not critically ill and at risk of hypercapnic respiratory failure

This includes patients with comorbid COPD who have risk factors for hypercapnic respiratory failure and an acute condition, but are not critically ill.[103]

Give controlled oxygen therapy and use an initial target oxygen saturation of 88% to 92%.[102][103]

Check blood gas and recheck after 30 to 60 minutes.[103]

Not critically ill and NOT at risk of hypercapnic respiratory failure

As an example, a patient may have stable, mild COPD with minimal symptoms.

Use an initial target oxygen saturation as recommended by guidelines for the presenting acute condition.

Evidence suggests that for most acutely ill patients, targeting an upper oxygen saturation level of 96% may be preferred compared with a higher level.[107][108]

Measure blood gas as soon as possible[103]

Subsequently, you may need to adjust to controlled oxygen therapy with a target oxygen saturation range of 88% to 92% depending on the blood gas results.[103]

High-flow nasal cannula (HFNC)

Decreasing the work of breathing[109][110]
A theoretical provision of low-level positive end-expiratory pressure (PEEP)[109][110][111]
Facilitating secretion mobilization.[109][110]

Ventilatory support

Start noninvasive bilevel ventilation (BiPAP) if the patient has at least one of the following:[102]

Respiratory acidosis (PaCO₂ ≥45 mmHg [6 kPa] and arterial pH ≤7.35)
Severe dyspnea and/or increased work of breathing (e.g., use of respiratory muscles, paradoxical movement of the abdomen, retraction of the intercostal spaces)
Persistent hypoxemia despite supplemental oxygen.

Start invasive mechanical ventilation support if this is indicated and the patient is considered suitable. Indications for invasive mechanical ventilation include:[102]

Inability to tolerate, or failure of, noninvasive ventilation (particularly if they have life-threatening hypoxemia)
Status post respiratory or cardiac arrest
Reduced consciousness, or psychomotor agitation that is inadequately controlled by sedation
Massive aspiration or persistent vomiting
Persistent inability to remove respiratory secretions
Severe hemodynamic instability without response to fluids or vasoactive drugs
Severe ventricular or supraventricular arrhythmias.

When considering endotracheal intubation with mechanical ventilation, always take into account the patient's wishes (e.g., advance directives).[102]

Vasopressors should be given to patients with hypotension or poor perfusion who do not respond promptly to fluid resuscitation.[74] Consult a specialist for guidance on suitable vasopressor/inotrope regimens.

Assess fluid status and manage fluid balance particularly closely

In a patient with heart failure and/or chronic kidney disease (CKD), judicial use of fluids is crucial to preventing clinically significant volume overload.

Be aware that hypovolemia may be difficult to assess in a person with heart failure and/or CKD.

As with any patient presenting acutely, look for signs of volume depletion on physical exam, by assessing:[112]

Vital signs:
- Blood pressure, (particularly systolic blood pressure [SBP] and mean arterial pressure)
- Pulse
- Postural hypotension
Peripheral perfusion
Capillary refill time
Jugular venous distension
Passive leg raise.

More info: The RUSH exam

The RUSH exam involves a three-part physiologic assessment using point of care ultrasound (POCUS):[114]

1. The pump, i.e., the cardiac status
- Evaluate cardiac status by looking for: pericardial effusions and cardiac tamponade, left ventricular contractility, and right ventricular size
2. The tank, i.e., the effective intravascular volume status
- Assess the fullness of the tank by examining the inferior vena cava (IVC) and/or internal jugular veins
- Evaluate for "leakiness" of the tank, or free fluid in the abdominal and thoracic cavities, by performing Focused Assessment of Sonography for Trauma (FAST) and thoracic ultrasound to assess for fluid in the abdominal and thoracic cavities[115][116]
- Assess compromise of the tank by assessing for pneumothorax
3. The pipes, i.e., the arterial and venous sides of the circulatory system
- Assess the aorta looking for aortic aneurysm, rupture, dissection
- Assess lower extremity and/or upper extremity veins for deep vein thrombosis.

Other variations of RUSH have been described.[113]

Practical tip

Heart failure

Be aware that an SBP of <90 mmHg may suggest hypotension, but a patient on medication for chronic heart failure can have a baseline SBP of <90 mmHg.

Consider consultation with a cardiologist and/or intensivist.

With a suspected low output or cardiogenic shock state
With massive fluid overload, when high doses of diuretic are needed or with diuretic resistance
When unable to establish volume state
When titrating inotropes.

CKD

A patient with CKD who is hypovolemic needs immediate fluid resuscitation.

Reassess your patient after initial fluid challenge and further address the cause of hypovolemia.
If they do not rapidly stabilize:
- Consider activating the rapid response team and obtaining specialist consultation
- Consider transferring your patient to an intensive care setting where hemodynamic monitoring is possible (based on expert opinion).

Continue to monitor fluid balance particularly closely

Accurate monitoring of volume status is essential in a person with heart failure and/or chronic kidney disease (CKD).[117]

There is a significant risk of pulmonary edema with fluid resuscitation in a patient with heart failure and/or CKD, so monitor closely.
Monitoring should include:
- Regular clinical assessment of volume status (pulse, BP, jugular venous distension [JVD], and check for pulmonary and peripheral edema)
- Fluid balance (input/output chart) and daily weight
- BUN and serum creatinine to monitor kidney function, at least daily.
Consider bladder catheterization if urinary output is difficult to measure, but be aware of increased risk of infection and trauma.
Patients with greater clinical complexity, such as those with heart failure and/or advanced CKD may need admission to the intensive care unit for more invasive monitoring and interventions. If noninvasive bedside assessments are not adequate for monitoring, consider a central venous pressure catheter or pulmonary artery catheter.[117][118][119]

Practical tip

De-escalation

Your patient is euvolemic
The problem requiring fluids has been successfully reversed.

Monitor volume status consistently to try to avoid volume overload.

Immediately stop fluid administration
Consider consultation with specialist
Consider intravenous diuretics, and
Arrange an urgent chest x-ray if pulmonary edema is suspected (based on expert opinion).

Unless there are extenuating circumstances, diuretics and intravenous fluids are not generally given together (based on expert opinion).

Recommendations from an intensive care specialist and/or cardiologist and/or nephrologist may be needed.

Withhold antihypertensives and/or diuretics if hypotensive

Withhold antihypertensives and/or diuretics if your patient:

Is in shock, or
Has a blood pressure ≥40 mmHg lower than their baseline.

Consider withholding antihypertensives and/or diuretics if your patient:

Is hypotensive, or
Has developed orthostatic hypotension or has postural symptoms (based on expert opinion).
- Orthostatic hypotension is defined, by consensus, as a fall in systolic blood pressure ≥20 mmHg and/or a fall in diastolic blood pressure ≥10 mmHg on assuming an upright posture.[120]
- In people with classic orthostatic hypotension, the blood pressure change occurs within 3 minutes of standing.[121] In practice, take standing blood pressure after the person has been standing for at least 1 minute (based on expert opinion).

People with hypertension, coronary artery disease, heart failure, stroke, or chronic kidney disease (CKD) will typically be taking one or more of these types of drug.

Establish your patient's baseline blood pressure and assess volume status.

Patients with treated heart failure may have chronically low blood pressure (e.g., systolic BP ≤90 mmHg). If their systolic blood pressure falls by >10-15 mmHg and is associated with symptoms (such as presyncope or syncope), it may be appropriate to withhold medications that may lower blood pressure but have no or little prognostic benefit for heart failure (such as amlodipine, doxazosin).
- If clinically appropriate, consider changing the time of administration of medication that has a prognostic benefit for heart failure (e.g., sacubitril/valsartan, beta-blockers) to night time, or splitting or reducing the dose (based on expert opinion).
- Consider consultation with a cardiologist and/or intensivist.

If diuretics are withheld in a patient with heart failure and/or CKD, close monitoring is needed as fluid can quickly accumulate.

Be aware that sodium-glucose cotransporter-2 (SGLT2) inhibitors, a class of medication with a prognostic benefit for both heart failure and CKD, also have a weak diuretic effect.[122]

If antihypertensives or diuretics have been withheld during the acute illness, consider restarting them before discharge if clinically appropriate (based on expert opinion).

Restart one at a time at a lower dose and ask the primary care physician (PCP) to titrate back to normal dose.
- Most patients won't tolerate restarting all medications at the original doses simultaneously.
- If it is not clinically appropriate to restart these medicines before discharge, ensure that the patient has follow-up to decide when the medications can be reintroduced.
- Ensure you have communicated clearly to the PCP at discharge.

Meningococcal disease is a notifiable disease in many countries, including the US; cases should be reported immediately to local and national health departments.[19]

Plus – review diabetes medication (NEVER stop insulin in a person with type 1 diabetes)

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Plus –

review diabetes medication (NEVER stop insulin in a person with type 1 diabetes)

Treatment recommended for ALL patients in selected patient group

Check your patient's blood glucose on admission. In addition, check HbA1c if no result is available from the previous 3 months.[124][132]

Exclude hypoglycemia, diabetic ketoacidosis (DKA), and hyperosmolar hyperglycemic state (HHS).
Test for blood beta-hydroxybutyrate or ketones if:[133][134]
- Your patient was taking a sodium-glucose cotransporter-2 (SGLT2) inhibitor (e.g., dapagliflozin, canagliflozin, empagliflozin) before unplanned hospitalization, and/or
- There is acidosis, an increased anion gap, nausea/vomiting, or a combination of these.
Admission HbA1c may give you an indication of your patient’s previous diabetes control and may influence your treatment at discharge.

Insulin deficiency (e.g., due to delayed or missed doses) will rapidly cause ketoacidosis (based on expert opinion).

Practical tip

Critical illness

Consider starting a continuous intravenous insulin infusion for your critically ill patient for achieving glycemic goals and avoiding hypoglycemia.[124][125]

Use a validated protocol/order set for the continuous intravenous insulin infusion.[124]
This allows for predefined adjustments to the insulin infusion rate according to blood glucose measurements and past and current insulin infusion rates, to avoid hypoglycemia.[124]

More info: Continuous intravenous insulin infusion management

If a continuous intravenous insulin infusion is started:

In practice, subcutaneous basal insulin is generally discontinued (based on expert opinion).
- Less often, at some institutions, subcutaneous basal insulin may be continued (provided there is no hypotension and the patient is not on vasopressors) at 75% of the patient's usual dose.
Stop the patient’s usual subcutaneous rapid-acting and mixed insulins while on an intravenous insulin infusion.[135]
Use the continuous intravenous insulin infusion for as short a time as possible.[135]

Once ready to discontinue a continuous intravenous insulin infusion:

Follow an appropriate order set/transition protocol to switch to scheduled subcutaneous insulin.[124]
- This should include calculating the total daily dose of subcutaneous insulin needed, dividing into appropriate basal and bolus doses, monitoring and adjusting dose based on glucose monitoring, and having orders in place for potential hypoglycemic episodes (based on expert opinion).
Give subcutaneous basal insulin at least 2 hours before discontinuing the intravenous infusion to minimize rebound hyperglycemia.[124]
- Emerging data suggest that early administration of subcutaneous basal insulin alongside intravenous insulin infusion does not seem to increase the risk of hypoglycemia.[136][137]

Noncritical illness

Generally, an insulin regimen is preferred for managing hyperglycemia in individuals with diabetes receiving hospitalized care.[124]

If your patient is not eating or drinking or has poor oral intake, a subcutaneous basal insulin or basal plus bolus correction (every 4-6 hours) insulin plan is preferred.
If they are eating adequately, subcutaneous basal insulin with prandial (with each meal, up to 3-4 times a day) and correctional doses is preferred.

In a patient who is already managing their diabetes with insulin, consider whether there is any need to adjust insulin dose when they are admitted to the hospital.

If a patient with type 1 or type 2 diabetes uses insulin at home, has adequate glycemic management, and was not admitted with significant hyperglycemia, it may be appropriate to reduce their routine dose of subcutaneous basal insulin by 20%, particularly if they are eating less than usual. Another factor to keep in mind is that hospital meals generally contain less carbohydrate than meals patients would eat at home (based on expert opinion).
Conversely, patients who are acutely ill with an infection sometimes need more insulin.
Regular monitoring of blood glucose (at least four times daily) can help guide appropriate adjustments to insulin dosing.

More info: Patients using a continuous subcutaneous insulin infusion (CSII) (insulin pump) prior to hospital admission

If a patient with diabetes had been using an insulin pump prior to hospital admission:

Follow your hospital procedure, if available, and request a specialized inpatient diabetes team or endocrinology consult.
Safe continuation of an insulin pump during hospital admission has been advocated by several professional organizations.[124][138][139][140]
Key criteria for safe use include that:[124][141]
- The patient is medically stable, willing, and capable of self-management
- There are no contraindications
- The necessary supplies and resources are available
- There are hospital staff with the appropriate expertise and training, and institutional diabetes technology protocols in place
- Staff are available to perform confirmatory point-of-care (POC) glucose measurements for insulin dose decisions, hypoglycemia assessment and treatment, and at least four times a day (based on expert opinion).

Review noninsulin glucose-lowering medications if your patient had been taking any of these before admission and determine whether these are suitable to continue during admission.

For select patients with type 2 diabetes, it may be acceptable to continue noninsulin glucose-lowering medications, such as a dipeptidyl peptidase-4 (DPP-4) inhibitor.[124] Only consider this in a patient who is (based on expert opinion):
- Clinically stable with mild hyperglycemia
- Eating regularly
- Has no contraindications.
Metformin should be discontinued in patients with contraindications, including those with increased risk of lactic acidosis (e.g., those with renal impairment, shock, or hypoxia) and those with acute heart failure.[142][143] Consider restarting metformin after the acute condition has resolved (based on expert opinion).
In general, stop SGLT2 inhibitors for your patient with diabetes who is admitted to the hospital with an acute illness (based on expert opinion). This is due to the risk of euglycemic ketoacidosis.
- In particular, avoid SGLT2 inhibitors if your patient is severely ill, or if their clinical situation predisposes them to ketoacidosis (e.g., prolonged fasting due to acute illness or surgery).[124][133]
- Be aware that ketoacidosis associated with SGLT2 inhibitors may still be present despite a normal (or near normal) serum glucose level (euglycemic ketoacidosis).[134]
- If an SGLT2 inhibitor is being initiated during a hospital admission (e.g., for treatment of heart failure), this medication should be initiated after recovery from the acute illness.[124]
  - Remain aware of the risk of ketoacidosis which can occur spontaneously with SGLT2 inhibitors.[134]
  - Monitor hydration status and basic metabolic panel (BMP) daily for elevated anion gap and acidosis (based on expert opinion).
  - Check blood beta-hydroxybutyrate (or blood ketone) levels, especially if acidosis is present, or there are symptoms of ketoacidosis (e.g., nausea or vomiting) (based on expert opinion). Measure blood ketones as urinary ketone measurement may be unreliable.
  - Be aware that beta-hydroxybutyrate levels of ≥3.0 mmol/L, along with pH <7.3 or bicarbonate <18 mmol/L, indicate DKA.[134][144]
  - In this situation, stop SGLT2 inhibitor and treat DKA.[144]

Discharge

Start thinking about a discharge plan at the time of hospitalization or after stabilization (based on expert opinion). This should be structured and tailored to the individual.[124]

Provide inpatient diabetes self-management education, focusing on skills needed after discharge, and ensure follow-up and support strategies are in place.
Arrange medication reconciliation:
- Make sure this includes a strategy for switching back to the brand of insulin your patient was on at the time of hospitalization, if appropriate and approved by insurance or covered by other programs (based on expert opinion).
- Clarify regarding timing of restarting any noninsulin glucose-lowering medications that have been temporarily stopped (based on expert opinion).
Communicate promptly to the relevant outpatient healthcare professionals.

Plus – monitor comorbidities during hospital stay

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Plus –

monitor comorbidities during hospital stay

– baseline cognitive and delirium assessments with collateral history

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baseline neurologic exam

Treatment recommended for ALL patients in selected patient group

Perform a baseline neurologic exam at the earliest appropriate opportunity for any patient with a history of stroke.

A patient with an acute condition (e.g., an infection and illness-related hypotension) is at increased risk of stroke.[145][146][147] This risk is even higher in anyone with a history of stroke.
- In particular, ischemic stroke is a known complication of acute bacterial meningitis.[92][148][149]
- Less commonly, hemorrhagic stroke can also complicate bacterial meningitis.[148]
- If there is a change in neurologic status during admission, repeat the neurologic exam to evaluate for a new acute stroke.
Ensure the right level of nursing care for the patient’s condition and ensure that clear orders are written for the patient’s functional and cognitive status (e.g., fall precautions, 1:1, soft restraints, assistance with activities of daily living [ADLs]).
- A patient with a history of stroke has a higher risk of falls and injury.[150]

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baseline cognitive and delirium assessments with collateral history

Treatment recommended for ALL patients in selected patient group

Do a baseline cognitive assessment at the earliest opportunity in any patient with a history of dementia.

Take a collateral history from family, friend, or caregiver to establish whether your patient's cognitive function is stable, gradually declining, or acutely declined.[151]
Check your patient’s level of alertness and orientation to time, place, and person, and corroborate with caregivers and review your patient’s prior medical records (based on expert opinion).
If time allows, a standardized cognitive assessment score is helpful for tracking clinical progress, and determining discharge needs (based on expert opinion).
Validated scoring tools for cognitive assessment include:
- The Mini-Cog Alzheimer's Association: Mini-Cog(TM) Opens in new window
- The Montreal Cognitive Assessment (MoCA)[152]
- The Saint Louis University Mental Status Examination (SLUMS). Saint Louis University: SLUMS Opens in new window
These scores are often best interpreted alongside a functional assessment, usually performed by an occupational therapist and/or a physical therapist.
These scores may not represent the person's usual baseline for cognition due to the impact of the acute condition and its treatment, but it is still good practice to record and repeat it when the person has recovered (based on expert opinion).

Practical tip

Mind (mentation, dementia, depression, and delirium)
Mobility (gait, balance, and falls prevention)
Medications (polypharmacy, deprescribing, optimal prescribing, and adverse medication effects and medication burden)
Multicomplexity (multimorbidity and complex psychosocial situations)
Matters Most to Me (each individual's health outcome goals and care preferences).

Assess for delirium whenever a patient with dementia presents with acute illness.

People living with dementia are at increased risk of delirium when they are admitted to the hospital and throughout their admission.[151][155]
Delirium is not the same as dementia. It is a potentially life-threatening acute, fluctuating change in mental functioning, with inattention, disorganized thinking, and altered levels of consciousness.[156]
Use a screening tool to detect probable delirium, taking the setting into account. Commonly used tools include:
- The Delirium Triage Screen (DTS), which may be rapidly administered in an emergency department setting and assesses arousal and attention. If positive, confirm with a more specific tool, such as the brief Confusion Assessment Method (bCAM).[151][157][158]
- The Confusion Assessment Method (CAM), if your patient is not in a critical care setting.[151][159][160]
- The Confusion Assessment Method for the Intensive Care Unit (CAM-ICU) or the Intensive Care Delirium Screening Checklist (ICDSC) if your patient is in a critical care setting, or in the recovery room after surgery.[155][161][162][163]

Practical tip

Depression can mimic delirium in older adults, particularly in patients with cognitive impairment or other comorbid medical conditions.[151]

Ask if your patient has a diagnosis of depression. If not, use a very brief screening test, such as the Patient Health Questionnaire-2 or Emergency Department Depression Screening Instrument to screen older adults for depression.
A positive screen for depression should prompt further questions, e.g., on suicidal thoughts.

Helping with orientation; make sure patients have their own glasses and/or hearing aids
Getting patients mobilized as soon as possible
Controlling pain adequately
Keeping patients well hydrated and helping them to eat adequately
Monitoring and maintaining regular bowel and bladder function
Using supplemental oxygen as needed
Monitoring for and treating postoperative complications as soon as possible
Reviewing the patient's medications
- Identify and avoid medications that are high-risk for precipitating delirium, such as benzodiazepines, corticosteroids, and anticholinergics.[151][168]

Foster familiarity, e.g., consider facilitating the patient's usual caregiver to stay with the patient and bring in familiar objects from home.[151][158]

Practical tip

Dementia is a risk factor for postoperative delirium.[167][169]

Evaluate baseline cognition using a brief screening tool preoperatively.
Consider the most appropriate method of analgesia to reduce the risk of postoperative delirium.
Monitor for postoperative delirium using a validated screening instrument (e.g., CAM-Short Form).[170]

Evidence: Primary prevention of delirium in hospital using nonpharmacologic interventions

There is evidence that a nonpharmacologic approach reduces the risk of delirium in non-ICU patients in hospital.

A systematic review compared nonpharmacologic interventions designed to prevent delirium with usual care or active control in adults in a non-ICU hospital setting.[171]

Interventions were multicomponent or single components, targeted at a specific risk factor, such as disorientation or dehydration.
Meta-analysis of 14 studies on multicomponent interventions found a significant reduction in incident delirium compared with usual care (RR 0.57, 95% CI 0.46 to 0.71).
There is emerging evidence that multicomponent interventions may reduce hospital length of stay (MD -1.3 days, 95% CI -2.56 to -0.04 days), but there is significant heterogeneity between the studies.
There is little information specifically on people with dementia as this group was frequently excluded from trials despite their increased risk of developing delirium.

More info: Initial investigations for a patient with delirium

If your patient has delirium, check for and treat life-threatening causes:[151][167][172]

Hypoxia
Hypoglycemia
Hypotension
Sepsis
Drug intoxication or withdrawal, including alcohol withdrawal
Acute myocardial infarction

Although every evaluation should be tailored to the individual patient, most patients should receive:[151]

Complete blood count
Comprehensive metabolic panel
Point-of-care glucose
Urinalysis with culture
ECG

Additional tests that may be needed include (based on expert opinion):

Thyroid function tests
Folate and vitamin B12
C-reactive protein
Blood cultures (if bacteremia is suspected)
Chest x-ray

Consider whether your patient requires computed tomography (CT) of the brain.[151]

CT brain should be arranged if your patient has focal neurological deficits, head trauma, reduced level of consciousness, or has a history of fall.
CT brain should also be considered if your patient takes anticoagulants.
In practice, a patient in the hospital setting who has a change in mental status will usually receive a CT brain (based on expert opinion).

Check for and treat any reversible causes of delirium:[151][158][167][172]

Pain
Infection
Poor nutrition
Constipation
Dehydration
Medications
- Ask about recently prescribed medications, especially opioid analgesics, anxiolytics, antipsychotics, corticosteroids, or anticholinergics
Immobility
Poor sleep
Sensory impairment (e.g., ear wax or loss of glasses)

More info: Management of a patient with delirium

Manage patients with delirium initially with nonpharmacologic treatment.[151][158][167]

Reduce disorientation by providing a well-lit room, with a clock and calendar visible (e.g., on the wall).
Encourage and facilitate family, friends, and caregivers to visit the patient.
Use verbal and nonverbal techniques to de-escalate conflict and distress.

Any new antipsychotic prescribed for this purpose must be regularly reviewed, and discontinued as soon as possible.[168][173]
Be aware that the evidence on the efficacy of antipsychotics for delirium is inconclusive, and guidance regarding choice of antipsychotic varies.[151][158][167]
Antipsychotics should be used with caution in patients with a history of dementia as there is an increased risk of mortality in these patients[151][173]
- A systematic review of antipsychotics for delirium in hospitalized adults concluded that the evidence did not support routine use of haloperidol or atypical antipsychotics for this purpose[174]
- All antipsychotics have a warning that they are not approved for dementia-related psychosis.[151]
Haloperidol is contraindicated in patients with Parkinson disease or in patients with dementia with Lewy bodies.[163] Check for all contraindications.
Consider baseline ECG before starting any antipsychotic medication (based on expert opinion).

Document the diagnosis of delirium clearly (based on expert opinion).

Evidence: Risks and safe withdrawal of antipsychotics in older adults

Antipsychotics are associated with increased mortality in people with dementia.

A Cochrane review found very low certainty evidence that typical antipsychotics such as haloperidol improve agitation, but reported that they may improve psychosis slightly in people with Alzheimer disease and vascular dementia. Atypical antipsychotics probably reduce agitation. Both types increase the risk of somnolence and extrapyramidal symptoms.[175]
A network meta-analysis found that people who take atypical antipsychotics for behavioral and psychological symptoms of dementia may have a small improvement in behavioral and psychological symptoms but have increased safety risks including for cerebrovascular adverse events, compared with those taking placebo.[176]
Contrary to popular belief, long-term antipsychotic use can be safely withdrawn in most people with dementia once behavior has settled.[177]

– establish goals of care, taking into account any advance directives

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assess your patient’s level of frailty

Treatment recommended for ALL patients in selected patient group

Assess your patient's level of frailty to:[178][179]

Establish whether management plans are consistent with goals of care, and
Identify whether further assessment and enhanced care is needed.

Practical tip

Ask your patient (with input from caregivers if relevant) about their functional capability 2 weeks BEFORE this acute episode to determine baseline state.[184]
Use the Clinical Frailty Scale (CFS) if your patient is ≥65 years old.[185][186] Dalhousie University: Clinical Frailty Scale Opens in new window
- This tool is a practical aid to identify frailty, but should not be relied on in isolation.
- Do not use the CFS to assess younger patients, or those with disabilities that reflect single-system problems (e.g., spinal cord injury).[184]
- If your patient scores 5 or higher, consider arranging a comprehensive geriatric assessment, if this is feasible and clinically appropriate, at the earliest opportunity.[181]
- A higher prehospital frailty score is associated with an increased risk of adverse outcomes including risk of mortality in-hospital, at 1, 3, 6, and 12 months; all-cause readmission within 30 days; extended length of stay; discharge to a nursing home, residential care, hospital, or a high level of care; and functional decline.[187]
Look for nonspecific complaints, such as delirium and falls.
Help to implement multidisciplinary care and to tailor the management approach according to the patient's values and goals of care.[188]

Practical tip

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establish goals of care, taking into account any advance directives

Treatment recommended for ALL patients in selected patient group

Ask your patient if they have an advance directive (e.g., a living will, a healthcare proxy) and/or a Do Not Resuscitate (DNR) or Do Not Intubate (DNI) order.[193]

This applies to all patients, but may be particularly relevant to patients living with frailty and/or with certain comorbidities, such as dementia, stroke, heart failure, COPD, and late-stage CKD (based on expert opinion).
Ensure any existing advance directives align with your patient's current preferences and goals of care.[193]

Practical tip

Discuss specific treatment options and health trajectory to help your patient (or surrogate decision-maker) make informed decisions about their care.[193][195][196]

This should include (based on expert opinion):
- Code status (e.g., Do Not Resuscitate [DNR] order, Do Not Intubate [DNI] order)
- Other life-sustaining treatment options (e.g., vasopressors, extracorporeal membrane oxygenation [ECMO], kidney replacement therapy, blood transfusions, parenteral/enteral nutrition).

Assess and document decision-making capacity (the ability to make a specific decision at the time that the decision needs to be made).[197][198][199]
- Attempt to improve your patient’s capacity to participate in decision-making by addressing communication barriers and alleviating exacerbating factors, such as delirium.[200]
- Be aware that an individual’s decision-making capacity can vary over time so should be reassessed periodically.[200]
If your patient lacks decision-making capacity, establish whether they have an advance directive.[195][198][199]
- This may include a living will and/or a designated proxy known as a Durable Power of Attorney for Healthcare (DPAHC). [198]
If your patient who lacks decision-making capacity has no applicable advance directive, including no designated proxy, identify a surrogate decision-maker from a priority list of individuals such as spouse, adult child, and adult sibling.[198][199]
- The hierarchy of this list, and the scope of surrogates' decision-making, varies from state to state.
- Ensure a surrogate's decisions are consistent with patient preferences and best interests.
- In the case of conflict, consider consulting your hospital's ethics committees.
If your patient is an older adult and is unrepresented (a patient without decision-making capacity for a particular medical intervention who lacks both a relevant advance directive and a surrogate decision-maker), the American Geriatrics Society recommends:[200]
- Attempting to identify a nontraditional surrogate (e.g., a close friend, live-in companion, neighbor, or other individual who knows the patient well), in the absence of a traditional surrogate (next of kin), who is willing and able to represent your patient’s wishes and values
- Avoiding unilateral decision-making in the absence of a suitable surrogate, which could carry a risk of bias. The AGS favors a structured multidisciplinary consensus approach to decision-making.

Check your relevant state law and practice accordingly. There may be no available out-of-court process to allow nontraditional surrogates in many states.
If your unrepresented patient is in an urgent or life-threatening situation:[198][199]
- Use all available information on a patient's preferences, values, and beliefs to guide treatment decisions. If preferences are not known, urgent care decisions should be made in the patient's best interests.[195][198][201]
- Consider using the Four Box Model (also known as the Four Quadrant Model) to aid ethical decision-making. This consists of four principles:[200][202]
  - Medical indications for treatment
  - Patient preferences for care
  - Quality of life
  - Contextual features (this includes being mindful of provider biases, the patient’s psychosocial context, and how the treatment and cost of care may impact the patient).
In a less urgent situation, rarely, a court-appointed guardian may be appointed to make decisions in this context.[195][198][200]

– monitor and manage blood glucose during the hospital admission

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monitor and manage blood glucose during the hospital admission

Treatment recommended for ALL patients in selected patient group

The risk of hypo- and hyperglycemia increases when a person with diabetes is admitted to the hospital acutely (based on expert opinion).
More frequent monitoring is needed after any episode of hyperglycemia or hypoglycemia and after any change in hypoglycemic medication (based on expert opinion). If a correction dose of insulin is given at bedtime, check blood glucose about 4 to 6 hours later (usually about 2 a.m.) (based on expert opinion).
If your patient is having surgery, the American Diabetes Association (ADA) recommends monitoring blood glucose at least every 2 to 4 hours while the individual is taking nothing by mouth (npo).[124]
Any patient on an intravenous insulin infusion needs more frequent blood glucose measurements, ranging from every 30 minutes to every 2 hours.[124]

Practical tip

Decide on target blood glucose levels.

There is a general consensus among different guideline organizations on target blood glucose levels for people with diabetes in the hospital.

For most critically ill patients, the ADA recommends a target range of 140 to 180 mg/dL (7.8 to 10.0 mmol/L) once treatment has been started for persistent hyperglycemia.[124]
- Stricter target ranges, such as 110 to 140 mg/dL (6.1 to 7.8 mmol/L), may be acceptable in select critically ill patients, but only if they can be achieved without significant hypoglycemia.[124]
For most noncritically ill patients, the ADA and the Endocrine Society recommend a target range of 100 to 180 mg/dL (5.6 to 10.0 mmol/L).[124][138]
- Less stringent goals are appropriate in some patients, for instance those at high risk of hypoglycemia, advanced kidney failure, and those who are terminally ill. The ADA recommends that the focus in these people should be on avoiding hypoglycemia and symptomatic hyperglycemia.[124]

Evidence: Blood glucose targets for critically ill patients with hyperglycemia

Evidence argues against very tight glucose control in critically ill patients (a mixed population with and without a history of diabetes).

Intensive care setting:
- A randomized controlled trial (RCT) of critically ill patients in a primarily surgical intensive care setting found lower patient mortality with tight glucose control, 80 to 110 mg/dL (4.4 to 6.1 mmol/L), compared with "conventional" more liberal glucose control.[203]
- However, a subsequent multicenter RCT in critically ill medical and surgical patients in other intensive care settings found increased mortality with tighter glucose control, possibly due to more frequent episodes of hypoglycemia.[204]
- In 2017, two network meta-analyses found no benefit in mortality with tight glycemic control when compared with less tight control (79.2 to <109.8 mg/dL [4.4 to <6.1 mmol/L] vs.140.4 to <219.6 mg/dL [7.8 to <12.2 mmol/L] in one report; <110 to 144 mg/dL [<6.1 to 8.0 mmol/L] vs.144 to >180 mg/dL [8.0 to >10.0 mmol/L] in the second report) but a significant increase in the risk of hypoglycemia.[205][206]

More info: Hyperglycemia during the ongoing hospital admission

Hyperglycemia in admitted patients, whether with known diabetes or not, is associated with adverse patient outcomes, including increased mortality.[142]

Act promptly to treat hyperglycemia to avoid diabetic ketoacidosis (DKA) and hyperosmolar hyperglycemic state (HHS).
For persistent hyperglycemia, defined as blood glucose ≥180 mg/dL (≥10.0 mmol/L) confirmed on two occasions within 24 hours, the ADA recommends:[124]
- Starting or intensifying insulin therapy for most critically ill patients.
- Starting or intensifying insulin and/or other glucose-lowering therapies for most noncritically ill patients.

If your patient has DKA or HHS, consider the appropriate unit for management.

Indications for management in the intensive care unit (ICU) include:[134]
- Severe DKA or severe HHS
- Critical illness as the precipitating cause (e.g., sepsis, acute myocardial infarction, gastrointestinal bleeding)
- Altered mental status
- Another concurrent indication for ICU admission.
See Diabetic ketoacidosis or Hyperosmolar hyperglycemic state.

Be aware that the following interventions may be associated with hyperglycemia and may need to be reviewed:[207]

Corticosteroids
Some second-generation antipsychotics (e.g., olanzapine, clozapine)
Fluoroquinolone antibiotics (e.g., ciprofloxacin)
Calcineurin inhibitors (e.g., tacrolimus)
Protease inhibitors (e.g., ritonavir)
Artificial nutrition (parenteral or enteral).

Ask for a specialized inpatient diabetes team consult, if available, or endocrinology consult where hyperglycemia is difficult to control.

More info: Hypoglycemia during the ongoing hospital admission

Monitor blood glucose and adjust medication in response to illness and hospital meal times, to reduce the risk of hypoglycemic episodes.

Ensure that a hypoglycemia management surveillance protocol is in place, with an individualized plan for preventing, identifying, and treating hypoglycemia.[124]
- Immediately correct level 2 hypoglycemia (blood glucose levels <54 mg/dL [<3.0 mmol/L]) and level 3 hypoglycemia (characterized by altered mental and/or physical functioning, requiring assistance for treatment of hypoglycemia from another person for recovery, with no defined glucose level).
- Promptly treat level 1 hypoglycemia (blood glucose levels <70 mg/dL [<3.9 mmol/L] and ≥54 mg/dL [≥3.0 mmol/L]) to prevent progression to more significant levels of hypoglycemia.
- Ensure hypoglycemia treatment is included in all insulin orders.
Treat hypoglycemia, which usually involves provision of 15 g of fast-acting carbohydrates (oral or enteric juice or table sugar; intravenous dextrose). Check blood glucose 15 minutes after the treatment. If the blood glucose is not in a safe range (usually considered to be >90 mg/dL [>5.0 mmol/L]), repeat the treatment. If the oral and enteric route is not available, administer intravenous dextrose. If the patient has no intravenous access, administer glucagon (based on expert opinion). See Diabetic hypoglycemia.
Be aware that hypoglycemia may be induced by treatment of hyperglycemia/diabetes.[208]
- Sliding scale insulin (correctional or supplemental insulin without basal insulin) is associated with the highest rates of hypoglycemia (based on expert opinion). Sole use of sliding scale insulin is not recommended for most individuals in a hospital inpatient setting.[124]
- Be aware of the risk of hypoglycemia in patients on intensive insulin regimens (e.g., multiple daily injections, continuous subcutaneous insulin infusion, or automated insulin delivery systems), and those on basal insulin, sulfonylureas, or meglitinides.
- A combination of insulin and sulfonylureas further increases hypoglycemia risk.
Review and adapt your patient’s treatment plan to prevent recurrent episodes of hypoglycemia.[124]
- Be aware that level 1 hypoglycemia often predicts subsequent level 3 hypoglycemia.
Document any episodes of hypoglycemia in the electronic health record.[124]

Causes of hypoglycemia include:[124]

Inappropriate insulin dose or dose adjustment
Insulin or oral hypoglycemic medication error
Wrong timing of insulin in relation to meals
Inadequate follow-up of first episode of hypoglycemia
Patients eating less but taking the same amount of diabetes medication
Reduced appetite or vomiting
Unexpected interruption of enteral or parenteral feedings
Reduced infusion rate of intravenous dextrose
Delayed or missed blood glucose checks
Sudden reduction of corticosteroid dose
Altered ability of a patient to report symptoms
Recovery from an acute illness.

These medications include:
- Some antibiotics (e.g., fluoroquinolones, trimethoprim/sulfamethoxazole, chloramphenicol)[209][210]
- Other nondiabetic medications (e.g., ACE inhibitors, beta-blockers, chloroquine, disopyramide, pentamidine, salicylates)[209]
Polypharmacy of multiple hypoglycemia-causing medications also increases this risk.[208]
This list is not exhaustive. Consult your local drug information source (based on expert opinion).

Take action if blood glucose falls below 100 mg/dL (<5.6 mmol/L) (based on expert opinion). Fasting blood glucose levels <100 mg/dL (<5.6 mmol/L) are predictive of next-day hypoglycemia.[124]

Give extra carbohydrates to prevent hypoglycemia unless your patient is going to eat a meal within an hour (based on expert opinion).
Modify insulin doses to prevent glucose from going below the target for the patient.

Take steps to reduce the risk of hypoglycemia at night. Assuming your patient is not npo (nothing by mouth), they are likely to have a smaller evening meal in the hospital than at home.

In the absence of significant hyperglycemia, consider reducing the evening basal insulin by 20% on admission (based on expert opinion).
Remember that for many patients with very high insulin needs at home, the needs are often much lower in the hospital, presumably because of changes in diet.
Review the dose used during recent prior hospitalization(s) when deciding the starting dose of insulin (based on expert opinion).

More info: Self-management of diabetes in the hospital

The ADA recommends that suitable candidates for self-managing their diabetes in the hospital include those who:[124]

Normally perform self-management at home
Have the necessary cognitive and physical skills while in the hospital
Have adequate oral intake
Are proficient in carbohydrate estimation
Take multiple daily insulin injections or use insulin pumps
Have stable insulin requirements, and
Understand sick-day management.

The patient and hospital care team should review the decision on self-management on a daily basis.[124]

Inspect injection sites if your patient is on insulin injections at home (based on expert opinion).

Check for insulin lipodystrophy and re-educate on injection technique, if needed.

Continuous glucose monitoring

Consider continuing personal continuous glucose monitoring (CGM) for any individual who uses this wearable technology at home.[211] Consult with the inpatient diabetes team if available.[140]

Although not approved by the Food and Drug Administration (FDA), emergency use authorization was granted during the coronavirus disease 2019 (COVID-19) pandemic and several professional bodies suggest this may be useful if complying with institutional policies and safety regulations.[124][211][132][140]
Confirmatory point-of-care glucose measurements are still needed for assessment of hypoglycemia and to guide decisions on insulin dosing.[124]
Be aware that some concomitant medications, such as acetaminophen (above a certain dose), dopamine, heparin, vitamin C, and hydroxyurea, may result in inaccurate measurements by CGM devices.[211]

More info: Management of patients with diabetes who are receiving end-of-life care

If a patient with diabetes is receiving end-of-life care:

Discuss with your patient and their family/caregivers and agree on the level of intensity of care. Less stringent targets for blood glucose levels are appropriate, with the aim of avoiding hypoglycemia and symptomatic hyperglycemia.[124][132][212]
Prioritize providing comfort and reducing the burdens of strict blood glucose management.[212]
Be aware that stopping basal insulin in a person with type 1 diabetes can lead to dehydration, ketoacidosis, nausea, and associated vomiting; therefore, continuing basal insulin in such a person could be considered as a comfort care (based on expert opinion).

– ensure monitoring is in place to detect any asthma exacerbation during your patient's hospital admission

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examine your patient’s feet

Treatment recommended for ALL patients in selected patient group

Examine the feet of any adult with diabetes on their admission to the hospital and whenever they become ill.[213]

This is to detect new ulcerations or infection, which may be unnoticed by the patient and may even be the cause of their acute illness (e.g., patient presenting with sepsis, or endocarditis where the original focus of infection is the foot lesion).

Inspect the foot for lesions and examine for loss of protective sensation.

To perform a comprehensive foot examination:[214]

Inspect the skin.
Assess any foot deformities.
Do a neurologic exam, including 10-g monofilament testing or Ipswich touch test, with at least one other assessment (pinprick, temperature, or vibration).[215]
Do a vascular exam, including pulses in the legs and feet.

If your patient has reduced sensation, they are at risk for diabetic foot ulceration.[214] Provide pressure relieving devices.

Order daily heel checks for signs of pressure trauma. There is a debate about whether compression stockings should or should not be used in people with diabetes; do not use them if there is known peripheral vascular disease.

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ensure monitoring is in place to detect any asthma exacerbation during your patient's hospital admission

Treatment recommended for ALL patients in selected patient group

Acute worsening of respiratory symptoms may suggest a patient with comorbid asthma is having an acute exacerbation of their asthma.

Follow guideline recommendations on assessing severity and managing an acute exacerbation of asthma in adults.[97]
See Acute asthma exacerbation in adults.

This is due to concern over possible additive anticholinergic adverse effects.
Ensure to represcribe the LAMA once the nebulizer treatment has been stopped.

Be aware that the long-term use of beta-2 agonists to manage asthma may increase the risk of cardiovascular events.

Evidence: Cardiovascular harm with beta-2 agonists

Beta-2 agonists may increase the risk of myocardial infarction and other adverse cardiovascular events.

Beta-2 agonists increase heart rate and reduce potassium levels.[216] They are absorbed into the systemic circulation and there is evidence that long-term regular use may be associated with an increased risk of myocardial infarction, unstable angina, congestive heart failure, and arrhythmias.[217][216]
However, it is not routine practice to discontinue beta-2 agonists if they are needed for comorbid asthma.

– ensure monitoring is in place to detect any COPD exacerbation during your patient's hospital admission

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ensure monitoring is in place to detect any COPD exacerbation during your patient's hospital admission

Treatment recommended for ALL patients in selected patient group

Acute worsening of respiratory symptoms may suggest a patient with comorbid COPD is having an acute exacerbation.[102]

Differentiate from other conditions, such as a pulmonary embolism, acute heart failure, and pneumonia.
Follow guideline recommendations.[102] See Acute exacerbation of COPD.

This is due to concern over possible additive anticholinergic adverse effects.
Ensure the LAMA is represcribed once the nebulizer treatment has been stopped.

Be aware that the long-term use of beta-2 agonists to manage COPD may increase the risk of cardiovascular events.

Evidence: Cardiovascular harm with beta-2 agonists

Beta-2 agonists may increase the risk of myocardial infarction and other adverse cardiovascular events.

Beta-2 agonists increase heart rate and reduce potassium levels.[216] They are absorbed into the systemic circulation and there is evidence that long-term regular use may be associated with an increased risk of myocardial infarction, unstable angina, congestive heart failure, and arrhythmias.[216][217]
However, the Global Initiative for Chronic Obstructive Lung Disease states that there has been no reported association between beta-2-agonist use and increased mortality in people with COPD.[102] It is not routine practice to discontinue beta-2 agonists if they are needed for comorbid COPD.

– continue your patient's inhalers as prescribed for asthma or COPD

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mental status exam

Treatment recommended for ALL patients in selected patient group

Perform a mental status exam as the clinical situation allows (based on expert opinion).

The mental status exam is one of the main clinical tools routinely used in psychiatric practice, aiding diagnosis and guiding further management. Mood is one of the assessed domains.

Consider assessing current symptoms of depression using the PHQ-9 questionnaire.[218][219]

The PHQ-9 questionnaire can be used as a reliable and valid measure of depression severity in patients with a known diagnosis of depression, as well as a screening tool.
This can be self-administered or administered by the clinician, and takes less than 3 minutes to complete.
Results indicate severity of depressive symptoms.

Take into account other factors that may be influencing the patient's mental status (e.g., the effect of any illicit drug use or alcohol).[219][220]

In particular, consider whether symptoms of depression could be part of the acute medical illness (based on expert opinion).

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review current treatment for depression

Treatment recommended for ALL patients in selected patient group

Continue the patient’s usual antidepressant, unless there are good reasons not to (based on expert opinion).

If antidepressants are stopped abruptly, the patient may develop antidepressant discontinuation syndrome.[221]
The severity of the symptoms of discontinuation may vary, but they may be unpleasant and may complicate the management of the acute medical condition.

When reviewing current medications, consider:

Current and previous adverse effects
Recent changes in dose
Recent medication changes from a different drug class
The specific diagnostic subtypes of depression when prescribing medications (e.g., it is likely that patients suffering from psychotic depression would be coprescribed an antipsychotic)
Augmenting strategies that may be used when treating resistant depression (e.g., lithium or quetiapine augmentation of a selective serotonin-reuptake inhibitor [SSRI]).

Consider drug-drug interactions.

Antidepressants (particularly those that inhibit the CYP450 pathway) may cause significant interactions with drugs used for other conditions.[222]

Consider psychiatric complications when prescribing nonpsychotropic drugs.

Take particular care when prescribing anticonvulsants, antiparkinsonian drugs, and corticosteroids.

Consider adverse effects, which may include the following:

Hyponatremia, caused by antidepressants, especially SSRIs, and compounded by other coprescribed drugs (e.g., diuretics).[223][224][225][226] Review your patient’s serum electrolyte results and consider antidepressants as a potential contributing factor if they have hyponatremia.
Serotonin syndrome (altered mental state, agitation, tremor, hyper-reflexia, ocular clonus or inducible clonus, muscle rigidity, diaphoresis, tachycardia, increased bowel sounds, temperature >100.4°F [>38°C]), especially with polypharmacy and/or overdose of a serotonergic agent.[227][228] See Serotonin syndrome.
- Be particularly aware of increased risk of serotonin syndrome in patients with kidney failure on SSRIs.[229][230]
Hepatotoxicity.[231] Adjust doses of antidepressants in patients with hepatic impairment as necessary.
- However, antidepressants are rarely the cause of hepatic impairment.[231]
Prolonged QTc, arrhythmias, increased heart rate, postural hypotension with tricyclic antidepressants.[232][233] Obtain an ECG, especially in people at risk of arrhythmias.[234]
Gastrointestinal bleeding. SSRIs are associated with an increased risk of gastrointestinal bleeding.[223][235][236] Risk is particularly increased when coprescribed with aspirin, nonsteroidal anti-inflammatory drugs (NSAIDs), or oral anticoagulants.[236][237][238] Monitor closely and consider gastroprotection with proton-pump inhibitors if SSRI use cannot be avoided (based on expert opinion).

This list of adverse effects is not exhaustive - consult your drug information sources or hospital pharmacist for further information, and consider a psychiatric consult for advice.

Practical tip

Ask your patient about nonpharmacologic treatments for their depression and check the current level of community support.

This may include other outpatient healthcare professionals, charities, and family and social networks.

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consider psychiatric consult

Treatment recommended for ALL patients in selected patient group

Consider a psychiatric consult for any patient with comorbid depression who is admitted to the hospital with an acute condition.

Consult is strongly advised in patients with severe symptoms of depression or additional symptoms such as self harm, suicidal ideation, homicidal ideation, catatonia, psychosis (based on expert opinion).
Consult may not be required if there are no concerns that depression and/or its management (e.g., medication) may be affecting the acute condition (based on expert opinion).
Accidents of unclear circumstances, self-injurious behaviors, and/or suicide attempts (including alleged "accidental" overdose of medication) should trigger clinical suspicion of comorbid mental health disorder (based on expert opinion).

Ensure your patient has adequate support with their treatment post-discharge.

Keep in mind that the psychological impact of comorbid depression may be associated with poor adherence with recommended physical health treatments, from medication to rehabilitation.[242][243][244] This may lead to worse clinical outcomes, including higher readmission risk.[245][246]
Most importantly, affective symptoms, including depression, have been linked with excess mortality, though a causal link remains to be proven.[247][248]

1st line – targeted antibiotic therapy

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manage tobacco dependence

Treatment recommended for ALL patients in selected patient group

If your patient currently uses tobacco, assess their tobacco use and provide assistance and support with tobacco cessation interventions.[249][250][251]

Advise:

That nicotine is highly addictive and nicotine withdrawal can be extremely distressing and uncomfortable.[250]
NRT prevents rapid withdrawal.[250]
That there are a number of highly effective treatment options that offer the best chance of stopping smoking.[249][250][251]

Ensure a sufficient dose of NRT is prescribed to adequately address withdrawal symptoms.[255]
Ask the patient how many cigarettes they smoke per day; this may determine the starting dose of NRT.
Ask about the type of tobacco product used, including e-cigarettes, water pipe use, and other smokeless tobacco products (snuff, ground, or chewing tobacco), as use of these products also results in nicotine addiction.
Check drug information sources for any contraindications or cautions, particularly if your patient has one or more comorbidity and/or is hemodynamically unstable.
Assess for symptoms of withdrawal daily (based on expert opinion).

One Cochrane Review found high-certainty evidence that varenicline is an effective treatment for tobacco dependence.[257] The same review found that people taking varenicline likely have an increased chance of a more serious adverse effect (e.g., cardiac) that could result in hospital admission; however, these are still rare (2.7% to 4% of people on varenicline, compared with 2.7% of people not taking varenicline) and may include events that are unrelated to varenicline.[257] Check drug information sources for a full list of contraindications and cautions or seek pharmacist advice.
Mental health illness is NOT a contraindication to prescribing varenicline. However, varenicline should be used with caution in people with a pre-existing psychiatric illness as it may worsen symptoms.
Bupropion is an alternative option to varenicline for tobacco cessation but is less likely to result in successful quitting.[257] Consider the potential for drug-drug interactions.

Ensure your patient has follow-up with their primary care practitioner or addiction medicine physician to continue treatment for tobacco dependence.

Practical tip

See Smoking cessation for more information.

ACUTE

confirmed meningococcal meningitis: penicillin-susceptible

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targeted antibiotic therapy

After diagnosis is confirmed (generally within 12-48 hours of admission to the hospital), antimicrobial therapy can be modified according to the causative organism and antibiotic susceptibilities.[67][76] Typically, the duration of antibacterial treatment depends on the clinical response and the cerebrospinal fluid microbiologic response after treatment has started. Most experts advise discontinuing corticosteroids for bacterial meningitis if the causative organism is proven to be Neisseria meningitidis, although some advise that adjunctive treatment should be continued irrespective of the pathogen.[54]

Neisseria meningitidis that is penicillin-susceptible (minimum inhibitory concentration [MIC] <0.1 micrograms/mL) should be treated with ampicillin or penicillin-G. Alternatives include a third-generation cephalosporin (e.g., ceftriaxone).[67][77]

Treatment course: 7 days.

Check baseline kidney function and monitor closely

Check baseline kidney function as you would on admission for any acutely ill patient and monitor closely, especially if your patient has risk factors for acute kidney injury, including a history of CKD, diabetes, and/or heart failure.[123]

Acute illness also increases the risk of deterioration in kidney function.
Monitor for and respond to oliguria.

Primary options

penicillin G potassium: neonates: consult specialist for guidance on dose; children: 250,000 to 400,000 units/kg/day intravenously given in divided doses every 4-6 hours, maximum 24 million units/day; adults: 2 million units intravenously every 2 hours

penicillin G potassium : neonates: consult specialist for guidance on dose; children: 250,000 to 400,000 units/kg/day intravenously given in divided doses every 4-6 hours, maximum 24 million units/day; adults: 2 million units intravenously every 2 hours

ampicillin : neonates: consult specialist for guidance on dose; children: 200-400 mg/kg/day intravenously given in divided doses every 4-6 hours, maximum 12 g/day; adults: 1-2 g intravenously every 3-4 hours

Secondary options

ceftriaxone : neonates: consult specialist for guidance on dose; children: 80-100 mg/kg/day intravenously given in divided doses every 12-24 hours, maximum 4 g/day; adults: 2 g intravenously every 12 hours

These drug options and doses relate to a patient with no comorbidities.

Primary options

penicillin G potassium : neonates: consult specialist for guidance on dose; children: 250,000 to 400,000 units/kg/day intravenously given in divided doses every 4-6 hours, maximum 24 million units/day; adults: 2 million units intravenously every 2 hours

ampicillin : neonates: consult specialist for guidance on dose; children: 200-400 mg/kg/day intravenously given in divided doses every 4-6 hours, maximum 12 g/day; adults: 1-2 g intravenously every 3-4 hours

Secondary options

ceftriaxone : neonates: consult specialist for guidance on dose; children: 80-100 mg/kg/day intravenously given in divided doses every 12-24 hours, maximum 4 g/day; adults: 2 g intravenously every 12 hours

Show drug information for a patient with no comorbidities

Drug choice, dose and interactions may be affected by the patient's comorbidities. Check your local drug formulary.

Primary options

penicillin G potassium

For patients with CKD, please check your local drug formulary

For patients with CKD see dose in the Renal Drug HandbookFor patients with CKD see dose in the Renal Drug Handbook

ampicillin

For patients with CKD, please check your local drug formulary

For patients with CKD see dose in the Renal Drug HandbookFor patients with CKD see dose in the Renal Drug Handbook

Secondary options

ceftriaxone

For patients with CKD, please check your local drug formulary

For patients with CKD see dose in the Renal Drug HandbookFor patients with CKD see dose in the Renal Drug Handbook

Plus – review diabetes medication (NEVER stop insulin in a person with type 1 diabetes)

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supportive care

Treatment recommended for ALL patients in selected patient group

Patients with meningococcal infections must be monitored closely for complications such as shock, elevated intracranial pressure, seizures, and coagulopathy.

Severe meningococcal infections are frequently complicated by hypoglycemia or hyperglycemia, acidosis, and other biochemical abnormalities that require attention.

Oxygen therapy in your patient with asthma

Measure resting oxygen saturation in all acutely ill patients.

Be aware that pulse oximetry may overestimate oxygen saturation in patients with darker skin tones.[97]
If your patient's asthma is stable, follow guideline recommendations for oxygen saturation target for the presenting acute condition.
If the acute presenting condition triggers an acute exacerbation of your patient's asthma, the Global Initiative for Asthma recommends controlled oxygen to maintain saturations between 93% and 95%.[97]
Adjust oxygen saturation targets for altitude, where appropriate.[97]
Hypercapnia in asthma is an indicator of very severe disease showing a patient is tiring and needs ventilatory support.[98][99][100]

Oxygen therapy in your patient with COPD

Obtain a blood gas measurement if your patient with COPD has oxygen saturation <90%, clinical signs of hypercapnia (e.g., altered mental status), or respiratory distress (based on expert opinion).
- An arterial blood gas (ABG) should be used to assess patients with respiratory failure and should always be obtained if hypoxemia is an issue.[103][104]
  - Peripheral venous blood gas (VBG) analysis has increasingly been used to estimate carbon dioxide, pH, and other variables.[105] It is less painful for the patient and may be associated with fewer complications than an ABG.[105]
  - One Cochrane Review found limited data of low to very low certainty evidence that VBG is sensitive for the diagnosis of respiratory failure and isolated hypercarbia.[105] However, it has poor specificity compared with ABG analysis, making it less reliable when precise data are necessary.[105]
Recheck blood gas as clinically indicated.[102]

Chronic hypercapnia[106]
Hypercapnia on presentation
Previous history of hypercapnic respiratory failure[103]
Moderate or severe COPD, particularly if on long-term oxygen therapy[103]
Evidence of chronic hypoventilation for other reasons, e.g., obesity hypoventilation syndrome, taking sedatives or hypnotic drugs.[102][106]

Critically ill and needs high levels of oxygen

This includes patients with comorbid COPD who need high levels of oxygen due to a critical illness such as shock, sepsis, major head injury, status epilepticus, anaphylaxis, or major trauma.

In this scenario, some guidelines recommend an initial target oxygen saturation in line with the recommendation for patients without COPD.[103]

Evidence suggests that targeting an upper oxygen saturation level of 96% may be preferred compared with a higher level.[107][108]
Subsequently, you may need to adjust to controlled oxygen therapy with a target oxygen saturation range of 88% to 92% depending on the blood gas results.[103]

Acutely but not critically ill and at risk of hypercapnic respiratory failure

This includes patients with comorbid COPD who have risk factors for hypercapnic respiratory failure and an acute condition, but are not critically ill.[103]

Give controlled oxygen therapy and use an initial target oxygen saturation of 88% to 92%.[102][103]

Check blood gas and recheck after 30 to 60 minutes.[103]

Not critically ill and NOT at risk of hypercapnic respiratory failure

As an example, a patient may have stable, mild COPD with minimal symptoms.

Use an initial target oxygen saturation as recommended by guidelines for the presenting acute condition.

Evidence suggests that for most acutely ill patients, targeting an upper oxygen saturation level of 96% may be preferred compared with a higher level.[107][108]

Measure blood gas as soon as possible[103]

Subsequently, you may need to adjust to controlled oxygen therapy with a target oxygen saturation range of 88% to 92% depending on the blood gas results.[103]

High-flow nasal cannula (HFNC)

Decreasing the work of breathing[109][110]
A theoretical provision of low-level positive end-expiratory pressure (PEEP)[109][110][111]
Facilitating secretion mobilization.[109][110]

Ventilatory support

Start noninvasive bilevel ventilation (BiPAP) if the patient has at least one of the following:[102]

Respiratory acidosis (PaCO₂ ≥45 mmHg [6 kPa] and arterial pH ≤7.35)
Severe dyspnea and/or increased work of breathing (e.g., use of respiratory muscles, paradoxical movement of the abdomen, retraction of the intercostal spaces)
Persistent hypoxemia despite supplemental oxygen.

Start invasive mechanical ventilation support if this is indicated and the patient is considered suitable. Indications for invasive mechanical ventilation include:[102]

Inability to tolerate, or failure of, noninvasive ventilation (particularly if they have life-threatening hypoxemia)
Status post respiratory or cardiac arrest
Reduced consciousness, or psychomotor agitation that is inadequately controlled by sedation
Massive aspiration or persistent vomiting
Persistent inability to remove respiratory secretions
Severe hemodynamic instability without response to fluids or vasoactive drugs
Severe ventricular or supraventricular arrhythmias.

When considering endotracheal intubation with mechanical ventilation, always take into account the patient's wishes (e.g., advance directives).[102]

Assess fluid status and manage fluid balance particularly closely

In a patient with heart failure and/or chronic kidney disease (CKD), judicial use of fluids is crucial to preventing clinically significant volume overload.

Be aware that hypovolemia may be difficult to assess in a person with heart failure and/or CKD.

As with any patient presenting acutely, look for signs of volume depletion on physical exam, by assessing:[112]

Vital signs:
- Blood pressure, (particularly systolic blood pressure [SBP] and mean arterial pressure)
- Pulse
- Postural hypotension
Peripheral perfusion
Capillary refill time
Jugular venous distension
Passive leg raise.

More info: The RUSH exam

The RUSH exam involves a three-part physiologic assessment using point of care ultrasound (POCUS):[114]

1. The pump, i.e., the cardiac status
- Evaluate cardiac status by looking for: pericardial effusions and cardiac tamponade, left ventricular contractility, and right ventricular size
2. The tank, i.e., the effective intravascular volume status
- Assess the fullness of the tank by examining the inferior vena cava (IVC) and/or internal jugular veins
- Evaluate for "leakiness" of the tank, or free fluid in the abdominal and thoracic cavities, by performing Focused Assessment of Sonography for Trauma (FAST) and thoracic ultrasound to assess for fluid in the abdominal and thoracic cavities[115][116]
- Assess compromise of the tank by assessing for pneumothorax
3. The pipes, i.e., the arterial and venous sides of the circulatory system
- Assess the aorta looking for aortic aneurysm, rupture, dissection
- Assess lower extremity and/or upper extremity veins for deep vein thrombosis.

Other variations of RUSH have been described.[113]

Practical tip

Heart failure

Be aware that an SBP of <90 mmHg may suggest hypotension, but a patient on medication for chronic heart failure can have a baseline SBP of <90 mmHg.

Consider consultation with a cardiologist and/or intensivist.

With a suspected low output or cardiogenic shock state
With massive fluid overload, when high doses of diuretic are needed or with diuretic resistance
When unable to establish volume state
When titrating inotropes.

CKD

A patient with CKD who is hypovolemic needs immediate fluid resuscitation.

Reassess your patient after initial fluid challenge and further address the cause of hypovolemia.
If they do not rapidly stabilize:
- Consider activating the rapid response team and obtaining specialist consultation
- Consider transferring your patient to an intensive care setting where hemodynamic monitoring is possible (based on expert opinion).

Continue to monitor fluid balance particularly closely

Accurate monitoring of volume status is essential in a person with heart failure and/or chronic kidney disease (CKD).[117]

There is a significant risk of pulmonary edema with fluid resuscitation in a patient with heart failure and/or CKD, so monitor closely.
Monitoring should include:
- Regular clinical assessment of volume status (pulse, BP, jugular venous distension [JVD], and check for pulmonary and peripheral edema)
- Fluid balance (input/output chart) and daily weight
- BUN and serum creatinine to monitor kidney function, at least daily.
Consider bladder catheterization if urinary output is difficult to measure, but be aware of increased risk of infection and trauma.
Patients with greater clinical complexity, such as those with heart failure and/or advanced CKD may need admission to the intensive care unit for more invasive monitoring and interventions. If noninvasive bedside assessments are not adequate for monitoring, consider a central venous pressure catheter or pulmonary artery catheter.[117][118][119]

Practical tip

De-escalation

Your patient is euvolemic
The problem requiring fluids has been successfully reversed.

Monitor volume status consistently to try to avoid volume overload.

Immediately stop fluid administration
Consider consultation with specialist
Consider intravenous diuretics, and
Arrange an urgent chest x-ray if pulmonary edema is suspected (based on expert opinion).

Unless there are extenuating circumstances, diuretics and intravenous fluids are not generally given together (based on expert opinion).

Recommendations from an intensive care specialist and/or cardiologist and/or nephrologist may be needed.

Withhold antihypertensives and/or diuretics if hypotensive

Withhold antihypertensives and/or diuretics if your patient:

Is in shock, or
Has a blood pressure ≥40 mmHg lower than their baseline.

Consider withholding antihypertensives and/or diuretics if your patient:

Is hypotensive, or
Has developed orthostatic hypotension or has postural symptoms (based on expert opinion).
- Orthostatic hypotension is defined, by consensus, as a fall in systolic blood pressure ≥20 mmHg and/or a fall in diastolic blood pressure ≥10 mmHg on assuming an upright posture.[120]
- In people with classic orthostatic hypotension, the blood pressure change occurs within 3 minutes of standing.[121] In practice, take standing blood pressure after the person has been standing for at least 1 minute (based on expert opinion).

People with hypertension, coronary artery disease, heart failure, stroke, or chronic kidney disease (CKD) will typically be taking one or more of these types of drug.

Establish your patient's baseline blood pressure and assess volume status.

Patients with treated heart failure may have chronically low blood pressure (e.g., systolic BP ≤90 mmHg). If their systolic blood pressure falls by >10-15 mmHg and is associated with symptoms (such as presyncope or syncope), it may be appropriate to withhold medications that may lower blood pressure but have no or little prognostic benefit for heart failure (such as amlodipine, doxazosin).
- If clinically appropriate, consider changing the time of administration of medication that has a prognostic benefit for heart failure (e.g., sacubitril/valsartan, beta-blockers) to night time, or splitting or reducing the dose (based on expert opinion).
- Consider consultation with a cardiologist and/or intensivist.

If diuretics are withheld in a patient with heart failure and/or CKD, close monitoring is needed as fluid can quickly accumulate.

Be aware that sodium-glucose cotransporter-2 (SGLT2) inhibitors, a class of medication with a prognostic benefit for both heart failure and CKD, also have a weak diuretic effect.[122]

If antihypertensives or diuretics have been withheld during the acute illness, consider restarting them before discharge if clinically appropriate (based on expert opinion).

Restart one at a time at a lower dose and ask the primary care physician (PCP) to titrate back to normal dose.
- Most patients won't tolerate restarting all medications at the original doses simultaneously.
- If it is not clinically appropriate to restart these medicines before discharge, ensure that the patient has follow-up to decide when the medications can be reintroduced.
- Ensure you have communicated clearly to the PCP at discharge.

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review diabetes medication (NEVER stop insulin in a person with type 1 diabetes)

Treatment recommended for ALL patients in selected patient group

Check your patient's blood glucose on admission. In addition, check HbA1c if no result is available from the previous 3 months.[124][132]

Exclude hypoglycemia, diabetic ketoacidosis (DKA), and hyperosmolar hyperglycemic state (HHS).
Test for blood beta-hydroxybutyrate or ketones if:[133][134]
- Your patient was taking a sodium-glucose cotransporter-2 (SGLT2) inhibitor (e.g., dapagliflozin, canagliflozin, empagliflozin) before unplanned hospitalization, and/or
- There is acidosis, an increased anion gap, nausea/vomiting, or a combination of these.
Admission HbA1c may give you an indication of your patient’s previous diabetes control and may influence your treatment at discharge.

Insulin deficiency (e.g., due to delayed or missed doses) will rapidly cause ketoacidosis (based on expert opinion).

Practical tip

Critical illness

Consider starting a continuous intravenous insulin infusion for your critically ill patient for achieving glycemic goals and avoiding hypoglycemia.[124][125]

Use a validated protocol/order set for the continuous intravenous insulin infusion.[124]
This allows for predefined adjustments to the insulin infusion rate according to blood glucose measurements and past and current insulin infusion rates, to avoid hypoglycemia.[124]

More info: Continuous intravenous insulin infusion management

If a continuous intravenous insulin infusion is started:

In practice, subcutaneous basal insulin is generally discontinued (based on expert opinion).
- Less often, at some institutions, subcutaneous basal insulin may be continued (provided there is no hypotension and the patient is not on vasopressors) at 75% of the patient's usual dose.
Stop the patient’s usual subcutaneous rapid-acting and mixed insulins while on an intravenous insulin infusion.[135]
Use the continuous intravenous insulin infusion for as short a time as possible.[135]

Once ready to discontinue a continuous intravenous insulin infusion:

Follow an appropriate order set/transition protocol to switch to scheduled subcutaneous insulin.[124]
- This should include calculating the total daily dose of subcutaneous insulin needed, dividing into appropriate basal and bolus doses, monitoring and adjusting dose based on glucose monitoring, and having orders in place for potential hypoglycemic episodes (based on expert opinion).
Give subcutaneous basal insulin at least 2 hours before discontinuing the intravenous infusion to minimize rebound hyperglycemia.[124]
- Emerging data suggest that early administration of subcutaneous basal insulin alongside intravenous insulin infusion does not seem to increase the risk of hypoglycemia.[136][137]

Noncritical illness

Generally, an insulin regimen is preferred for managing hyperglycemia in individuals with diabetes receiving hospitalized care.[124]

If your patient is not eating or drinking or has poor oral intake, a subcutaneous basal insulin or basal plus bolus correction (every 4-6 hours) insulin plan is preferred.
If they are eating adequately, subcutaneous basal insulin with prandial (with each meal, up to 3-4 times a day) and correctional doses is preferred.

In a patient who is already managing their diabetes with insulin, consider whether there is any need to adjust insulin dose when they are admitted to the hospital.

If a patient with type 1 or type 2 diabetes uses insulin at home, has adequate glycemic management, and was not admitted with significant hyperglycemia, it may be appropriate to reduce their routine dose of subcutaneous basal insulin by 20%, particularly if they are eating less than usual. Another factor to keep in mind is that hospital meals generally contain less carbohydrate than meals patients would eat at home (based on expert opinion).
Conversely, patients who are acutely ill with an infection sometimes need more insulin.
Regular monitoring of blood glucose (at least four times daily) can help guide appropriate adjustments to insulin dosing.

More info: Patients using a continuous subcutaneous insulin infusion (CSII) (insulin pump) prior to hospital admission

If a patient with diabetes had been using an insulin pump prior to hospital admission:

Follow your hospital procedure, if available, and request a specialized inpatient diabetes team or endocrinology consult.
Safe continuation of an insulin pump during hospital admission has been advocated by several professional organizations.[124][138][139][140]
Key criteria for safe use include that:[124][141]
- The patient is medically stable, willing, and capable of self-management
- There are no contraindications
- The necessary supplies and resources are available
- There are hospital staff with the appropriate expertise and training, and institutional diabetes technology protocols in place
- Staff are available to perform confirmatory point-of-care (POC) glucose measurements for insulin dose decisions, hypoglycemia assessment and treatment, and at least four times a day (based on expert opinion).

Review noninsulin glucose-lowering medications if your patient had been taking any of these before admission and determine whether these are suitable to continue during admission.

For select patients with type 2 diabetes, it may be acceptable to continue noninsulin glucose-lowering medications, such as a dipeptidyl peptidase-4 (DPP-4) inhibitor.[124] Only consider this in a patient who is (based on expert opinion):
- Clinically stable with mild hyperglycemia
- Eating regularly
- Has no contraindications.
Metformin should be discontinued in patients with contraindications, including those with increased risk of lactic acidosis (e.g., those with renal impairment, shock, or hypoxia) and those with acute heart failure.[142][143] Consider restarting metformin after the acute condition has resolved (based on expert opinion).
In general, stop SGLT2 inhibitors for your patient with diabetes who is admitted to the hospital with an acute illness (based on expert opinion). This is due to the risk of euglycemic ketoacidosis.
- In particular, avoid SGLT2 inhibitors if your patient is severely ill, or if their clinical situation predisposes them to ketoacidosis (e.g., prolonged fasting due to acute illness or surgery).[124][133]
- Be aware that ketoacidosis associated with SGLT2 inhibitors may still be present despite a normal (or near normal) serum glucose level (euglycemic ketoacidosis).[134]
- If an SGLT2 inhibitor is being initiated during a hospital admission (e.g., for treatment of heart failure), this medication should be initiated after recovery from the acute illness.[124]
  - Remain aware of the risk of ketoacidosis which can occur spontaneously with SGLT2 inhibitors.[134]
  - Monitor hydration status and basic metabolic panel (BMP) daily for elevated anion gap and acidosis (based on expert opinion).
  - Check blood beta-hydroxybutyrate (or blood ketone) levels, especially if acidosis is present, or there are symptoms of ketoacidosis (e.g., nausea or vomiting) (based on expert opinion). Measure blood ketones as urinary ketone measurement may be unreliable.
  - Be aware that beta-hydroxybutyrate levels of ≥3.0 mmol/L, along with pH <7.3 or bicarbonate <18 mmol/L, indicate DKA.[134][144]
  - In this situation, stop SGLT2 inhibitor and treat DKA.[144]

Discharge

Start thinking about a discharge plan at the time of hospitalization or after stabilization (based on expert opinion). This should be structured and tailored to the individual.[124]

Provide inpatient diabetes self-management education, focusing on skills needed after discharge, and ensure follow-up and support strategies are in place.
Arrange medication reconciliation:
- Make sure this includes a strategy for switching back to the brand of insulin your patient was on at the time of hospitalization, if appropriate and approved by insurance or covered by other programs (based on expert opinion).
- Clarify regarding timing of restarting any noninsulin glucose-lowering medications that have been temporarily stopped (based on expert opinion).
Communicate promptly to the relevant outpatient healthcare professionals.

Plus – nasopharyngeal eradication predischarge

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Plus –

nasopharyngeal eradication predischarge

Treatment recommended for ALL patients in selected patient group

Patients with invasive meningococcal infections who are not treated with ceftriaxone or cefotaxime should also receive rifampin, ciprofloxacin, or ceftriaxone before discharge from the hospital, to eradicate nasopharyngeal colonization.[4][50]

These treatments are equally effective. Choice is based on the age of the patient and the presence of any contraindications to an individual drug. Specialist advice should be sought for newborns.

Primary options

rifampin: children: 20 mg/kg/day orally given in 2 divided doses for 2 days, maximum 600 mg/dose; adults: 600 mg orally twice daily for 2 days

rifampin : children: 20 mg/kg/day orally given in 2 divided doses for 2 days, maximum 600 mg/dose; adults: 600 mg orally twice daily for 2 days

rifampin: children: 20 mg/kg/day orally given in 2 divided doses for 2 days, maximum 600 mg/dose; adults: 600 mg orally twice daily for 2 days

ceftriaxone: children: 125 mg intramuscularly as a single dose; adults: 250 mg intramuscularly as a single dose

ceftriaxone : children: 125 mg intramuscularly as a single dose; adults: 250 mg intramuscularly as a single dose

ceftriaxone: children: 125 mg intramuscularly as a single dose; adults: 250 mg intramuscularly as a single dose

ciprofloxacin: adults: 500 mg orally as a single dose

ciprofloxacin : adults: 500 mg orally as a single dose

ciprofloxacin: adults: 500 mg orally as a single dose

Drug choice, dose and interactions may be affected by the patient's comorbidities. Check your local drug formulary.

Show drug information for a patient with no comorbidities

Primary options

rifampin

For patients with CKD, please check your local drug formulary

For patients with CKD see dose in the Renal Drug HandbookFor patients with CKD see dose in the Renal Drug Handbook

ceftriaxone

For patients with CKD, please check your local drug formulary

For patients with CKD see dose in the Renal Drug HandbookFor patients with CKD see dose in the Renal Drug Handbook

ciprofloxacin

For patients with CKD, please check your local drug formulary

For patients with CKD see dose in the Renal Drug HandbookFor patients with CKD see dose in the Renal Drug Handbook

Plus – monitor comorbidities during hospital stay

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Plus –

monitor comorbidities during hospital stay

– baseline cognitive and delirium assessments with collateral history

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–

baseline neurologic exam

Treatment recommended for ALL patients in selected patient group

Perform a baseline neurologic exam at the earliest appropriate opportunity for any patient with a history of stroke.

A patient with an acute condition (e.g., an infection and illness-related hypotension) is at increased risk of stroke.[145][146][147] This risk is even higher in anyone with a history of stroke.
- In particular, ischemic stroke is a known complication of acute bacterial meningitis.[92][148][149]
- Less commonly, hemorrhagic stroke can also complicate bacterial meningitis.[148]
- If there is a change in neurologic status during admission, repeat the neurologic exam to evaluate for a new acute stroke.
Ensure the right level of nursing care for the patient’s condition and ensure that clear orders are written for the patient’s functional and cognitive status (e.g., fall precautions, 1:1, soft restraints, assistance with activities of daily living [ADLs]).
- A patient with a history of stroke has a higher risk of falls and injury.[150]

Back

–

baseline cognitive and delirium assessments with collateral history

Treatment recommended for ALL patients in selected patient group

Do a baseline cognitive assessment at the earliest opportunity in any patient with a history of dementia.

Take a collateral history from family, friend, or caregiver to establish whether your patient's cognitive function is stable, gradually declining, or acutely declined.[151]
Check your patient’s level of alertness and orientation to time, place, and person, and corroborate with caregivers and review your patient’s prior medical records (based on expert opinion).
If time allows, a standardized cognitive assessment score is helpful for tracking clinical progress, and determining discharge needs (based on expert opinion).
Validated scoring tools for cognitive assessment include:
- The Mini-Cog Alzheimer's Association: Mini-Cog(TM) Opens in new window
- The Montreal Cognitive Assessment (MoCA)[152]
- The Saint Louis University Mental Status Examination (SLUMS). Saint Louis University: SLUMS Opens in new window
These scores are often best interpreted alongside a functional assessment, usually performed by an occupational therapist and/or a physical therapist.
These scores may not represent the person's usual baseline for cognition due to the impact of the acute condition and its treatment, but it is still good practice to record and repeat it when the person has recovered (based on expert opinion).

Practical tip

Mind (mentation, dementia, depression, and delirium)
Mobility (gait, balance, and falls prevention)
Medications (polypharmacy, deprescribing, optimal prescribing, and adverse medication effects and medication burden)
Multicomplexity (multimorbidity and complex psychosocial situations)
Matters Most to Me (each individual's health outcome goals and care preferences).

Assess for delirium whenever a patient with dementia presents with acute illness.

People living with dementia are at increased risk of delirium when they are admitted to the hospital and throughout their admission.[151][155]
Delirium is not the same as dementia. It is a potentially life-threatening acute, fluctuating change in mental functioning, with inattention, disorganized thinking, and altered levels of consciousness.[156]
Use a screening tool to detect probable delirium, taking the setting into account. Commonly used tools include:
- The Delirium Triage Screen (DTS), which may be rapidly administered in an emergency department setting and assesses arousal and attention. If positive, confirm with a more specific tool, such as the brief Confusion Assessment Method (bCAM).[151][157][158]
- The Confusion Assessment Method (CAM), if your patient is not in a critical care setting.[151][159][160]
- The Confusion Assessment Method for the Intensive Care Unit (CAM-ICU) or the Intensive Care Delirium Screening Checklist (ICDSC) if your patient is in a critical care setting, or in the recovery room after surgery.[155][161][162][163]

Practical tip

Depression can mimic delirium in older adults, particularly in patients with cognitive impairment or other comorbid medical conditions.[151]

Ask if your patient has a diagnosis of depression. If not, use a very brief screening test, such as the Patient Health Questionnaire-2 or Emergency Department Depression Screening Instrument to screen older adults for depression.
A positive screen for depression should prompt further questions, e.g., on suicidal thoughts.

Helping with orientation; make sure patients have their own glasses and/or hearing aids
Getting patients mobilized as soon as possible
Controlling pain adequately
Keeping patients well hydrated and helping them to eat adequately
Monitoring and maintaining regular bowel and bladder function
Using supplemental oxygen as needed
Monitoring for and treating postoperative complications as soon as possible
Reviewing the patient's medications
- Identify and avoid medications that are high-risk for precipitating delirium, such as benzodiazepines, corticosteroids, and anticholinergics.[151][168]

Foster familiarity, e.g., consider facilitating the patient's usual caregiver to stay with the patient and bring in familiar objects from home.[151][158]

Practical tip

Dementia is a risk factor for postoperative delirium.[167][169]

Evaluate baseline cognition using a brief screening tool preoperatively.
Consider the most appropriate method of analgesia to reduce the risk of postoperative delirium.
Monitor for postoperative delirium using a validated screening instrument (e.g., CAM-Short Form).[170]

Evidence: Primary prevention of delirium in hospital using nonpharmacologic interventions

There is evidence that a nonpharmacologic approach reduces the risk of delirium in non-ICU patients in hospital.

A systematic review compared nonpharmacologic interventions designed to prevent delirium with usual care or active control in adults in a non-ICU hospital setting.[171]

Interventions were multicomponent or single components, targeted at a specific risk factor, such as disorientation or dehydration.
Meta-analysis of 14 studies on multicomponent interventions found a significant reduction in incident delirium compared with usual care (RR 0.57, 95% CI 0.46 to 0.71).
There is emerging evidence that multicomponent interventions may reduce hospital length of stay (MD -1.3 days, 95% CI -2.56 to -0.04 days), but there is significant heterogeneity between the studies.
There is little information specifically on people with dementia as this group was frequently excluded from trials despite their increased risk of developing delirium.

More info: Initial investigations for a patient with delirium

If your patient has delirium, check for and treat life-threatening causes:[151][167][172]

Hypoxia
Hypoglycemia
Hypotension
Sepsis
Drug intoxication or withdrawal, including alcohol withdrawal
Acute myocardial infarction

Although every evaluation should be tailored to the individual patient, most patients should receive:[151]

Complete blood count
Comprehensive metabolic panel
Point-of-care glucose
Urinalysis with culture
ECG

Additional tests that may be needed include (based on expert opinion):

Thyroid function tests
Folate and vitamin B12
C-reactive protein
Blood cultures (if bacteremia is suspected)
Chest x-ray

Consider whether your patient requires computed tomography (CT) of the brain.[151]

CT brain should be arranged if your patient has focal neurological deficits, head trauma, reduced level of consciousness, or has a history of fall.
CT brain should also be considered if your patient takes anticoagulants.
In practice, a patient in the hospital setting who has a change in mental status will usually receive a CT brain (based on expert opinion).

Check for and treat any reversible causes of delirium:[151][158][167][172]

Pain
Infection
Poor nutrition
Constipation
Dehydration
Medications
- Ask about recently prescribed medications, especially opioid analgesics, anxiolytics, antipsychotics, corticosteroids, or anticholinergics
Immobility
Poor sleep
Sensory impairment (e.g., ear wax or loss of glasses)

More info: Management of a patient with delirium

Manage patients with delirium initially with nonpharmacologic treatment.[151][158][167]

Reduce disorientation by providing a well-lit room, with a clock and calendar visible (e.g., on the wall).
Encourage and facilitate family, friends, and caregivers to visit the patient.
Use verbal and nonverbal techniques to de-escalate conflict and distress.

Any new antipsychotic prescribed for this purpose must be regularly reviewed, and discontinued as soon as possible.[168][173]
Be aware that the evidence on the efficacy of antipsychotics for delirium is inconclusive, and guidance regarding choice of antipsychotic varies.[151][158][167]
Antipsychotics should be used with caution in patients with a history of dementia as there is an increased risk of mortality in these patients[151][173]
- A systematic review of antipsychotics for delirium in hospitalized adults concluded that the evidence did not support routine use of haloperidol or atypical antipsychotics for this purpose[174]
- All antipsychotics have a warning that they are not approved for dementia-related psychosis.[151]
Haloperidol is contraindicated in patients with Parkinson disease or in patients with dementia with Lewy bodies.[163] Check for all contraindications.
Consider baseline ECG before starting any antipsychotic medication (based on expert opinion).

Document the diagnosis of delirium clearly (based on expert opinion).

Evidence: Risks and safe withdrawal of antipsychotics in older adults

Antipsychotics are associated with increased mortality in people with dementia.

A Cochrane review found very low certainty evidence that typical antipsychotics such as haloperidol improve agitation, but reported that they may improve psychosis slightly in people with Alzheimer disease and vascular dementia. Atypical antipsychotics probably reduce agitation. Both types increase the risk of somnolence and extrapyramidal symptoms.[175]
A network meta-analysis found that people who take atypical antipsychotics for behavioral and psychological symptoms of dementia may have a small improvement in behavioral and psychological symptoms but have increased safety risks including for cerebrovascular adverse events, compared with those taking placebo.[176]
Contrary to popular belief, long-term antipsychotic use can be safely withdrawn in most people with dementia once behavior has settled.[177]

– establish goals of care, taking into account any advance directives

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assess your patient’s level of frailty

Treatment recommended for ALL patients in selected patient group

Assess your patient's level of frailty to:[178][179]

Establish whether management plans are consistent with goals of care, and
Identify whether further assessment and enhanced care is needed.

Practical tip

Ask your patient (with input from caregivers if relevant) about their functional capability 2 weeks BEFORE this acute episode to determine baseline state.[184]
Use the Clinical Frailty Scale (CFS) if your patient is ≥65 years old.[185][186] Dalhousie University: Clinical Frailty Scale Opens in new window
- This tool is a practical aid to identify frailty, but should not be relied on in isolation.
- Do not use the CFS to assess younger patients, or those with disabilities that reflect single-system problems (e.g., spinal cord injury).[184]
- If your patient scores 5 or higher, consider arranging a comprehensive geriatric assessment, if this is feasible and clinically appropriate, at the earliest opportunity.[181]
- A higher prehospital frailty score is associated with an increased risk of adverse outcomes including risk of mortality in-hospital, at 1, 3, 6, and 12 months; all-cause readmission within 30 days; extended length of stay; discharge to a nursing home, residential care, hospital, or a high level of care; and functional decline.[187]
Look for nonspecific complaints, such as delirium and falls.
Help to implement multidisciplinary care and to tailor the management approach according to the patient's values and goals of care.[188]

Practical tip

Back

–

establish goals of care, taking into account any advance directives

Treatment recommended for ALL patients in selected patient group

Ask your patient if they have an advance directive (e.g., a living will, a healthcare proxy) and/or a Do Not Resuscitate (DNR) or Do Not Intubate (DNI) order.[193]

This applies to all patients, but may be particularly relevant to patients living with frailty and/or with certain comorbidities, such as dementia, stroke, heart failure, COPD, and late-stage CKD (based on expert opinion).
Ensure any existing advance directives align with your patient's current preferences and goals of care.[193]

Practical tip

Discuss specific treatment options and health trajectory to help your patient (or surrogate decision-maker) make informed decisions about their care.[193][195][196]

This should include (based on expert opinion):
- Code status (e.g., Do Not Resuscitate [DNR] order, Do Not Intubate [DNI] order)
- Other life-sustaining treatment options (e.g., vasopressors, extracorporeal membrane oxygenation [ECMO], kidney replacement therapy, blood transfusions, parenteral/enteral nutrition).

Assess and document decision-making capacity (the ability to make a specific decision at the time that the decision needs to be made).[197][198][199]
- Attempt to improve your patient’s capacity to participate in decision-making by addressing communication barriers and alleviating exacerbating factors, such as delirium.[200]
- Be aware that an individual’s decision-making capacity can vary over time so should be reassessed periodically.[200]
If your patient lacks decision-making capacity, establish whether they have an advance directive.[195][198][199]
- This may include a living will and/or a designated proxy known as a Durable Power of Attorney for Healthcare (DPAHC). [198]
If your patient who lacks decision-making capacity has no applicable advance directive, including no designated proxy, identify a surrogate decision-maker from a priority list of individuals such as spouse, adult child, and adult sibling.[198][199]
- The hierarchy of this list, and the scope of surrogates' decision-making, varies from state to state.
- Ensure a surrogate's decisions are consistent with patient preferences and best interests.
- In the case of conflict, consider consulting your hospital's ethics committees.
If your patient is an older adult and is unrepresented (a patient without decision-making capacity for a particular medical intervention who lacks both a relevant advance directive and a surrogate decision-maker), the American Geriatrics Society recommends:[200]
- Attempting to identify a nontraditional surrogate (e.g., a close friend, live-in companion, neighbor, or other individual who knows the patient well), in the absence of a traditional surrogate (next of kin), who is willing and able to represent your patient’s wishes and values
- Avoiding unilateral decision-making in the absence of a suitable surrogate, which could carry a risk of bias. The AGS favors a structured multidisciplinary consensus approach to decision-making.

Check your relevant state law and practice accordingly. There may be no available out-of-court process to allow nontraditional surrogates in many states.
If your unrepresented patient is in an urgent or life-threatening situation:[198][199]
- Use all available information on a patient's preferences, values, and beliefs to guide treatment decisions. If preferences are not known, urgent care decisions should be made in the patient's best interests.[195][198][201]
- Consider using the Four Box Model (also known as the Four Quadrant Model) to aid ethical decision-making. This consists of four principles:[200][202]
  - Medical indications for treatment
  - Patient preferences for care
  - Quality of life
  - Contextual features (this includes being mindful of provider biases, the patient’s psychosocial context, and how the treatment and cost of care may impact the patient).
In a less urgent situation, rarely, a court-appointed guardian may be appointed to make decisions in this context.[195][198][200]

– monitor and manage blood glucose during the hospital admission

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monitor and manage blood glucose during the hospital admission

Treatment recommended for ALL patients in selected patient group

The risk of hypo- and hyperglycemia increases when a person with diabetes is admitted to the hospital acutely (based on expert opinion).
More frequent monitoring is needed after any episode of hyperglycemia or hypoglycemia and after any change in hypoglycemic medication (based on expert opinion). If a correction dose of insulin is given at bedtime, check blood glucose about 4 to 6 hours later (usually about 2 a.m.) (based on expert opinion).
If your patient is having surgery, the American Diabetes Association (ADA) recommends monitoring blood glucose at least every 2 to 4 hours while the individual is taking nothing by mouth (npo).[124]
Any patient on an intravenous insulin infusion needs more frequent blood glucose measurements, ranging from every 30 minutes to every 2 hours.[124]

Practical tip

Decide on target blood glucose levels.

There is a general consensus among different guideline organizations on target blood glucose levels for people with diabetes in the hospital.

For most critically ill patients, the ADA recommends a target range of 140 to 180 mg/dL (7.8 to 10.0 mmol/L) once treatment has been started for persistent hyperglycemia.[124]
- Stricter target ranges, such as 110 to 140 mg/dL (6.1 to 7.8 mmol/L), may be acceptable in select critically ill patients, but only if they can be achieved without significant hypoglycemia.[124]
For most noncritically ill patients, the ADA and the Endocrine Society recommend a target range of 100 to 180 mg/dL (5.6 to 10.0 mmol/L).[124][138]
- Less stringent goals are appropriate in some patients, for instance those at high risk of hypoglycemia, advanced kidney failure, and those who are terminally ill. The ADA recommends that the focus in these people should be on avoiding hypoglycemia and symptomatic hyperglycemia.[124]

Evidence: Blood glucose targets for critically ill patients with hyperglycemia

Evidence argues against very tight glucose control in critically ill patients (a mixed population with and without a history of diabetes).

Intensive care setting:
- A randomized controlled trial (RCT) of critically ill patients in a primarily surgical intensive care setting found lower patient mortality with tight glucose control, 80 to 110 mg/dL (4.4 to 6.1 mmol/L), compared with "conventional" more liberal glucose control.[203]
- However, a subsequent multicenter RCT in critically ill medical and surgical patients in other intensive care settings found increased mortality with tighter glucose control, possibly due to more frequent episodes of hypoglycemia.[204]
- In 2017, two network meta-analyses found no benefit in mortality with tight glycemic control when compared with less tight control (79.2 to <109.8 mg/dL [4.4 to <6.1 mmol/L] vs.140.4 to <219.6 mg/dL [7.8 to <12.2 mmol/L] in one report; <110 to 144 mg/dL [<6.1 to 8.0 mmol/L] vs.144 to >180 mg/dL [8.0 to >10.0 mmol/L] in the second report) but a significant increase in the risk of hypoglycemia.[205][206]

More info: Hyperglycemia during the ongoing hospital admission

Hyperglycemia in admitted patients, whether with known diabetes or not, is associated with adverse patient outcomes, including increased mortality.[142]

Act promptly to treat hyperglycemia to avoid diabetic ketoacidosis (DKA) and hyperosmolar hyperglycemic state (HHS).
For persistent hyperglycemia, defined as blood glucose ≥180 mg/dL (≥10.0 mmol/L) confirmed on two occasions within 24 hours, the ADA recommends:[124]
- Starting or intensifying insulin therapy for most critically ill patients.
- Starting or intensifying insulin and/or other glucose-lowering therapies for most noncritically ill patients.

If your patient has DKA or HHS, consider the appropriate unit for management.

Indications for management in the intensive care unit (ICU) include:[134]
- Severe DKA or severe HHS
- Critical illness as the precipitating cause (e.g., sepsis, acute myocardial infarction, gastrointestinal bleeding)
- Altered mental status
- Another concurrent indication for ICU admission.
See Diabetic ketoacidosis or Hyperosmolar hyperglycemic state.

Be aware that the following interventions may be associated with hyperglycemia and may need to be reviewed:[207]

Corticosteroids
Some second-generation antipsychotics (e.g., olanzapine, clozapine)
Fluoroquinolone antibiotics (e.g., ciprofloxacin)
Calcineurin inhibitors (e.g., tacrolimus)
Protease inhibitors (e.g., ritonavir)
Artificial nutrition (parenteral or enteral).

Ask for a specialized inpatient diabetes team consult, if available, or endocrinology consult where hyperglycemia is difficult to control.

More info: Hypoglycemia during the ongoing hospital admission

Monitor blood glucose and adjust medication in response to illness and hospital meal times, to reduce the risk of hypoglycemic episodes.

Ensure that a hypoglycemia management surveillance protocol is in place, with an individualized plan for preventing, identifying, and treating hypoglycemia.[124]
- Immediately correct level 2 hypoglycemia (blood glucose levels <54 mg/dL [<3.0 mmol/L]) and level 3 hypoglycemia (characterized by altered mental and/or physical functioning, requiring assistance for treatment of hypoglycemia from another person for recovery, with no defined glucose level).
- Promptly treat level 1 hypoglycemia (blood glucose levels <70 mg/dL [<3.9 mmol/L] and ≥54 mg/dL [≥3.0 mmol/L]) to prevent progression to more significant levels of hypoglycemia.
- Ensure hypoglycemia treatment is included in all insulin orders.
Treat hypoglycemia, which usually involves provision of 15 g of fast-acting carbohydrates (oral or enteric juice or table sugar; intravenous dextrose). Check blood glucose 15 minutes after the treatment. If the blood glucose is not in a safe range (usually considered to be >90 mg/dL [>5.0 mmol/L]), repeat the treatment. If the oral and enteric route is not available, administer intravenous dextrose. If the patient has no intravenous access, administer glucagon (based on expert opinion). See Diabetic hypoglycemia.
Be aware that hypoglycemia may be induced by treatment of hyperglycemia/diabetes.[208]
- Sliding scale insulin (correctional or supplemental insulin without basal insulin) is associated with the highest rates of hypoglycemia (based on expert opinion). Sole use of sliding scale insulin is not recommended for most individuals in a hospital inpatient setting.[124]
- Be aware of the risk of hypoglycemia in patients on intensive insulin regimens (e.g., multiple daily injections, continuous subcutaneous insulin infusion, or automated insulin delivery systems), and those on basal insulin, sulfonylureas, or meglitinides.
- A combination of insulin and sulfonylureas further increases hypoglycemia risk.
Review and adapt your patient’s treatment plan to prevent recurrent episodes of hypoglycemia.[124]
- Be aware that level 1 hypoglycemia often predicts subsequent level 3 hypoglycemia.
Document any episodes of hypoglycemia in the electronic health record.[124]

Causes of hypoglycemia include:[124]

Inappropriate insulin dose or dose adjustment
Insulin or oral hypoglycemic medication error
Wrong timing of insulin in relation to meals
Inadequate follow-up of first episode of hypoglycemia
Patients eating less but taking the same amount of diabetes medication
Reduced appetite or vomiting
Unexpected interruption of enteral or parenteral feedings
Reduced infusion rate of intravenous dextrose
Delayed or missed blood glucose checks
Sudden reduction of corticosteroid dose
Altered ability of a patient to report symptoms
Recovery from an acute illness.

These medications include:
- Some antibiotics (e.g., fluoroquinolones, trimethoprim/sulfamethoxazole, chloramphenicol)[209][210]
- Other nondiabetic medications (e.g., ACE inhibitors, beta-blockers, chloroquine, disopyramide, pentamidine, salicylates)[209]
Polypharmacy of multiple hypoglycemia-causing medications also increases this risk.[208]
This list is not exhaustive. Consult your local drug information source (based on expert opinion).

Take action if blood glucose falls below 100 mg/dL (<5.6 mmol/L) (based on expert opinion). Fasting blood glucose levels <100 mg/dL (<5.6 mmol/L) are predictive of next-day hypoglycemia.[124]

Give extra carbohydrates to prevent hypoglycemia unless your patient is going to eat a meal within an hour (based on expert opinion).
Modify insulin doses to prevent glucose from going below the target for the patient.

Take steps to reduce the risk of hypoglycemia at night. Assuming your patient is not npo (nothing by mouth), they are likely to have a smaller evening meal in the hospital than at home.

In the absence of significant hyperglycemia, consider reducing the evening basal insulin by 20% on admission (based on expert opinion).
Remember that for many patients with very high insulin needs at home, the needs are often much lower in the hospital, presumably because of changes in diet.
Review the dose used during recent prior hospitalization(s) when deciding the starting dose of insulin (based on expert opinion).

More info: Self-management of diabetes in the hospital

The ADA recommends that suitable candidates for self-managing their diabetes in the hospital include those who:[124]

Normally perform self-management at home
Have the necessary cognitive and physical skills while in the hospital
Have adequate oral intake
Are proficient in carbohydrate estimation
Take multiple daily insulin injections or use insulin pumps
Have stable insulin requirements, and
Understand sick-day management.

The patient and hospital care team should review the decision on self-management on a daily basis.[124]

Inspect injection sites if your patient is on insulin injections at home (based on expert opinion).

Check for insulin lipodystrophy and re-educate on injection technique, if needed.

Continuous glucose monitoring

Consider continuing personal continuous glucose monitoring (CGM) for any individual who uses this wearable technology at home.[211] Consult with the inpatient diabetes team if available.[140]

Although not approved by the Food and Drug Administration (FDA), emergency use authorization was granted during the coronavirus disease 2019 (COVID-19) pandemic and several professional bodies suggest this may be useful if complying with institutional policies and safety regulations.[124][211][132][140]
Confirmatory point-of-care glucose measurements are still needed for assessment of hypoglycemia and to guide decisions on insulin dosing.[124]
Be aware that some concomitant medications, such as acetaminophen (above a certain dose), dopamine, heparin, vitamin C, and hydroxyurea, may result in inaccurate measurements by CGM devices.[211]

More info: Management of patients with diabetes who are receiving end-of-life care

If a patient with diabetes is receiving end-of-life care:

Discuss with your patient and their family/caregivers and agree on the level of intensity of care. Less stringent targets for blood glucose levels are appropriate, with the aim of avoiding hypoglycemia and symptomatic hyperglycemia.[124][132][212]
Prioritize providing comfort and reducing the burdens of strict blood glucose management.[212]
Be aware that stopping basal insulin in a person with type 1 diabetes can lead to dehydration, ketoacidosis, nausea, and associated vomiting; therefore, continuing basal insulin in such a person could be considered as a comfort care (based on expert opinion).

– ensure monitoring is in place to detect any asthma exacerbation during your patient's hospital admission

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examine your patient’s feet

Treatment recommended for ALL patients in selected patient group

Examine the feet of any adult with diabetes on their admission to the hospital and whenever they become ill.[213]

This is to detect new ulcerations or infection, which may be unnoticed by the patient and may even be the cause of their acute illness (e.g., patient presenting with sepsis, or endocarditis where the original focus of infection is the foot lesion).

Inspect the foot for lesions and examine for loss of protective sensation.

To perform a comprehensive foot examination:[214]

Inspect the skin.
Assess any foot deformities.
Do a neurologic exam, including 10-g monofilament testing or Ipswich touch test, with at least one other assessment (pinprick, temperature, or vibration).[215]
Do a vascular exam, including pulses in the legs and feet.

If your patient has reduced sensation, they are at risk for diabetic foot ulceration.[214] Provide pressure relieving devices.

Order daily heel checks for signs of pressure trauma. There is a debate about whether compression stockings should or should not be used in people with diabetes; do not use them if there is known peripheral vascular disease.

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ensure monitoring is in place to detect any asthma exacerbation during your patient's hospital admission

Treatment recommended for ALL patients in selected patient group

Acute worsening of respiratory symptoms may suggest a patient with comorbid asthma is having an acute exacerbation of their asthma.

Follow guideline recommendations on assessing severity and managing an acute exacerbation of asthma in adults.[97]
See Acute asthma exacerbation in adults.

This is due to concern over possible additive anticholinergic adverse effects.
Ensure to represcribe the LAMA once the nebulizer treatment has been stopped.

Be aware that the long-term use of beta-2 agonists to manage asthma may increase the risk of cardiovascular events.

Evidence: Cardiovascular harm with beta-2 agonists

Beta-2 agonists may increase the risk of myocardial infarction and other adverse cardiovascular events.

Beta-2 agonists increase heart rate and reduce potassium levels.[216] They are absorbed into the systemic circulation and there is evidence that long-term regular use may be associated with an increased risk of myocardial infarction, unstable angina, congestive heart failure, and arrhythmias.[217][216]
However, it is not routine practice to discontinue beta-2 agonists if they are needed for comorbid asthma.

– ensure monitoring is in place to detect any COPD exacerbation during your patient's hospital admission

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ensure monitoring is in place to detect any COPD exacerbation during your patient's hospital admission

Treatment recommended for ALL patients in selected patient group

Acute worsening of respiratory symptoms may suggest a patient with comorbid COPD is having an acute exacerbation.[102]

Differentiate from other conditions, such as a pulmonary embolism, acute heart failure, and pneumonia.
Follow guideline recommendations.[102] See Acute exacerbation of COPD.

This is due to concern over possible additive anticholinergic adverse effects.
Ensure the LAMA is represcribed once the nebulizer treatment has been stopped.

Be aware that the long-term use of beta-2 agonists to manage COPD may increase the risk of cardiovascular events.

Evidence: Cardiovascular harm with beta-2 agonists

Beta-2 agonists may increase the risk of myocardial infarction and other adverse cardiovascular events.

Beta-2 agonists increase heart rate and reduce potassium levels.[216] They are absorbed into the systemic circulation and there is evidence that long-term regular use may be associated with an increased risk of myocardial infarction, unstable angina, congestive heart failure, and arrhythmias.[216][217]
However, the Global Initiative for Chronic Obstructive Lung Disease states that there has been no reported association between beta-2-agonist use and increased mortality in people with COPD.[102] It is not routine practice to discontinue beta-2 agonists if they are needed for comorbid COPD.

– continue your patient's inhalers as prescribed for asthma or COPD

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mental status exam

Treatment recommended for ALL patients in selected patient group

Perform a mental status exam as the clinical situation allows (based on expert opinion).

The mental status exam is one of the main clinical tools routinely used in psychiatric practice, aiding diagnosis and guiding further management. Mood is one of the assessed domains.

Consider assessing current symptoms of depression using the PHQ-9 questionnaire.[218][219]

The PHQ-9 questionnaire can be used as a reliable and valid measure of depression severity in patients with a known diagnosis of depression, as well as a screening tool.
This can be self-administered or administered by the clinician, and takes less than 3 minutes to complete.
Results indicate severity of depressive symptoms.

Take into account other factors that may be influencing the patient's mental status (e.g., the effect of any illicit drug use or alcohol).[219][220]

In particular, consider whether symptoms of depression could be part of the acute medical illness (based on expert opinion).

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review current treatment for depression

Treatment recommended for ALL patients in selected patient group

Continue the patient’s usual antidepressant, unless there are good reasons not to (based on expert opinion).

If antidepressants are stopped abruptly, the patient may develop antidepressant discontinuation syndrome.[221]
The severity of the symptoms of discontinuation may vary, but they may be unpleasant and may complicate the management of the acute medical condition.

When reviewing current medications, consider:

Current and previous adverse effects
Recent changes in dose
Recent medication changes from a different drug class
The specific diagnostic subtypes of depression when prescribing medications (e.g., it is likely that patients suffering from psychotic depression would be coprescribed an antipsychotic)
Augmenting strategies that may be used when treating resistant depression (e.g., lithium or quetiapine augmentation of a selective serotonin-reuptake inhibitor [SSRI]).

Consider drug-drug interactions.

Antidepressants (particularly those that inhibit the CYP450 pathway) may cause significant interactions with drugs used for other conditions.[222]

Consider psychiatric complications when prescribing nonpsychotropic drugs.

Take particular care when prescribing anticonvulsants, antiparkinsonian drugs, and corticosteroids.

Consider adverse effects, which may include the following:

Hyponatremia, caused by antidepressants, especially SSRIs, and compounded by other coprescribed drugs (e.g., diuretics).[223][224][225][226] Review your patient’s serum electrolyte results and consider antidepressants as a potential contributing factor if they have hyponatremia.
Serotonin syndrome (altered mental state, agitation, tremor, hyper-reflexia, ocular clonus or inducible clonus, muscle rigidity, diaphoresis, tachycardia, increased bowel sounds, temperature >100.4°F [>38°C]), especially with polypharmacy and/or overdose of a serotonergic agent.[227][228] See Serotonin syndrome.
- Be particularly aware of increased risk of serotonin syndrome in patients with kidney failure on SSRIs.[229][230]
Hepatotoxicity.[231] Adjust doses of antidepressants in patients with hepatic impairment as necessary.
- However, antidepressants are rarely the cause of hepatic impairment.[231]
Prolonged QTc, arrhythmias, increased heart rate, postural hypotension with tricyclic antidepressants.[232][233] Obtain an ECG, especially in people at risk of arrhythmias.[234]
Gastrointestinal bleeding. SSRIs are associated with an increased risk of gastrointestinal bleeding.[223][235][236] Risk is particularly increased when coprescribed with aspirin, nonsteroidal anti-inflammatory drugs (NSAIDs), or oral anticoagulants.[236][237][238] Monitor closely and consider gastroprotection with proton-pump inhibitors if SSRI use cannot be avoided (based on expert opinion).

This list of adverse effects is not exhaustive - consult your drug information sources or hospital pharmacist for further information, and consider a psychiatric consult for advice.

Practical tip

Ask your patient about nonpharmacologic treatments for their depression and check the current level of community support.

This may include other outpatient healthcare professionals, charities, and family and social networks.

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consider psychiatric consult

Treatment recommended for ALL patients in selected patient group

Consider a psychiatric consult for any patient with comorbid depression who is admitted to the hospital with an acute condition.

Consult is strongly advised in patients with severe symptoms of depression or additional symptoms such as self harm, suicidal ideation, homicidal ideation, catatonia, psychosis (based on expert opinion).
Consult may not be required if there are no concerns that depression and/or its management (e.g., medication) may be affecting the acute condition (based on expert opinion).
Accidents of unclear circumstances, self-injurious behaviors, and/or suicide attempts (including alleged "accidental" overdose of medication) should trigger clinical suspicion of comorbid mental health disorder (based on expert opinion).

Ensure your patient has adequate support with their treatment post-discharge.

Keep in mind that the psychological impact of comorbid depression may be associated with poor adherence with recommended physical health treatments, from medication to rehabilitation.[242][243][244] This may lead to worse clinical outcomes, including higher readmission risk.[245][246]
Most importantly, affective symptoms, including depression, have been linked with excess mortality, though a causal link remains to be proven.[247][248]

1st line – targeted antibiotic therapy

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manage tobacco dependence

Treatment recommended for ALL patients in selected patient group

If your patient currently uses tobacco, assess their tobacco use and provide assistance and support with tobacco cessation interventions.[249][250][251]

Advise:

That nicotine is highly addictive and nicotine withdrawal can be extremely distressing and uncomfortable.[250]
NRT prevents rapid withdrawal.[250]
That there are a number of highly effective treatment options that offer the best chance of stopping smoking.[249][250][251]

Ensure a sufficient dose of NRT is prescribed to adequately address withdrawal symptoms.[255]
Ask the patient how many cigarettes they smoke per day; this may determine the starting dose of NRT.
Ask about the type of tobacco product used, including e-cigarettes, water pipe use, and other smokeless tobacco products (snuff, ground, or chewing tobacco), as use of these products also results in nicotine addiction.
Check drug information sources for any contraindications or cautions, particularly if your patient has one or more comorbidity and/or is hemodynamically unstable.
Assess for symptoms of withdrawal daily (based on expert opinion).

One Cochrane Review found high-certainty evidence that varenicline is an effective treatment for tobacco dependence.[257] The same review found that people taking varenicline likely have an increased chance of a more serious adverse effect (e.g., cardiac) that could result in hospital admission; however, these are still rare (2.7% to 4% of people on varenicline, compared with 2.7% of people not taking varenicline) and may include events that are unrelated to varenicline.[257] Check drug information sources for a full list of contraindications and cautions or seek pharmacist advice.
Mental health illness is NOT a contraindication to prescribing varenicline. However, varenicline should be used with caution in people with a pre-existing psychiatric illness as it may worsen symptoms.
Bupropion is an alternative option to varenicline for tobacco cessation but is less likely to result in successful quitting.[257] Consider the potential for drug-drug interactions.

Ensure your patient has follow-up with their primary care practitioner or addiction medicine physician to continue treatment for tobacco dependence.

Practical tip

See Smoking cessation for more information.

confirmed meningococcal meningitis: penicillin-intermediate sensitivity

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1st line –

targeted antibiotic therapy

Neisseria meningitidis that is penicillin-intermediate susceptible (minimum inhibitory concentration [MIC] 0.1 to 1.0 micrograms/mL) should be treated with ceftriaxone or cefotaxime. Alternatives include a fluoroquinolone (e.g., levofloxacin, ciprofloxacin) or meropenem.[67][77]

Systemic fluoroquinolone antibiotics may cause serious, disabling, and potentially long-lasting or irreversible adverse events. This includes, but is not limited to: tendinopathy/tendon rupture; peripheral neuropathy; arthropathy/arthralgia; aortic aneurysm and dissection; heart valve regurgitation; dysglycemia; and central nervous system effects including seizures, depression, psychosis, and suicidal thoughts and behavior.[78] Prescribing restrictions apply to the use of fluoroquinolones, and these restrictions may vary between countries. In general, fluoroquinolones should be restricted for use in serious, life-threatening bacterial infections only. Some regulatory agencies may also recommend that they must only be used in situations where other antibiotics that are commonly recommended for the infection are inappropriate (e.g., resistance, contraindications, treatment failure, unavailability). Consult your local guidelines and drug information source for more information on suitability, contraindications, and precautions.

Treatment course: 7 days.

Check baseline kidney function and monitor closely

Acute illness also increases the risk of deterioration in kidney function.
Monitor for and respond to oliguria.

Primary options

ceftriaxone : neonates: consult specialist for guidance on dose; children: 80-100 mg/kg/day intravenously given in divided doses every 12-24 hours, maximum 4 g/day; adults: 2 g intravenously every 12 hours

cefotaxime : neonates: consult specialist for guidance on dose; children: 200-300 mg/kg/day intravenously given in divided doses every 6-8 hours, maximum 12 g/day; adults: 2 g intravenously every 4-6 hours

Secondary options

meropenem : children ≥3 months of age and <50 kg body weight: 40 mg/kg intravenously every 8 hours, maximum 6 g/day; children ≥3 months of age and ≥50 kg body weight and adults: 2 g intravenously every 8 hours

levofloxacin: children: consult specialist for guidance on dose; adults: 750 mg intravenously every 24 hours

levofloxacin : children: consult specialist for guidance on dose; adults: 750 mg intravenously every 24 hours

levofloxacin: children: consult specialist for guidance on dose; adults: 750 mg intravenously every 24 hours

ciprofloxacin: children: consult specialist for guidance on dose; adults: 400 mg intravenously every 8-12 hours

ciprofloxacin : children: consult specialist for guidance on dose; adults: 400 mg intravenously every 8-12 hours

ciprofloxacin: children: consult specialist for guidance on dose; adults: 400 mg intravenously every 8-12 hours

These drug options and doses relate to a patient with no comorbidities.

Primary options

ceftriaxone : neonates: consult specialist for guidance on dose; children: 80-100 mg/kg/day intravenously given in divided doses every 12-24 hours, maximum 4 g/day; adults: 2 g intravenously every 12 hours

cefotaxime : neonates: consult specialist for guidance on dose; children: 200-300 mg/kg/day intravenously given in divided doses every 6-8 hours, maximum 12 g/day; adults: 2 g intravenously every 4-6 hours

Secondary options

meropenem : children ≥3 months of age and <50 kg body weight: 40 mg/kg intravenously every 8 hours, maximum 6 g/day; children ≥3 months of age and ≥50 kg body weight and adults: 2 g intravenously every 8 hours

levofloxacin: children: consult specialist for guidance on dose; adults: 750 mg intravenously every 24 hours

levofloxacin : children: consult specialist for guidance on dose; adults: 750 mg intravenously every 24 hours

levofloxacin: children: consult specialist for guidance on dose; adults: 750 mg intravenously every 24 hours

ciprofloxacin: children: consult specialist for guidance on dose; adults: 400 mg intravenously every 8-12 hours

ciprofloxacin : children: consult specialist for guidance on dose; adults: 400 mg intravenously every 8-12 hours

ciprofloxacin: children: consult specialist for guidance on dose; adults: 400 mg intravenously every 8-12 hours

Show drug information for a patient with no comorbidities

Drug choice, dose and interactions may be affected by the patient's comorbidities. Check your local drug formulary.

Primary options

ceftriaxone

For patients with CKD, please check your local drug formulary

For patients with CKD see dose in the Renal Drug HandbookFor patients with CKD see dose in the Renal Drug Handbook

cefotaxime

For patients with CKD, please check your local drug formulary

For patients with CKD see dose in the Renal Drug HandbookFor patients with CKD see dose in the Renal Drug Handbook

Secondary options

meropenem

For patients with CKD, please check your local drug formulary

For patients with CKD see dose in the Renal Drug HandbookFor patients with CKD see dose in the Renal Drug Handbook

levofloxacin

For patients with CKD, please check your local drug formulary

For patients with CKD see dose in the Renal Drug HandbookFor patients with CKD see dose in the Renal Drug Handbook

ciprofloxacin

For patients with CKD, please check your local drug formulary

For patients with CKD see dose in the Renal Drug HandbookFor patients with CKD see dose in the Renal Drug Handbook

Plus – review diabetes medication (NEVER stop insulin in a person with type 1 diabetes)

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Plus –

supportive care

Treatment recommended for ALL patients in selected patient group

Patients with meningococcal infections must be monitored closely for complications such as shock, elevated intracranial pressure, seizures, and coagulopathy.

Severe meningococcal infections are frequently complicated by hypoglycemia or hyperglycemia, acidosis, and other biochemical abnormalities that require attention.

Oxygen therapy in your patient with asthma

Measure resting oxygen saturation in all acutely ill patients.

Be aware that pulse oximetry may overestimate oxygen saturation in patients with darker skin tones.[97]
If your patient's asthma is stable, follow guideline recommendations for oxygen saturation target for the presenting acute condition.
If the acute presenting condition triggers an acute exacerbation of your patient's asthma, the Global Initiative for Asthma recommends controlled oxygen to maintain saturations between 93% and 95%.[97]
Adjust oxygen saturation targets for altitude, where appropriate.[97]
Hypercapnia in asthma is an indicator of very severe disease showing a patient is tiring and needs ventilatory support.[98][99][100]

Oxygen therapy in your patient with COPD

Obtain a blood gas measurement if your patient with COPD has oxygen saturation <90%, clinical signs of hypercapnia (e.g., altered mental status), or respiratory distress (based on expert opinion).
- An arterial blood gas (ABG) should be used to assess patients with respiratory failure and should always be obtained if hypoxemia is an issue.[103][104]
  - Peripheral venous blood gas (VBG) analysis has increasingly been used to estimate carbon dioxide, pH, and other variables.[105] It is less painful for the patient and may be associated with fewer complications than an ABG.[105]
  - One Cochrane Review found limited data of low to very low certainty evidence that VBG is sensitive for the diagnosis of respiratory failure and isolated hypercarbia.[105] However, it has poor specificity compared with ABG analysis, making it less reliable when precise data are necessary.[105]
Recheck blood gas as clinically indicated.[102]

Chronic hypercapnia[106]
Hypercapnia on presentation
Previous history of hypercapnic respiratory failure[103]
Moderate or severe COPD, particularly if on long-term oxygen therapy[103]
Evidence of chronic hypoventilation for other reasons, e.g., obesity hypoventilation syndrome, taking sedatives or hypnotic drugs.[102][106]

Critically ill and needs high levels of oxygen

This includes patients with comorbid COPD who need high levels of oxygen due to a critical illness such as shock, sepsis, major head injury, status epilepticus, anaphylaxis, or major trauma.

In this scenario, some guidelines recommend an initial target oxygen saturation in line with the recommendation for patients without COPD.[103]

Evidence suggests that targeting an upper oxygen saturation level of 96% may be preferred compared with a higher level.[107][108]
Subsequently, you may need to adjust to controlled oxygen therapy with a target oxygen saturation range of 88% to 92% depending on the blood gas results.[103]

Acutely but not critically ill and at risk of hypercapnic respiratory failure

This includes patients with comorbid COPD who have risk factors for hypercapnic respiratory failure and an acute condition, but are not critically ill.[103]

Give controlled oxygen therapy and use an initial target oxygen saturation of 88% to 92%.[102][103]

Check blood gas and recheck after 30 to 60 minutes.[103]

Not critically ill and NOT at risk of hypercapnic respiratory failure

As an example, a patient may have stable, mild COPD with minimal symptoms.

Use an initial target oxygen saturation as recommended by guidelines for the presenting acute condition.

Evidence suggests that for most acutely ill patients, targeting an upper oxygen saturation level of 96% may be preferred compared with a higher level.[107][108]

Measure blood gas as soon as possible[103]

Subsequently, you may need to adjust to controlled oxygen therapy with a target oxygen saturation range of 88% to 92% depending on the blood gas results.[103]

High-flow nasal cannula (HFNC)

Decreasing the work of breathing[109][110]
A theoretical provision of low-level positive end-expiratory pressure (PEEP)[109][110][111]
Facilitating secretion mobilization.[109][110]

Ventilatory support

Start noninvasive bilevel ventilation (BiPAP) if the patient has at least one of the following:[102]

Respiratory acidosis (PaCO₂ ≥45 mmHg [6 kPa] and arterial pH ≤7.35)
Severe dyspnea and/or increased work of breathing (e.g., use of respiratory muscles, paradoxical movement of the abdomen, retraction of the intercostal spaces)
Persistent hypoxemia despite supplemental oxygen.

Start invasive mechanical ventilation support if this is indicated and the patient is considered suitable. Indications for invasive mechanical ventilation include:[102]

Inability to tolerate, or failure of, noninvasive ventilation (particularly if they have life-threatening hypoxemia)
Status post respiratory or cardiac arrest
Reduced consciousness, or psychomotor agitation that is inadequately controlled by sedation
Massive aspiration or persistent vomiting
Persistent inability to remove respiratory secretions
Severe hemodynamic instability without response to fluids or vasoactive drugs
Severe ventricular or supraventricular arrhythmias.

When considering endotracheal intubation with mechanical ventilation, always take into account the patient's wishes (e.g., advance directives).[102]

Assess fluid status and manage fluid balance particularly closely

In a patient with heart failure and/or chronic kidney disease (CKD), judicial use of fluids is crucial to preventing clinically significant volume overload.

Be aware that hypovolemia may be difficult to assess in a person with heart failure and/or CKD.

As with any patient presenting acutely, look for signs of volume depletion on physical exam, by assessing:[112]

Vital signs:
- Blood pressure, (particularly systolic blood pressure [SBP] and mean arterial pressure)
- Pulse
- Postural hypotension
Peripheral perfusion
Capillary refill time
Jugular venous distension
Passive leg raise.

More info: The RUSH exam

The RUSH exam involves a three-part physiologic assessment using point of care ultrasound (POCUS):[114]

1. The pump, i.e., the cardiac status
- Evaluate cardiac status by looking for: pericardial effusions and cardiac tamponade, left ventricular contractility, and right ventricular size
2. The tank, i.e., the effective intravascular volume status
- Assess the fullness of the tank by examining the inferior vena cava (IVC) and/or internal jugular veins
- Evaluate for "leakiness" of the tank, or free fluid in the abdominal and thoracic cavities, by performing Focused Assessment of Sonography for Trauma (FAST) and thoracic ultrasound to assess for fluid in the abdominal and thoracic cavities[115][116]
- Assess compromise of the tank by assessing for pneumothorax
3. The pipes, i.e., the arterial and venous sides of the circulatory system
- Assess the aorta looking for aortic aneurysm, rupture, dissection
- Assess lower extremity and/or upper extremity veins for deep vein thrombosis.

Other variations of RUSH have been described.[113]

Practical tip

Heart failure

Be aware that an SBP of <90 mmHg may suggest hypotension, but a patient on medication for chronic heart failure can have a baseline SBP of <90 mmHg.

Consider consultation with a cardiologist and/or intensivist.

With a suspected low output or cardiogenic shock state
With massive fluid overload, when high doses of diuretic are needed or with diuretic resistance
When unable to establish volume state
When titrating inotropes.

CKD

A patient with CKD who is hypovolemic needs immediate fluid resuscitation.

Reassess your patient after initial fluid challenge and further address the cause of hypovolemia.
If they do not rapidly stabilize:
- Consider activating the rapid response team and obtaining specialist consultation
- Consider transferring your patient to an intensive care setting where hemodynamic monitoring is possible (based on expert opinion).

Continue to monitor fluid balance particularly closely

Accurate monitoring of volume status is essential in a person with heart failure and/or chronic kidney disease (CKD).[117]

There is a significant risk of pulmonary edema with fluid resuscitation in a patient with heart failure and/or CKD, so monitor closely.
Monitoring should include:
- Regular clinical assessment of volume status (pulse, BP, jugular venous distension [JVD], and check for pulmonary and peripheral edema)
- Fluid balance (input/output chart) and daily weight
- BUN and serum creatinine to monitor kidney function, at least daily.
Consider bladder catheterization if urinary output is difficult to measure, but be aware of increased risk of infection and trauma.
Patients with greater clinical complexity, such as those with heart failure and/or advanced CKD may need admission to the intensive care unit for more invasive monitoring and interventions. If noninvasive bedside assessments are not adequate for monitoring, consider a central venous pressure catheter or pulmonary artery catheter.[117][118][119]

Practical tip

De-escalation

Your patient is euvolemic
The problem requiring fluids has been successfully reversed.

Monitor volume status consistently to try to avoid volume overload.

Immediately stop fluid administration
Consider consultation with specialist
Consider intravenous diuretics, and
Arrange an urgent chest x-ray if pulmonary edema is suspected (based on expert opinion).

Unless there are extenuating circumstances, diuretics and intravenous fluids are not generally given together (based on expert opinion).

Recommendations from an intensive care specialist and/or cardiologist and/or nephrologist may be needed.

Withhold antihypertensives and/or diuretics if hypotensive

Withhold antihypertensives and/or diuretics if your patient:

Is in shock, or
Has a blood pressure ≥40 mmHg lower than their baseline.

Consider withholding antihypertensives and/or diuretics if your patient:

Is hypotensive, or
Has developed orthostatic hypotension or has postural symptoms (based on expert opinion).
- Orthostatic hypotension is defined, by consensus, as a fall in systolic blood pressure ≥20 mmHg and/or a fall in diastolic blood pressure ≥10 mmHg on assuming an upright posture.[120]
- In people with classic orthostatic hypotension, the blood pressure change occurs within 3 minutes of standing.[121] In practice, take standing blood pressure after the person has been standing for at least 1 minute (based on expert opinion).

People with hypertension, coronary artery disease, heart failure, stroke, or chronic kidney disease (CKD) will typically be taking one or more of these types of drug.

Establish your patient's baseline blood pressure and assess volume status.

Patients with treated heart failure may have chronically low blood pressure (e.g., systolic BP ≤90 mmHg). If their systolic blood pressure falls by >10-15 mmHg and is associated with symptoms (such as presyncope or syncope), it may be appropriate to withhold medications that may lower blood pressure but have no or little prognostic benefit for heart failure (such as amlodipine, doxazosin).
- If clinically appropriate, consider changing the time of administration of medication that has a prognostic benefit for heart failure (e.g., sacubitril/valsartan, beta-blockers) to night time, or splitting or reducing the dose (based on expert opinion).
- Consider consultation with a cardiologist and/or intensivist.

If diuretics are withheld in a patient with heart failure and/or CKD, close monitoring is needed as fluid can quickly accumulate.

Be aware that sodium-glucose cotransporter-2 (SGLT2) inhibitors, a class of medication with a prognostic benefit for both heart failure and CKD, also have a weak diuretic effect.[122]

If antihypertensives or diuretics have been withheld during the acute illness, consider restarting them before discharge if clinically appropriate (based on expert opinion).

Restart one at a time at a lower dose and ask the primary care physician (PCP) to titrate back to normal dose.
- Most patients won't tolerate restarting all medications at the original doses simultaneously.
- If it is not clinically appropriate to restart these medicines before discharge, ensure that the patient has follow-up to decide when the medications can be reintroduced.
- Ensure you have communicated clearly to the PCP at discharge.

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Plus –

review diabetes medication (NEVER stop insulin in a person with type 1 diabetes)

Treatment recommended for ALL patients in selected patient group

Check your patient's blood glucose on admission. In addition, check HbA1c if no result is available from the previous 3 months.[124][132]

Exclude hypoglycemia, diabetic ketoacidosis (DKA), and hyperosmolar hyperglycemic state (HHS).
Test for blood beta-hydroxybutyrate or ketones if:[133][134]
- Your patient was taking a sodium-glucose cotransporter-2 (SGLT2) inhibitor (e.g., dapagliflozin, canagliflozin, empagliflozin) before unplanned hospitalization, and/or
- There is acidosis, an increased anion gap, nausea/vomiting, or a combination of these.
Admission HbA1c may give you an indication of your patient’s previous diabetes control and may influence your treatment at discharge.

Insulin deficiency (e.g., due to delayed or missed doses) will rapidly cause ketoacidosis (based on expert opinion).

Practical tip

Critical illness

Consider starting a continuous intravenous insulin infusion for your critically ill patient for achieving glycemic goals and avoiding hypoglycemia.[124][125]

Use a validated protocol/order set for the continuous intravenous insulin infusion.[124]
This allows for predefined adjustments to the insulin infusion rate according to blood glucose measurements and past and current insulin infusion rates, to avoid hypoglycemia.[124]

More info: Continuous intravenous insulin infusion management

If a continuous intravenous insulin infusion is started:

In practice, subcutaneous basal insulin is generally discontinued (based on expert opinion).
- Less often, at some institutions, subcutaneous basal insulin may be continued (provided there is no hypotension and the patient is not on vasopressors) at 75% of the patient's usual dose.
Stop the patient’s usual subcutaneous rapid-acting and mixed insulins while on an intravenous insulin infusion.[135]
Use the continuous intravenous insulin infusion for as short a time as possible.[135]

Once ready to discontinue a continuous intravenous insulin infusion:

Follow an appropriate order set/transition protocol to switch to scheduled subcutaneous insulin.[124]
- This should include calculating the total daily dose of subcutaneous insulin needed, dividing into appropriate basal and bolus doses, monitoring and adjusting dose based on glucose monitoring, and having orders in place for potential hypoglycemic episodes (based on expert opinion).
Give subcutaneous basal insulin at least 2 hours before discontinuing the intravenous infusion to minimize rebound hyperglycemia.[124]
- Emerging data suggest that early administration of subcutaneous basal insulin alongside intravenous insulin infusion does not seem to increase the risk of hypoglycemia.[136][137]

Noncritical illness

Generally, an insulin regimen is preferred for managing hyperglycemia in individuals with diabetes receiving hospitalized care.[124]

If your patient is not eating or drinking or has poor oral intake, a subcutaneous basal insulin or basal plus bolus correction (every 4-6 hours) insulin plan is preferred.
If they are eating adequately, subcutaneous basal insulin with prandial (with each meal, up to 3-4 times a day) and correctional doses is preferred.

In a patient who is already managing their diabetes with insulin, consider whether there is any need to adjust insulin dose when they are admitted to the hospital.

If a patient with type 1 or type 2 diabetes uses insulin at home, has adequate glycemic management, and was not admitted with significant hyperglycemia, it may be appropriate to reduce their routine dose of subcutaneous basal insulin by 20%, particularly if they are eating less than usual. Another factor to keep in mind is that hospital meals generally contain less carbohydrate than meals patients would eat at home (based on expert opinion).
Conversely, patients who are acutely ill with an infection sometimes need more insulin.
Regular monitoring of blood glucose (at least four times daily) can help guide appropriate adjustments to insulin dosing.

More info: Patients using a continuous subcutaneous insulin infusion (CSII) (insulin pump) prior to hospital admission

If a patient with diabetes had been using an insulin pump prior to hospital admission:

Follow your hospital procedure, if available, and request a specialized inpatient diabetes team or endocrinology consult.
Safe continuation of an insulin pump during hospital admission has been advocated by several professional organizations.[124][138][139][140]
Key criteria for safe use include that:[124][141]
- The patient is medically stable, willing, and capable of self-management
- There are no contraindications
- The necessary supplies and resources are available
- There are hospital staff with the appropriate expertise and training, and institutional diabetes technology protocols in place
- Staff are available to perform confirmatory point-of-care (POC) glucose measurements for insulin dose decisions, hypoglycemia assessment and treatment, and at least four times a day (based on expert opinion).

Review noninsulin glucose-lowering medications if your patient had been taking any of these before admission and determine whether these are suitable to continue during admission.

For select patients with type 2 diabetes, it may be acceptable to continue noninsulin glucose-lowering medications, such as a dipeptidyl peptidase-4 (DPP-4) inhibitor.[124] Only consider this in a patient who is (based on expert opinion):
- Clinically stable with mild hyperglycemia
- Eating regularly
- Has no contraindications.
Metformin should be discontinued in patients with contraindications, including those with increased risk of lactic acidosis (e.g., those with renal impairment, shock, or hypoxia) and those with acute heart failure.[142][143] Consider restarting metformin after the acute condition has resolved (based on expert opinion).
In general, stop SGLT2 inhibitors for your patient with diabetes who is admitted to the hospital with an acute illness (based on expert opinion). This is due to the risk of euglycemic ketoacidosis.
- In particular, avoid SGLT2 inhibitors if your patient is severely ill, or if their clinical situation predisposes them to ketoacidosis (e.g., prolonged fasting due to acute illness or surgery).[124][133]
- Be aware that ketoacidosis associated with SGLT2 inhibitors may still be present despite a normal (or near normal) serum glucose level (euglycemic ketoacidosis).[134]
- If an SGLT2 inhibitor is being initiated during a hospital admission (e.g., for treatment of heart failure), this medication should be initiated after recovery from the acute illness.[124]
  - Remain aware of the risk of ketoacidosis which can occur spontaneously with SGLT2 inhibitors.[134]
  - Monitor hydration status and basic metabolic panel (BMP) daily for elevated anion gap and acidosis (based on expert opinion).
  - Check blood beta-hydroxybutyrate (or blood ketone) levels, especially if acidosis is present, or there are symptoms of ketoacidosis (e.g., nausea or vomiting) (based on expert opinion). Measure blood ketones as urinary ketone measurement may be unreliable.
  - Be aware that beta-hydroxybutyrate levels of ≥3.0 mmol/L, along with pH <7.3 or bicarbonate <18 mmol/L, indicate DKA.[134][144]
  - In this situation, stop SGLT2 inhibitor and treat DKA.[144]

Discharge

Start thinking about a discharge plan at the time of hospitalization or after stabilization (based on expert opinion). This should be structured and tailored to the individual.[124]

Provide inpatient diabetes self-management education, focusing on skills needed after discharge, and ensure follow-up and support strategies are in place.
Arrange medication reconciliation:
- Make sure this includes a strategy for switching back to the brand of insulin your patient was on at the time of hospitalization, if appropriate and approved by insurance or covered by other programs (based on expert opinion).
- Clarify regarding timing of restarting any noninsulin glucose-lowering medications that have been temporarily stopped (based on expert opinion).
Communicate promptly to the relevant outpatient healthcare professionals.

Plus – nasopharyngeal eradication predischarge

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Plus –

nasopharyngeal eradication predischarge

Treatment recommended for ALL patients in selected patient group

These treatments are equally effective. Choice is based on the age of the patient and the presence of any contraindications to an individual drug. Specialist advice should be sought for newborns.

Primary options

rifampin: children: 20 mg/kg/day orally given in 2 divided doses for 2 days, maximum 600 mg/dose; adults: 600 mg orally twice daily for 2 days

rifampin : children: 20 mg/kg/day orally given in 2 divided doses for 2 days, maximum 600 mg/dose; adults: 600 mg orally twice daily for 2 days

rifampin: children: 20 mg/kg/day orally given in 2 divided doses for 2 days, maximum 600 mg/dose; adults: 600 mg orally twice daily for 2 days

ceftriaxone: children: 125 mg intramuscularly as a single dose; adults: 250 mg intramuscularly as a single dose

ceftriaxone : children: 125 mg intramuscularly as a single dose; adults: 250 mg intramuscularly as a single dose

ceftriaxone: children: 125 mg intramuscularly as a single dose; adults: 250 mg intramuscularly as a single dose

ciprofloxacin: adults: 500 mg orally as a single dose

ciprofloxacin : adults: 500 mg orally as a single dose

ciprofloxacin: adults: 500 mg orally as a single dose

Drug choice, dose and interactions may be affected by the patient's comorbidities. Check your local drug formulary.

Show drug information for a patient with no comorbidities

Primary options

rifampin

For patients with CKD, please check your local drug formulary

For patients with CKD see dose in the Renal Drug HandbookFor patients with CKD see dose in the Renal Drug Handbook

ceftriaxone

For patients with CKD, please check your local drug formulary

For patients with CKD see dose in the Renal Drug HandbookFor patients with CKD see dose in the Renal Drug Handbook

ciprofloxacin

For patients with CKD, please check your local drug formulary

For patients with CKD see dose in the Renal Drug HandbookFor patients with CKD see dose in the Renal Drug Handbook

Plus – monitor comorbidities during hospital stay

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Plus –

monitor comorbidities during hospital stay

– baseline cognitive and delirium assessments with collateral history

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–

baseline neurologic exam

Treatment recommended for ALL patients in selected patient group

Perform a baseline neurologic exam at the earliest appropriate opportunity for any patient with a history of stroke.

A patient with an acute condition (e.g., an infection and illness-related hypotension) is at increased risk of stroke.[145][146][147] This risk is even higher in anyone with a history of stroke.
- In particular, ischemic stroke is a known complication of acute bacterial meningitis.[92][148][149]
- Less commonly, hemorrhagic stroke can also complicate bacterial meningitis.[148]
- If there is a change in neurologic status during admission, repeat the neurologic exam to evaluate for a new acute stroke.
Ensure the right level of nursing care for the patient’s condition and ensure that clear orders are written for the patient’s functional and cognitive status (e.g., fall precautions, 1:1, soft restraints, assistance with activities of daily living [ADLs]).
- A patient with a history of stroke has a higher risk of falls and injury.[150]

Back

–

baseline cognitive and delirium assessments with collateral history

Treatment recommended for ALL patients in selected patient group

Do a baseline cognitive assessment at the earliest opportunity in any patient with a history of dementia.

Take a collateral history from family, friend, or caregiver to establish whether your patient's cognitive function is stable, gradually declining, or acutely declined.[151]
Check your patient’s level of alertness and orientation to time, place, and person, and corroborate with caregivers and review your patient’s prior medical records (based on expert opinion).
If time allows, a standardized cognitive assessment score is helpful for tracking clinical progress, and determining discharge needs (based on expert opinion).
Validated scoring tools for cognitive assessment include:
- The Mini-Cog Alzheimer's Association: Mini-Cog(TM) Opens in new window
- The Montreal Cognitive Assessment (MoCA)[152]
- The Saint Louis University Mental Status Examination (SLUMS). Saint Louis University: SLUMS Opens in new window
These scores are often best interpreted alongside a functional assessment, usually performed by an occupational therapist and/or a physical therapist.
These scores may not represent the person's usual baseline for cognition due to the impact of the acute condition and its treatment, but it is still good practice to record and repeat it when the person has recovered (based on expert opinion).

Practical tip

Mind (mentation, dementia, depression, and delirium)
Mobility (gait, balance, and falls prevention)
Medications (polypharmacy, deprescribing, optimal prescribing, and adverse medication effects and medication burden)
Multicomplexity (multimorbidity and complex psychosocial situations)
Matters Most to Me (each individual's health outcome goals and care preferences).

Assess for delirium whenever a patient with dementia presents with acute illness.

People living with dementia are at increased risk of delirium when they are admitted to the hospital and throughout their admission.[151][155]
Delirium is not the same as dementia. It is a potentially life-threatening acute, fluctuating change in mental functioning, with inattention, disorganized thinking, and altered levels of consciousness.[156]
Use a screening tool to detect probable delirium, taking the setting into account. Commonly used tools include:
- The Delirium Triage Screen (DTS), which may be rapidly administered in an emergency department setting and assesses arousal and attention. If positive, confirm with a more specific tool, such as the brief Confusion Assessment Method (bCAM).[151][157][158]
- The Confusion Assessment Method (CAM), if your patient is not in a critical care setting.[151][159][160]
- The Confusion Assessment Method for the Intensive Care Unit (CAM-ICU) or the Intensive Care Delirium Screening Checklist (ICDSC) if your patient is in a critical care setting, or in the recovery room after surgery.[155][161][162][163]

Practical tip

Depression can mimic delirium in older adults, particularly in patients with cognitive impairment or other comorbid medical conditions.[151]

Ask if your patient has a diagnosis of depression. If not, use a very brief screening test, such as the Patient Health Questionnaire-2 or Emergency Department Depression Screening Instrument to screen older adults for depression.
A positive screen for depression should prompt further questions, e.g., on suicidal thoughts.

Helping with orientation; make sure patients have their own glasses and/or hearing aids
Getting patients mobilized as soon as possible
Controlling pain adequately
Keeping patients well hydrated and helping them to eat adequately
Monitoring and maintaining regular bowel and bladder function
Using supplemental oxygen as needed
Monitoring for and treating postoperative complications as soon as possible
Reviewing the patient's medications
- Identify and avoid medications that are high-risk for precipitating delirium, such as benzodiazepines, corticosteroids, and anticholinergics.[151][168]

Foster familiarity, e.g., consider facilitating the patient's usual caregiver to stay with the patient and bring in familiar objects from home.[151][158]

Practical tip

Dementia is a risk factor for postoperative delirium.[167][169]

Evaluate baseline cognition using a brief screening tool preoperatively.
Consider the most appropriate method of analgesia to reduce the risk of postoperative delirium.
Monitor for postoperative delirium using a validated screening instrument (e.g., CAM-Short Form).[170]

Evidence: Primary prevention of delirium in hospital using nonpharmacologic interventions

There is evidence that a nonpharmacologic approach reduces the risk of delirium in non-ICU patients in hospital.

A systematic review compared nonpharmacologic interventions designed to prevent delirium with usual care or active control in adults in a non-ICU hospital setting.[171]

Interventions were multicomponent or single components, targeted at a specific risk factor, such as disorientation or dehydration.
Meta-analysis of 14 studies on multicomponent interventions found a significant reduction in incident delirium compared with usual care (RR 0.57, 95% CI 0.46 to 0.71).
There is emerging evidence that multicomponent interventions may reduce hospital length of stay (MD -1.3 days, 95% CI -2.56 to -0.04 days), but there is significant heterogeneity between the studies.
There is little information specifically on people with dementia as this group was frequently excluded from trials despite their increased risk of developing delirium.

More info: Initial investigations for a patient with delirium

If your patient has delirium, check for and treat life-threatening causes:[151][167][172]

Hypoxia
Hypoglycemia
Hypotension
Sepsis
Drug intoxication or withdrawal, including alcohol withdrawal
Acute myocardial infarction

Although every evaluation should be tailored to the individual patient, most patients should receive:[151]

Complete blood count
Comprehensive metabolic panel
Point-of-care glucose
Urinalysis with culture
ECG

Additional tests that may be needed include (based on expert opinion):

Thyroid function tests
Folate and vitamin B12
C-reactive protein
Blood cultures (if bacteremia is suspected)
Chest x-ray

Consider whether your patient requires computed tomography (CT) of the brain.[151]

CT brain should be arranged if your patient has focal neurological deficits, head trauma, reduced level of consciousness, or has a history of fall.
CT brain should also be considered if your patient takes anticoagulants.
In practice, a patient in the hospital setting who has a change in mental status will usually receive a CT brain (based on expert opinion).

Check for and treat any reversible causes of delirium:[151][158][167][172]

Pain
Infection
Poor nutrition
Constipation
Dehydration
Medications
- Ask about recently prescribed medications, especially opioid analgesics, anxiolytics, antipsychotics, corticosteroids, or anticholinergics
Immobility
Poor sleep
Sensory impairment (e.g., ear wax or loss of glasses)

More info: Management of a patient with delirium

Manage patients with delirium initially with nonpharmacologic treatment.[151][158][167]

Reduce disorientation by providing a well-lit room, with a clock and calendar visible (e.g., on the wall).
Encourage and facilitate family, friends, and caregivers to visit the patient.
Use verbal and nonverbal techniques to de-escalate conflict and distress.

Any new antipsychotic prescribed for this purpose must be regularly reviewed, and discontinued as soon as possible.[168][173]
Be aware that the evidence on the efficacy of antipsychotics for delirium is inconclusive, and guidance regarding choice of antipsychotic varies.[151][158][167]
Antipsychotics should be used with caution in patients with a history of dementia as there is an increased risk of mortality in these patients[151][173]
- A systematic review of antipsychotics for delirium in hospitalized adults concluded that the evidence did not support routine use of haloperidol or atypical antipsychotics for this purpose[174]
- All antipsychotics have a warning that they are not approved for dementia-related psychosis.[151]
Haloperidol is contraindicated in patients with Parkinson disease or in patients with dementia with Lewy bodies.[163] Check for all contraindications.
Consider baseline ECG before starting any antipsychotic medication (based on expert opinion).

Document the diagnosis of delirium clearly (based on expert opinion).

Evidence: Risks and safe withdrawal of antipsychotics in older adults

Antipsychotics are associated with increased mortality in people with dementia.

A Cochrane review found very low certainty evidence that typical antipsychotics such as haloperidol improve agitation, but reported that they may improve psychosis slightly in people with Alzheimer disease and vascular dementia. Atypical antipsychotics probably reduce agitation. Both types increase the risk of somnolence and extrapyramidal symptoms.[175]
A network meta-analysis found that people who take atypical antipsychotics for behavioral and psychological symptoms of dementia may have a small improvement in behavioral and psychological symptoms but have increased safety risks including for cerebrovascular adverse events, compared with those taking placebo.[176]
Contrary to popular belief, long-term antipsychotic use can be safely withdrawn in most people with dementia once behavior has settled.[177]

– establish goals of care, taking into account any advance directives

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assess your patient’s level of frailty

Treatment recommended for ALL patients in selected patient group

Assess your patient's level of frailty to:[178][179]

Establish whether management plans are consistent with goals of care, and
Identify whether further assessment and enhanced care is needed.

Practical tip

Ask your patient (with input from caregivers if relevant) about their functional capability 2 weeks BEFORE this acute episode to determine baseline state.[184]
Use the Clinical Frailty Scale (CFS) if your patient is ≥65 years old.[185][186] Dalhousie University: Clinical Frailty Scale Opens in new window
- This tool is a practical aid to identify frailty, but should not be relied on in isolation.
- Do not use the CFS to assess younger patients, or those with disabilities that reflect single-system problems (e.g., spinal cord injury).[184]
- If your patient scores 5 or higher, consider arranging a comprehensive geriatric assessment, if this is feasible and clinically appropriate, at the earliest opportunity.[181]
- A higher prehospital frailty score is associated with an increased risk of adverse outcomes including risk of mortality in-hospital, at 1, 3, 6, and 12 months; all-cause readmission within 30 days; extended length of stay; discharge to a nursing home, residential care, hospital, or a high level of care; and functional decline.[187]
Look for nonspecific complaints, such as delirium and falls.
Help to implement multidisciplinary care and to tailor the management approach according to the patient's values and goals of care.[188]

Practical tip

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–

establish goals of care, taking into account any advance directives

Treatment recommended for ALL patients in selected patient group

Ask your patient if they have an advance directive (e.g., a living will, a healthcare proxy) and/or a Do Not Resuscitate (DNR) or Do Not Intubate (DNI) order.[193]

This applies to all patients, but may be particularly relevant to patients living with frailty and/or with certain comorbidities, such as dementia, stroke, heart failure, COPD, and late-stage CKD (based on expert opinion).
Ensure any existing advance directives align with your patient's current preferences and goals of care.[193]

Practical tip

Discuss specific treatment options and health trajectory to help your patient (or surrogate decision-maker) make informed decisions about their care.[193][195][196]

This should include (based on expert opinion):
- Code status (e.g., Do Not Resuscitate [DNR] order, Do Not Intubate [DNI] order)
- Other life-sustaining treatment options (e.g., vasopressors, extracorporeal membrane oxygenation [ECMO], kidney replacement therapy, blood transfusions, parenteral/enteral nutrition).

Assess and document decision-making capacity (the ability to make a specific decision at the time that the decision needs to be made).[197][198][199]
- Attempt to improve your patient’s capacity to participate in decision-making by addressing communication barriers and alleviating exacerbating factors, such as delirium.[200]
- Be aware that an individual’s decision-making capacity can vary over time so should be reassessed periodically.[200]
If your patient lacks decision-making capacity, establish whether they have an advance directive.[195][198][199]
- This may include a living will and/or a designated proxy known as a Durable Power of Attorney for Healthcare (DPAHC). [198]
If your patient who lacks decision-making capacity has no applicable advance directive, including no designated proxy, identify a surrogate decision-maker from a priority list of individuals such as spouse, adult child, and adult sibling.[198][199]
- The hierarchy of this list, and the scope of surrogates' decision-making, varies from state to state.
- Ensure a surrogate's decisions are consistent with patient preferences and best interests.
- In the case of conflict, consider consulting your hospital's ethics committees.
If your patient is an older adult and is unrepresented (a patient without decision-making capacity for a particular medical intervention who lacks both a relevant advance directive and a surrogate decision-maker), the American Geriatrics Society recommends:[200]
- Attempting to identify a nontraditional surrogate (e.g., a close friend, live-in companion, neighbor, or other individual who knows the patient well), in the absence of a traditional surrogate (next of kin), who is willing and able to represent your patient’s wishes and values
- Avoiding unilateral decision-making in the absence of a suitable surrogate, which could carry a risk of bias. The AGS favors a structured multidisciplinary consensus approach to decision-making.

Check your relevant state law and practice accordingly. There may be no available out-of-court process to allow nontraditional surrogates in many states.
If your unrepresented patient is in an urgent or life-threatening situation:[198][199]
- Use all available information on a patient's preferences, values, and beliefs to guide treatment decisions. If preferences are not known, urgent care decisions should be made in the patient's best interests.[195][198][201]
- Consider using the Four Box Model (also known as the Four Quadrant Model) to aid ethical decision-making. This consists of four principles:[200][202]
  - Medical indications for treatment
  - Patient preferences for care
  - Quality of life
  - Contextual features (this includes being mindful of provider biases, the patient’s psychosocial context, and how the treatment and cost of care may impact the patient).
In a less urgent situation, rarely, a court-appointed guardian may be appointed to make decisions in this context.[195][198][200]

– monitor and manage blood glucose during the hospital admission

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monitor and manage blood glucose during the hospital admission

Treatment recommended for ALL patients in selected patient group

The risk of hypo- and hyperglycemia increases when a person with diabetes is admitted to the hospital acutely (based on expert opinion).
More frequent monitoring is needed after any episode of hyperglycemia or hypoglycemia and after any change in hypoglycemic medication (based on expert opinion). If a correction dose of insulin is given at bedtime, check blood glucose about 4 to 6 hours later (usually about 2 a.m.) (based on expert opinion).
If your patient is having surgery, the American Diabetes Association (ADA) recommends monitoring blood glucose at least every 2 to 4 hours while the individual is taking nothing by mouth (npo).[124]
Any patient on an intravenous insulin infusion needs more frequent blood glucose measurements, ranging from every 30 minutes to every 2 hours.[124]

Practical tip

Decide on target blood glucose levels.

There is a general consensus among different guideline organizations on target blood glucose levels for people with diabetes in the hospital.

For most critically ill patients, the ADA recommends a target range of 140 to 180 mg/dL (7.8 to 10.0 mmol/L) once treatment has been started for persistent hyperglycemia.[124]
- Stricter target ranges, such as 110 to 140 mg/dL (6.1 to 7.8 mmol/L), may be acceptable in select critically ill patients, but only if they can be achieved without significant hypoglycemia.[124]
For most noncritically ill patients, the ADA and the Endocrine Society recommend a target range of 100 to 180 mg/dL (5.6 to 10.0 mmol/L).[124][138]
- Less stringent goals are appropriate in some patients, for instance those at high risk of hypoglycemia, advanced kidney failure, and those who are terminally ill. The ADA recommends that the focus in these people should be on avoiding hypoglycemia and symptomatic hyperglycemia.[124]

Evidence: Blood glucose targets for critically ill patients with hyperglycemia

Evidence argues against very tight glucose control in critically ill patients (a mixed population with and without a history of diabetes).

Intensive care setting:
- A randomized controlled trial (RCT) of critically ill patients in a primarily surgical intensive care setting found lower patient mortality with tight glucose control, 80 to 110 mg/dL (4.4 to 6.1 mmol/L), compared with "conventional" more liberal glucose control.[203]
- However, a subsequent multicenter RCT in critically ill medical and surgical patients in other intensive care settings found increased mortality with tighter glucose control, possibly due to more frequent episodes of hypoglycemia.[204]
- In 2017, two network meta-analyses found no benefit in mortality with tight glycemic control when compared with less tight control (79.2 to <109.8 mg/dL [4.4 to <6.1 mmol/L] vs.140.4 to <219.6 mg/dL [7.8 to <12.2 mmol/L] in one report; <110 to 144 mg/dL [<6.1 to 8.0 mmol/L] vs.144 to >180 mg/dL [8.0 to >10.0 mmol/L] in the second report) but a significant increase in the risk of hypoglycemia.[205][206]

More info: Hyperglycemia during the ongoing hospital admission

Hyperglycemia in admitted patients, whether with known diabetes or not, is associated with adverse patient outcomes, including increased mortality.[142]

Act promptly to treat hyperglycemia to avoid diabetic ketoacidosis (DKA) and hyperosmolar hyperglycemic state (HHS).
For persistent hyperglycemia, defined as blood glucose ≥180 mg/dL (≥10.0 mmol/L) confirmed on two occasions within 24 hours, the ADA recommends:[124]
- Starting or intensifying insulin therapy for most critically ill patients.
- Starting or intensifying insulin and/or other glucose-lowering therapies for most noncritically ill patients.

If your patient has DKA or HHS, consider the appropriate unit for management.

Indications for management in the intensive care unit (ICU) include:[134]
- Severe DKA or severe HHS
- Critical illness as the precipitating cause (e.g., sepsis, acute myocardial infarction, gastrointestinal bleeding)
- Altered mental status
- Another concurrent indication for ICU admission.
See Diabetic ketoacidosis or Hyperosmolar hyperglycemic state.

Be aware that the following interventions may be associated with hyperglycemia and may need to be reviewed:[207]

Corticosteroids
Some second-generation antipsychotics (e.g., olanzapine, clozapine)
Fluoroquinolone antibiotics (e.g., ciprofloxacin)
Calcineurin inhibitors (e.g., tacrolimus)
Protease inhibitors (e.g., ritonavir)
Artificial nutrition (parenteral or enteral).

Ask for a specialized inpatient diabetes team consult, if available, or endocrinology consult where hyperglycemia is difficult to control.

More info: Hypoglycemia during the ongoing hospital admission

Monitor blood glucose and adjust medication in response to illness and hospital meal times, to reduce the risk of hypoglycemic episodes.

Ensure that a hypoglycemia management surveillance protocol is in place, with an individualized plan for preventing, identifying, and treating hypoglycemia.[124]
- Immediately correct level 2 hypoglycemia (blood glucose levels <54 mg/dL [<3.0 mmol/L]) and level 3 hypoglycemia (characterized by altered mental and/or physical functioning, requiring assistance for treatment of hypoglycemia from another person for recovery, with no defined glucose level).
- Promptly treat level 1 hypoglycemia (blood glucose levels <70 mg/dL [<3.9 mmol/L] and ≥54 mg/dL [≥3.0 mmol/L]) to prevent progression to more significant levels of hypoglycemia.
- Ensure hypoglycemia treatment is included in all insulin orders.
Treat hypoglycemia, which usually involves provision of 15 g of fast-acting carbohydrates (oral or enteric juice or table sugar; intravenous dextrose). Check blood glucose 15 minutes after the treatment. If the blood glucose is not in a safe range (usually considered to be >90 mg/dL [>5.0 mmol/L]), repeat the treatment. If the oral and enteric route is not available, administer intravenous dextrose. If the patient has no intravenous access, administer glucagon (based on expert opinion). See Diabetic hypoglycemia.
Be aware that hypoglycemia may be induced by treatment of hyperglycemia/diabetes.[208]
- Sliding scale insulin (correctional or supplemental insulin without basal insulin) is associated with the highest rates of hypoglycemia (based on expert opinion). Sole use of sliding scale insulin is not recommended for most individuals in a hospital inpatient setting.[124]
- Be aware of the risk of hypoglycemia in patients on intensive insulin regimens (e.g., multiple daily injections, continuous subcutaneous insulin infusion, or automated insulin delivery systems), and those on basal insulin, sulfonylureas, or meglitinides.
- A combination of insulin and sulfonylureas further increases hypoglycemia risk.
Review and adapt your patient’s treatment plan to prevent recurrent episodes of hypoglycemia.[124]
- Be aware that level 1 hypoglycemia often predicts subsequent level 3 hypoglycemia.
Document any episodes of hypoglycemia in the electronic health record.[124]

Causes of hypoglycemia include:[124]

Inappropriate insulin dose or dose adjustment
Insulin or oral hypoglycemic medication error
Wrong timing of insulin in relation to meals
Inadequate follow-up of first episode of hypoglycemia
Patients eating less but taking the same amount of diabetes medication
Reduced appetite or vomiting
Unexpected interruption of enteral or parenteral feedings
Reduced infusion rate of intravenous dextrose
Delayed or missed blood glucose checks
Sudden reduction of corticosteroid dose
Altered ability of a patient to report symptoms
Recovery from an acute illness.

These medications include:
- Some antibiotics (e.g., fluoroquinolones, trimethoprim/sulfamethoxazole, chloramphenicol)[209][210]
- Other nondiabetic medications (e.g., ACE inhibitors, beta-blockers, chloroquine, disopyramide, pentamidine, salicylates)[209]
Polypharmacy of multiple hypoglycemia-causing medications also increases this risk.[208]
This list is not exhaustive. Consult your local drug information source (based on expert opinion).

Take action if blood glucose falls below 100 mg/dL (<5.6 mmol/L) (based on expert opinion). Fasting blood glucose levels <100 mg/dL (<5.6 mmol/L) are predictive of next-day hypoglycemia.[124]

Give extra carbohydrates to prevent hypoglycemia unless your patient is going to eat a meal within an hour (based on expert opinion).
Modify insulin doses to prevent glucose from going below the target for the patient.

Take steps to reduce the risk of hypoglycemia at night. Assuming your patient is not npo (nothing by mouth), they are likely to have a smaller evening meal in the hospital than at home.

In the absence of significant hyperglycemia, consider reducing the evening basal insulin by 20% on admission (based on expert opinion).
Remember that for many patients with very high insulin needs at home, the needs are often much lower in the hospital, presumably because of changes in diet.
Review the dose used during recent prior hospitalization(s) when deciding the starting dose of insulin (based on expert opinion).

More info: Self-management of diabetes in the hospital

The ADA recommends that suitable candidates for self-managing their diabetes in the hospital include those who:[124]

Normally perform self-management at home
Have the necessary cognitive and physical skills while in the hospital
Have adequate oral intake
Are proficient in carbohydrate estimation
Take multiple daily insulin injections or use insulin pumps
Have stable insulin requirements, and
Understand sick-day management.

The patient and hospital care team should review the decision on self-management on a daily basis.[124]

Inspect injection sites if your patient is on insulin injections at home (based on expert opinion).

Check for insulin lipodystrophy and re-educate on injection technique, if needed.

Continuous glucose monitoring

Consider continuing personal continuous glucose monitoring (CGM) for any individual who uses this wearable technology at home.[211] Consult with the inpatient diabetes team if available.[140]

Although not approved by the Food and Drug Administration (FDA), emergency use authorization was granted during the coronavirus disease 2019 (COVID-19) pandemic and several professional bodies suggest this may be useful if complying with institutional policies and safety regulations.[124][211][132][140]
Confirmatory point-of-care glucose measurements are still needed for assessment of hypoglycemia and to guide decisions on insulin dosing.[124]
Be aware that some concomitant medications, such as acetaminophen (above a certain dose), dopamine, heparin, vitamin C, and hydroxyurea, may result in inaccurate measurements by CGM devices.[211]

More info: Management of patients with diabetes who are receiving end-of-life care

If a patient with diabetes is receiving end-of-life care:

Discuss with your patient and their family/caregivers and agree on the level of intensity of care. Less stringent targets for blood glucose levels are appropriate, with the aim of avoiding hypoglycemia and symptomatic hyperglycemia.[124][132][212]
Prioritize providing comfort and reducing the burdens of strict blood glucose management.[212]
Be aware that stopping basal insulin in a person with type 1 diabetes can lead to dehydration, ketoacidosis, nausea, and associated vomiting; therefore, continuing basal insulin in such a person could be considered as a comfort care (based on expert opinion).

– ensure monitoring is in place to detect any asthma exacerbation during your patient's hospital admission

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examine your patient’s feet

Treatment recommended for ALL patients in selected patient group

Examine the feet of any adult with diabetes on their admission to the hospital and whenever they become ill.[213]

This is to detect new ulcerations or infection, which may be unnoticed by the patient and may even be the cause of their acute illness (e.g., patient presenting with sepsis, or endocarditis where the original focus of infection is the foot lesion).

Inspect the foot for lesions and examine for loss of protective sensation.

To perform a comprehensive foot examination:[214]

Inspect the skin.
Assess any foot deformities.
Do a neurologic exam, including 10-g monofilament testing or Ipswich touch test, with at least one other assessment (pinprick, temperature, or vibration).[215]
Do a vascular exam, including pulses in the legs and feet.

If your patient has reduced sensation, they are at risk for diabetic foot ulceration.[214] Provide pressure relieving devices.

Order daily heel checks for signs of pressure trauma. There is a debate about whether compression stockings should or should not be used in people with diabetes; do not use them if there is known peripheral vascular disease.

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ensure monitoring is in place to detect any asthma exacerbation during your patient's hospital admission

Treatment recommended for ALL patients in selected patient group

Acute worsening of respiratory symptoms may suggest a patient with comorbid asthma is having an acute exacerbation of their asthma.

Follow guideline recommendations on assessing severity and managing an acute exacerbation of asthma in adults.[97]
See Acute asthma exacerbation in adults.

This is due to concern over possible additive anticholinergic adverse effects.
Ensure to represcribe the LAMA once the nebulizer treatment has been stopped.

Be aware that the long-term use of beta-2 agonists to manage asthma may increase the risk of cardiovascular events.

Evidence: Cardiovascular harm with beta-2 agonists

Beta-2 agonists may increase the risk of myocardial infarction and other adverse cardiovascular events.

Beta-2 agonists increase heart rate and reduce potassium levels.[216] They are absorbed into the systemic circulation and there is evidence that long-term regular use may be associated with an increased risk of myocardial infarction, unstable angina, congestive heart failure, and arrhythmias.[217][216]
However, it is not routine practice to discontinue beta-2 agonists if they are needed for comorbid asthma.

– ensure monitoring is in place to detect any COPD exacerbation during your patient's hospital admission

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ensure monitoring is in place to detect any COPD exacerbation during your patient's hospital admission

Treatment recommended for ALL patients in selected patient group

Acute worsening of respiratory symptoms may suggest a patient with comorbid COPD is having an acute exacerbation.[102]

Differentiate from other conditions, such as a pulmonary embolism, acute heart failure, and pneumonia.
Follow guideline recommendations.[102] See Acute exacerbation of COPD.

This is due to concern over possible additive anticholinergic adverse effects.
Ensure the LAMA is represcribed once the nebulizer treatment has been stopped.

Be aware that the long-term use of beta-2 agonists to manage COPD may increase the risk of cardiovascular events.

Evidence: Cardiovascular harm with beta-2 agonists

Beta-2 agonists may increase the risk of myocardial infarction and other adverse cardiovascular events.

Beta-2 agonists increase heart rate and reduce potassium levels.[216] They are absorbed into the systemic circulation and there is evidence that long-term regular use may be associated with an increased risk of myocardial infarction, unstable angina, congestive heart failure, and arrhythmias.[216][217]
However, the Global Initiative for Chronic Obstructive Lung Disease states that there has been no reported association between beta-2-agonist use and increased mortality in people with COPD.[102] It is not routine practice to discontinue beta-2 agonists if they are needed for comorbid COPD.

– continue your patient's inhalers as prescribed for asthma or COPD

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mental status exam

Treatment recommended for ALL patients in selected patient group

Perform a mental status exam as the clinical situation allows (based on expert opinion).

The mental status exam is one of the main clinical tools routinely used in psychiatric practice, aiding diagnosis and guiding further management. Mood is one of the assessed domains.

Consider assessing current symptoms of depression using the PHQ-9 questionnaire.[218][219]

The PHQ-9 questionnaire can be used as a reliable and valid measure of depression severity in patients with a known diagnosis of depression, as well as a screening tool.
This can be self-administered or administered by the clinician, and takes less than 3 minutes to complete.
Results indicate severity of depressive symptoms.

Take into account other factors that may be influencing the patient's mental status (e.g., the effect of any illicit drug use or alcohol).[219][220]

In particular, consider whether symptoms of depression could be part of the acute medical illness (based on expert opinion).

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review current treatment for depression

Treatment recommended for ALL patients in selected patient group

Continue the patient’s usual antidepressant, unless there are good reasons not to (based on expert opinion).

If antidepressants are stopped abruptly, the patient may develop antidepressant discontinuation syndrome.[221]
The severity of the symptoms of discontinuation may vary, but they may be unpleasant and may complicate the management of the acute medical condition.

When reviewing current medications, consider:

Current and previous adverse effects
Recent changes in dose
Recent medication changes from a different drug class
The specific diagnostic subtypes of depression when prescribing medications (e.g., it is likely that patients suffering from psychotic depression would be coprescribed an antipsychotic)
Augmenting strategies that may be used when treating resistant depression (e.g., lithium or quetiapine augmentation of a selective serotonin-reuptake inhibitor [SSRI]).

Consider drug-drug interactions.

Antidepressants (particularly those that inhibit the CYP450 pathway) may cause significant interactions with drugs used for other conditions.[222]

Consider psychiatric complications when prescribing nonpsychotropic drugs.

Take particular care when prescribing anticonvulsants, antiparkinsonian drugs, and corticosteroids.

Consider adverse effects, which may include the following:

Hyponatremia, caused by antidepressants, especially SSRIs, and compounded by other coprescribed drugs (e.g., diuretics).[223][224][225][226] Review your patient’s serum electrolyte results and consider antidepressants as a potential contributing factor if they have hyponatremia.
Serotonin syndrome (altered mental state, agitation, tremor, hyper-reflexia, ocular clonus or inducible clonus, muscle rigidity, diaphoresis, tachycardia, increased bowel sounds, temperature >100.4°F [>38°C]), especially with polypharmacy and/or overdose of a serotonergic agent.[227][228] See Serotonin syndrome.
- Be particularly aware of increased risk of serotonin syndrome in patients with kidney failure on SSRIs.[229][230]
Hepatotoxicity.[231] Adjust doses of antidepressants in patients with hepatic impairment as necessary.
- However, antidepressants are rarely the cause of hepatic impairment.[231]
Prolonged QTc, arrhythmias, increased heart rate, postural hypotension with tricyclic antidepressants.[232][233] Obtain an ECG, especially in people at risk of arrhythmias.[234]
Gastrointestinal bleeding. SSRIs are associated with an increased risk of gastrointestinal bleeding.[223][235][236] Risk is particularly increased when coprescribed with aspirin, nonsteroidal anti-inflammatory drugs (NSAIDs), or oral anticoagulants.[236][237][238] Monitor closely and consider gastroprotection with proton-pump inhibitors if SSRI use cannot be avoided (based on expert opinion).

This list of adverse effects is not exhaustive - consult your drug information sources or hospital pharmacist for further information, and consider a psychiatric consult for advice.

Practical tip

Ask your patient about nonpharmacologic treatments for their depression and check the current level of community support.

This may include other outpatient healthcare professionals, charities, and family and social networks.

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consider psychiatric consult

Treatment recommended for ALL patients in selected patient group

Consider a psychiatric consult for any patient with comorbid depression who is admitted to the hospital with an acute condition.

Consult is strongly advised in patients with severe symptoms of depression or additional symptoms such as self harm, suicidal ideation, homicidal ideation, catatonia, psychosis (based on expert opinion).
Consult may not be required if there are no concerns that depression and/or its management (e.g., medication) may be affecting the acute condition (based on expert opinion).
Accidents of unclear circumstances, self-injurious behaviors, and/or suicide attempts (including alleged "accidental" overdose of medication) should trigger clinical suspicion of comorbid mental health disorder (based on expert opinion).

Ensure your patient has adequate support with their treatment post-discharge.

Keep in mind that the psychological impact of comorbid depression may be associated with poor adherence with recommended physical health treatments, from medication to rehabilitation.[242][243][244] This may lead to worse clinical outcomes, including higher readmission risk.[245][246]
Most importantly, affective symptoms, including depression, have been linked with excess mortality, though a causal link remains to be proven.[247][248]

1st line – targeted antibiotic therapy

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manage tobacco dependence

Treatment recommended for ALL patients in selected patient group

If your patient currently uses tobacco, assess their tobacco use and provide assistance and support with tobacco cessation interventions.[249][250][251]

Advise:

That nicotine is highly addictive and nicotine withdrawal can be extremely distressing and uncomfortable.[250]
NRT prevents rapid withdrawal.[250]
That there are a number of highly effective treatment options that offer the best chance of stopping smoking.[249][250][251]

Ensure a sufficient dose of NRT is prescribed to adequately address withdrawal symptoms.[255]
Ask the patient how many cigarettes they smoke per day; this may determine the starting dose of NRT.
Ask about the type of tobacco product used, including e-cigarettes, water pipe use, and other smokeless tobacco products (snuff, ground, or chewing tobacco), as use of these products also results in nicotine addiction.
Check drug information sources for any contraindications or cautions, particularly if your patient has one or more comorbidity and/or is hemodynamically unstable.
Assess for symptoms of withdrawal daily (based on expert opinion).

One Cochrane Review found high-certainty evidence that varenicline is an effective treatment for tobacco dependence.[257] The same review found that people taking varenicline likely have an increased chance of a more serious adverse effect (e.g., cardiac) that could result in hospital admission; however, these are still rare (2.7% to 4% of people on varenicline, compared with 2.7% of people not taking varenicline) and may include events that are unrelated to varenicline.[257] Check drug information sources for a full list of contraindications and cautions or seek pharmacist advice.
Mental health illness is NOT a contraindication to prescribing varenicline. However, varenicline should be used with caution in people with a pre-existing psychiatric illness as it may worsen symptoms.
Bupropion is an alternative option to varenicline for tobacco cessation but is less likely to result in successful quitting.[257] Consider the potential for drug-drug interactions.

Ensure your patient has follow-up with their primary care practitioner or addiction medicine physician to continue treatment for tobacco dependence.

Practical tip

See Smoking cessation for more information.

confirmed meningococcal bacteremia

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1st line –

targeted antibiotic therapy

Once the diagnosis of a meningococcal infection is confirmed, the patient should be treated with an intravenous cephalosporin (e.g., ceftriaxone or cefotaxime). Treatment is usually for a duration of 5-7 days depending on the patient's age, severity of infection, and response to initial therapy.[50]

If the patient is receiving dexamethasone for suspected meningitis, this should be discontinued.[47][54]

Check baseline kidney function and monitor closely

Acute illness also increases the risk of deterioration in kidney function.
Monitor for and respond to oliguria.

Primary options

ceftriaxone : neonates: consult specialist for guidance on dose; children: 80-100 mg/kg/day intravenously given in divided doses every 12-24 hours, maximum 4 g/day; adults: 2 g intravenously every 12 hours

cefotaxime : neonates: consult specialist for guidance on dose; children: 200-300 mg/kg/day intravenously given in divided doses every 6-8 hours, maximum 12 g/day; adults: 2 g intravenously every 4-6 hours

Drug choice, dose and interactions may be affected by the patient's comorbidities. Check your local drug formulary.

Show drug information for a patient with no comorbidities

Primary options

ceftriaxone

For patients with CKD, please check your local drug formulary

For patients with CKD see dose in the Renal Drug HandbookFor patients with CKD see dose in the Renal Drug Handbook

cefotaxime

For patients with CKD, please check your local drug formulary

For patients with CKD see dose in the Renal Drug HandbookFor patients with CKD see dose in the Renal Drug Handbook

Plus – review diabetes medication (NEVER stop insulin in a person with type 1 diabetes)

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supportive care

Treatment recommended for ALL patients in selected patient group

Patients with meningococcal infections must be monitored closely for complications such as shock, elevated intracranial pressure, seizures, and coagulopathy.

Severe meningococcal infections are frequently complicated by hypoglycemia or hyperglycemia, acidosis, and other biochemical abnormalities that require attention.

Oxygen therapy in your patient with asthma

Measure resting oxygen saturation in all acutely ill patients.

Be aware that pulse oximetry may overestimate oxygen saturation in patients with darker skin tones.[97]
If your patient's asthma is stable, follow guideline recommendations for oxygen saturation target for the presenting acute condition.
If the acute presenting condition triggers an acute exacerbation of your patient's asthma, the Global Initiative for Asthma recommends controlled oxygen to maintain saturations between 93% and 95%.[97]
Adjust oxygen saturation targets for altitude, where appropriate.[97]
Hypercapnia in asthma is an indicator of very severe disease showing a patient is tiring and needs ventilatory support.[98][99][100]

Oxygen therapy in your patient with COPD

Obtain a blood gas measurement if your patient with COPD has oxygen saturation <90%, clinical signs of hypercapnia (e.g., altered mental status), or respiratory distress (based on expert opinion).
- An arterial blood gas (ABG) should be used to assess patients with respiratory failure and should always be obtained if hypoxemia is an issue.[103][104]
  - Peripheral venous blood gas (VBG) analysis has increasingly been used to estimate carbon dioxide, pH, and other variables.[105] It is less painful for the patient and may be associated with fewer complications than an ABG.[105]
  - One Cochrane Review found limited data of low to very low certainty evidence that VBG is sensitive for the diagnosis of respiratory failure and isolated hypercarbia.[105] However, it has poor specificity compared with ABG analysis, making it less reliable when precise data are necessary.[105]
Recheck blood gas as clinically indicated.[102]

Chronic hypercapnia[106]
Hypercapnia on presentation
Previous history of hypercapnic respiratory failure[103]
Moderate or severe COPD, particularly if on long-term oxygen therapy[103]
Evidence of chronic hypoventilation for other reasons, e.g., obesity hypoventilation syndrome, taking sedatives or hypnotic drugs.[102][106]

Critically ill and needs high levels of oxygen

This includes patients with comorbid COPD who need high levels of oxygen due to a critical illness such as shock, sepsis, major head injury, status epilepticus, anaphylaxis, or major trauma.

In this scenario, some guidelines recommend an initial target oxygen saturation in line with the recommendation for patients without COPD.[103]

Evidence suggests that targeting an upper oxygen saturation level of 96% may be preferred compared with a higher level.[107][108]
Subsequently, you may need to adjust to controlled oxygen therapy with a target oxygen saturation range of 88% to 92% depending on the blood gas results.[103]

Acutely but not critically ill and at risk of hypercapnic respiratory failure

This includes patients with comorbid COPD who have risk factors for hypercapnic respiratory failure and an acute condition, but are not critically ill.[103]

Give controlled oxygen therapy and use an initial target oxygen saturation of 88% to 92%.[102][103]

Check blood gas and recheck after 30 to 60 minutes.[103]

Not critically ill and NOT at risk of hypercapnic respiratory failure

As an example, a patient may have stable, mild COPD with minimal symptoms.

Use an initial target oxygen saturation as recommended by guidelines for the presenting acute condition.

Evidence suggests that for most acutely ill patients, targeting an upper oxygen saturation level of 96% may be preferred compared with a higher level.[107][108]

Measure blood gas as soon as possible[103]

Subsequently, you may need to adjust to controlled oxygen therapy with a target oxygen saturation range of 88% to 92% depending on the blood gas results.[103]

High-flow nasal cannula (HFNC)

Decreasing the work of breathing[109][110]
A theoretical provision of low-level positive end-expiratory pressure (PEEP)[109][110][111]
Facilitating secretion mobilization.[109][110]

Ventilatory support

Start noninvasive bilevel ventilation (BiPAP) if the patient has at least one of the following:[102]

Respiratory acidosis (PaCO₂ ≥45 mmHg [6 kPa] and arterial pH ≤7.35)
Severe dyspnea and/or increased work of breathing (e.g., use of respiratory muscles, paradoxical movement of the abdomen, retraction of the intercostal spaces)
Persistent hypoxemia despite supplemental oxygen.

Start invasive mechanical ventilation support if this is indicated and the patient is considered suitable. Indications for invasive mechanical ventilation include:[102]

Inability to tolerate, or failure of, noninvasive ventilation (particularly if they have life-threatening hypoxemia)
Status post respiratory or cardiac arrest
Reduced consciousness, or psychomotor agitation that is inadequately controlled by sedation
Massive aspiration or persistent vomiting
Persistent inability to remove respiratory secretions
Severe hemodynamic instability without response to fluids or vasoactive drugs
Severe ventricular or supraventricular arrhythmias.

When considering endotracheal intubation with mechanical ventilation, always take into account the patient's wishes (e.g., advance directives).[102]

Assess fluid status and manage fluid balance particularly closely

In a patient with heart failure and/or chronic kidney disease (CKD), judicial use of fluids is crucial to preventing clinically significant volume overload.

Be aware that hypovolemia may be difficult to assess in a person with heart failure and/or CKD.

As with any patient presenting acutely, look for signs of volume depletion on physical exam, by assessing:[112]

Vital signs:
- Blood pressure, (particularly systolic blood pressure [SBP] and mean arterial pressure)
- Pulse
- Postural hypotension
Peripheral perfusion
Capillary refill time
Jugular venous distension
Passive leg raise.

More info: The RUSH exam

The RUSH exam involves a three-part physiologic assessment using point of care ultrasound (POCUS):[114]

1. The pump, i.e., the cardiac status
- Evaluate cardiac status by looking for: pericardial effusions and cardiac tamponade, left ventricular contractility, and right ventricular size
2. The tank, i.e., the effective intravascular volume status
- Assess the fullness of the tank by examining the inferior vena cava (IVC) and/or internal jugular veins
- Evaluate for "leakiness" of the tank, or free fluid in the abdominal and thoracic cavities, by performing Focused Assessment of Sonography for Trauma (FAST) and thoracic ultrasound to assess for fluid in the abdominal and thoracic cavities[115][116]
- Assess compromise of the tank by assessing for pneumothorax
3. The pipes, i.e., the arterial and venous sides of the circulatory system
- Assess the aorta looking for aortic aneurysm, rupture, dissection
- Assess lower extremity and/or upper extremity veins for deep vein thrombosis.

Other variations of RUSH have been described.[113]

Practical tip

Heart failure

Be aware that an SBP of <90 mmHg may suggest hypotension, but a patient on medication for chronic heart failure can have a baseline SBP of <90 mmHg.

Consider consultation with a cardiologist and/or intensivist.

With a suspected low output or cardiogenic shock state
With massive fluid overload, when high doses of diuretic are needed or with diuretic resistance
When unable to establish volume state
When titrating inotropes.

CKD

A patient with CKD who is hypovolemic needs immediate fluid resuscitation.

Reassess your patient after initial fluid challenge and further address the cause of hypovolemia.
If they do not rapidly stabilize:
- Consider activating the rapid response team and obtaining specialist consultation
- Consider transferring your patient to an intensive care setting where hemodynamic monitoring is possible (based on expert opinion).

Continue to monitor fluid balance particularly closely

Accurate monitoring of volume status is essential in a person with heart failure and/or chronic kidney disease (CKD).[117]

There is a significant risk of pulmonary edema with fluid resuscitation in a patient with heart failure and/or CKD, so monitor closely.
Monitoring should include:
- Regular clinical assessment of volume status (pulse, BP, jugular venous distension [JVD], and check for pulmonary and peripheral edema)
- Fluid balance (input/output chart) and daily weight
- BUN and serum creatinine to monitor kidney function, at least daily.
Consider bladder catheterization if urinary output is difficult to measure, but be aware of increased risk of infection and trauma.
Patients with greater clinical complexity, such as those with heart failure and/or advanced CKD may need admission to the intensive care unit for more invasive monitoring and interventions. If noninvasive bedside assessments are not adequate for monitoring, consider a central venous pressure catheter or pulmonary artery catheter.[117][118][119]

Practical tip

De-escalation

Your patient is euvolemic
The problem requiring fluids has been successfully reversed.

Monitor volume status consistently to try to avoid volume overload.

Immediately stop fluid administration
Consider consultation with specialist
Consider intravenous diuretics, and
Arrange an urgent chest x-ray if pulmonary edema is suspected (based on expert opinion).

Unless there are extenuating circumstances, diuretics and intravenous fluids are not generally given together (based on expert opinion).

Recommendations from an intensive care specialist and/or cardiologist and/or nephrologist may be needed.

Withhold antihypertensives and/or diuretics if hypotensive

Withhold antihypertensives and/or diuretics if your patient:

Is in shock, or
Has a blood pressure ≥40 mmHg lower than their baseline.

Consider withholding antihypertensives and/or diuretics if your patient:

Is hypotensive, or
Has developed orthostatic hypotension or has postural symptoms (based on expert opinion).
- Orthostatic hypotension is defined, by consensus, as a fall in systolic blood pressure ≥20 mmHg and/or a fall in diastolic blood pressure ≥10 mmHg on assuming an upright posture.[120]
- In people with classic orthostatic hypotension, the blood pressure change occurs within 3 minutes of standing.[121] In practice, take standing blood pressure after the person has been standing for at least 1 minute (based on expert opinion).

People with hypertension, coronary artery disease, heart failure, stroke, or chronic kidney disease (CKD) will typically be taking one or more of these types of drug.

Establish your patient's baseline blood pressure and assess volume status.

Patients with treated heart failure may have chronically low blood pressure (e.g., systolic BP ≤90 mmHg). If their systolic blood pressure falls by >10-15 mmHg and is associated with symptoms (such as presyncope or syncope), it may be appropriate to withhold medications that may lower blood pressure but have no or little prognostic benefit for heart failure (such as amlodipine, doxazosin).
- If clinically appropriate, consider changing the time of administration of medication that has a prognostic benefit for heart failure (e.g., sacubitril/valsartan, beta-blockers) to night time, or splitting or reducing the dose (based on expert opinion).
- Consider consultation with a cardiologist and/or intensivist.

If diuretics are withheld in a patient with heart failure and/or CKD, close monitoring is needed as fluid can quickly accumulate.

Be aware that sodium-glucose cotransporter-2 (SGLT2) inhibitors, a class of medication with a prognostic benefit for both heart failure and CKD, also have a weak diuretic effect.[122]

If antihypertensives or diuretics have been withheld during the acute illness, consider restarting them before discharge if clinically appropriate (based on expert opinion).

Restart one at a time at a lower dose and ask the primary care physician (PCP) to titrate back to normal dose.
- Most patients won't tolerate restarting all medications at the original doses simultaneously.
- If it is not clinically appropriate to restart these medicines before discharge, ensure that the patient has follow-up to decide when the medications can be reintroduced.
- Ensure you have communicated clearly to the PCP at discharge.

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review diabetes medication (NEVER stop insulin in a person with type 1 diabetes)

Treatment recommended for ALL patients in selected patient group

Check your patient's blood glucose on admission. In addition, check HbA1c if no result is available from the previous 3 months.[124][132]

Exclude hypoglycemia, diabetic ketoacidosis (DKA), and hyperosmolar hyperglycemic state (HHS).
Test for blood beta-hydroxybutyrate or ketones if:[133][134]
- Your patient was taking a sodium-glucose cotransporter-2 (SGLT2) inhibitor (e.g., dapagliflozin, canagliflozin, empagliflozin) before unplanned hospitalization, and/or
- There is acidosis, an increased anion gap, nausea/vomiting, or a combination of these.
Admission HbA1c may give you an indication of your patient’s previous diabetes control and may influence your treatment at discharge.

Insulin deficiency (e.g., due to delayed or missed doses) will rapidly cause ketoacidosis (based on expert opinion).

Practical tip

Critical illness

Consider starting a continuous intravenous insulin infusion for your critically ill patient for achieving glycemic goals and avoiding hypoglycemia.[124][125]

Use a validated protocol/order set for the continuous intravenous insulin infusion.[124]
This allows for predefined adjustments to the insulin infusion rate according to blood glucose measurements and past and current insulin infusion rates, to avoid hypoglycemia.[124]

More info: Continuous intravenous insulin infusion management

If a continuous intravenous insulin infusion is started:

In practice, subcutaneous basal insulin is generally discontinued (based on expert opinion).
- Less often, at some institutions, subcutaneous basal insulin may be continued (provided there is no hypotension and the patient is not on vasopressors) at 75% of the patient's usual dose.
Stop the patient’s usual subcutaneous rapid-acting and mixed insulins while on an intravenous insulin infusion.[135]
Use the continuous intravenous insulin infusion for as short a time as possible.[135]

Once ready to discontinue a continuous intravenous insulin infusion:

Follow an appropriate order set/transition protocol to switch to scheduled subcutaneous insulin.[124]
- This should include calculating the total daily dose of subcutaneous insulin needed, dividing into appropriate basal and bolus doses, monitoring and adjusting dose based on glucose monitoring, and having orders in place for potential hypoglycemic episodes (based on expert opinion).
Give subcutaneous basal insulin at least 2 hours before discontinuing the intravenous infusion to minimize rebound hyperglycemia.[124]
- Emerging data suggest that early administration of subcutaneous basal insulin alongside intravenous insulin infusion does not seem to increase the risk of hypoglycemia.[136][137]

Noncritical illness

Generally, an insulin regimen is preferred for managing hyperglycemia in individuals with diabetes receiving hospitalized care.[124]

If your patient is not eating or drinking or has poor oral intake, a subcutaneous basal insulin or basal plus bolus correction (every 4-6 hours) insulin plan is preferred.
If they are eating adequately, subcutaneous basal insulin with prandial (with each meal, up to 3-4 times a day) and correctional doses is preferred.

In a patient who is already managing their diabetes with insulin, consider whether there is any need to adjust insulin dose when they are admitted to the hospital.

If a patient with type 1 or type 2 diabetes uses insulin at home, has adequate glycemic management, and was not admitted with significant hyperglycemia, it may be appropriate to reduce their routine dose of subcutaneous basal insulin by 20%, particularly if they are eating less than usual. Another factor to keep in mind is that hospital meals generally contain less carbohydrate than meals patients would eat at home (based on expert opinion).
Conversely, patients who are acutely ill with an infection sometimes need more insulin.
Regular monitoring of blood glucose (at least four times daily) can help guide appropriate adjustments to insulin dosing.

More info: Patients using a continuous subcutaneous insulin infusion (CSII) (insulin pump) prior to hospital admission

If a patient with diabetes had been using an insulin pump prior to hospital admission:

Follow your hospital procedure, if available, and request a specialized inpatient diabetes team or endocrinology consult.
Safe continuation of an insulin pump during hospital admission has been advocated by several professional organizations.[124][138][139][140]
Key criteria for safe use include that:[124][141]
- The patient is medically stable, willing, and capable of self-management
- There are no contraindications
- The necessary supplies and resources are available
- There are hospital staff with the appropriate expertise and training, and institutional diabetes technology protocols in place
- Staff are available to perform confirmatory point-of-care (POC) glucose measurements for insulin dose decisions, hypoglycemia assessment and treatment, and at least four times a day (based on expert opinion).

Review noninsulin glucose-lowering medications if your patient had been taking any of these before admission and determine whether these are suitable to continue during admission.

For select patients with type 2 diabetes, it may be acceptable to continue noninsulin glucose-lowering medications, such as a dipeptidyl peptidase-4 (DPP-4) inhibitor.[124] Only consider this in a patient who is (based on expert opinion):
- Clinically stable with mild hyperglycemia
- Eating regularly
- Has no contraindications.
Metformin should be discontinued in patients with contraindications, including those with increased risk of lactic acidosis (e.g., those with renal impairment, shock, or hypoxia) and those with acute heart failure.[142][143] Consider restarting metformin after the acute condition has resolved (based on expert opinion).
In general, stop SGLT2 inhibitors for your patient with diabetes who is admitted to the hospital with an acute illness (based on expert opinion). This is due to the risk of euglycemic ketoacidosis.
- In particular, avoid SGLT2 inhibitors if your patient is severely ill, or if their clinical situation predisposes them to ketoacidosis (e.g., prolonged fasting due to acute illness or surgery).[124][133]
- Be aware that ketoacidosis associated with SGLT2 inhibitors may still be present despite a normal (or near normal) serum glucose level (euglycemic ketoacidosis).[134]
- If an SGLT2 inhibitor is being initiated during a hospital admission (e.g., for treatment of heart failure), this medication should be initiated after recovery from the acute illness.[124]
  - Remain aware of the risk of ketoacidosis which can occur spontaneously with SGLT2 inhibitors.[134]
  - Monitor hydration status and basic metabolic panel (BMP) daily for elevated anion gap and acidosis (based on expert opinion).
  - Check blood beta-hydroxybutyrate (or blood ketone) levels, especially if acidosis is present, or there are symptoms of ketoacidosis (e.g., nausea or vomiting) (based on expert opinion). Measure blood ketones as urinary ketone measurement may be unreliable.
  - Be aware that beta-hydroxybutyrate levels of ≥3.0 mmol/L, along with pH <7.3 or bicarbonate <18 mmol/L, indicate DKA.[134][144]
  - In this situation, stop SGLT2 inhibitor and treat DKA.[144]

Discharge

Start thinking about a discharge plan at the time of hospitalization or after stabilization (based on expert opinion). This should be structured and tailored to the individual.[124]

Provide inpatient diabetes self-management education, focusing on skills needed after discharge, and ensure follow-up and support strategies are in place.
Arrange medication reconciliation:
- Make sure this includes a strategy for switching back to the brand of insulin your patient was on at the time of hospitalization, if appropriate and approved by insurance or covered by other programs (based on expert opinion).
- Clarify regarding timing of restarting any noninsulin glucose-lowering medications that have been temporarily stopped (based on expert opinion).
Communicate promptly to the relevant outpatient healthcare professionals.

Plus – monitor comorbidities during hospital stay

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Plus –

monitor comorbidities during hospital stay

– baseline cognitive and delirium assessments with collateral history

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baseline neurologic exam

Treatment recommended for ALL patients in selected patient group

Perform a baseline neurologic exam at the earliest appropriate opportunity for any patient with a history of stroke.

A patient with an acute condition (e.g., an infection and illness-related hypotension) is at increased risk of stroke.[145][146][147] This risk is even higher in anyone with a history of stroke.
- In particular, ischemic stroke is a known complication of acute bacterial meningitis.[92][148][149]
- Less commonly, hemorrhagic stroke can also complicate bacterial meningitis.[148]
- If there is a change in neurologic status during admission, repeat the neurologic exam to evaluate for a new acute stroke.
Ensure the right level of nursing care for the patient’s condition and ensure that clear orders are written for the patient’s functional and cognitive status (e.g., fall precautions, 1:1, soft restraints, assistance with activities of daily living [ADLs]).
- A patient with a history of stroke has a higher risk of falls and injury.[150]

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baseline cognitive and delirium assessments with collateral history

Treatment recommended for ALL patients in selected patient group

Do a baseline cognitive assessment at the earliest opportunity in any patient with a history of dementia.

Take a collateral history from family, friend, or caregiver to establish whether your patient's cognitive function is stable, gradually declining, or acutely declined.[151]
Check your patient’s level of alertness and orientation to time, place, and person, and corroborate with caregivers and review your patient’s prior medical records (based on expert opinion).
If time allows, a standardized cognitive assessment score is helpful for tracking clinical progress, and determining discharge needs (based on expert opinion).
Validated scoring tools for cognitive assessment include:
- The Mini-Cog Alzheimer's Association: Mini-Cog(TM) Opens in new window
- The Montreal Cognitive Assessment (MoCA)[152]
- The Saint Louis University Mental Status Examination (SLUMS). Saint Louis University: SLUMS Opens in new window
These scores are often best interpreted alongside a functional assessment, usually performed by an occupational therapist and/or a physical therapist.
These scores may not represent the person's usual baseline for cognition due to the impact of the acute condition and its treatment, but it is still good practice to record and repeat it when the person has recovered (based on expert opinion).

Practical tip

Mind (mentation, dementia, depression, and delirium)
Mobility (gait, balance, and falls prevention)
Medications (polypharmacy, deprescribing, optimal prescribing, and adverse medication effects and medication burden)
Multicomplexity (multimorbidity and complex psychosocial situations)
Matters Most to Me (each individual's health outcome goals and care preferences).

Assess for delirium whenever a patient with dementia presents with acute illness.

People living with dementia are at increased risk of delirium when they are admitted to the hospital and throughout their admission.[151][155]
Delirium is not the same as dementia. It is a potentially life-threatening acute, fluctuating change in mental functioning, with inattention, disorganized thinking, and altered levels of consciousness.[156]
Use a screening tool to detect probable delirium, taking the setting into account. Commonly used tools include:
- The Delirium Triage Screen (DTS), which may be rapidly administered in an emergency department setting and assesses arousal and attention. If positive, confirm with a more specific tool, such as the brief Confusion Assessment Method (bCAM).[151][157][158]
- The Confusion Assessment Method (CAM), if your patient is not in a critical care setting.[151][159][160]
- The Confusion Assessment Method for the Intensive Care Unit (CAM-ICU) or the Intensive Care Delirium Screening Checklist (ICDSC) if your patient is in a critical care setting, or in the recovery room after surgery.[155][161][162][163]

Practical tip

Depression can mimic delirium in older adults, particularly in patients with cognitive impairment or other comorbid medical conditions.[151]

Ask if your patient has a diagnosis of depression. If not, use a very brief screening test, such as the Patient Health Questionnaire-2 or Emergency Department Depression Screening Instrument to screen older adults for depression.
A positive screen for depression should prompt further questions, e.g., on suicidal thoughts.

Helping with orientation; make sure patients have their own glasses and/or hearing aids
Getting patients mobilized as soon as possible
Controlling pain adequately
Keeping patients well hydrated and helping them to eat adequately
Monitoring and maintaining regular bowel and bladder function
Using supplemental oxygen as needed
Monitoring for and treating postoperative complications as soon as possible
Reviewing the patient's medications
- Identify and avoid medications that are high-risk for precipitating delirium, such as benzodiazepines, corticosteroids, and anticholinergics.[151][168]

Foster familiarity, e.g., consider facilitating the patient's usual caregiver to stay with the patient and bring in familiar objects from home.[151][158]

Practical tip

Dementia is a risk factor for postoperative delirium.[167][169]

Evaluate baseline cognition using a brief screening tool preoperatively.
Consider the most appropriate method of analgesia to reduce the risk of postoperative delirium.
Monitor for postoperative delirium using a validated screening instrument (e.g., CAM-Short Form).[170]

Evidence: Primary prevention of delirium in hospital using nonpharmacologic interventions

There is evidence that a nonpharmacologic approach reduces the risk of delirium in non-ICU patients in hospital.

A systematic review compared nonpharmacologic interventions designed to prevent delirium with usual care or active control in adults in a non-ICU hospital setting.[171]

Interventions were multicomponent or single components, targeted at a specific risk factor, such as disorientation or dehydration.
Meta-analysis of 14 studies on multicomponent interventions found a significant reduction in incident delirium compared with usual care (RR 0.57, 95% CI 0.46 to 0.71).
There is emerging evidence that multicomponent interventions may reduce hospital length of stay (MD -1.3 days, 95% CI -2.56 to -0.04 days), but there is significant heterogeneity between the studies.
There is little information specifically on people with dementia as this group was frequently excluded from trials despite their increased risk of developing delirium.

More info: Initial investigations for a patient with delirium

If your patient has delirium, check for and treat life-threatening causes:[151][167][172]

Hypoxia
Hypoglycemia
Hypotension
Sepsis
Drug intoxication or withdrawal, including alcohol withdrawal
Acute myocardial infarction

Although every evaluation should be tailored to the individual patient, most patients should receive:[151]

Complete blood count
Comprehensive metabolic panel
Point-of-care glucose
Urinalysis with culture
ECG

Additional tests that may be needed include (based on expert opinion):

Thyroid function tests
Folate and vitamin B12
C-reactive protein
Blood cultures (if bacteremia is suspected)
Chest x-ray

Consider whether your patient requires computed tomography (CT) of the brain.[151]

CT brain should be arranged if your patient has focal neurological deficits, head trauma, reduced level of consciousness, or has a history of fall.
CT brain should also be considered if your patient takes anticoagulants.
In practice, a patient in the hospital setting who has a change in mental status will usually receive a CT brain (based on expert opinion).

Check for and treat any reversible causes of delirium:[151][158][167][172]

Pain
Infection
Poor nutrition
Constipation
Dehydration
Medications
- Ask about recently prescribed medications, especially opioid analgesics, anxiolytics, antipsychotics, corticosteroids, or anticholinergics
Immobility
Poor sleep
Sensory impairment (e.g., ear wax or loss of glasses)

More info: Management of a patient with delirium

Manage patients with delirium initially with nonpharmacologic treatment.[151][158][167]

Reduce disorientation by providing a well-lit room, with a clock and calendar visible (e.g., on the wall).
Encourage and facilitate family, friends, and caregivers to visit the patient.
Use verbal and nonverbal techniques to de-escalate conflict and distress.

Any new antipsychotic prescribed for this purpose must be regularly reviewed, and discontinued as soon as possible.[168][173]
Be aware that the evidence on the efficacy of antipsychotics for delirium is inconclusive, and guidance regarding choice of antipsychotic varies.[151][158][167]
Antipsychotics should be used with caution in patients with a history of dementia as there is an increased risk of mortality in these patients[151][173]
- A systematic review of antipsychotics for delirium in hospitalized adults concluded that the evidence did not support routine use of haloperidol or atypical antipsychotics for this purpose[174]
- All antipsychotics have a warning that they are not approved for dementia-related psychosis.[151]
Haloperidol is contraindicated in patients with Parkinson disease or in patients with dementia with Lewy bodies.[163] Check for all contraindications.
Consider baseline ECG before starting any antipsychotic medication (based on expert opinion).

Document the diagnosis of delirium clearly (based on expert opinion).

Evidence: Risks and safe withdrawal of antipsychotics in older adults

Antipsychotics are associated with increased mortality in people with dementia.

A Cochrane review found very low certainty evidence that typical antipsychotics such as haloperidol improve agitation, but reported that they may improve psychosis slightly in people with Alzheimer disease and vascular dementia. Atypical antipsychotics probably reduce agitation. Both types increase the risk of somnolence and extrapyramidal symptoms.[175]
A network meta-analysis found that people who take atypical antipsychotics for behavioral and psychological symptoms of dementia may have a small improvement in behavioral and psychological symptoms but have increased safety risks including for cerebrovascular adverse events, compared with those taking placebo.[176]
Contrary to popular belief, long-term antipsychotic use can be safely withdrawn in most people with dementia once behavior has settled.[177]

– establish goals of care, taking into account any advance directives

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assess your patient’s level of frailty

Treatment recommended for ALL patients in selected patient group

Assess your patient's level of frailty to:[178][179]

Establish whether management plans are consistent with goals of care, and
Identify whether further assessment and enhanced care is needed.

Practical tip

Ask your patient (with input from caregivers if relevant) about their functional capability 2 weeks BEFORE this acute episode to determine baseline state.[184]
Use the Clinical Frailty Scale (CFS) if your patient is ≥65 years old.[185][186] Dalhousie University: Clinical Frailty Scale Opens in new window
- This tool is a practical aid to identify frailty, but should not be relied on in isolation.
- Do not use the CFS to assess younger patients, or those with disabilities that reflect single-system problems (e.g., spinal cord injury).[184]
- If your patient scores 5 or higher, consider arranging a comprehensive geriatric assessment, if this is feasible and clinically appropriate, at the earliest opportunity.[181]
- A higher prehospital frailty score is associated with an increased risk of adverse outcomes including risk of mortality in-hospital, at 1, 3, 6, and 12 months; all-cause readmission within 30 days; extended length of stay; discharge to a nursing home, residential care, hospital, or a high level of care; and functional decline.[187]
Look for nonspecific complaints, such as delirium and falls.
Help to implement multidisciplinary care and to tailor the management approach according to the patient's values and goals of care.[188]

Practical tip

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establish goals of care, taking into account any advance directives

Treatment recommended for ALL patients in selected patient group

Ask your patient if they have an advance directive (e.g., a living will, a healthcare proxy) and/or a Do Not Resuscitate (DNR) or Do Not Intubate (DNI) order.[193]

This applies to all patients, but may be particularly relevant to patients living with frailty and/or with certain comorbidities, such as dementia, stroke, heart failure, COPD, and late-stage CKD (based on expert opinion).
Ensure any existing advance directives align with your patient's current preferences and goals of care.[193]

Practical tip

Discuss specific treatment options and health trajectory to help your patient (or surrogate decision-maker) make informed decisions about their care.[193][195][196]

This should include (based on expert opinion):
- Code status (e.g., Do Not Resuscitate [DNR] order, Do Not Intubate [DNI] order)
- Other life-sustaining treatment options (e.g., vasopressors, extracorporeal membrane oxygenation [ECMO], kidney replacement therapy, blood transfusions, parenteral/enteral nutrition).

Assess and document decision-making capacity (the ability to make a specific decision at the time that the decision needs to be made).[197][198][199]
- Attempt to improve your patient’s capacity to participate in decision-making by addressing communication barriers and alleviating exacerbating factors, such as delirium.[200]
- Be aware that an individual’s decision-making capacity can vary over time so should be reassessed periodically.[200]
If your patient lacks decision-making capacity, establish whether they have an advance directive.[195][198][199]
- This may include a living will and/or a designated proxy known as a Durable Power of Attorney for Healthcare (DPAHC). [198]
If your patient who lacks decision-making capacity has no applicable advance directive, including no designated proxy, identify a surrogate decision-maker from a priority list of individuals such as spouse, adult child, and adult sibling.[198][199]
- The hierarchy of this list, and the scope of surrogates' decision-making, varies from state to state.
- Ensure a surrogate's decisions are consistent with patient preferences and best interests.
- In the case of conflict, consider consulting your hospital's ethics committees.
If your patient is an older adult and is unrepresented (a patient without decision-making capacity for a particular medical intervention who lacks both a relevant advance directive and a surrogate decision-maker), the American Geriatrics Society recommends:[200]
- Attempting to identify a nontraditional surrogate (e.g., a close friend, live-in companion, neighbor, or other individual who knows the patient well), in the absence of a traditional surrogate (next of kin), who is willing and able to represent your patient’s wishes and values
- Avoiding unilateral decision-making in the absence of a suitable surrogate, which could carry a risk of bias. The AGS favors a structured multidisciplinary consensus approach to decision-making.

Check your relevant state law and practice accordingly. There may be no available out-of-court process to allow nontraditional surrogates in many states.
If your unrepresented patient is in an urgent or life-threatening situation:[198][199]
- Use all available information on a patient's preferences, values, and beliefs to guide treatment decisions. If preferences are not known, urgent care decisions should be made in the patient's best interests.[195][198][201]
- Consider using the Four Box Model (also known as the Four Quadrant Model) to aid ethical decision-making. This consists of four principles:[200][202]
  - Medical indications for treatment
  - Patient preferences for care
  - Quality of life
  - Contextual features (this includes being mindful of provider biases, the patient’s psychosocial context, and how the treatment and cost of care may impact the patient).
In a less urgent situation, rarely, a court-appointed guardian may be appointed to make decisions in this context.[195][198][200]

– monitor and manage blood glucose during the hospital admission

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monitor and manage blood glucose during the hospital admission

Treatment recommended for ALL patients in selected patient group

The risk of hypo- and hyperglycemia increases when a person with diabetes is admitted to the hospital acutely (based on expert opinion).
More frequent monitoring is needed after any episode of hyperglycemia or hypoglycemia and after any change in hypoglycemic medication (based on expert opinion). If a correction dose of insulin is given at bedtime, check blood glucose about 4 to 6 hours later (usually about 2 a.m.) (based on expert opinion).
If your patient is having surgery, the American Diabetes Association (ADA) recommends monitoring blood glucose at least every 2 to 4 hours while the individual is taking nothing by mouth (npo).[124]
Any patient on an intravenous insulin infusion needs more frequent blood glucose measurements, ranging from every 30 minutes to every 2 hours.[124]

Practical tip

Decide on target blood glucose levels.

There is a general consensus among different guideline organizations on target blood glucose levels for people with diabetes in the hospital.

For most critically ill patients, the ADA recommends a target range of 140 to 180 mg/dL (7.8 to 10.0 mmol/L) once treatment has been started for persistent hyperglycemia.[124]
- Stricter target ranges, such as 110 to 140 mg/dL (6.1 to 7.8 mmol/L), may be acceptable in select critically ill patients, but only if they can be achieved without significant hypoglycemia.[124]
For most noncritically ill patients, the ADA and the Endocrine Society recommend a target range of 100 to 180 mg/dL (5.6 to 10.0 mmol/L).[124][138]
- Less stringent goals are appropriate in some patients, for instance those at high risk of hypoglycemia, advanced kidney failure, and those who are terminally ill. The ADA recommends that the focus in these people should be on avoiding hypoglycemia and symptomatic hyperglycemia.[124]

Evidence: Blood glucose targets for critically ill patients with hyperglycemia

Evidence argues against very tight glucose control in critically ill patients (a mixed population with and without a history of diabetes).

Intensive care setting:
- A randomized controlled trial (RCT) of critically ill patients in a primarily surgical intensive care setting found lower patient mortality with tight glucose control, 80 to 110 mg/dL (4.4 to 6.1 mmol/L), compared with "conventional" more liberal glucose control.[203]
- However, a subsequent multicenter RCT in critically ill medical and surgical patients in other intensive care settings found increased mortality with tighter glucose control, possibly due to more frequent episodes of hypoglycemia.[204]
- In 2017, two network meta-analyses found no benefit in mortality with tight glycemic control when compared with less tight control (79.2 to <109.8 mg/dL [4.4 to <6.1 mmol/L] vs.140.4 to <219.6 mg/dL [7.8 to <12.2 mmol/L] in one report; <110 to 144 mg/dL [<6.1 to 8.0 mmol/L] vs.144 to >180 mg/dL [8.0 to >10.0 mmol/L] in the second report) but a significant increase in the risk of hypoglycemia.[205][206]

More info: Hyperglycemia during the ongoing hospital admission

Hyperglycemia in admitted patients, whether with known diabetes or not, is associated with adverse patient outcomes, including increased mortality.[142]

Act promptly to treat hyperglycemia to avoid diabetic ketoacidosis (DKA) and hyperosmolar hyperglycemic state (HHS).
For persistent hyperglycemia, defined as blood glucose ≥180 mg/dL (≥10.0 mmol/L) confirmed on two occasions within 24 hours, the ADA recommends:[124]
- Starting or intensifying insulin therapy for most critically ill patients.
- Starting or intensifying insulin and/or other glucose-lowering therapies for most noncritically ill patients.

If your patient has DKA or HHS, consider the appropriate unit for management.

Indications for management in the intensive care unit (ICU) include:[134]
- Severe DKA or severe HHS
- Critical illness as the precipitating cause (e.g., sepsis, acute myocardial infarction, gastrointestinal bleeding)
- Altered mental status
- Another concurrent indication for ICU admission.
See Diabetic ketoacidosis or Hyperosmolar hyperglycemic state.

Be aware that the following interventions may be associated with hyperglycemia and may need to be reviewed:[207]

Corticosteroids
Some second-generation antipsychotics (e.g., olanzapine, clozapine)
Fluoroquinolone antibiotics (e.g., ciprofloxacin)
Calcineurin inhibitors (e.g., tacrolimus)
Protease inhibitors (e.g., ritonavir)
Artificial nutrition (parenteral or enteral).

Ask for a specialized inpatient diabetes team consult, if available, or endocrinology consult where hyperglycemia is difficult to control.

More info: Hypoglycemia during the ongoing hospital admission

Monitor blood glucose and adjust medication in response to illness and hospital meal times, to reduce the risk of hypoglycemic episodes.

Ensure that a hypoglycemia management surveillance protocol is in place, with an individualized plan for preventing, identifying, and treating hypoglycemia.[124]
- Immediately correct level 2 hypoglycemia (blood glucose levels <54 mg/dL [<3.0 mmol/L]) and level 3 hypoglycemia (characterized by altered mental and/or physical functioning, requiring assistance for treatment of hypoglycemia from another person for recovery, with no defined glucose level).
- Promptly treat level 1 hypoglycemia (blood glucose levels <70 mg/dL [<3.9 mmol/L] and ≥54 mg/dL [≥3.0 mmol/L]) to prevent progression to more significant levels of hypoglycemia.
- Ensure hypoglycemia treatment is included in all insulin orders.
Treat hypoglycemia, which usually involves provision of 15 g of fast-acting carbohydrates (oral or enteric juice or table sugar; intravenous dextrose). Check blood glucose 15 minutes after the treatment. If the blood glucose is not in a safe range (usually considered to be >90 mg/dL [>5.0 mmol/L]), repeat the treatment. If the oral and enteric route is not available, administer intravenous dextrose. If the patient has no intravenous access, administer glucagon (based on expert opinion). See Diabetic hypoglycemia.
Be aware that hypoglycemia may be induced by treatment of hyperglycemia/diabetes.[208]
- Sliding scale insulin (correctional or supplemental insulin without basal insulin) is associated with the highest rates of hypoglycemia (based on expert opinion). Sole use of sliding scale insulin is not recommended for most individuals in a hospital inpatient setting.[124]
- Be aware of the risk of hypoglycemia in patients on intensive insulin regimens (e.g., multiple daily injections, continuous subcutaneous insulin infusion, or automated insulin delivery systems), and those on basal insulin, sulfonylureas, or meglitinides.
- A combination of insulin and sulfonylureas further increases hypoglycemia risk.
Review and adapt your patient’s treatment plan to prevent recurrent episodes of hypoglycemia.[124]
- Be aware that level 1 hypoglycemia often predicts subsequent level 3 hypoglycemia.
Document any episodes of hypoglycemia in the electronic health record.[124]

Causes of hypoglycemia include:[124]

Inappropriate insulin dose or dose adjustment
Insulin or oral hypoglycemic medication error
Wrong timing of insulin in relation to meals
Inadequate follow-up of first episode of hypoglycemia
Patients eating less but taking the same amount of diabetes medication
Reduced appetite or vomiting
Unexpected interruption of enteral or parenteral feedings
Reduced infusion rate of intravenous dextrose
Delayed or missed blood glucose checks
Sudden reduction of corticosteroid dose
Altered ability of a patient to report symptoms
Recovery from an acute illness.

These medications include:
- Some antibiotics (e.g., fluoroquinolones, trimethoprim/sulfamethoxazole, chloramphenicol)[209][210]
- Other nondiabetic medications (e.g., ACE inhibitors, beta-blockers, chloroquine, disopyramide, pentamidine, salicylates)[209]
Polypharmacy of multiple hypoglycemia-causing medications also increases this risk.[208]
This list is not exhaustive. Consult your local drug information source (based on expert opinion).

Take action if blood glucose falls below 100 mg/dL (<5.6 mmol/L) (based on expert opinion). Fasting blood glucose levels <100 mg/dL (<5.6 mmol/L) are predictive of next-day hypoglycemia.[124]

Give extra carbohydrates to prevent hypoglycemia unless your patient is going to eat a meal within an hour (based on expert opinion).
Modify insulin doses to prevent glucose from going below the target for the patient.

Take steps to reduce the risk of hypoglycemia at night. Assuming your patient is not npo (nothing by mouth), they are likely to have a smaller evening meal in the hospital than at home.

In the absence of significant hyperglycemia, consider reducing the evening basal insulin by 20% on admission (based on expert opinion).
Remember that for many patients with very high insulin needs at home, the needs are often much lower in the hospital, presumably because of changes in diet.
Review the dose used during recent prior hospitalization(s) when deciding the starting dose of insulin (based on expert opinion).

More info: Self-management of diabetes in the hospital

The ADA recommends that suitable candidates for self-managing their diabetes in the hospital include those who:[124]

Normally perform self-management at home
Have the necessary cognitive and physical skills while in the hospital
Have adequate oral intake
Are proficient in carbohydrate estimation
Take multiple daily insulin injections or use insulin pumps
Have stable insulin requirements, and
Understand sick-day management.

The patient and hospital care team should review the decision on self-management on a daily basis.[124]

Inspect injection sites if your patient is on insulin injections at home (based on expert opinion).

Check for insulin lipodystrophy and re-educate on injection technique, if needed.

Continuous glucose monitoring

Consider continuing personal continuous glucose monitoring (CGM) for any individual who uses this wearable technology at home.[211] Consult with the inpatient diabetes team if available.[140]

Although not approved by the Food and Drug Administration (FDA), emergency use authorization was granted during the coronavirus disease 2019 (COVID-19) pandemic and several professional bodies suggest this may be useful if complying with institutional policies and safety regulations.[124][211][132][140]
Confirmatory point-of-care glucose measurements are still needed for assessment of hypoglycemia and to guide decisions on insulin dosing.[124]
Be aware that some concomitant medications, such as acetaminophen (above a certain dose), dopamine, heparin, vitamin C, and hydroxyurea, may result in inaccurate measurements by CGM devices.[211]

More info: Management of patients with diabetes who are receiving end-of-life care

If a patient with diabetes is receiving end-of-life care:

Discuss with your patient and their family/caregivers and agree on the level of intensity of care. Less stringent targets for blood glucose levels are appropriate, with the aim of avoiding hypoglycemia and symptomatic hyperglycemia.[124][132][212]
Prioritize providing comfort and reducing the burdens of strict blood glucose management.[212]
Be aware that stopping basal insulin in a person with type 1 diabetes can lead to dehydration, ketoacidosis, nausea, and associated vomiting; therefore, continuing basal insulin in such a person could be considered as a comfort care (based on expert opinion).

– ensure monitoring is in place to detect any asthma exacerbation during your patient's hospital admission

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examine your patient’s feet

Treatment recommended for ALL patients in selected patient group

Examine the feet of any adult with diabetes on their admission to the hospital and whenever they become ill.[213]

This is to detect new ulcerations or infection, which may be unnoticed by the patient and may even be the cause of their acute illness (e.g., patient presenting with sepsis, or endocarditis where the original focus of infection is the foot lesion).

Inspect the foot for lesions and examine for loss of protective sensation.

To perform a comprehensive foot examination:[214]

Inspect the skin.
Assess any foot deformities.
Do a neurologic exam, including 10-g monofilament testing or Ipswich touch test, with at least one other assessment (pinprick, temperature, or vibration).[215]
Do a vascular exam, including pulses in the legs and feet.

If your patient has reduced sensation, they are at risk for diabetic foot ulceration.[214] Provide pressure relieving devices.

Order daily heel checks for signs of pressure trauma. There is a debate about whether compression stockings should or should not be used in people with diabetes; do not use them if there is known peripheral vascular disease.

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ensure monitoring is in place to detect any asthma exacerbation during your patient's hospital admission

Treatment recommended for ALL patients in selected patient group

Acute worsening of respiratory symptoms may suggest a patient with comorbid asthma is having an acute exacerbation of their asthma.

Follow guideline recommendations on assessing severity and managing an acute exacerbation of asthma in adults.[97]
See Acute asthma exacerbation in adults.

This is due to concern over possible additive anticholinergic adverse effects.
Ensure to represcribe the LAMA once the nebulizer treatment has been stopped.

Be aware that the long-term use of beta-2 agonists to manage asthma may increase the risk of cardiovascular events.

Evidence: Cardiovascular harm with beta-2 agonists

Beta-2 agonists may increase the risk of myocardial infarction and other adverse cardiovascular events.

Beta-2 agonists increase heart rate and reduce potassium levels.[216] They are absorbed into the systemic circulation and there is evidence that long-term regular use may be associated with an increased risk of myocardial infarction, unstable angina, congestive heart failure, and arrhythmias.[217][216]
However, it is not routine practice to discontinue beta-2 agonists if they are needed for comorbid asthma.

– ensure monitoring is in place to detect any COPD exacerbation during your patient's hospital admission

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ensure monitoring is in place to detect any COPD exacerbation during your patient's hospital admission

Treatment recommended for ALL patients in selected patient group

Acute worsening of respiratory symptoms may suggest a patient with comorbid COPD is having an acute exacerbation.[102]

Differentiate from other conditions, such as a pulmonary embolism, acute heart failure, and pneumonia.
Follow guideline recommendations.[102] See Acute exacerbation of COPD.

This is due to concern over possible additive anticholinergic adverse effects.
Ensure the LAMA is represcribed once the nebulizer treatment has been stopped.

Be aware that the long-term use of beta-2 agonists to manage COPD may increase the risk of cardiovascular events.

Evidence: Cardiovascular harm with beta-2 agonists

Beta-2 agonists may increase the risk of myocardial infarction and other adverse cardiovascular events.

Beta-2 agonists increase heart rate and reduce potassium levels.[216] They are absorbed into the systemic circulation and there is evidence that long-term regular use may be associated with an increased risk of myocardial infarction, unstable angina, congestive heart failure, and arrhythmias.[216][217]
However, the Global Initiative for Chronic Obstructive Lung Disease states that there has been no reported association between beta-2-agonist use and increased mortality in people with COPD.[102] It is not routine practice to discontinue beta-2 agonists if they are needed for comorbid COPD.

– continue your patient's inhalers as prescribed for asthma or COPD

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mental status exam

Treatment recommended for ALL patients in selected patient group

Perform a mental status exam as the clinical situation allows (based on expert opinion).

The mental status exam is one of the main clinical tools routinely used in psychiatric practice, aiding diagnosis and guiding further management. Mood is one of the assessed domains.

Consider assessing current symptoms of depression using the PHQ-9 questionnaire.[218][219]

The PHQ-9 questionnaire can be used as a reliable and valid measure of depression severity in patients with a known diagnosis of depression, as well as a screening tool.
This can be self-administered or administered by the clinician, and takes less than 3 minutes to complete.
Results indicate severity of depressive symptoms.

Take into account other factors that may be influencing the patient's mental status (e.g., the effect of any illicit drug use or alcohol).[219][220]

In particular, consider whether symptoms of depression could be part of the acute medical illness (based on expert opinion).

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review current treatment for depression

Treatment recommended for ALL patients in selected patient group

Continue the patient’s usual antidepressant, unless there are good reasons not to (based on expert opinion).

If antidepressants are stopped abruptly, the patient may develop antidepressant discontinuation syndrome.[221]
The severity of the symptoms of discontinuation may vary, but they may be unpleasant and may complicate the management of the acute medical condition.

When reviewing current medications, consider:

Current and previous adverse effects
Recent changes in dose
Recent medication changes from a different drug class
The specific diagnostic subtypes of depression when prescribing medications (e.g., it is likely that patients suffering from psychotic depression would be coprescribed an antipsychotic)
Augmenting strategies that may be used when treating resistant depression (e.g., lithium or quetiapine augmentation of a selective serotonin-reuptake inhibitor [SSRI]).

Consider drug-drug interactions.

Antidepressants (particularly those that inhibit the CYP450 pathway) may cause significant interactions with drugs used for other conditions.[222]

Consider psychiatric complications when prescribing nonpsychotropic drugs.

Take particular care when prescribing anticonvulsants, antiparkinsonian drugs, and corticosteroids.

Consider adverse effects, which may include the following:

Hyponatremia, caused by antidepressants, especially SSRIs, and compounded by other coprescribed drugs (e.g., diuretics).[223][224][225][226] Review your patient’s serum electrolyte results and consider antidepressants as a potential contributing factor if they have hyponatremia.
Serotonin syndrome (altered mental state, agitation, tremor, hyper-reflexia, ocular clonus or inducible clonus, muscle rigidity, diaphoresis, tachycardia, increased bowel sounds, temperature >100.4°F [>38°C]), especially with polypharmacy and/or overdose of a serotonergic agent.[227][228] See Serotonin syndrome.
- Be particularly aware of increased risk of serotonin syndrome in patients with kidney failure on SSRIs.[229][230]
Hepatotoxicity.[231] Adjust doses of antidepressants in patients with hepatic impairment as necessary.
- However, antidepressants are rarely the cause of hepatic impairment.[231]
Prolonged QTc, arrhythmias, increased heart rate, postural hypotension with tricyclic antidepressants.[232][233] Obtain an ECG, especially in people at risk of arrhythmias.[234]
Gastrointestinal bleeding. SSRIs are associated with an increased risk of gastrointestinal bleeding.[223][235][236] Risk is particularly increased when coprescribed with aspirin, nonsteroidal anti-inflammatory drugs (NSAIDs), or oral anticoagulants.[236][237][238] Monitor closely and consider gastroprotection with proton-pump inhibitors if SSRI use cannot be avoided (based on expert opinion).

This list of adverse effects is not exhaustive - consult your drug information sources or hospital pharmacist for further information, and consider a psychiatric consult for advice.

Practical tip

Ask your patient about nonpharmacologic treatments for their depression and check the current level of community support.

This may include other outpatient healthcare professionals, charities, and family and social networks.

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consider psychiatric consult

Treatment recommended for ALL patients in selected patient group

Consider a psychiatric consult for any patient with comorbid depression who is admitted to the hospital with an acute condition.

Consult is strongly advised in patients with severe symptoms of depression or additional symptoms such as self harm, suicidal ideation, homicidal ideation, catatonia, psychosis (based on expert opinion).
Consult may not be required if there are no concerns that depression and/or its management (e.g., medication) may be affecting the acute condition (based on expert opinion).
Accidents of unclear circumstances, self-injurious behaviors, and/or suicide attempts (including alleged "accidental" overdose of medication) should trigger clinical suspicion of comorbid mental health disorder (based on expert opinion).

Ensure your patient has adequate support with their treatment post-discharge.

Keep in mind that the psychological impact of comorbid depression may be associated with poor adherence with recommended physical health treatments, from medication to rehabilitation.[242][243][244] This may lead to worse clinical outcomes, including higher readmission risk.[245][246]
Most importantly, affective symptoms, including depression, have been linked with excess mortality, though a causal link remains to be proven.[247][248]

2nd line – alternative targeted antibiotic therapy

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manage tobacco dependence

Treatment recommended for ALL patients in selected patient group

If your patient currently uses tobacco, assess their tobacco use and provide assistance and support with tobacco cessation interventions.[249][250][251]

Advise:

That nicotine is highly addictive and nicotine withdrawal can be extremely distressing and uncomfortable.[250]
NRT prevents rapid withdrawal.[250]
That there are a number of highly effective treatment options that offer the best chance of stopping smoking.[249][250][251]

Ensure a sufficient dose of NRT is prescribed to adequately address withdrawal symptoms.[255]
Ask the patient how many cigarettes they smoke per day; this may determine the starting dose of NRT.
Ask about the type of tobacco product used, including e-cigarettes, water pipe use, and other smokeless tobacco products (snuff, ground, or chewing tobacco), as use of these products also results in nicotine addiction.
Check drug information sources for any contraindications or cautions, particularly if your patient has one or more comorbidity and/or is hemodynamically unstable.
Assess for symptoms of withdrawal daily (based on expert opinion).

One Cochrane Review found high-certainty evidence that varenicline is an effective treatment for tobacco dependence.[257] The same review found that people taking varenicline likely have an increased chance of a more serious adverse effect (e.g., cardiac) that could result in hospital admission; however, these are still rare (2.7% to 4% of people on varenicline, compared with 2.7% of people not taking varenicline) and may include events that are unrelated to varenicline.[257] Check drug information sources for a full list of contraindications and cautions or seek pharmacist advice.
Mental health illness is NOT a contraindication to prescribing varenicline. However, varenicline should be used with caution in people with a pre-existing psychiatric illness as it may worsen symptoms.
Bupropion is an alternative option to varenicline for tobacco cessation but is less likely to result in successful quitting.[257] Consider the potential for drug-drug interactions.

Ensure your patient has follow-up with their primary care practitioner or addiction medicine physician to continue treatment for tobacco dependence.

Practical tip

See Smoking cessation for more information.

Back

2nd line –

alternative targeted antibiotic therapy

Where a cephalosporin is not appropriate, alternative agents include penicillin-G, ampicillin, meropenem, or chloramphenicol. Choice of agent is based on individual patient age, circumstances, and antibiotic susceptibilities, and on local availability.

Treatment of infections caused by resistant strains should be based on results of antibiotic susceptibility testing.

If the patient is receiving dexamethasone for suspected meningitis, this should be discontinued.[47][54]

Specialist advice should be sought for newborns.

Check baseline kidney function and monitor closely

Acute illness also increases the risk of deterioration in kidney function.
Monitor for and respond to oliguria.

Primary options

penicillin G potassium : neonates: consult specialist for guidance on dose; children: 250,000 to 400,000 units/kg/day intravenously given in divided doses every 4-6 hours, maximum 24 million units/day; adults: 2 million units intravenously every 2 hours

ampicillin : neonates: consult specialist for guidance on dose; children: 200-400 mg/kg/day intravenously given in divided doses every 4-6 hours, maximum 12 g/day; adults: 1-2 g intravenously every 3-4 hours

meropenem : children ≥3 months of age and <50 kg body weight: 40 mg/kg intravenously every 8 hours, maximum 6 g/day; children ≥3 months of age and ≥50 kg body weight and adults: 2 g intravenously every 8 hours

chloramphenicol: children ≥1 month of age and adults: 75-100 mg/kg/day intravenously given in divided doses every 6 hours, maximum 4 g/day

chloramphenicol : children ≥1 month of age and adults: 75-100 mg/kg/day intravenously given in divided doses every 6 hours, maximum 4 g/day

chloramphenicol: children ≥1 month of age and adults: 75-100 mg/kg/day intravenously given in divided doses every 6 hours, maximum 4 g/day

These drug options and doses relate to a patient with no comorbidities.

Primary options

penicillin G potassium : neonates: consult specialist for guidance on dose; children: 250,000 to 400,000 units/kg/day intravenously given in divided doses every 4-6 hours, maximum 24 million units/day; adults: 2 million units intravenously every 2 hours

ampicillin : neonates: consult specialist for guidance on dose; children: 200-400 mg/kg/day intravenously given in divided doses every 4-6 hours, maximum 12 g/day; adults: 1-2 g intravenously every 3-4 hours

meropenem : children ≥3 months of age and <50 kg body weight: 40 mg/kg intravenously every 8 hours, maximum 6 g/day; children ≥3 months of age and ≥50 kg body weight and adults: 2 g intravenously every 8 hours

chloramphenicol: children ≥1 month of age and adults: 75-100 mg/kg/day intravenously given in divided doses every 6 hours, maximum 4 g/day

chloramphenicol : children ≥1 month of age and adults: 75-100 mg/kg/day intravenously given in divided doses every 6 hours, maximum 4 g/day

chloramphenicol: children ≥1 month of age and adults: 75-100 mg/kg/day intravenously given in divided doses every 6 hours, maximum 4 g/day

Show drug information for a patient with no comorbidities

Drug choice, dose and interactions may be affected by the patient's comorbidities. Check your local drug formulary.

Primary options

penicillin G potassium

For patients with CKD, please check your local drug formulary

For patients with CKD see dose in the Renal Drug HandbookFor patients with CKD see dose in the Renal Drug Handbook

ampicillin

For patients with CKD, please check your local drug formulary

For patients with CKD see dose in the Renal Drug HandbookFor patients with CKD see dose in the Renal Drug Handbook

meropenem

For patients with CKD, please check your local drug formulary

For patients with CKD see dose in the Renal Drug HandbookFor patients with CKD see dose in the Renal Drug Handbook

chloramphenicol

For patients with CKD, please check your local drug formulary

For patients with CKD see dose in the Renal Drug HandbookFor patients with CKD see dose in the Renal Drug Handbook

Plus – review diabetes medication (NEVER stop insulin in a person with type 1 diabetes)

Back

Plus –

supportive care

Treatment recommended for ALL patients in selected patient group

Patients with meningococcal infections must be monitored closely for complications such as shock, elevated intracranial pressure, seizures, and coagulopathy.

Severe meningococcal infections are frequently complicated by hypoglycemia or hyperglycemia, acidosis, and other biochemical abnormalities that require attention.

Oxygen therapy in your patient with asthma

Measure resting oxygen saturation in all acutely ill patients.

Be aware that pulse oximetry may overestimate oxygen saturation in patients with darker skin tones.[97]
If your patient's asthma is stable, follow guideline recommendations for oxygen saturation target for the presenting acute condition.
If the acute presenting condition triggers an acute exacerbation of your patient's asthma, the Global Initiative for Asthma recommends controlled oxygen to maintain saturations between 93% and 95%.[97]
Adjust oxygen saturation targets for altitude, where appropriate.[97]
Hypercapnia in asthma is an indicator of very severe disease showing a patient is tiring and needs ventilatory support.[98][99][100]

Oxygen therapy in your patient with COPD

Obtain a blood gas measurement if your patient with COPD has oxygen saturation <90%, clinical signs of hypercapnia (e.g., altered mental status), or respiratory distress (based on expert opinion).
- An arterial blood gas (ABG) should be used to assess patients with respiratory failure and should always be obtained if hypoxemia is an issue.[103][104]
  - Peripheral venous blood gas (VBG) analysis has increasingly been used to estimate carbon dioxide, pH, and other variables.[105] It is less painful for the patient and may be associated with fewer complications than an ABG.[105]
  - One Cochrane Review found limited data of low to very low certainty evidence that VBG is sensitive for the diagnosis of respiratory failure and isolated hypercarbia.[105] However, it has poor specificity compared with ABG analysis, making it less reliable when precise data are necessary.[105]
Recheck blood gas as clinically indicated.[102]

Chronic hypercapnia[106]
Hypercapnia on presentation
Previous history of hypercapnic respiratory failure[103]
Moderate or severe COPD, particularly if on long-term oxygen therapy[103]
Evidence of chronic hypoventilation for other reasons, e.g., obesity hypoventilation syndrome, taking sedatives or hypnotic drugs.[102][106]

Critically ill and needs high levels of oxygen

This includes patients with comorbid COPD who need high levels of oxygen due to a critical illness such as shock, sepsis, major head injury, status epilepticus, anaphylaxis, or major trauma.

In this scenario, some guidelines recommend an initial target oxygen saturation in line with the recommendation for patients without COPD.[103]

Evidence suggests that targeting an upper oxygen saturation level of 96% may be preferred compared with a higher level.[107][108]
Subsequently, you may need to adjust to controlled oxygen therapy with a target oxygen saturation range of 88% to 92% depending on the blood gas results.[103]

Acutely but not critically ill and at risk of hypercapnic respiratory failure

This includes patients with comorbid COPD who have risk factors for hypercapnic respiratory failure and an acute condition, but are not critically ill.[103]

Give controlled oxygen therapy and use an initial target oxygen saturation of 88% to 92%.[102][103]

Check blood gas and recheck after 30 to 60 minutes.[103]

Not critically ill and NOT at risk of hypercapnic respiratory failure

As an example, a patient may have stable, mild COPD with minimal symptoms.

Use an initial target oxygen saturation as recommended by guidelines for the presenting acute condition.

Evidence suggests that for most acutely ill patients, targeting an upper oxygen saturation level of 96% may be preferred compared with a higher level.[107][108]

Measure blood gas as soon as possible[103]

Subsequently, you may need to adjust to controlled oxygen therapy with a target oxygen saturation range of 88% to 92% depending on the blood gas results.[103]

High-flow nasal cannula (HFNC)

Decreasing the work of breathing[109][110]
A theoretical provision of low-level positive end-expiratory pressure (PEEP)[109][110][111]
Facilitating secretion mobilization.[109][110]

Ventilatory support

Start noninvasive bilevel ventilation (BiPAP) if the patient has at least one of the following:[102]

Respiratory acidosis (PaCO₂ ≥45 mmHg [6 kPa] and arterial pH ≤7.35)
Severe dyspnea and/or increased work of breathing (e.g., use of respiratory muscles, paradoxical movement of the abdomen, retraction of the intercostal spaces)
Persistent hypoxemia despite supplemental oxygen.

Start invasive mechanical ventilation support if this is indicated and the patient is considered suitable. Indications for invasive mechanical ventilation include:[102]

Inability to tolerate, or failure of, noninvasive ventilation (particularly if they have life-threatening hypoxemia)
Status post respiratory or cardiac arrest
Reduced consciousness, or psychomotor agitation that is inadequately controlled by sedation
Massive aspiration or persistent vomiting
Persistent inability to remove respiratory secretions
Severe hemodynamic instability without response to fluids or vasoactive drugs
Severe ventricular or supraventricular arrhythmias.

When considering endotracheal intubation with mechanical ventilation, always take into account the patient's wishes (e.g., advance directives).[102]

Assess fluid status and manage fluid balance particularly closely

In a patient with heart failure and/or chronic kidney disease (CKD), judicial use of fluids is crucial to preventing clinically significant volume overload.

Be aware that hypovolemia may be difficult to assess in a person with heart failure and/or CKD.

As with any patient presenting acutely, look for signs of volume depletion on physical exam, by assessing:[112]

Vital signs:
- Blood pressure, (particularly systolic blood pressure [SBP] and mean arterial pressure)
- Pulse
- Postural hypotension
Peripheral perfusion
Capillary refill time
Jugular venous distension
Passive leg raise.

More info: The RUSH exam

The RUSH exam involves a three-part physiologic assessment using point of care ultrasound (POCUS):[114]

1. The pump, i.e., the cardiac status
- Evaluate cardiac status by looking for: pericardial effusions and cardiac tamponade, left ventricular contractility, and right ventricular size
2. The tank, i.e., the effective intravascular volume status
- Assess the fullness of the tank by examining the inferior vena cava (IVC) and/or internal jugular veins
- Evaluate for "leakiness" of the tank, or free fluid in the abdominal and thoracic cavities, by performing Focused Assessment of Sonography for Trauma (FAST) and thoracic ultrasound to assess for fluid in the abdominal and thoracic cavities[115][116]
- Assess compromise of the tank by assessing for pneumothorax
3. The pipes, i.e., the arterial and venous sides of the circulatory system
- Assess the aorta looking for aortic aneurysm, rupture, dissection
- Assess lower extremity and/or upper extremity veins for deep vein thrombosis.

Other variations of RUSH have been described.[113]

Practical tip

Heart failure

Be aware that an SBP of <90 mmHg may suggest hypotension, but a patient on medication for chronic heart failure can have a baseline SBP of <90 mmHg.

Consider consultation with a cardiologist and/or intensivist.

With a suspected low output or cardiogenic shock state
With massive fluid overload, when high doses of diuretic are needed or with diuretic resistance
When unable to establish volume state
When titrating inotropes.

CKD

A patient with CKD who is hypovolemic needs immediate fluid resuscitation.

Reassess your patient after initial fluid challenge and further address the cause of hypovolemia.
If they do not rapidly stabilize:
- Consider activating the rapid response team and obtaining specialist consultation
- Consider transferring your patient to an intensive care setting where hemodynamic monitoring is possible (based on expert opinion).

Continue to monitor fluid balance particularly closely

Accurate monitoring of volume status is essential in a person with heart failure and/or chronic kidney disease (CKD).[117]

There is a significant risk of pulmonary edema with fluid resuscitation in a patient with heart failure and/or CKD, so monitor closely.
Monitoring should include:
- Regular clinical assessment of volume status (pulse, BP, jugular venous distension [JVD], and check for pulmonary and peripheral edema)
- Fluid balance (input/output chart) and daily weight
- BUN and serum creatinine to monitor kidney function, at least daily.
Consider bladder catheterization if urinary output is difficult to measure, but be aware of increased risk of infection and trauma.
Patients with greater clinical complexity, such as those with heart failure and/or advanced CKD may need admission to the intensive care unit for more invasive monitoring and interventions. If noninvasive bedside assessments are not adequate for monitoring, consider a central venous pressure catheter or pulmonary artery catheter.[117][118][119]

Practical tip

De-escalation

Your patient is euvolemic
The problem requiring fluids has been successfully reversed.

Monitor volume status consistently to try to avoid volume overload.

Immediately stop fluid administration
Consider consultation with specialist
Consider intravenous diuretics, and
Arrange an urgent chest x-ray if pulmonary edema is suspected (based on expert opinion).

Unless there are extenuating circumstances, diuretics and intravenous fluids are not generally given together (based on expert opinion).

Recommendations from an intensive care specialist and/or cardiologist and/or nephrologist may be needed.

Withhold antihypertensives and/or diuretics if hypotensive

Withhold antihypertensives and/or diuretics if your patient:

Is in shock, or
Has a blood pressure ≥40 mmHg lower than their baseline.

Consider withholding antihypertensives and/or diuretics if your patient:

Is hypotensive, or
Has developed orthostatic hypotension or has postural symptoms (based on expert opinion).
- Orthostatic hypotension is defined, by consensus, as a fall in systolic blood pressure ≥20 mmHg and/or a fall in diastolic blood pressure ≥10 mmHg on assuming an upright posture.[120]
- In people with classic orthostatic hypotension, the blood pressure change occurs within 3 minutes of standing.[121] In practice, take standing blood pressure after the person has been standing for at least 1 minute (based on expert opinion).

People with hypertension, coronary artery disease, heart failure, stroke, or chronic kidney disease (CKD) will typically be taking one or more of these types of drug.

Establish your patient's baseline blood pressure and assess volume status.

Patients with treated heart failure may have chronically low blood pressure (e.g., systolic BP ≤90 mmHg). If their systolic blood pressure falls by >10-15 mmHg and is associated with symptoms (such as presyncope or syncope), it may be appropriate to withhold medications that may lower blood pressure but have no or little prognostic benefit for heart failure (such as amlodipine, doxazosin).
- If clinically appropriate, consider changing the time of administration of medication that has a prognostic benefit for heart failure (e.g., sacubitril/valsartan, beta-blockers) to night time, or splitting or reducing the dose (based on expert opinion).
- Consider consultation with a cardiologist and/or intensivist.

If diuretics are withheld in a patient with heart failure and/or CKD, close monitoring is needed as fluid can quickly accumulate.

Be aware that sodium-glucose cotransporter-2 (SGLT2) inhibitors, a class of medication with a prognostic benefit for both heart failure and CKD, also have a weak diuretic effect.[122]

If antihypertensives or diuretics have been withheld during the acute illness, consider restarting them before discharge if clinically appropriate (based on expert opinion).

Restart one at a time at a lower dose and ask the primary care physician (PCP) to titrate back to normal dose.
- Most patients won't tolerate restarting all medications at the original doses simultaneously.
- If it is not clinically appropriate to restart these medicines before discharge, ensure that the patient has follow-up to decide when the medications can be reintroduced.
- Ensure you have communicated clearly to the PCP at discharge.

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Plus –

review diabetes medication (NEVER stop insulin in a person with type 1 diabetes)

Treatment recommended for ALL patients in selected patient group

Check your patient's blood glucose on admission. In addition, check HbA1c if no result is available from the previous 3 months.[124][132]

Exclude hypoglycemia, diabetic ketoacidosis (DKA), and hyperosmolar hyperglycemic state (HHS).
Test for blood beta-hydroxybutyrate or ketones if:[133][134]
- Your patient was taking a sodium-glucose cotransporter-2 (SGLT2) inhibitor (e.g., dapagliflozin, canagliflozin, empagliflozin) before unplanned hospitalization, and/or
- There is acidosis, an increased anion gap, nausea/vomiting, or a combination of these.
Admission HbA1c may give you an indication of your patient’s previous diabetes control and may influence your treatment at discharge.

Insulin deficiency (e.g., due to delayed or missed doses) will rapidly cause ketoacidosis (based on expert opinion).

Practical tip

Critical illness

Consider starting a continuous intravenous insulin infusion for your critically ill patient for achieving glycemic goals and avoiding hypoglycemia.[124][125]

Use a validated protocol/order set for the continuous intravenous insulin infusion.[124]
This allows for predefined adjustments to the insulin infusion rate according to blood glucose measurements and past and current insulin infusion rates, to avoid hypoglycemia.[124]

More info: Continuous intravenous insulin infusion management

If a continuous intravenous insulin infusion is started:

In practice, subcutaneous basal insulin is generally discontinued (based on expert opinion).
- Less often, at some institutions, subcutaneous basal insulin may be continued (provided there is no hypotension and the patient is not on vasopressors) at 75% of the patient's usual dose.
Stop the patient’s usual subcutaneous rapid-acting and mixed insulins while on an intravenous insulin infusion.[135]
Use the continuous intravenous insulin infusion for as short a time as possible.[135]

Once ready to discontinue a continuous intravenous insulin infusion:

Follow an appropriate order set/transition protocol to switch to scheduled subcutaneous insulin.[124]
- This should include calculating the total daily dose of subcutaneous insulin needed, dividing into appropriate basal and bolus doses, monitoring and adjusting dose based on glucose monitoring, and having orders in place for potential hypoglycemic episodes (based on expert opinion).
Give subcutaneous basal insulin at least 2 hours before discontinuing the intravenous infusion to minimize rebound hyperglycemia.[124]
- Emerging data suggest that early administration of subcutaneous basal insulin alongside intravenous insulin infusion does not seem to increase the risk of hypoglycemia.[136][137]

Noncritical illness

Generally, an insulin regimen is preferred for managing hyperglycemia in individuals with diabetes receiving hospitalized care.[124]

If your patient is not eating or drinking or has poor oral intake, a subcutaneous basal insulin or basal plus bolus correction (every 4-6 hours) insulin plan is preferred.
If they are eating adequately, subcutaneous basal insulin with prandial (with each meal, up to 3-4 times a day) and correctional doses is preferred.

In a patient who is already managing their diabetes with insulin, consider whether there is any need to adjust insulin dose when they are admitted to the hospital.

If a patient with type 1 or type 2 diabetes uses insulin at home, has adequate glycemic management, and was not admitted with significant hyperglycemia, it may be appropriate to reduce their routine dose of subcutaneous basal insulin by 20%, particularly if they are eating less than usual. Another factor to keep in mind is that hospital meals generally contain less carbohydrate than meals patients would eat at home (based on expert opinion).
Conversely, patients who are acutely ill with an infection sometimes need more insulin.
Regular monitoring of blood glucose (at least four times daily) can help guide appropriate adjustments to insulin dosing.

More info: Patients using a continuous subcutaneous insulin infusion (CSII) (insulin pump) prior to hospital admission

If a patient with diabetes had been using an insulin pump prior to hospital admission:

Follow your hospital procedure, if available, and request a specialized inpatient diabetes team or endocrinology consult.
Safe continuation of an insulin pump during hospital admission has been advocated by several professional organizations.[124][138][139][140]
Key criteria for safe use include that:[124][141]
- The patient is medically stable, willing, and capable of self-management
- There are no contraindications
- The necessary supplies and resources are available
- There are hospital staff with the appropriate expertise and training, and institutional diabetes technology protocols in place
- Staff are available to perform confirmatory point-of-care (POC) glucose measurements for insulin dose decisions, hypoglycemia assessment and treatment, and at least four times a day (based on expert opinion).

Review noninsulin glucose-lowering medications if your patient had been taking any of these before admission and determine whether these are suitable to continue during admission.

For select patients with type 2 diabetes, it may be acceptable to continue noninsulin glucose-lowering medications, such as a dipeptidyl peptidase-4 (DPP-4) inhibitor.[124] Only consider this in a patient who is (based on expert opinion):
- Clinically stable with mild hyperglycemia
- Eating regularly
- Has no contraindications.
Metformin should be discontinued in patients with contraindications, including those with increased risk of lactic acidosis (e.g., those with renal impairment, shock, or hypoxia) and those with acute heart failure.[142][143] Consider restarting metformin after the acute condition has resolved (based on expert opinion).
In general, stop SGLT2 inhibitors for your patient with diabetes who is admitted to the hospital with an acute illness (based on expert opinion). This is due to the risk of euglycemic ketoacidosis.
- In particular, avoid SGLT2 inhibitors if your patient is severely ill, or if their clinical situation predisposes them to ketoacidosis (e.g., prolonged fasting due to acute illness or surgery).[124][133]
- Be aware that ketoacidosis associated with SGLT2 inhibitors may still be present despite a normal (or near normal) serum glucose level (euglycemic ketoacidosis).[134]
- If an SGLT2 inhibitor is being initiated during a hospital admission (e.g., for treatment of heart failure), this medication should be initiated after recovery from the acute illness.[124]
  - Remain aware of the risk of ketoacidosis which can occur spontaneously with SGLT2 inhibitors.[134]
  - Monitor hydration status and basic metabolic panel (BMP) daily for elevated anion gap and acidosis (based on expert opinion).
  - Check blood beta-hydroxybutyrate (or blood ketone) levels, especially if acidosis is present, or there are symptoms of ketoacidosis (e.g., nausea or vomiting) (based on expert opinion). Measure blood ketones as urinary ketone measurement may be unreliable.
  - Be aware that beta-hydroxybutyrate levels of ≥3.0 mmol/L, along with pH <7.3 or bicarbonate <18 mmol/L, indicate DKA.[134][144]
  - In this situation, stop SGLT2 inhibitor and treat DKA.[144]

Discharge

Start thinking about a discharge plan at the time of hospitalization or after stabilization (based on expert opinion). This should be structured and tailored to the individual.[124]

Provide inpatient diabetes self-management education, focusing on skills needed after discharge, and ensure follow-up and support strategies are in place.
Arrange medication reconciliation:
- Make sure this includes a strategy for switching back to the brand of insulin your patient was on at the time of hospitalization, if appropriate and approved by insurance or covered by other programs (based on expert opinion).
- Clarify regarding timing of restarting any noninsulin glucose-lowering medications that have been temporarily stopped (based on expert opinion).
Communicate promptly to the relevant outpatient healthcare professionals.

Plus – nasopharyngeal eradication predischarge

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Plus –

nasopharyngeal eradication predischarge

Treatment recommended for ALL patients in selected patient group

These treatments are equally effective. Choice is based on the age of the patient and the presence of any contraindications to an individual drug. Specialist advice should be sought for newborns.

Primary options

rifampin: children: 20 mg/kg/day orally given in 2 divided for 2 days, maximum 600 mg/dose; adults: 600 mg orally twice daily for 2 days

rifampin : children: 20 mg/kg/day orally given in 2 divided for 2 days, maximum 600 mg/dose; adults: 600 mg orally twice daily for 2 days

rifampin: children: 20 mg/kg/day orally given in 2 divided for 2 days, maximum 600 mg/dose; adults: 600 mg orally twice daily for 2 days

ceftriaxone: children: 125 mg intramuscularly as a single dose; adults: 250 mg intramuscularly as a single dose

ceftriaxone : children: 125 mg intramuscularly as a single dose; adults: 250 mg intramuscularly as a single dose

ceftriaxone: children: 125 mg intramuscularly as a single dose; adults: 250 mg intramuscularly as a single dose

ciprofloxacin: adults: 500 mg orally as a single dose

ciprofloxacin : adults: 500 mg orally as a single dose

ciprofloxacin: adults: 500 mg orally as a single dose

Drug choice, dose and interactions may be affected by the patient's comorbidities. Check your local drug formulary.

Show drug information for a patient with no comorbidities

Primary options

rifampin

For patients with CKD, please check your local drug formulary

For patients with CKD see dose in the Renal Drug HandbookFor patients with CKD see dose in the Renal Drug Handbook

ceftriaxone

For patients with CKD, please check your local drug formulary

For patients with CKD see dose in the Renal Drug HandbookFor patients with CKD see dose in the Renal Drug Handbook

ciprofloxacin

For patients with CKD, please check your local drug formulary

For patients with CKD see dose in the Renal Drug HandbookFor patients with CKD see dose in the Renal Drug Handbook

Plus – monitor comorbidities during hospital stay

Back

Plus –

monitor comorbidities during hospital stay

– baseline cognitive and delirium assessments with collateral history

Back

–

baseline neurologic exam

Treatment recommended for ALL patients in selected patient group

Perform a baseline neurologic exam at the earliest appropriate opportunity for any patient with a history of stroke.

A patient with an acute condition (e.g., an infection and illness-related hypotension) is at increased risk of stroke.[145][146][147] This risk is even higher in anyone with a history of stroke.
- In particular, ischemic stroke is a known complication of acute bacterial meningitis.[92][148][149]
- Less commonly, hemorrhagic stroke can also complicate bacterial meningitis.[148]
- If there is a change in neurologic status during admission, repeat the neurologic exam to evaluate for a new acute stroke.
Ensure the right level of nursing care for the patient’s condition and ensure that clear orders are written for the patient’s functional and cognitive status (e.g., fall precautions, 1:1, soft restraints, assistance with activities of daily living [ADLs]).
- A patient with a history of stroke has a higher risk of falls and injury.[150]

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–

baseline cognitive and delirium assessments with collateral history

Treatment recommended for ALL patients in selected patient group

Do a baseline cognitive assessment at the earliest opportunity in any patient with a history of dementia.

Take a collateral history from family, friend, or caregiver to establish whether your patient's cognitive function is stable, gradually declining, or acutely declined.[151]
Check your patient’s level of alertness and orientation to time, place, and person, and corroborate with caregivers and review your patient’s prior medical records (based on expert opinion).
If time allows, a standardized cognitive assessment score is helpful for tracking clinical progress, and determining discharge needs (based on expert opinion).
Validated scoring tools for cognitive assessment include:
- The Mini-Cog Alzheimer's Association: Mini-Cog(TM) Opens in new window
- The Montreal Cognitive Assessment (MoCA)[152]
- The Saint Louis University Mental Status Examination (SLUMS). Saint Louis University: SLUMS Opens in new window
These scores are often best interpreted alongside a functional assessment, usually performed by an occupational therapist and/or a physical therapist.
These scores may not represent the person's usual baseline for cognition due to the impact of the acute condition and its treatment, but it is still good practice to record and repeat it when the person has recovered (based on expert opinion).

Practical tip

Mind (mentation, dementia, depression, and delirium)
Mobility (gait, balance, and falls prevention)
Medications (polypharmacy, deprescribing, optimal prescribing, and adverse medication effects and medication burden)
Multicomplexity (multimorbidity and complex psychosocial situations)
Matters Most to Me (each individual's health outcome goals and care preferences).

Assess for delirium whenever a patient with dementia presents with acute illness.

People living with dementia are at increased risk of delirium when they are admitted to the hospital and throughout their admission.[151][155]
Delirium is not the same as dementia. It is a potentially life-threatening acute, fluctuating change in mental functioning, with inattention, disorganized thinking, and altered levels of consciousness.[156]
Use a screening tool to detect probable delirium, taking the setting into account. Commonly used tools include:
- The Delirium Triage Screen (DTS), which may be rapidly administered in an emergency department setting and assesses arousal and attention. If positive, confirm with a more specific tool, such as the brief Confusion Assessment Method (bCAM).[151][157][158]
- The Confusion Assessment Method (CAM), if your patient is not in a critical care setting.[151][159][160]
- The Confusion Assessment Method for the Intensive Care Unit (CAM-ICU) or the Intensive Care Delirium Screening Checklist (ICDSC) if your patient is in a critical care setting, or in the recovery room after surgery.[155][161][162][163]

Practical tip

Depression can mimic delirium in older adults, particularly in patients with cognitive impairment or other comorbid medical conditions.[151]

Ask if your patient has a diagnosis of depression. If not, use a very brief screening test, such as the Patient Health Questionnaire-2 or Emergency Department Depression Screening Instrument to screen older adults for depression.
A positive screen for depression should prompt further questions, e.g., on suicidal thoughts.

Helping with orientation; make sure patients have their own glasses and/or hearing aids
Getting patients mobilized as soon as possible
Controlling pain adequately
Keeping patients well hydrated and helping them to eat adequately
Monitoring and maintaining regular bowel and bladder function
Using supplemental oxygen as needed
Monitoring for and treating postoperative complications as soon as possible
Reviewing the patient's medications
- Identify and avoid medications that are high-risk for precipitating delirium, such as benzodiazepines, corticosteroids, and anticholinergics.[151][168]

Foster familiarity, e.g., consider facilitating the patient's usual caregiver to stay with the patient and bring in familiar objects from home.[151][158]

Practical tip

Dementia is a risk factor for postoperative delirium.[167][169]

Evaluate baseline cognition using a brief screening tool preoperatively.
Consider the most appropriate method of analgesia to reduce the risk of postoperative delirium.
Monitor for postoperative delirium using a validated screening instrument (e.g., CAM-Short Form).[170]

Evidence: Primary prevention of delirium in hospital using nonpharmacologic interventions

There is evidence that a nonpharmacologic approach reduces the risk of delirium in non-ICU patients in hospital.

A systematic review compared nonpharmacologic interventions designed to prevent delirium with usual care or active control in adults in a non-ICU hospital setting.[171]

Interventions were multicomponent or single components, targeted at a specific risk factor, such as disorientation or dehydration.
Meta-analysis of 14 studies on multicomponent interventions found a significant reduction in incident delirium compared with usual care (RR 0.57, 95% CI 0.46 to 0.71).
There is emerging evidence that multicomponent interventions may reduce hospital length of stay (MD -1.3 days, 95% CI -2.56 to -0.04 days), but there is significant heterogeneity between the studies.
There is little information specifically on people with dementia as this group was frequently excluded from trials despite their increased risk of developing delirium.

More info: Initial investigations for a patient with delirium

If your patient has delirium, check for and treat life-threatening causes:[151][167][172]

Hypoxia
Hypoglycemia
Hypotension
Sepsis
Drug intoxication or withdrawal, including alcohol withdrawal
Acute myocardial infarction

Although every evaluation should be tailored to the individual patient, most patients should receive:[151]

Complete blood count
Comprehensive metabolic panel
Point-of-care glucose
Urinalysis with culture
ECG

Additional tests that may be needed include (based on expert opinion):

Thyroid function tests
Folate and vitamin B12
C-reactive protein
Blood cultures (if bacteremia is suspected)
Chest x-ray

Consider whether your patient requires computed tomography (CT) of the brain.[151]

CT brain should be arranged if your patient has focal neurological deficits, head trauma, reduced level of consciousness, or has a history of fall.
CT brain should also be considered if your patient takes anticoagulants.
In practice, a patient in the hospital setting who has a change in mental status will usually receive a CT brain (based on expert opinion).

Check for and treat any reversible causes of delirium:[151][158][167][172]

Pain
Infection
Poor nutrition
Constipation
Dehydration
Medications
- Ask about recently prescribed medications, especially opioid analgesics, anxiolytics, antipsychotics, corticosteroids, or anticholinergics
Immobility
Poor sleep
Sensory impairment (e.g., ear wax or loss of glasses)

More info: Management of a patient with delirium

Manage patients with delirium initially with nonpharmacologic treatment.[151][158][167]

Reduce disorientation by providing a well-lit room, with a clock and calendar visible (e.g., on the wall).
Encourage and facilitate family, friends, and caregivers to visit the patient.
Use verbal and nonverbal techniques to de-escalate conflict and distress.

Any new antipsychotic prescribed for this purpose must be regularly reviewed, and discontinued as soon as possible.[168][173]
Be aware that the evidence on the efficacy of antipsychotics for delirium is inconclusive, and guidance regarding choice of antipsychotic varies.[151][158][167]
Antipsychotics should be used with caution in patients with a history of dementia as there is an increased risk of mortality in these patients[151][173]
- A systematic review of antipsychotics for delirium in hospitalized adults concluded that the evidence did not support routine use of haloperidol or atypical antipsychotics for this purpose[174]
- All antipsychotics have a warning that they are not approved for dementia-related psychosis.[151]
Haloperidol is contraindicated in patients with Parkinson disease or in patients with dementia with Lewy bodies.[163] Check for all contraindications.
Consider baseline ECG before starting any antipsychotic medication (based on expert opinion).

Document the diagnosis of delirium clearly (based on expert opinion).

Evidence: Risks and safe withdrawal of antipsychotics in older adults

Antipsychotics are associated with increased mortality in people with dementia.

A Cochrane review found very low certainty evidence that typical antipsychotics such as haloperidol improve agitation, but reported that they may improve psychosis slightly in people with Alzheimer disease and vascular dementia. Atypical antipsychotics probably reduce agitation. Both types increase the risk of somnolence and extrapyramidal symptoms.[175]
A network meta-analysis found that people who take atypical antipsychotics for behavioral and psychological symptoms of dementia may have a small improvement in behavioral and psychological symptoms but have increased safety risks including for cerebrovascular adverse events, compared with those taking placebo.[176]
Contrary to popular belief, long-term antipsychotic use can be safely withdrawn in most people with dementia once behavior has settled.[177]

– establish goals of care, taking into account any advance directives

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assess your patient’s level of frailty

Treatment recommended for ALL patients in selected patient group

Assess your patient's level of frailty to:[178][179]

Establish whether management plans are consistent with goals of care, and
Identify whether further assessment and enhanced care is needed.

Practical tip

Ask your patient (with input from caregivers if relevant) about their functional capability 2 weeks BEFORE this acute episode to determine baseline state.[184]
Use the Clinical Frailty Scale (CFS) if your patient is ≥65 years old.[185][186] Dalhousie University: Clinical Frailty Scale Opens in new window
- This tool is a practical aid to identify frailty, but should not be relied on in isolation.
- Do not use the CFS to assess younger patients, or those with disabilities that reflect single-system problems (e.g., spinal cord injury).[184]
- If your patient scores 5 or higher, consider arranging a comprehensive geriatric assessment, if this is feasible and clinically appropriate, at the earliest opportunity.[181]
- A higher prehospital frailty score is associated with an increased risk of adverse outcomes including risk of mortality in-hospital, at 1, 3, 6, and 12 months; all-cause readmission within 30 days; extended length of stay; discharge to a nursing home, residential care, hospital, or a high level of care; and functional decline.[187]
Look for nonspecific complaints, such as delirium and falls.
Help to implement multidisciplinary care and to tailor the management approach according to the patient's values and goals of care.[188]

Practical tip

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establish goals of care, taking into account any advance directives

Treatment recommended for ALL patients in selected patient group

Ask your patient if they have an advance directive (e.g., a living will, a healthcare proxy) and/or a Do Not Resuscitate (DNR) or Do Not Intubate (DNI) order.[193]

This applies to all patients, but may be particularly relevant to patients living with frailty and/or with certain comorbidities, such as dementia, stroke, heart failure, COPD, and late-stage CKD (based on expert opinion).
Ensure any existing advance directives align with your patient's current preferences and goals of care.[193]

Practical tip

Discuss specific treatment options and health trajectory to help your patient (or surrogate decision-maker) make informed decisions about their care.[193][195][196]

This should include (based on expert opinion):
- Code status (e.g., Do Not Resuscitate [DNR] order, Do Not Intubate [DNI] order)
- Other life-sustaining treatment options (e.g., vasopressors, extracorporeal membrane oxygenation [ECMO], kidney replacement therapy, blood transfusions, parenteral/enteral nutrition).

Assess and document decision-making capacity (the ability to make a specific decision at the time that the decision needs to be made).[197][198][199]
- Attempt to improve your patient’s capacity to participate in decision-making by addressing communication barriers and alleviating exacerbating factors, such as delirium.[200]
- Be aware that an individual’s decision-making capacity can vary over time so should be reassessed periodically.[200]
If your patient lacks decision-making capacity, establish whether they have an advance directive.[195][198][199]
- This may include a living will and/or a designated proxy known as a Durable Power of Attorney for Healthcare (DPAHC). [198]
If your patient who lacks decision-making capacity has no applicable advance directive, including no designated proxy, identify a surrogate decision-maker from a priority list of individuals such as spouse, adult child, and adult sibling.[198][199]
- The hierarchy of this list, and the scope of surrogates' decision-making, varies from state to state.
- Ensure a surrogate's decisions are consistent with patient preferences and best interests.
- In the case of conflict, consider consulting your hospital's ethics committees.
If your patient is an older adult and is unrepresented (a patient without decision-making capacity for a particular medical intervention who lacks both a relevant advance directive and a surrogate decision-maker), the American Geriatrics Society recommends:[200]
- Attempting to identify a nontraditional surrogate (e.g., a close friend, live-in companion, neighbor, or other individual who knows the patient well), in the absence of a traditional surrogate (next of kin), who is willing and able to represent your patient’s wishes and values
- Avoiding unilateral decision-making in the absence of a suitable surrogate, which could carry a risk of bias. The AGS favors a structured multidisciplinary consensus approach to decision-making.

Check your relevant state law and practice accordingly. There may be no available out-of-court process to allow nontraditional surrogates in many states.
If your unrepresented patient is in an urgent or life-threatening situation:[198][199]
- Use all available information on a patient's preferences, values, and beliefs to guide treatment decisions. If preferences are not known, urgent care decisions should be made in the patient's best interests.[195][198][201]
- Consider using the Four Box Model (also known as the Four Quadrant Model) to aid ethical decision-making. This consists of four principles:[200][202]
  - Medical indications for treatment
  - Patient preferences for care
  - Quality of life
  - Contextual features (this includes being mindful of provider biases, the patient’s psychosocial context, and how the treatment and cost of care may impact the patient).
In a less urgent situation, rarely, a court-appointed guardian may be appointed to make decisions in this context.[195][198][200]

– monitor and manage blood glucose during the hospital admission

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monitor and manage blood glucose during the hospital admission

Treatment recommended for ALL patients in selected patient group

The risk of hypo- and hyperglycemia increases when a person with diabetes is admitted to the hospital acutely (based on expert opinion).
More frequent monitoring is needed after any episode of hyperglycemia or hypoglycemia and after any change in hypoglycemic medication (based on expert opinion). If a correction dose of insulin is given at bedtime, check blood glucose about 4 to 6 hours later (usually about 2 a.m.) (based on expert opinion).
If your patient is having surgery, the American Diabetes Association (ADA) recommends monitoring blood glucose at least every 2 to 4 hours while the individual is taking nothing by mouth (npo).[124]
Any patient on an intravenous insulin infusion needs more frequent blood glucose measurements, ranging from every 30 minutes to every 2 hours.[124]

Practical tip

Decide on target blood glucose levels.

There is a general consensus among different guideline organizations on target blood glucose levels for people with diabetes in the hospital.

For most critically ill patients, the ADA recommends a target range of 140 to 180 mg/dL (7.8 to 10.0 mmol/L) once treatment has been started for persistent hyperglycemia.[124]
- Stricter target ranges, such as 110 to 140 mg/dL (6.1 to 7.8 mmol/L), may be acceptable in select critically ill patients, but only if they can be achieved without significant hypoglycemia.[124]
For most noncritically ill patients, the ADA and the Endocrine Society recommend a target range of 100 to 180 mg/dL (5.6 to 10.0 mmol/L).[124][138]
- Less stringent goals are appropriate in some patients, for instance those at high risk of hypoglycemia, advanced kidney failure, and those who are terminally ill. The ADA recommends that the focus in these people should be on avoiding hypoglycemia and symptomatic hyperglycemia.[124]

Evidence: Blood glucose targets for critically ill patients with hyperglycemia

Evidence argues against very tight glucose control in critically ill patients (a mixed population with and without a history of diabetes).

Intensive care setting:
- A randomized controlled trial (RCT) of critically ill patients in a primarily surgical intensive care setting found lower patient mortality with tight glucose control, 80 to 110 mg/dL (4.4 to 6.1 mmol/L), compared with "conventional" more liberal glucose control.[203]
- However, a subsequent multicenter RCT in critically ill medical and surgical patients in other intensive care settings found increased mortality with tighter glucose control, possibly due to more frequent episodes of hypoglycemia.[204]
- In 2017, two network meta-analyses found no benefit in mortality with tight glycemic control when compared with less tight control (79.2 to <109.8 mg/dL [4.4 to <6.1 mmol/L] vs.140.4 to <219.6 mg/dL [7.8 to <12.2 mmol/L] in one report; <110 to 144 mg/dL [<6.1 to 8.0 mmol/L] vs.144 to >180 mg/dL [8.0 to >10.0 mmol/L] in the second report) but a significant increase in the risk of hypoglycemia.[205][206]

More info: Hyperglycemia during the ongoing hospital admission

Hyperglycemia in admitted patients, whether with known diabetes or not, is associated with adverse patient outcomes, including increased mortality.[142]

Act promptly to treat hyperglycemia to avoid diabetic ketoacidosis (DKA) and hyperosmolar hyperglycemic state (HHS).
For persistent hyperglycemia, defined as blood glucose ≥180 mg/dL (≥10.0 mmol/L) confirmed on two occasions within 24 hours, the ADA recommends:[124]
- Starting or intensifying insulin therapy for most critically ill patients.
- Starting or intensifying insulin and/or other glucose-lowering therapies for most noncritically ill patients.

If your patient has DKA or HHS, consider the appropriate unit for management.

Indications for management in the intensive care unit (ICU) include:[134]
- Severe DKA or severe HHS
- Critical illness as the precipitating cause (e.g., sepsis, acute myocardial infarction, gastrointestinal bleeding)
- Altered mental status
- Another concurrent indication for ICU admission.
See Diabetic ketoacidosis or Hyperosmolar hyperglycemic state.

Be aware that the following interventions may be associated with hyperglycemia and may need to be reviewed:[207]

Corticosteroids
Some second-generation antipsychotics (e.g., olanzapine, clozapine)
Fluoroquinolone antibiotics (e.g., ciprofloxacin)
Calcineurin inhibitors (e.g., tacrolimus)
Protease inhibitors (e.g., ritonavir)
Artificial nutrition (parenteral or enteral).

Ask for a specialized inpatient diabetes team consult, if available, or endocrinology consult where hyperglycemia is difficult to control.

More info: Hypoglycemia during the ongoing hospital admission

Monitor blood glucose and adjust medication in response to illness and hospital meal times, to reduce the risk of hypoglycemic episodes.

Ensure that a hypoglycemia management surveillance protocol is in place, with an individualized plan for preventing, identifying, and treating hypoglycemia.[124]
- Immediately correct level 2 hypoglycemia (blood glucose levels <54 mg/dL [<3.0 mmol/L]) and level 3 hypoglycemia (characterized by altered mental and/or physical functioning, requiring assistance for treatment of hypoglycemia from another person for recovery, with no defined glucose level).
- Promptly treat level 1 hypoglycemia (blood glucose levels <70 mg/dL [<3.9 mmol/L] and ≥54 mg/dL [≥3.0 mmol/L]) to prevent progression to more significant levels of hypoglycemia.
- Ensure hypoglycemia treatment is included in all insulin orders.
Treat hypoglycemia, which usually involves provision of 15 g of fast-acting carbohydrates (oral or enteric juice or table sugar; intravenous dextrose). Check blood glucose 15 minutes after the treatment. If the blood glucose is not in a safe range (usually considered to be >90 mg/dL [>5.0 mmol/L]), repeat the treatment. If the oral and enteric route is not available, administer intravenous dextrose. If the patient has no intravenous access, administer glucagon (based on expert opinion). See Diabetic hypoglycemia.
Be aware that hypoglycemia may be induced by treatment of hyperglycemia/diabetes.[208]
- Sliding scale insulin (correctional or supplemental insulin without basal insulin) is associated with the highest rates of hypoglycemia (based on expert opinion). Sole use of sliding scale insulin is not recommended for most individuals in a hospital inpatient setting.[124]
- Be aware of the risk of hypoglycemia in patients on intensive insulin regimens (e.g., multiple daily injections, continuous subcutaneous insulin infusion, or automated insulin delivery systems), and those on basal insulin, sulfonylureas, or meglitinides.
- A combination of insulin and sulfonylureas further increases hypoglycemia risk.
Review and adapt your patient’s treatment plan to prevent recurrent episodes of hypoglycemia.[124]
- Be aware that level 1 hypoglycemia often predicts subsequent level 3 hypoglycemia.
Document any episodes of hypoglycemia in the electronic health record.[124]

Causes of hypoglycemia include:[124]

Inappropriate insulin dose or dose adjustment
Insulin or oral hypoglycemic medication error
Wrong timing of insulin in relation to meals
Inadequate follow-up of first episode of hypoglycemia
Patients eating less but taking the same amount of diabetes medication
Reduced appetite or vomiting
Unexpected interruption of enteral or parenteral feedings
Reduced infusion rate of intravenous dextrose
Delayed or missed blood glucose checks
Sudden reduction of corticosteroid dose
Altered ability of a patient to report symptoms
Recovery from an acute illness.

These medications include:
- Some antibiotics (e.g., fluoroquinolones, trimethoprim/sulfamethoxazole, chloramphenicol)[209][210]
- Other nondiabetic medications (e.g., ACE inhibitors, beta-blockers, chloroquine, disopyramide, pentamidine, salicylates)[209]
Polypharmacy of multiple hypoglycemia-causing medications also increases this risk.[208]
This list is not exhaustive. Consult your local drug information source (based on expert opinion).

Take action if blood glucose falls below 100 mg/dL (<5.6 mmol/L) (based on expert opinion). Fasting blood glucose levels <100 mg/dL (<5.6 mmol/L) are predictive of next-day hypoglycemia.[124]

Give extra carbohydrates to prevent hypoglycemia unless your patient is going to eat a meal within an hour (based on expert opinion).
Modify insulin doses to prevent glucose from going below the target for the patient.

Take steps to reduce the risk of hypoglycemia at night. Assuming your patient is not npo (nothing by mouth), they are likely to have a smaller evening meal in the hospital than at home.

In the absence of significant hyperglycemia, consider reducing the evening basal insulin by 20% on admission (based on expert opinion).
Remember that for many patients with very high insulin needs at home, the needs are often much lower in the hospital, presumably because of changes in diet.
Review the dose used during recent prior hospitalization(s) when deciding the starting dose of insulin (based on expert opinion).

More info: Self-management of diabetes in the hospital

The ADA recommends that suitable candidates for self-managing their diabetes in the hospital include those who:[124]

Normally perform self-management at home
Have the necessary cognitive and physical skills while in the hospital
Have adequate oral intake
Are proficient in carbohydrate estimation
Take multiple daily insulin injections or use insulin pumps
Have stable insulin requirements, and
Understand sick-day management.

The patient and hospital care team should review the decision on self-management on a daily basis.[124]

Inspect injection sites if your patient is on insulin injections at home (based on expert opinion).

Check for insulin lipodystrophy and re-educate on injection technique, if needed.

Continuous glucose monitoring

Consider continuing personal continuous glucose monitoring (CGM) for any individual who uses this wearable technology at home.[211] Consult with the inpatient diabetes team if available.[140]

Although not approved by the Food and Drug Administration (FDA), emergency use authorization was granted during the coronavirus disease 2019 (COVID-19) pandemic and several professional bodies suggest this may be useful if complying with institutional policies and safety regulations.[124][211][132][140]
Confirmatory point-of-care glucose measurements are still needed for assessment of hypoglycemia and to guide decisions on insulin dosing.[124]
Be aware that some concomitant medications, such as acetaminophen (above a certain dose), dopamine, heparin, vitamin C, and hydroxyurea, may result in inaccurate measurements by CGM devices.[211]

More info: Management of patients with diabetes who are receiving end-of-life care

If a patient with diabetes is receiving end-of-life care:

Discuss with your patient and their family/caregivers and agree on the level of intensity of care. Less stringent targets for blood glucose levels are appropriate, with the aim of avoiding hypoglycemia and symptomatic hyperglycemia.[124][132][212]
Prioritize providing comfort and reducing the burdens of strict blood glucose management.[212]
Be aware that stopping basal insulin in a person with type 1 diabetes can lead to dehydration, ketoacidosis, nausea, and associated vomiting; therefore, continuing basal insulin in such a person could be considered as a comfort care (based on expert opinion).

– ensure monitoring is in place to detect any asthma exacerbation during your patient's hospital admission

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examine your patient’s feet

Treatment recommended for ALL patients in selected patient group

Examine the feet of any adult with diabetes on their admission to the hospital and whenever they become ill.[213]

This is to detect new ulcerations or infection, which may be unnoticed by the patient and may even be the cause of their acute illness (e.g., patient presenting with sepsis, or endocarditis where the original focus of infection is the foot lesion).

Inspect the foot for lesions and examine for loss of protective sensation.

To perform a comprehensive foot examination:[214]

Inspect the skin.
Assess any foot deformities.
Do a neurologic exam, including 10-g monofilament testing or Ipswich touch test, with at least one other assessment (pinprick, temperature, or vibration).[215]
Do a vascular exam, including pulses in the legs and feet.

If your patient has reduced sensation, they are at risk for diabetic foot ulceration.[214] Provide pressure relieving devices.

Order daily heel checks for signs of pressure trauma. There is a debate about whether compression stockings should or should not be used in people with diabetes; do not use them if there is known peripheral vascular disease.

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ensure monitoring is in place to detect any asthma exacerbation during your patient's hospital admission

Treatment recommended for ALL patients in selected patient group

Acute worsening of respiratory symptoms may suggest a patient with comorbid asthma is having an acute exacerbation of their asthma.

Follow guideline recommendations on assessing severity and managing an acute exacerbation of asthma in adults.[97]
See Acute asthma exacerbation in adults.

This is due to concern over possible additive anticholinergic adverse effects.
Ensure to represcribe the LAMA once the nebulizer treatment has been stopped.

Be aware that the long-term use of beta-2 agonists to manage asthma may increase the risk of cardiovascular events.

Evidence: Cardiovascular harm with beta-2 agonists

Beta-2 agonists may increase the risk of myocardial infarction and other adverse cardiovascular events.

Beta-2 agonists increase heart rate and reduce potassium levels.[216] They are absorbed into the systemic circulation and there is evidence that long-term regular use may be associated with an increased risk of myocardial infarction, unstable angina, congestive heart failure, and arrhythmias.[217][216]
However, it is not routine practice to discontinue beta-2 agonists if they are needed for comorbid asthma.

– ensure monitoring is in place to detect any COPD exacerbation during your patient's hospital admission

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ensure monitoring is in place to detect any COPD exacerbation during your patient's hospital admission

Treatment recommended for ALL patients in selected patient group

Acute worsening of respiratory symptoms may suggest a patient with comorbid COPD is having an acute exacerbation.[102]

Differentiate from other conditions, such as a pulmonary embolism, acute heart failure, and pneumonia.
Follow guideline recommendations.[102] See Acute exacerbation of COPD.

This is due to concern over possible additive anticholinergic adverse effects.
Ensure the LAMA is represcribed once the nebulizer treatment has been stopped.

Be aware that the long-term use of beta-2 agonists to manage COPD may increase the risk of cardiovascular events.

Evidence: Cardiovascular harm with beta-2 agonists

Beta-2 agonists may increase the risk of myocardial infarction and other adverse cardiovascular events.

Beta-2 agonists increase heart rate and reduce potassium levels.[216] They are absorbed into the systemic circulation and there is evidence that long-term regular use may be associated with an increased risk of myocardial infarction, unstable angina, congestive heart failure, and arrhythmias.[216][217]
However, the Global Initiative for Chronic Obstructive Lung Disease states that there has been no reported association between beta-2-agonist use and increased mortality in people with COPD.[102] It is not routine practice to discontinue beta-2 agonists if they are needed for comorbid COPD.

– continue your patient's inhalers as prescribed for asthma or COPD

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mental status exam

Treatment recommended for ALL patients in selected patient group

Perform a mental status exam as the clinical situation allows (based on expert opinion).

The mental status exam is one of the main clinical tools routinely used in psychiatric practice, aiding diagnosis and guiding further management. Mood is one of the assessed domains.

Consider assessing current symptoms of depression using the PHQ-9 questionnaire.[218][219]

The PHQ-9 questionnaire can be used as a reliable and valid measure of depression severity in patients with a known diagnosis of depression, as well as a screening tool.
This can be self-administered or administered by the clinician, and takes less than 3 minutes to complete.
Results indicate severity of depressive symptoms.

Take into account other factors that may be influencing the patient's mental status (e.g., the effect of any illicit drug use or alcohol).[219][220]

In particular, consider whether symptoms of depression could be part of the acute medical illness (based on expert opinion).

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review current treatment for depression

Treatment recommended for ALL patients in selected patient group

Continue the patient’s usual antidepressant, unless there are good reasons not to (based on expert opinion).

If antidepressants are stopped abruptly, the patient may develop antidepressant discontinuation syndrome.[221]
The severity of the symptoms of discontinuation may vary, but they may be unpleasant and may complicate the management of the acute medical condition.

When reviewing current medications, consider:

Current and previous adverse effects
Recent changes in dose
Recent medication changes from a different drug class
The specific diagnostic subtypes of depression when prescribing medications (e.g., it is likely that patients suffering from psychotic depression would be coprescribed an antipsychotic)
Augmenting strategies that may be used when treating resistant depression (e.g., lithium or quetiapine augmentation of a selective serotonin-reuptake inhibitor [SSRI]).

Consider drug-drug interactions.

Antidepressants (particularly those that inhibit the CYP450 pathway) may cause significant interactions with drugs used for other conditions.[222]

Consider psychiatric complications when prescribing nonpsychotropic drugs.

Take particular care when prescribing anticonvulsants, antiparkinsonian drugs, and corticosteroids.

Consider adverse effects, which may include the following:

Hyponatremia, caused by antidepressants, especially SSRIs, and compounded by other coprescribed drugs (e.g., diuretics).[223][224][225][226] Review your patient’s serum electrolyte results and consider antidepressants as a potential contributing factor if they have hyponatremia.
Serotonin syndrome (altered mental state, agitation, tremor, hyper-reflexia, ocular clonus or inducible clonus, muscle rigidity, diaphoresis, tachycardia, increased bowel sounds, temperature >100.4°F [>38°C]), especially with polypharmacy and/or overdose of a serotonergic agent.[227][228] See Serotonin syndrome.
- Be particularly aware of increased risk of serotonin syndrome in patients with kidney failure on SSRIs.[229][230]
Hepatotoxicity.[231] Adjust doses of antidepressants in patients with hepatic impairment as necessary.
- However, antidepressants are rarely the cause of hepatic impairment.[231]
Prolonged QTc, arrhythmias, increased heart rate, postural hypotension with tricyclic antidepressants.[232][233] Obtain an ECG, especially in people at risk of arrhythmias.[234]
Gastrointestinal bleeding. SSRIs are associated with an increased risk of gastrointestinal bleeding.[223][235][236] Risk is particularly increased when coprescribed with aspirin, nonsteroidal anti-inflammatory drugs (NSAIDs), or oral anticoagulants.[236][237][238] Monitor closely and consider gastroprotection with proton-pump inhibitors if SSRI use cannot be avoided (based on expert opinion).

This list of adverse effects is not exhaustive - consult your drug information sources or hospital pharmacist for further information, and consider a psychiatric consult for advice.

Practical tip

Ask your patient about nonpharmacologic treatments for their depression and check the current level of community support.

This may include other outpatient healthcare professionals, charities, and family and social networks.

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consider psychiatric consult

Treatment recommended for ALL patients in selected patient group

Consider a psychiatric consult for any patient with comorbid depression who is admitted to the hospital with an acute condition.

Consult is strongly advised in patients with severe symptoms of depression or additional symptoms such as self harm, suicidal ideation, homicidal ideation, catatonia, psychosis (based on expert opinion).
Consult may not be required if there are no concerns that depression and/or its management (e.g., medication) may be affecting the acute condition (based on expert opinion).
Accidents of unclear circumstances, self-injurious behaviors, and/or suicide attempts (including alleged "accidental" overdose of medication) should trigger clinical suspicion of comorbid mental health disorder (based on expert opinion).

Ensure your patient has adequate support with their treatment post-discharge.

Keep in mind that the psychological impact of comorbid depression may be associated with poor adherence with recommended physical health treatments, from medication to rehabilitation.[242][243][244] This may lead to worse clinical outcomes, including higher readmission risk.[245][246]
Most importantly, affective symptoms, including depression, have been linked with excess mortality, though a causal link remains to be proven.[247][248]