Hospital management of diabetes

International consensus statement on allergy and rhinology: rhinosinusitis 2021

I.

EXECUTIVE SUMMARY

BACKGROUND: The 5 years since the publication of the first International Consensus Statement on Allergy and Rhinology: Rhinosinusitis (ICAR-RS) has witnessed foundational progress in our understanding and treatment of rhinologic disease. These advances are reflected within the more than 40 new topics covered within the ICAR-RS-2021 as well as updates to the original 140 topics. This executive summary consolidates the evidence-based findings of the document.

METHODS

ICAR-RS presents over 180 topics in the forms of evidence-based reviews with recommendations (EBRRs), evidence-based reviews, and literature reviews. The highest grade structured recommendations of the EBRR sections are summarized in this executive summary.

RESULTS

ICAR-RS-2021 covers 22 topics regarding the medical management of RS, which are grade A/B and are presented in the executive summary. Additionally, 4 topics regarding the surgical management of RS are grade A/B and are presented in the executive summary. Finally, a comprehensive evidence-based management algorithm is provided.

CONCLUSION

This ICAR-RS-2021 executive summary provides a compilation of the evidence-based recommendations for medical and surgical treatment of the most common forms of RS.

The GesTIO protocol experience: safety of a standardized order set for subcutaneous insulin regimen in elderly hospitalized patients

BACKGROUNDS

In non-critical hospitalized patients with diabetes mellitus, guidelines suggest subcutaneous insulin therapy with basal-bolus regimen, even in old and vulnerable inpatients.

AIM

To evaluate safety, efficacy, and benefit on clinical management of the GesTIO protocol, a set of subcutaneous insulin administration rules, in old and vulnerable non-ICU inpatients.

METHODS

Retrospective, observational study. Patients admitted to Geriatric Clinic of Padua were studied. 88 patients matched the inclusion criteria: type 2 diabetes or hospital-related hyperglycemia, ≥65 years, regular measurements of capillary glycemia, and basal-bolus subcutaneous insulin regimen managed by "GesTIO protocol" for five consecutive days.

MAIN OUTCOME MEASURES

ratio of patients with blood glucose (BG) <3.9 mmol/l; number of BG per patient in target range (5-11.1 mmol/l); daily mean BG; and calls to physicians for adjusting insulin therapy.

RESULTS

Mean age was 82 ± 7 years. 9.1% patients experienced mild hypoglycaemia, and no severe hypoglycaemia was reported. The median number of BG per patients in target range increased from 2.0 ± 2 to 3.0 ± 2 (p < 0.001). The daily mean BG decreased from 11.06 ± 3.03 to 9.64 ± 2.58 mmol/l (-12.8%, p < 0.005). The mean number of calls to physicians per patient decreased from 0.83 to 0.45 (p < 0.05).

CONCLUSIONS

Treatment with GesTIO protocol allows a safe and effective treatment even in very old and vulnerable inpatients with a faster management insulin therapy.

Implementation of a New Intravenous Insulin Method on Intermediate-Care Units in Hospitalized Patients

Good blood glucose control in hospitalized adults leads to reduced mortality. Intravenous (IV) insulin has been shown to be an effective way to achieve tight control of blood glucose. Managing IV insulin is a labor-intensive task for nurses and is generally done in intensive care units with high nurse-to-patient ratios. In this 3-month study, intermediate-care general medicine units with a nurse-to-patient ratio of 1 to 5 or 6 were evaluated for effectiveness of monitoring IV insulin. The project, which relied on intensive in-service education, an audit tool, and continuous positive feedback for nurses, yielded positive results.

Ketosis After Cardiopulmonary Bypass in Children Is Associated With an Inadequate Balance Between Oxygen Transport and Consumption

OBJECTIVES

Hyperglycemia after cardiac surgery and cardiopulmonary bypass in children has been associated with worse outcome; however, causality has never been proven. Furthermore, the benefit of tight glycemic control is inconsistent. The purpose of this study was to describe the metabolic constellation of children before, during, and after cardiopulmonary bypass, in order to identify a subset of patients that might benefit from insulin treatment.

DESIGN

Prospective observational study, in which insulin treatment was initiated when postoperative blood glucose levels were more than 12 mmol/L (216 mg/dL).

SETTING

Tertiary PICU.

PATIENTS

Ninety-six patients 6 months to 16 years old undergoing cardiac surgery with cardiopulmonary bypass.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

Metabolic tests were performed before anesthesia, at the end of cardiopulmonary bypass, at PICU admission, and 4 and 12 hours after PICU admission, as well as 4 hours after initiation of insulin treatment. Ketosis was present in 17.9% patients at the end of cardiopulmonary bypass and in 31.2% at PICU admission. Young age was an independent risk factor for this condition. Ketosis at PICU admission was an independent risk factor for an increased difference between arterial and venous oxygen saturation. Four hours after admission (p = 0.05). Insulin corrected ketosis within 4 hours.

CONCLUSIONS

In this study, we found a high prevalence of ketosis at PICU admission, especially in young children. This was independently associated with an imbalance between oxygen transport and consumption and was corrected by insulin. These results set the basis for future randomized controlled trials, to test whether this subgroup of patients might benefit from increased glucose intake and insulin during surgery to avoid ketosis, as improving oxygen transport and consumption might improve patient outcome.

Effectiveness of Sliding-Scale Insulin in Inpatients with Diabetes Mellitus

Objective:

To compare the incidence of hypoglycemia and hyperglycemia among sliding-scale insulin (SSI) regimens and determine patient characteristics that influence glycemic control in inpatients with diabetes mellitus.

Methods:

Main outcome measures for this retrospective chart review were rates of hyperglycemic (≥200 mg/dL) and hypoglycemic (≤60 mg/dL or symptomatic) episodes. Patients were excluded if a diabetic complication led to hospitalization. SSI regimens as well as patient demographics and clinical characteristics were evaluated for influence on glycemic control.

Results:

Seventy-four patients with 1020 capillary glucose measurements were analyzed. Regarding overall glycemic control, 80% of patients had ≥2 hyperglycemic events and 4% had ≥2 hypoglycemic events. Factors that significantly increased the risk of hyperglycemia were insulin use prior to admission (p ≤ 0.0001), corticosteroid use (p ≤ 0.0001), antibiotic use (p = 0.009), and dextrose-containing intravenous fluids (p = 0.004). Implementation of an SSI order form (which was associated with selection of more aggressive SSI regimens) significantly decreased the incidence of hyperglycemia (p ≤ 0.0001) without increasing the incidence of hypoglycemia. When analyzed for interactions among variables, insulin use prior to admission and concurrent corticosteroid use remained as independent predictors of hyperglycemia.

Conclusions:

Suboptimal glycemic control is common in hospitalized patients with diabetes. Patients receiving insulin prior to admission, corticosteroid therapy, dextrose-containing intravenous fluids, or treatment for an active infection are at increased risk. An aggressive SSI regimen does not appear to increase the incidence of hypoglycemia and may lead to better glycemic control. Whether initiating treatment at blood glucose concentrations <150 mg/dL would improve control remains unknown.

Randomized study comparing a Basal-bolus with a basal plus correction insulin regimen for the hospital management of medical and surgical patients with type 2 diabetes: basal plus trial

OBJECTIVE

Effective and easily implemented insulin regimens are needed to facilitate hospital glycemic control in general medical and surgical patients with type 2 diabetes (T2D).

RESEARCH DESIGN AND METHODS

This multicenter trial randomized 375 patients with T2D treated with diet, oral antidiabetic agents, or low-dose insulin (≤ 0.4 units/kg/day) to receive a basal-bolus regimen with glargine once daily and glulisine before meals, a basal plus regimen with glargine once daily and supplemental doses of glulisine, and sliding scale regular insulin (SSI).

RESULTS

Improvement in mean daily blood glucose (BG) after the first day of therapy was similar between basal-bolus and basal plus groups (P = 0.16), and both regimens resulted in a lower mean daily BG than did SSI (P = 0.04). In addition, treatment with basal-bolus and basal plus regimens resulted in less treatment failure (defined as >2 consecutive BG >240 mg/dL or a mean daily BG >240 mg/dL) than did treatment with SSI (0 vs. 2 vs. 19%, respectively; P < 0.001). A BG <70 mg/dL occurred in 16% of patients in the basal-bolus group, 13% in the basal plus group, and 3% in the SSI group (P = 0.02). There was no difference among the groups in the frequency of severe hypoglycemia (<40 mg/dL; P = 0.76).

CONCLUSIONS

The use of a basal plus regimen with glargine once daily plus corrective doses with glulisine insulin before meals resulted in glycemic control similar to a standard basal-bolus regimen. The basal plus approach is an effective alternative to the use of a basal-bolus regimen in general medical and surgical patients with T2D.

Importance of perioperative glycemic control in general surgery: a report from the Surgical Care and Outcomes Assessment Program

OBJECTIVE

To determine the relationship of perioperative hyperglycemia and insulin administration on outcomes in elective colon/rectal and bariatric operations.

BACKGROUND

There is limited evidence to characterize the impact of perioperative hyperglycemia and insulin on adverse outcomes in patients, with and without diabetes, undergoing general surgical procedures.

METHODS

The Surgical Care and Outcomes Assessment Program is a Washington State quality improvement benchmarking-based initiative. We evaluated the relationship of perioperative hyperglycemia (>180 mg/dL) and insulin administration on mortality, reoperative interventions, and infections for patients undergoing elective colorectal and bariatric surgery at 47 participating hospitals between fourth quarter of 2005 and fourth quarter of 2010.

RESULTS

Of the 11,633 patients (55.4 ± 15.3 years; 65.7% women) with a serum glucose determination on the day of surgery, postoperative day 1, or postoperative day 2, 29.1% of patients were hyperglycemic. After controlling for clinical factors, those with hyperglycemia had a significantly increased risk of infection [odds ratio (OR) 2.0; 95% confidence interval (CI), 1.63-2.44], reoperative interventions (OR, 1.8; 95% CI, 1.41-2.3), and death (OR, 2.71; 95% CI, 1.72-4.28). Increased risk of poor outcomes was observed both for patients with and without diabetes. Those with hyperglycemia on the day of surgery who received insulin had no significant increase in infections (OR, 1.01; 95% CI, 0.72-1.42), reoperative interventions (OR, 1.29; 95% CI, 0.89-1.89), or deaths (OR, 1.21; 95% CI, 0.61-2.42). A dose-effect relationship was found between the effectiveness of insulin-related glucose control (worst 180-250 mg/dL, best <130 mg/dL) and adverse outcomes.

CONCLUSIONS

Perioperative hyperglycemia was associated with adverse outcomes in general surgery patients with and without diabetes. However, patients with hyperglycemia who received insulin were at no greater risk than those with normal blood glucoses. Perioperative glucose evaluation and insulin administration in patients with hyperglycemia are important quality targets.

Novel views on new-onset diabetes after transplantation: development, prevention and treatment

New-onset diabetes after transplantation (NODAT) is associated with increased risk of allograft failure, cardiovascular disease and mortality, and therefore, jeopardizes the success of renal transplantation. Increased awareness of NODAT and the prediabetic states (impaired fasting glucose and impaired glucose tolerance, IGT) has fostered previous and present recommendations, based on the management of type 2 diabetes mellitus (T2DM). Unfortunately, the idea that NODAT merely resembles T2DM is potentially misleading, because the opportunity to initiate adequate anti-hyperglycaemic treatment early after transplantation might be given away for 'tailored' immunosuppression in patients who have developed NODAT or carry personal risk factors. Risk factor-independent mechanisms, however, seem to render postoperative hyperglycaemia with subsequent development of overt or 'full-blown' NODAT, the unavoidable consequence of the transplant and immunosuppressive process itself, at least in many cases. A proof of the concept that timely preventive intervention with exogenous insulin against post-transplant hyperglycaemia may decrease NODAT was recently provided by a small clinical trial, which is awaiting confirmation from a multicentre study. However, because early insulin therapy aimed at beta-cell protection seems to contrast the currently recommended, stepwise approach of 'watchful waiting' prior to pancreatic decompensation, we here aim at reviewing recent concepts regarding the development, prevention and treatment of NODAT, some of which seem to challenge the traditional view on T2DM and NODAT. In summary, we suggest a novel, risk factor-independent management approach to NODAT, which includes glycaemic monitoring and anti-hyperglycaemic treatment in virtually everybody after transplantation. This approach has widespread implications for future research and is intended to tackle NODAT and also ultimately cardiovascular disease.

Steroid-induced diabetes: is it just unmasking of type 2 diabetes?

Aims. We compared the demographic profile and clinical characteristics of individuals with new onset steroid-induced diabetes (NOSID) to Type 2 diabetes (T2DM) patients with and without steroid treatment. Methods. The demographic profile and clinical characteristics of 60 individuals who developed NOSID were examined and matched to 60 type 2 diabetes patients receiving steroid therapy (T2DM+S) and 360 diabetic patients not on steroids (T2DM) for age, duration of diabetes, HbA1c, gender, and ethnicity. Results. Patients who developed NOSID had less family history of diabetes (P ≤ 0.05) and were less overweight (P ≤ 0.02). NOSID was more commonly treated with insulin. Despite a matching duration of diabetes and glycaemic control, significantly less retinopathy was found in the group of patients with NOSID (P < 0.03). Conclusions. It appears that steroid treatment primarily precipitated diabetes in a group of individuals otherwise less affected by risk factors of diabetes at that point in time, rather than just opportunistically unmasking preexisting diabetes. Furthermore, the absence of retinopathy suggests that patients with NOSID had not been exposed to long periods of hyperglycaemia. However, the impact of the underlying conditions necessitating steroid treatment and concomitant medications such as immunosuppressants on diabetes development remain to be defined.

Breast abscess, an early indicator for diabetes mellitus in non-lactating women: a retrospective study from rural India

INTRODUCTION

Breast abscess is commonly seen in lactating and non-lactating women. Diabetes mellitus (DM) frequently predisposes to soft tissue infections and has many different presentations. But DM presenting in the form of breast abscess is yet to be studied, and we believe our study is the first to explore this connection.

METHODS

We collected 30 cases of breast abscess in women who presented to our hospital from May 2010 to June 2011 retrospectively. They were classified into lactating and non-lactating women, and their glycemic status was evaluated, together with length of hospital stay, management, recurrence, and follow-up status after 6 months.

RESULTS

We found that of the 30 patients in our study, 20% had high blood sugar levels. And 37.5% of the non-lactating women were diagnosed newly with DM.

CONCLUSIONS

This study shows that DM can present as breast abscess in non-lactating women. Therefore, non-lactating women with a breast abscess should be evaluated for DM.

Insulin therapy for the management of hyperglycemia in hospitalized patients

It has long been established that hyperglycemia with or without a prior diagnosis of diabetes increases both mortality and disease-specific morbidity in hospitalized patients and that goal-directed insulin therapy can improve outcomes. This article reviews the pathophysiology of hyperglycemia during illness, the mechanisms for increased complications and mortality due to hyperglycemia and hypoglycemia, and beneficial mechanistic effects of insulin therapy and provides updated recommendations for the inpatient management of diabetes in the critical care setting and in the general medicine and surgical settings.

Glycemic control in critically ill patients

Hyperglycemia is common in critically ill patients and can be caused by various mechanisms, including nutrition, medications, and insufficient insulin. In the past, hyperglycemia was thought to be an adaptive response to stress, but hyperglycemia is no longer considered a benign condition in patients with critical illnesses. Indeed, hyperglycemia can increase morbidity and mortality in critically ill patients. Correction of hyperglycemia may improve clinical outcomes. To date, a definite answer with regard to glucose management in general intensive care unit patients, including treatment thresholds and glucose target is undetermined. Meta-analyses of randomized controlled trials suggested no survival benefit of tight glycemic control and a significantly increased incidence of hypoglycemia. Studies have shown a J- or U-shaped relationship between average glucose values and mortality; maintaining glucose levels between 100 and 150 mg/dL was likely to be associated with the lowest mortality rates. Recent studies have shown glycemic control < 180 mg/dL is not inferior to near-normal glycemia in critically ill patients and is clearly safer. Glycemic variability is also an important aspect of glucose management in the critically ill patients. Higher glycemic variability may increase the mortality rate, even in patients with the same mean glucose level. Decreasing glucose variability is an important issue for glycemic control in critically ill patients. Continuous measurements with automatic closed-loop systems could be considered to ensure that blood glucose levels are controlled within a specific range and with minimal variability.

Randomized study of basal-bolus insulin therapy in the inpatient management of patients with type 2 diabetes undergoing general surgery (RABBIT 2 surgery)

OBJECTIVE

The optimal treatment of hyperglycemia in general surgical patients with type 2 diabetes mellitus is not known.

RESEARCH DESIGN AND METHODS

This randomized multicenter trial compared the safety and efficacy of a basal-bolus insulin regimen with glargine once daily and glulisine before meals (n = 104) to sliding scale regular insulin (SSI) four times daily (n = 107) in patients with type 2 diabetes mellitus undergoing general surgery. Outcomes included differences in daily blood glucose (BG) and a composite of postoperative complications including wound infection, pneumonia, bacteremia, and respiratory and acute renal failure.

RESULTS

The mean daily glucose concentration after the 1st day of basal-bolus insulin and SSI was 145 ± 32 mg/dL and 172 ± 47 mg/dL, respectively (P < 0.01). Glucose readings <140 mg/dL were recorded in 55% of patients in basal-bolus and 31% in the SSI group (P < 0.001). There were reductions with basal-bolus as compared with SSI in the composite outcome [24.3 and 8.6%; odds ratio 3.39 (95% CI 1.50-7.65); P = 0.003]. Glucose <70 mg/dL was reported in 23.1% of patients in the basal-bolus group and 4.7% in the SSI group (P < 0.001), but there were no significant differences in the frequency of BG <40 mg/dL between groups (P = 0.057).

CONCLUSIONS

Basal-bolus treatment with glargine once daily plus glulisine before meals improved glycemic control and reduced hospital complications compared with SSI in general surgery patients. Our study indicates that a basal-bolus insulin regimen is preferred over SSI in the hospital management of general surgery patients with type 2 diabetes.

Optimizing inpatient glycemic control with basal-bolus insulin therapy

Hyperglycemia is highly prevalent in the acute-care setting and is associated with an increased risk of morbidity and mortality. Evidence suggests that glycemic control in this population is suboptimal, due in part to continued use of nonphysiologic sliding-scale insulin strategies without scheduled basal insulin doses or prandial insulin with concomitant correction doses. Although the ineffectiveness and risks of sliding-scale insulin regimens have been criticized for decades, sliding-scale insulin is still the most commonly prescribed subcutaneous insulin regimen among inpatients. Improving inpatient management requires the use of scheduled basal-bolus insulin therapy that includes basal insulin, nutritional insulin, and supplemental, or correctional, insulin. Insulin analogs are the preferred insulins, as they provide a more physiologic action than human insulin regimens, are associated with a lower risk of hypoglycemia, and are more convenient to administer than human insulins. Standardized insulin protocols and subcutaneous insulin order sets are critical components of effective inpatient glycemic control. Although preliminary data have demonstrated that inpatient diabetes management programs involving basal-bolus insulin therapy are effective and well tolerated, more research is needed.

Management of hyperglycemia in hospitalized patients

Hyperglycemia is a common occurrence in hospitalized patients, and several studies have shown a strong association between hyperglycemia and the risk of complications, prolonged hospitalization, and death for patients with and without diabetes. Past studies have shown that glucose management in the intensive care setting improves clinical outcomes by reducing the risk of multiorgan failure, systemic infection, and mortality, and that the importance of hyperglycemia also applies to noncritically ill patients. Based on several past observational and interventional studies, aggressive control of blood glucose had been recommended for most adult patients with critical illness. Recent randomized controlled trials, however, have shown that aggressive glycemic control compared to conventional control with higher blood glucose targets is associated with an increased risk of hypoglycemia and may not result in the improvement in clinical outcomes. This review aims to give an overview of the evidence for tight glycemic control (blood glucose targets <140 mg/dL), the evidence against tight glycemic control, and the updated recommendations for the inpatient management of diabetes in the critical care setting and in the general wards.

Comparison of inpatient insulin regimens with detemir plus aspart versus neutral protamine hagedorn plus regular in medical patients with type 2 diabetes

BACKGROUND

Studies comparing the use of basal bolus with insulin analogs vs. split-mixed regimens with human insulins in hospitalized patients with type 2 diabetes are lacking.

RESEARCH DESIGN AND METHODS

In a controlled multicenter trial, we randomized 130 nonsurgical patients with blood glucose (BG) between 140 and 400 mg/dl to receive detemir once daily and aspart before meals (n = 67) or neutral protamine Hagedorn (NPH) and regular insulin twice daily (n = 63). Insulin dose was started at 0.4 U/kg.d for BG between 140 and 200 mg/dl or 0.5 U/kg.d for BG 201-400 mg/dl. Major study outcomes included differences in mean daily BG levels and frequency of hypoglycemic events between treatment groups.

RESULTS

Glycemic control improved similarly in both groups from a mean daily BG of 228 +/- 54 and 223 +/- 58 mg/dl (P = 0.61) to a mean daily BG level after the first day of 160 +/- 38 and 158 +/- 51 mg/dl in the detemir/aspart and NPH/regular insulin groups, respectively (P = 0.80). A BG target below 140 mg/dl before meals was achieved in 45% of patients in the detemir/aspart group and 48% in the NPH/regular group (P = 0.86). During treatment, 22 patients (32.8%) in the detemir/aspart group and 16 patients (25.4%) in the NPH/regular group had at least one episode of hypoglycemia (BG < 60 mg/dl) during the hospital stay (P = 0.34).

CONCLUSIONS

Treatment with basal/bolus regimen with detemir once daily and aspart before meals results in equivalent glycemic control and no differences in the frequency of hypoglycemia compared to a split-mixed regimen of NPH and regular insulin in patients with type 2 diabetes.

Evaluation of the VIA Blood Chemistry Monitor for Glucose in Healthy and Diabetic Volunteers

BACKGROUND

Manual methods of blood glucose monitoring are labor-intensive, costly, prone to error, and expose the caregiver to blood. The VIA(R) blood chemistry monitor for glucose can automatically measure plasma glucose (PG) every 5 minutes for 72 hours using blood sampled from a peripheral vein/artery or a central vein.

METHODS

VIA performance was evaluated in eight normal and five type 1 diabetic (T1DM) subjects in 15 separate experiments. The VIA device was connected to a peripheral vein and reported a PG value every 5 minutes during each 510-minute experiment. Blood samples were collected manually every 10 minutes and assayed using a HemoCue(R) beta-glucose analyzer (HC). Whole blood HC measurements were corrected to PG values. Paired HC/VIA measurements (n = 717) were analyzed.

RESULTS

Mean PG was 90 +/- 14 and 96 +/- 12 mg/dl in normal subjects and 194 +/- 64 and 173 +/- 48 mg/dl in T1DM subject as measured by the HC and VIA, respectively. Clark error grid analysis revealed 86% points in zone A, 11% points in zone B, and 2% points in zone D. Linear regression analysis yielded the following equation: VIA = 0.732 x HC + 30.5 (r(2) = 0.954). Residual analysis revealed a glucose-dependent bias between the HC and the VIA. VIA data were transformed using the linear regression equation to correct for bias. After the correction, the mean absolute relative difference between the VIA and the HC was less than 10%, and 99.6% of data were in zones A and B. The VIA was able to sample blood automatically every 5 minutes for more than 8 hours in the laboratory setting. On average, the VIA reported glucose values for 94% of the samples it attempted to obtain.

CONCLUSIONS

This study demonstrated that the VIA blood chemistry monitor for glucose can reliably sample blood frequently for a prolonged period of time safely and effectively in diabetic and nondiabetic volunteers. Agreement between the two devices was the closest at normal glucose concentrations. After correcting for a glucose-dependent bias between the devices, the MARD was consistently less than 10% for all glucose ranges.

Evidence for strict inpatient blood glucose control: time to revise glycemic goals in hospitalized patients

Inpatient hyperglycemia in patients with and without a history of diabetes is common and is associated with increased hospital morbidity and mortality. The objectives of this communication are to examine results of randomized clinical trials of strict inpatient glucose control in medical and surgical intensive care units and to provide guidelines for achieving and maintaining glycemic control in patients admitted to critical and noncritical settings. We propose a more conservative approach of glycemic control than current American Association of Clinical Endocrinology recommendations until results of prospective, multicenter, randomized studies become available.

Randomized study of basal-bolus insulin therapy in the inpatient management of patients with type 2 diabetes (RABBIT 2 trial)

OBJECTIVE

We sought to study the optimal management of hyperglycemia in non-intensive care unit patients with type 2 diabetes, as few studies thus far have focused on the subject.

RESEARCH DESIGN AND METHODS

We conducted a prospective, multicenter, randomized trial to compare the efficacy and safety of a basal-bolus insulin regimen with that of sliding-scale regular insulin (SSI) in patients with type 2 diabetes. A total of 130 insulin-naive patients were randomized to receive glargine and glulisine (n = 65) or a standard SSI protocol (n = 65). Glargine was given once daily and glulisine before meals at a starting dose of 0.4 units x kg(-1) x day(-1) for blood glucose 140-200 mg/dl or 0.5 units x kg(-1) x day(-1) for blood glucose 201-400 mg/dl. SSI was given four times per day for blood glucose >140 mg/dl.

RESULTS

The mean admission blood glucose was 229 +/- 6 mg/dl and A1C 8.8 +/- 2%. A blood glucose target of <140 mg/dl was achieved in 66% of patients in the glargine and glulisine group and in 38% of those in the SSI group. The mean daily blood glucose between groups ranged from 23 to 58 mg/dl, with an overall blood glucose difference of 27 mg/dl (P < 0.01). Despite increasing insulin doses, 14% of patients treated with SSI remained with blood glucose >240 mg/dl. There were no differences in the rate of hypoglycemia or length of hospital stay.

CONCLUSIONS

Treatment with insulin glargine and glulisine resulted in significant improvement in glycemic control compared with that achieved with the use of SSI alone. Our study indicates that a basal-bolus insulin regimen is preferred over SSI in the management of non-critically ill, hospitalized patients with type 2 diabetes.

Sliding scale insulin use: myth or insanity?

Inpatient hyperglycemia in people with or without diabetes is associated with an increased risk of complications and mortality, a longer hospital stay, a higher admission rate to the intensive care unit, and higher hospitalization costs. Despite increasing evidence that supports intensive glycemic control in hospitalized patients, blood glucose control continues to be challenging, and sliding scale insulin coverage, a practice associated with limited therapeutic success, continues to be the most frequent insulin regimen in hospitalized patients. Sliding scale insulin has been in use for more than 80 years without much evidence to support its use as the standard of care. Several studies have revealed evidence of poor glycemic control and deleterious effects in sliding scale insulin use. To understand its wide use and acceptance, we reviewed the origin, advantages, and disadvantages of sliding scale insulin in the inpatient setting.

Knowledge on inpatient diabetes among fourth-year medical students

OBJECTIVE

The importance of proper management of inpatient hyperglycemia is increasingly being recognized. However, the curriculum for 4th-year medical students has lagged behind current clinical recommendations. The aim of this study was to assess the baseline knowledge of medical subinterns on inpatient diabetes.

RESEARCH DESIGN AND METHODS

In the 2005-2006 school year, subinterns were given a pretest on inpatient diabetes. Descriptive analysis was used.

RESULTS

Students frequently recommended the sole use of sliding scale for diabetes management. Hyperglycemia in patients not known to have diabetes is less likely to be recognized. The students were more likely to provide appropriate management for chest pain than diabetes. Students were otherwise knowledgeable about the recognition of type of diabetes and the pharmacology of the medications.

CONCLUSIONS

This study demonstrates the gaps in knowledge about inpatient diabetes that exist before internship and residency. The findings can be used to design a curriculum appropriately targeted to the level of 4th-year medical students.

Intensive insulin therapy in critical care: a review of 12 protocols

OBJECTIVE

To review performance characteristics of 12 insulin infusion protocols.

RESEARCH DESIGN AND METHODS

We systematically identify and compare 12 protocols and then apply the protocols to generate insulin recommendations in the management of a patient with hyperglycemia. The main focus involves a comparison of insulin doses and patterns of insulin administration.

RESULTS

There is great variability in protocols. Areas of variation include differences in initiation and titration of insulin, use of bolus dosing, requirements for calculation in adjustment of the insulin infusion, and method of insulin protocol adjustments. Insulin recommendations for a sample patient are calculated to highlight differences between protocols, including the patterns and ranges of insulin dose recommended (range 27-115 units [mean +/- SD 66.7 +/- 27.9]), amount recommended for glucose readings >200 mg/dl, and adjustments nearing target glucose.

CONCLUSIONS

The lack of consensus in the delivery of intravenous insulin infusions is reflected in the wide variability of practice noted in this survey. This mandates close attention to the choice of a protocol. One protocol may not suffice for all patients.

Inpatient management of diabetes and hyperglycemia: implications for nutrition practice and the food and nutrition professional

Although numerous guidelines and standards address the management of diabetes in outpatient settings, only recently has evidence been provided to issue standards of care to guide clinicians in optimal inpatient glycemic control for hospitalized individuals with diabetes or illness-induced hyperglycemia. Both the American Diabetes Association and the American College of Endocrinology recommend critically ill patients keep their blood glucose level as close to 110 mg/dL (6.1 mmol/L) as possible. In the noncritically ill patient, the American Diabetes Association recommends to keep pre-meal blood glucose as close to 90 to 130 mg/dL (5.0 to 7.2 mmol/L) as possible, whereas the American College of Endocrinology recommends pre-meal blood glucose be kept at 110 mg/dL (6.1 mmol/L) or less. Both organizations agree that peak post-prandial blood glucose should be 180 mg/dL (10.0 mmol/L) or less. Recent evidence has also led the Joint Commission on Accreditation of Healthcare Organizations to develop standards for a voluntary certification in the management of the patient with diabetes in the inpatient setting. It is important that food and nutrition professionals familiarize themselves with these recommendations and implement nutrition interventions in collaboration with other members of the health care team to achieve these new glycemic control targets. Food and nutrition professionals have a key role in developing screening tools, and in implementing nutrition care guidelines, nutrition interventions, and medical treatment protocols needed to improve inpatient glycemic control.

Perioperative glucose control in the diabetic or nondiabetic patient

Patients with diabetes are more likely to undergo surgery than nondiabetics, and maintaining glycemic control in subjects with diabetes can be challenging during the perioperative period. Surgery in diabetic patients is associated with longer hospital stay, higher health care resource utilization, and greater perioperative mortality. In addition, several observational and interventional studies have indicated that hyperglycemia is associated with adverse clinical outcomes in surgical and critically ill patients. This paper reviews the pathophysiology of hyperglycemia during trauma and surgical stress and will provide practical recommendations for the preoperative, intraoperative, and postoperative care of diabetic patients.

Glucommander: a computer-directed intravenous insulin system shown to be safe, simple, and effective in 120,618 h of operation

OBJECTIVE

Intravenous insulin is now the recommended method of diabetes management in critically ill persons in the hospital. The published methods for administering the insulin are complex and are usually limited to intensive care units with a low patient-to-nurse ratio.

RESEARCH DESIGN AND METHODS

A computer-directed algorithm for advice on the delivery of intravenous insulin that is flexible in blood glucose timing and advises insulin dosing in a graduated manner has been developed. This software program, known as the Glucommander, has been used extensively by our group. The data were analyzed for this study.

RESULTS

The data from 5,080 intravenous insulin runs over 120,683 h show that blood glucose levels can be safely stabilized in a target range without significant hypoglycemia by nonspecialized nurses working on any unit of a general hospital. The mean glucose level reached <150 mg/dl in 3 h. Only 0.6% of all glucose values were <50 mg/dl. The prevalence of hypoglycemia <40 mg/dl was 2.6% of all runs. No hypoglycemia was severe.

CONCLUSIONS

This computer-directed algorithm is a simple, safe, effective, and robust method for maintaining glycemic control. It has been extensively studied and is applicable in a wide variety of conditions. In contrast to other published intravenous insulin protocols, which have been limited to intensive care units, Glucommander can be used in all units of any hospital.

An 18-year-old patient with type 1 diabetes undergoing surgery

A young patient with type 1 diabetes needs an elective operation under general anesthesia. How will you manage his diabetes before, during, and after the surgery?

Hyperglycemia in the Hospital Setting: The Case for Improved Control among Non-Diabetics

OBJECTIVE:

To review studies on the role of hyperglycemia in acutely ill adults, regardless of diabetes diagnosis, and the impact of glucose control on health outcomes.

DATA SOURCES:

Searches on Ovid MEDLINE, Ovid Evidence-Based Medicine (EBM), and PubMed MEDLINE, limited to articles written in English, trials conducted on adult subjects, and material published between 1994 and April 2004. Search words included the major MeSH term hyperglycemia and title words glucose, hyperglycemia/hyperglycemic, or insulin therapy, with text words admission, hospitalized, inhospital, or inpatient.

STUDY SELECTION AND DATA EXTRACTION:

All articles identified from the data sources were evaluated, and all information deemed relevant was included in this review.

DATA SYNTHESIS:

Hyperglycemia, even in patients without diabetes, has been shown to be detrimental among inpatients in medical and surgical units, as well as in critical care. A review of 25 outcomes studies indicated that the majority of research on this topic used retrospective or prospective cohort designs; only 2 were conducted as randomized controlled studies. In general, the findings demonstrated negative impact on outcomes among various patient populations with hyperglycemia including increased lengths of stay, health complications, utilization of resources, and risk of mortality.

CONCLUSIONS:

Studies report that hyperglycemia is a common but detrimental condition and that better control in the hospital setting decreases short- and long-term risk of mortality, illness complications, hospital lengths of stay, and healthcare costs. Increased efforts to treat hyperglycemia and screen for diabetes are needed in the hospital setting. Future studies on cost-effective approaches to glucose control are recommended.

The Intelligent Dosing System: application for insulin therapy and diabetes management

Diabetes mellitus is an increasing public health problem. Insulin is an essential tool in the management of hyperglycemia, but methods of dose adjustment are purely empirical. The Intelligent Dosing System (IDS, Dimensional Dosing Systems, Inc., Wexford, PA) is a software suite that incorporates patient-specific, dose-response data in a mathematical model and then calculates the new dose of the medication needed to achieve the next desired therapeutic goal. We discuss the application of the IDS in insulin management. The IDS concept and the initial modeling used to construct an insulin doser are reviewed first. Additional data are then provided on the use of the IDS for titrating insulin therapy in a clinical setting. Finally, recent modifications in the IDS software and future applications of this technology for insulin dosing and diabetes management are discussed.

Hospital hypoglycemia: not only treatment but also prevention

OBJECTIVE

To propose a strategy, applicable on general hospital wards, for prevention of hypoglycemia in hospitalized patients.

RESULTS

Although the mortality rate among hospitalized patients with hypoglycemia has been shown to be 22.2 to 27% in series that included patients with diabetes, some investigators have shown that hypoglycemia is not an independent predictor of mortality. Outside the critical care setting, the comparative risks of hyperglycemia and hypoglycemia and the relationship of hospital hypoglycemia to intensification of glycemic control have not been determined. The reported incidence of hospital hypoglycemia ranges from 1.2% for hospitalized adults to 20% for nonpregnant patients with diabetes admitted without a metabolic emergency. Among patients receiving antihyperglycemic therapy, the literature describes precipitating events--usually a sudden change of caloric exposure-- and predisposing conditions for hypoglycemic episodes.

CONCLUSION

Hospital hypoglycemia is predictable, and it is preventable by measures other than undertreatment of hyperglycemia. Physician orders for antihyperglycemic therapy should be written and, if necessary, be revised so as to respond to the presence of predisposing conditions for hypoglycemia. A ward-based protocol or hospital-wide policy should establish the appropriate response to triggering events. Within the time frame of action of previously administered antihyperglycemic drugs (after abrupt interruption of caloric exposure), the threshold for preventive intravenous administration of dextrose is a glucose concentration of 120 mg/dL.

Assessment and therapy of selected endocrine disorders

Diabetes remains the most commonly encountered endocrinopathy with the incidence of type 2 doubling in the past decade. The prevalence of diabetes is projected to continue to increase dramatically over the next several decades unless major public health initiatives are successful in stemming this growth. Both type I and 2 diabetics more frequently require surgical and critical care than their non-diabetic counterparts. Type 1 and 2 diabetics also sustain greater peri-operative morbidity and mortality. Careful preoperative assessment and appropriate perioperative intervention may limit this. There is increasing evidence that maintenance of normal blood glucose in the perioperative period and during critical illness is beneficial for diabetic and non-diabetic patients. More data will hopefully be forthcoming to substantiate recent reports and identify the mechanisms of improved outcome. Thyroid disease remains a commonly encountered pathology that is more readily identified and controlled in the modern era of radioimmune assays of thyroid hormone and successful medical and surgical therapies. Severe hypothyroidism and thyroid storm are associated with significant increases in perioperative morbidity and mortality. Recognition of these entities or those at risk for developing them post operatively is crucial in initiating timely and effective therapy. Primary Al is uncommon, but results in glucocorticoid and mineralocorticoid deficiency. Tertiary Al is far more common, most often secondary to iatrogenic therapy with exogenous glucocorticoids for the management of chronic diseases such as connective tissue disorders, anti-rejection regimes, and severe asthma. Glucocorticoid replacement or supplementation is needed on a case-by-case basis and should be individualized based on chronic steroid dose, duration, and stress of the surgical procedure. Perioperative steroid dosing regimes now recommend lower doses for shorter periods than previously suggested. More recently Al has been recognized in two populations, elderly patients undergoing major surgery and a subgroup of patients with septic shock. Timely diagnosis using synthetic ACTH stimulation testing and stress glucocorticoid, and possibly mineralocorticoid therapy, seems to reverse these processes and improve recovery. Although uncommon, patients with pheochromocytoma who undergo open or laparoscopic resections remain diagnostic and therapeutic challenges. Perioperative outcome seems to have improved, in part, related to newer therapies and less invasive surgeries when indicated. The appropriate preoperative assessment and management of patients with various endocrinopathies is important to optimize outcome and limit avoidable complications. Hopefully additional evidence based guidelines will be forth-coming particularly in caring for the ever increasingly encountered perioperative diabetic.

In-hospital management of type 2 diabetes mellitus

The increasing prevalence of type 2 diabetes brings with it a need to understand the particular impact of hospitalization in this patient population. Type 2 diabetes has been shown to increase length of stay, infection, and mortality rates. To optimize inpatient care, it is important to understand target glycemic goals as well as in-hospital glucose monitoring and diabetes management goals. A practical review of regimens for subcutaneous insulin administration,intravenous insulin infusion, and inpatient use of oral agents is presented. Methods for achieving adequate preparation and education of the patient and family for discharge to the outpatient setting are also discussed.

Current perspectives on the use of continuous subcutaneous insulin infusion in the acute care setting and overview of therapy

Continuous subcutaneous insulin infusion (CSII), also called the insulin pump, has emerged as a safe and effective therapy in the last 20 years. Utilization of CSII in several studies has shown reductions in hypoglycemia and improvement in glycemic control compared with multiple daily injections. Diabetes mellitus is often a comorbid condition in patients requiring critical care. Surprisingly, there exist no guidelines for use of CSII in the inpatient setting, and no tested protocols for management of CSII in the hospital. With solid evidence as to the benefits of this therapy in diabetes and the heightened attention to the importance of optimal inpatient glycemic control, guidelines and tested protocols for CSII use during hospitalization are warranted. We share our own guidelines for the inpatient management of the insulin pump which has allowed our hospital to address the unique challenges that pump users present with during acute illness. A general overview of the insulin pump's history, rationale for use, patient selection, and implementation is also discussed.

Intravenous Insulin Infusion Therapy: Indications, Methods, and Transition to Subcutaneous Insulin Therapy

OBJECTIVE

To describe indications for intravenous (IV) insulin infusion therapy and glycemic thresholds, discuss methods and protocols, and promote use of and access to IV insulin infusion therapy for all appropriate patients in the hospital setting.

RESULTS

Randomized, prospectively designed trials support the use of IV insulin infusion therapy for patients in the surgical intensive-care unit, including postoperative cardiac patients and patients having myocardial infarction. Among patients in the surgical intensive-care unit, reanalysis of the data suggested no threshold at which benefit occurred above the blood glucose level of 110 mg/dL. In another study, retrospective analysis of data among critically ill medical and surgical patients suggested a target blood glucose level of 145 mg/dL or less. In other populations, the threshold or ideal target blood glucose range has not been determined. Three protocols for IV insulin infusion are described that maintain blood glucose levels safely below the upper limit of their respective target ranges without substantial risk of hypoglycemia.

CONCLUSION

The threshold for initiation of IV insulin infusion is 110 mg/dL for critically ill surgical patients, 140 mg/dL for other medical or surgical patients, 180 mg/dL for patients in whom subcutaneous insulin regimens fail, and 100 mg/dL for pregnant women. The blood glucose target range is 80 to 110 mg/dL for selected critically ill surgical patients, 70 to 100 mg/dL for pregnant women, and 90 to 140 mg/dL for all other patients. Hospitals should develop procedures to make IV insulin infusion therapy available to all appropriate patients.

Perioperative management of type 1 diabetes mellitus

Clearly, perioperative management of diabetic patients requires thorough preoperative evaluation and planning whenever possible. A firm understanding of the pathophysiology of type 1 diabetes mellitus, the metabolic stress response, and the interactions between various forms of insulin and other variables such as supplemental nutrition and glucocorticoids can greatly assist in achieving a positive outcome. Consultation with an endocrinologist, internist, or other primary care provider comfortable with managing type 1 diabetes patients is strongly recommended to assist in the details of in-patient care and overseeing of proper ancillary support. It may also be helpful to allow the patient to function as an active decision-maker in the coordination of care, especially because a large percentage of type 1 diabetes patients (particularly those who are on insulin pumps) are well-educated about their disease process and their own physiologic idiosyncrasies. This knowledge can save valuable time and effort toward achieving the ultimate united goal of avoiding perioperative morbidity and mortality by maximizing glycemic control.

Management of Diabetes with Coronary Artery Disease

Persons with cardiovascular disease (CVD) and diabetes consistently have worse clinical outcomes than those without diabetes. Treatment of diabetes with CVD must target blood pressure, cholesterol, and glycemic targets. Control of blood pressure to pound 130/80 mm Hg and low-density lipoprotein cholesterol to less than 100 mg/dL is key to preventing and managing CVD with diabetes. Optimal glucose control should be a goal in treating diabetes and CVD, in both hospital and outpatient settings. This article focuses on the oral antihyperglycemic agents and insulins available for diabetes pharmacotherapy. Effective glucose management using these agents when interventional procedures and cardiac surgery are to be performed is possible. Practical strategies include combination therapies and use of insulins subcutaneously or by intravenous infusion. Emerging therapies may impact outcomes for diabetes with CVD, including use of insulin sensitizers, drug-eluting stents, and brachytherapy. Attention is currently focused on the insulin sensitizers (metformin and thiazolidinediones), as they appear to impact processes related to the insulin resistance syndrome and the vascular pathophysiologic changes of atherosclerosis. It remains to be seen whether or not the insulin-sensitizing agents will confer a definitive advantage in treating the patient with diabetes for the prevention of or intervention for CVD.

Diabetes mellitus and its chronic complications

Diabetes mellitus is a major cause of morbidity and mortality, and it is a major risk factor for early onset of coronary heart disease. Complications of diabetes are retinopathy, nephropathy, and peripheral neuropathy. Currently, treatment involves diet modification, weight reduction, exercise, oral medications, and insulin. In recent years, important advances have been made into the pathogenesis of diabetes that affect the cardiovascular, renal, and nervous systems; vision; and the lower extremities, especially the feet. The progression of diabetic retinopathy and nephropathy can be slowed or prevented with tight glucose and blood pressure control. Neuropathy remains a major problem causing significant impairment. Ongoing clinical trials and testing of various medications to determine their effectiveness in treating the complications of diabetes have met with some success, but there still is much to learn about this disease.