SAN FRANCISCO — Meeting the targets in consensus recommendations on inpatient glycemic control requires different protocols for different kinds of patients.
For hospitalized patients who are not critically ill, a protocol employing scheduled subcutaneous insulin therapy with basal, nutritional, and correctional components is effective, Dr. Mary T. Korytkowski said. For critically ill inpatients, intravenous insulin infusion protocols are better for achieving and maintaining glycemic control, she said at a meeting sponsored by the American Diabetes Association.
Many hospitals further subdivide the protocol for critically ill patients to have different glycemic targets for surgical and nonsurgical ICU patients, added Dr. Korytkowski, professor of medicine at the University of Pittsburgh's Center for Diabetes and Endocrinology.
A 2009 consensus statement from the American Association of Clinical Endocrinologists and the American Diabetes Association recommended maintaining glucose levels between 140 and 180 mg/dL in most critically ill patients, but added that glucose levels of 110-140 mg/dL may be appropriate in some, such as those in cardiothoracic intensive care.
“We don't have the data to prove that outside the surgical intensive care studies,” she said, “so many hospitals now have two protocols—one for their surgical patients, and one for nonsurgical patients.”
In noncritically ill inpatients, the consensus statement recommends targeting premeal glucose levels of 100-140 mg/dL and random glucose test results below 180 mg/dL (Endocr. Pract. 2009;15:353–69 and Diabetes Care 2009;32:1119–31).
Prolonged therapy with “sliding scale” insulin alone is not recommended, Dr. Korytkowski stressed. “This whole idea of putting patients on sliding scale insulin and continuing it for the duration of their hospitalization independent of what their blood sugar levels are needs to be stopped,” she said.
The 2009 consensus recommendations steered clinicians away from aiming for lower glucose levels of 80-110 mg/dL in hospitalized patients to reduce risk for complications related to uncontrolled hyperglycemia while also minimizing risk for sever hypoglycemia.
Institutions can choose from published protocols for managing inpatient glucose levels to meet consensus recommendations. For critically ill patients, it's better to initiate insulin infusions when glucose levels reach the lower end of the 140- to 180-mg/dL range rather than wait for levels to climb above 180 mg/dL, she said.
Her institution initiates insulin therapy by obtaining or estimating the patient's weight in kilograms, then calculating the total daily dose of insulin as 0.2-0.4 units/kg per day. Clinicians then choose the dosing schedule, usually giving 50%–60% of the total daily dose as basal insulin, with the remainder as premeal or nutritional bolus insulin divided up in three or four doses. Correction insulin is given when blood glucose levels exceed the goal range. “This is not a one-stop process,” Dr. Korytkowski said. Each day, the glucose levels are evaluated, and the insulin regimen is adjusted to avoid both hyper- and hypoglycemia.
The basal-bolus insulin protocol was shown to be safe when compared with sliding scale insulin in a prospective, randomized, controlled trial of 130 inpatients with type 2 diabetes, she noted (Diabetes Care 2007;30:2181–6).
Dr. Korytkowski also recommends monitoring glucose for at least 48 hours in all hospitalized patients who are starting glucocorticoid therapy or enteral or parenteral nutrition, because these are associated with increased risk for hyperglycemia. Prescribe insulin therapy as needed in these patients based on bedside blood glucose monitoring, and be proactive about adjusting insulin therapy especially during initiation and tapering of steroid therapy, she advised.
“One thing that's very important when patients go home and their steroid doses are tapered is that they need to know how to taper their insulin along with tapering their steroid, so they don't come back in 2-3 weeks in a hyperglycemic event,” she said.
Dr. Korytkowski and her associates published a glycemic management algorithm for patients receiving enteral nutrition that was shown to be safe in a prospective, randomized trial in 50 inpatients (Diabetes Care 2009;32:594–6).
Establishing a formal protocol for patients who enter the hospital on insulin pumps also can reduce confusion and treatment variability, she added. At her institution, patients who used insulin pumps before entering the hospital can continue to use them as inpatients provided that they have the mental and physical capacity to do so. Ideally, hospital staff who have experience in insulin pumps should be available if needed.
Dr. Korytkowski said she has no conflicts of interest to disclose.
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Glucose levels are evaluated daily, and the insulin regimen is adjusted to avoid hyper- and hypoglycemia.
Source DR. KORYTKOWSKI