2008 Clinical Practice Guidelines - Canadian Diabetes Association

2008 CLINICAL PRACTICE GUIDELINES
S72
nutrition, dextrose infusions should be provided.
To maintain effective blood levels of insulin, short- or
rapid-acting insulin should be administered 30 minutes to 2
hours before discontinuation of IV insulin infusion.The initial
dose of subcutaneous insulin given after discontinuation
of IV insulin infusion should be based on previously established
dose requirements or the rate and pattern of inhospital
IV insulin infusion. Other parameters that affect
subcutaneous insulin dose determination include body
weight, stress of illness and other comorbid conditions such
as renal insufficiency.
ORGANIZATION OF CARE
Healthcare institutions should implement a program to
improve glycemic control in the inpatient setting.This should
include the formation of a multidisciplinary steering committee
to provide educational programs, implement policies
to assess and monitor the quality of glycemic management,
and produce standardized order sets, protocols and algorithms
for diabetes care within the institution. The timely
consultation of such teams has been demonstrated to
improve quality, reduce length of stay and lower costs (8,9).
Self-management in the hospital may be appropriate for
competent adult patients who successfully conduct selfmanagement
of diabetes at home, have a stable level of consciousness,
and have the physical skills needed to self-administer
insulin and perform self-monitoring of blood glucose
(SMBG). A physician order for self-management should be
written with respect to selection of food, SMBG, self-determination
and administration of insulin dose and type.
Bedside BG monitoring
No study has compared the effect of frequency of bedside BG
testing on the incidence of hyper- or hypoglycemia in the
hospital. The frequency and timing of bedside BG monitoring
should be individualized. Healthcare institutions must
implement and maintain a quality-control program to ensure
the accuracy of bedside BG testing (10,11).
Safety – hypoglycemia
Hypoglycemia remains a major impediment to achieving
optimal glycemic control in hospitalized patients. Healthcare
institutions should have standardized treatment protocols
that address mild, moderate and severe hypoglycemia.
Healthcare workers should be educated about factors that
increase the risk of hypoglycemia, such as sudden reduction
in oral intake or discontinuation of enteral or parenteral
nutrition, unexpected transfer from nursing unit after rapidacting
insulin administration, and reduction in corticosteroid
dose (12).
Safety – insulin administration errors
Insulin is identified as 1 of the top 5 “high-risk medications”
in the hospital setting. A systems approach may work to
reduce errors. This includes preprinted, approved, unambiguous
standard orders for insulin administration, or
computerized order entry (13).
THE CRITICALLY ILL PATIENT
Acute hyperglycemia in the intensive care setting is not
unusual and results from a number of factors, including
stress-induced counterregulatory hormone secretion, and
possibly the effect of medications administered in the
intensive care unit (ICU) (14). Hyperglycemia in this setting
has effects on multiple systems, including the CV, neurologic
and immune systems (14). Van den Berghe and
colleagues (15) demonstrated impressive benefits of intensive
glycemic control with IV insulin infusion among predominantly
surgical patients admitted to the ICU and
requiring mechanical ventilation. A subsequent analysis of
a heterogeneous ICU population with predominantly medical
patients and utilizing historical controls demonstrated
a reduction in mortality, length of stay, renal dysfunction
and requirement of transfusion among those receiving
intensive glycemic control with an IV insulin infusion protocol
(16).
A meta-analysis of studies looking at the effects of insulin
therapy for critically ill adult patients also demonstrated an
overall reduction in mortality, particularly among those with
diabetes and if glycemic control was a primary goal (17).
However, this meta-analysis did not include any randomized
controlled trials (RCTs) of intensive insulin therapy in a
medical ICU.To date, there has been only 1 RCT of intensive
insulin therapy and glycemic control among medical ICU
patients (18). There was no difference in the primary outcome
of in-hospital mortality between the groups. However,
there was a significant reduction in the prespecified secondary
outcomes of renal dysfunction, length of stay and prolonged
mechanical ventilation. Mortality was increased
among patients who stayed in the ICU for 3 days.
Perioperative glycemic control
The management of individuals with diabetes at the time of
surgery poses a number of challenges. Acute hyperglycemia
is common secondary to the physiologic stress associated
with surgery. Pre-existing diabetes-related complications
and comorbidities may also influence clinical outcomes.
Acute hyperglycemia has been shown to adversely affect
immune function (19) and wound healing (20) in animal
models. Observational studies in humans have shown that
hyperglycemia increases the risk of postoperative infections
(21-23) and renal allograft rejection (24), and is associated
with increased resource utilization (25).
In patients undergoing coronary artery bypass surgery, a
pre-existing diagnosis of diabetes has been identified as a risk
factor for postoperative sternal wound infections, delirium,
renal dysfunction, respiratory insufficiency and prolonged