2008 Clinical Practice Guidelines - Canadian Diabetes Association

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<strong>2008</strong> 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
hospital stay (26-28). Intraoperative hyperglycemia during cardiopulmonary bypass has been associated with increased morbidity and mortality rates in individuals with and without diabetes (29-31). Studies investigating the role of diabetes as an independent risk factor for short- and long-term mortality rates postcoronary artery bypass surgery yield mixed results (26,32,33). Patients with known diabetes, undiagnosed diabetes and impaired fasting glucose identified by preoperative fasting plasma glucose (FPG) determination carry a higher risk of postoperative mortality than those with normal preoperative FPG levels (34). A diagnosis of diabetes may not influence early and midterm mortality in patients after offpump coronary artery bypass (35). In patients undergoing major noncardiac surgery, diabetes may increase the risk of postoperative complications, including mortality (36,37). Major surgery In patients undergoing coronary artery bypass surgery, improved intraoperative and postoperative glycemic control with a continuous IV insulin infusion or glucose insulin potassium (GIK) infusion to achieve plasma glucose (PG) levels between 5.5 and 10.0 mmol/L has been shown to decrease the rate of deep sternal wound infections and mortality (38-40).The use of GIK to maintain PG levels between 6.9 and 11.1 mmol/L was also associated with decreased rates of recurrent ischemia, atrial fibrillation and length of stay (40). However, among those without diabetes, tight intraoperative glycemic control initiated when PG levels rose above 5.6 mmol/L during coronary artery bypass surgery failed to decrease neurologic complications associated with the surgery (41). Among those with and without diabetes undergoing coronary artery bypass surgery, an RCT using a continuous IV insulin infusion to maintain intraoperative glycemic control between 4.4 and 5.6 mmol/L was compared with conventional intraoperative glycemic control (50% (48,49). Observational studies suggest that diabetes might increase the risk of mortality (50,51), infarct size or neurological impairment (49,50, 52,53) and reduce the benefit from acute thrombolytic revascularization (54). However, the results are inconsistent, and recent studies have failed to show an effect of diabetes on stroke morbidity or mortality (49,55). Patients with diabetes who have higher BG values in the days following a cerebral infarction are more likely to exhibit infarct expansion, cerebral edema and worse short-term outcome (52,53). In 1 small study of 25 patients, mean PG levels >7.0 mmol/L were associated with increased infarct size (52).These observations indicate the need for studies to determine the effect of aggressive BG lowering in the early stages of stroke management. A randomized trial performed on 933 patients with increased PG values (6.0 to 17.0 mmol/L) at the time of admission with acute stroke, compared the effect of GIK infusion with saline infusion. No reduction in mortality or significant disability at 90 days was observed, even though BG and blood pressure (BP) values were significantly better in the GIK group (56). This confirmed the findings of a smaller pilot study (57). Patients with undefined neurological conditions admitted to an ICU and managed with IV insulin infusion to achieve intensive glycemic targets also showed no improvement in mortality compared to the control group (18). At present, the apparent association between in-hospital hyperglycemia and adverse outcomes for ischemic stroke has not been accompanied by evidence that therapy to correct hyperglycemia is beneficial. In view of this, no specific recommendation regarding glycemic management during acute stroke can be made. S73 MANAGEMENT
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2008 Clinical Practice Guidelines - Canadian Diabetes Association

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