2008 Clinical Practice Guidelines - Canadian Diabetes Association

2008 CLINICAL PRACTICE GUIDELINES
S74
RECOMMENDATIONS
1. Provided that their medical conditions, dietary intake
and glycemic control are acceptable, patients with diabetes
should be maintained on their prehospitalization
oral antihyperglycemic agents or insulin regimens [Grade
D, Consensus].
2. For hospitalized patients with diabetes treated with
insulin, a proactive approach that may include basal,
prandial and correction-dose insulin, along with pattern
management, is preferred over the “sliding scale” reactive
approach using only short- or rapid-acting insulin
[Grade D, Consensus].
3.To maintain intraoperative glycemic levels between 5.5
and 10.0 mmol/L for patients with diabetes undergoing
coronary artery bypass surgery, a continuous IV insulin
infusion alone [Grade C, Level 3 (38,39)] or with the
addition of glucose and potassium [Grade B, Level 2
(40)], with an appropriate protocol and trained staff
to ensure the safe and effective implementation of
this therapy and to minimize the likelihood of hypoglycemia,
should be used.
4.A continuous IV insulin infusion should be used to
achieve glycemic levels of 4.5 to 6.0 mmol/L in postoperative
ICU patients with hyperglycemia (random
PG >6.1 mmol/L) requiring mechanical ventilation to
reduce morbidity and mortality [Grade A, Level 1A (15)],
and in medical ICU patients with hyperglycemia (random
PG >6.1 mmol/L) to reduce morbidity [Grade B,
Level 2 (18)].
5. Perioperative glycemic levels should be maintained
between 5.0 and 11.0 mmol/L for most other surgical
situations, with an appropriate protocol and trained staff
to ensure the safe and effective implementation of this
therapy and minimize the likelihood of hypoglycemia
[Grade D, Consensus].
6. In hospitalized patients, efforts must be made to ensure
that patients using insulin or insulin secretagogues have
ready access to an appropriate form of glucose at all
times, particularly when NPO or during diagnostic procedures
[Grade D, Consensus].
7. Measures to assess, monitor and improve glycemic control
within the inpatient setting should be implemented,
and include hypoglycemia management protocols and
diabetes-specific discharge planning [Grade D, Consensus].
Glucagon should be available for any patient at risk for
severe hypoglycemia when IV access is not readily available
[Grade D, Consensus].
OTHER RELEVANT GUIDELINES
Pharmacologic Management of Type 2 Diabetes,
p. S53
Management of Acute Coronary Syndromes, p. S119
Treatment of Diabetes in Patients With Heart Failure,
p. S123
REFERENCES
1. Roman SH, Chassin MR.Windows of opportunity to improve
diabetes care when patients with diabetes are hospitalized for
other conditions. Diabetes Care. 2001;24:1371-1376.
2. Campbell KB, Braithwaite SS. Hospital management of hyperglycemia.
Clin Diabetes. 2004;22:81-88.
3. Umpierrez GE, Isaacs SD, Bazargan N, et al. Hyperglycemia:
an independent marker of in-hospital mortality in patients
with undiagnosed diabetes. J Clin Endocrinol Metab. 2002;87:
978-982.
4. Vasa F. Systematic strategies for improved outcomes for the
hyperglycemic hospitalized patient with diabetes mellitus. Am
J Cardiol. 2005;96:41E-46E.
5. Magee MF, Clement S. Subcutaneous insulin therapy in the
hospital setting: issues, concerns, and implementation. Endocr
Pract. 2004;10(suppl 2):81-88.
6. Queale WS, Seidler AJ, Brancati FL. Glycemic control and sliding
scale insulin use in medical inpatients with diabetes mellitus.
Arch Intern Med. 1997;157:545-552.
7. Garber AJ, Moghissi ES, Bransome ED Jr, et al; American
College of Endocrinology Task Force on Inpatient Diabetes
Metabolic Control. American College of Endocrinology position
statement on inpatient diabetes and metabolic control.
Endocr Pract. 2004;10:77-82.
8. Levetan CS, Salas JR,Wilets IF, et al. Impact of endocrine and
diabetes team consultation on hospital length of stay for
patients with diabetes. Am J Med. 1995;99:22-28.
9. Koproski J, Pretto Z, Poretsky L. Effects of an intervention by
a diabetes team in hospitalized patients with diabetes. Diabetes
Care. 1997;20:1553-1555.
10. Lewandrowski K, Cheek R, Nathan DM, et al. Implementation
of capillary blood glucose monitoring in a teaching hospital
and determination of program requirements to maintain quality
testing. Am J Med. 1992;93:419-426.
11. Rumley AG. Improving the quality of near-patient blood glucose
measurement. Ann Clin Biochem. 1997;34:281-286.
12. Clement S, Braithwaite SS, Magee MF, et al;American Diabetes
Association Diabetes in Hospitals Writing Committee.
Management of diabetes and hyperglycemia in hospitals.
Diabetes Care. 2004;27:553-591.
13. Bates DW, Leape LL, Cullen DJ, et al. Effect of computerized
physician order entry and a team intervention on prevention of
serious medication errors. JAMA. 1998;280:1311-1316.
14. Lewis KS, Lane-Gill SL, Bobek MG, et al. Intensive insulin
therapy for critically ill patients. Ann Pharmacother. 2004;38:
1243-1251.
15. Van den Berghe G,Wouters P,Weekers F, et al. Intensive insulin
therapy in the critically ill patients. N Engl J Med. 2001;345:
1359-1367.
16. Krinsley JS. Effect of an intensive glucose management protocol
on the mortality of critically ill adult patients. Mayo Clin
Proc. 2004;79:992-1000.
17. Pittas AG, Siegel RD, Lau J. Insulin therapy for critically ill hospitalized
patients: a meta-analysis of randomized controlled