2008 Clinical Practice Guidelines - Canadian Diabetes Association

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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
trials. Arch Intern Med. 2004;164:2005-2011. 18. Van den Berghe G, Wilmer A, Hermans G, et al. Intensive insulin therapy in the medical ICU. N Engl J Med. 2006;354: 449-461. 19. Kwoun MO, Ling PR, Lydon E, et al. Immunologic effects of acute hyperglycemia in nondiabetic rats. J Parenter Enteral Nutr. 1997;21:91-95. 20. Verhofstad MH, Hendriks T. Complete prevention of impaired anastomotic healing in diabetic rats requires preoperative blood glucose control. Br J Surg. 1996;83:1717-1721. 21. Golden SH, Peart-Vigilance C, Kao WH, et al. Perioperative glycemic control and the risk of infectious complications in a cohort of adults with diabetes. Diabetes Care. 1999;22:1408- 1414. 22. Pomposelli JJ, Baxter JK 3rd, Babineau TJ, et al. Early postoperative glucose control predicts nosocomial infection rate in diabetic patients. J Parenter Enteral Nutr. 1998;22:77-81. 23. McAlister FA, Man J, Bistritz L, et al. Diabetes and coronary artery bypass surgery: an examination of perioperative glycemic control and outcomes. Diabetes Care. 2003;26:1518- 1524. 24. Thomas MC, Mathew TH, Russ GR, et al. Early peri-operative glycaemic control and allograft rejection in patients with diabetes mellitus: a pilot study. Transplantation. 2001;72:1321- 1324. 25. Estrada CA,Young JA, Nifong LW, et al. Outcomes and perioperative hyperglycemia in patients with or without diabetes mellitus undergoing coronary artery bypass grafting. Ann Thorac Surg. 2003;75:1392-1399. 26. Brandt M, Harder K, Walluscheck KP, et al. Coronary artery bypass surgery in diabetic patients. J Card Surg. 2004;19:36- 40. 27. Bucerius J, Gummert JF,Walther T, et al. Diabetes in patients undergoing coronary artery bypass grafting. Impact on perioperative outcome. Z Kardiol. 2005;94:575-582. 28. Bucerius J, Gummert JF, Walther T, et al. Impact of diabetes mellitus on cardiac surgery outcome. Thorac Cardiovasc Surg. 2003;51:11-16. 29. Doenst T, Wijeysundera D, Karkouti K, et al. Hyperglycemia during cardiopulmonary bypass is an independent risk factor for mortality in patients undergoing cardiac surgery. J Thorac Cardiovasc Surg. 2005;130:1144. 30. Gandhi GY, Nuttall GA, Abel MD, et al. Intraoperative hyperglycemia and perioperative outcomes in cardiac surgery patients. Mayo Clin Proc. 2005;80:862-866. 31. Ouattara A, Lecomte P, Le Manach Y, et al. Poor intraoperative blood glucose control is associated with a worsened hospital outcome after cardiac surgery in diabetic patients. Anesthesiology. 2005;103:687-694. 32. Kubal C, Srinivasan AK, Grayson AD, et al. Effect of riskadjusted diabetes on mortality and morbidity after coronary artery bypass surgery. Ann Thorac Surg. 2005;79:1570-1576. 33. Calafiore AM, Di Mauro M, Di Giammarco G, et al. Effect of diabetes on early and late survival after isolated first coronary bypass surgery in multivessel disease. J Thorac Cardiovasc Surg. 2003;125:144-154. 34. Anderson RE, Klerdal K, Ivert T, et al.Are even impaired fasting blood glucose levels preoperatively associated with increased mortality after CABG surgery? Eur Heart J. 2005; 26:1513-1518. 35. Choi JS, Cho KR, Kim KB. Does diabetes affect the postoperative outcomes after total arterial off-pump coronary bypass surgery in multivessel disease? Ann Thorac Surg. 2005;80:1353- 1360. 36. Ganesh SP, Pietrobon R, Cecilio WA, et al.The impact of diabetes on patient outcomes after ankle fracture. J Bone Joint Surg Am. 2005;87:1712-1718. 37. Juul AB,Wetterslev J, Kofoed-Enevoldsen A. Long-term postoperative mortality in diabetic patients undergoing major noncardiac surgery. Eur J Anaesthesiol. 2004;21:523-529. 38. Furnary AP, Zerr KJ, Grunkemeier GL, et al. Continuous intravenous insulin infusion reduces the incidence of deep sternal wound infection in diabetic patients after cardiac surgical procedures. Ann Thorac Surg. 1999;67:352-360. 39. Furnary AP, Gao G, Grunkemeier GL, et al. Continuous insulin infusion reduces mortality in patients with diabetes undergoing coronary artery bypass grafting. J Thorac Cardiovasc Surg. 2003;125:1007-1021. 40. Lazar HL, Chipkin SR, Fitzgerald CA, et al. Tight glycemic control in diabetic coronary artery bypass graft patients improves perioperative outcomes and decreases recurrent ischemic events. Circulation. 2004;109:1497-1502. 41. Butterworth J, Wagenknecht LE, Legault C, et al. Attempted control of hyperglycemia during cardiopulmonary bypass fails to improve neurologic or neurobehavioral outcomes in patients without diabetes mellitus undergoing coronary artery bypass grafting. J Thorac Cardiovasc Surg. 2005;130:1319. 42. Gandhi GY, Nuttall GA, Abel MD, et al. Intensive intraoperative insulin therapy versus conventional glucose management during cardiac surgery: a randomized trial. Ann Intern Med. 2007;146:233-243. 43. Raucoules-Aimé M, Lugrin D, Boussofara M, et al. Intraoperative glycaemic control in non-insulin-dependent and insulin-dependent diabetes. Br J Anaesth. 1994;73:443-449. 44. Hemmerling TM, Schmid MC, Schmidt J, et al. Comparison of a continuous glucose-insulin-potassium infusion versus intermittent bolus application of insulin on perioperative glucose control and hormone status in insulin-treated type 2 diabetics. J Clin Anesth. 2001;13:293-300. 45. Christiansen CL, Schurizek BA, Malling B, et al. Insulin treatment of the insulin-dependent diabetic patient undergoing minor surgery. Continuous intravenous infusion compared with subcutaneous administration. Anaesthesia. 1988;43:533-537. 46. Suto C, Hori S, Kato S, et al. Effect of perioperative glycemic control in progression of diabetic retinopathy and maculopathy. Arch Ophthalmol. 2006;124:38-45. 47. Kamio S, Kawasaki R,Yamashita H. Influence of systemic conditions and glycemic control on complications of vitrectomy S75 MANAGEMENT
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