Indications for Hospitalization in Diabetic Patients
DKA is characterized by a plasma glucose level of >250 mg/dL in association with an arterial pH <7.30 or serum bicarbonate level of <15 mEq/L and moderate ketonemia or ketonuria.
HHNKS (hyperglycemic hyperosmolar nonketotic state/syndrome) includes marked hyperglycemia (400 mg/dL or more) and elevated serum osmolality (>315 mOsm/kg), often accompanied by impaired mental status.
Hypoglycemia is an indication for hospitalization if induced by sulfonylurea (SFU) medication, deliberate drug overdose, or results in coma, seizure, injury, or persistent neurologic change.
New diagnosed T1DM or newly recognized GDM can be indications for hospitalization, even in absence of ketoacidosis
Patients with T2DM are rarely admitted to the hospital for initiation or change in insulin therapy unless hyperglycemia is severe and associated with mental status change or other organ dysfunction.
Treatment
Management of diabetes in hospitalized patients
Hyperglycemia is a common finding in hospitalized patients and may be due to previously diagnosed diabetes which is poorly controlled, undiagnosed DM, or stress-induced hyperglycemia. Upto 40% of general medical and surgical patient have hyperglycemia and approximately 80% of ICU patients have persistent hyperglycemia.
A1C can help identify previously undiagnosed diabetes in hospitalized patients and may assist in evaluation of prior glucose control. A1C is not accurate in patients who are bleeding, severely anemic, or hemolyzing or who have been transfused.
Tight glycemic control improves mortality and morbidity in patients after CABG, stroke, and cardiac surgery, however, some discrepancies have emerged in other randomized trials.
Glucose targets in hospitalized patients depend on severity of illness, comorbid conditions, and other factors. Glucose levels should be kept as close as 140 mg/dL in the ICU. In non-critical care units, preprandial glucose should be 90 - 130 mg/dL and maximal glucose <180 mg/dL.
Patients who have diabetes but hospitalized for other reasons than diabetes control, and are eating normally may continue with outpatient diabetes treatment, unless specifically contraindicated.
Any patients with BG >150 mg/dL should be considered for basal/bolus therapy.
Intermittent "sliding scale" therapy given only to patients with intermittent minor elevations of BG levels.
TDD = 0.5 units/kg. Give 50% as Lantus (basal), and 50% as aspart (bolus) divided over 3 doses AC tid, given with the first bite of food. Adjust moderate to high correction dose.
Example: 80 kg patient with BG level of 250 mg/dL.
TDD = 80 x 0.3 = 24 units
Give Lantus (glargine) 12 units sc qhs and Aspart, 4 units sc AC.
A correction dose of 1 - 2 units per 50 mg/dL of BG above 150 mg/dL, can be added to the premeal doses.
Basal insulin should be adjusted by 5% - 10% daily until the fasting glucose is consistently <130 mg/dL.
Type 1 DM require 0.5-1 units/kg/day of insulin divided into multiple doses, with ~50% of the insulin given as basal insulin.
To determine the meal component of the preprandial insulin dose, the patient uses an insulin:carbohydrate ratio (ratio 1.-1.5 units/10 g of carbohydrate, but this must be determined for each individual). To this add the correcting dose based on the preparndial blood glucose.
1 unit of insulin for every 50 mg/dL over the preprandial glucose target. Another formula uses (body wt in kg) x (blood glucose - desired glucose in mg/dL) / 1500.
BG levels should be monitored 3 - 4 times daily in patients treated with insulin, and dose adjusted accordingly.
Extreme values of BG (>300 or <60 mg/dL) from bedside capillary BG meters should be confirmed using laboratory measurements and may warrant immediate action.
Blood or urine should be tested for ketones whenever hyperglycemia >300 mg/dL persists on more than one measurement.
If significant or persistent hyperglycemia is observed in hospitalized patients, ketoacidosis should be ruled out with an assessment of acid-base status and plasma ketone measurement.
Oral medications for diabetes should be reviewed with regard to potential toxicities, risk of hypoglycemia, and other problems before ordering for hospitalized patients. It may be appropriate to restart home medications in stable patients after most diagnostic testing has been completed and the patient is on a stable treatment regimen (ready to go home!)
SFU: no no. May cause hypoglycemia if patient is not eating regularly. Generally not given in hospitalized patients.
Metformin should be withheld a day prior to diagnostic evaluation that involved radiocontrast dye. Can be restarted 48 hours after radiocontrast exposure and after confirming normal renal function (check BUN/Cr). C/I in CHF, sepsis, AKI, CKD, metabolic acidosis, and other conditions that may predispose to lactic acidosis.
TZDs should not be given to patients with CHF, edema, or hepatic dysfunction as indicated by elevated serum transaminase levels.
Glucosidase inhibitors may be continued if the patient is eating usual meals and does not have GI problems.
Patients hospitalized for reasons other than diabetes and who are required to fast should discontinue all oral antidiabetic medications.
IV insulin infusion is recommended for critical illness or major surgery. Alternatively give basal insulin with a modest dose reduction and to supplement with sliding scale.
D5W @ 25 - 100 mL/hr is provided to prevent ketosis and maintain plasma glucose between 90 - 150 mg/dL. Alternatively, 10% D5W @ 10 - 50 mL/hr can be infused to provide steady, consistent source of calories.
Transition from insulin drip to SC insulin must preferably occur before breakfast. D/C insulin drip 30 min - 1 h after patient has received SC regular insulin and intermediate acting insulin; however, if a rapid-acting insulin is used, the insulin drip can be discontinued shortly after SC insulin has been administered. For patients who need basal insulin, half the anticipated basal insulin can be given as NPH or determir before breakfast in addition to the usual short-acting insulin, and the usual dose of glargine or detemir resumed in the evening. If insulin drip is discontinued at another time point during the day, a prorated basal insulin should be provided until the usual dose schedule can be resumed.
In general, basal insulin is given regardless of NPO or dietary status and should not be held without a direct order.
Diabetic patients with emergency surgery
Exclude DKA and neuropathy complication mimicking surgical emergencies.
Check blood sugar, acid-base, electrolyte and fluid status.
Restore circulating volume and correct acidosis and potassium abnormalities if surgery can be delayed.
Administer IV insulin, supplemented with glucose, and potassium as needed to achieve target BG levels. Check BG measurements qh to adjust insulin and glucose infusions. Potassium should be monitored q2 h and replaced aggressively as required.
Enteral nutrition
Intermittent tube feeding needs either short acting or intermediate acting insulin.
If patients has baseline hyperglycemia add basal insulin dose in addition to doses given to cover tube feeds.
Night time enteral feeding 6 - 8 hours should be managed by NPH, with or without basal insulin dose. NPH can be given tid or qid for continuous tube feeds, allowing a change in insulin dose if feeding is interrupted.
TPN in T2DM need large amounts of insulin.
Continuous SC insulin infusion using an insulin pump is for intensive diabetes control
A typical regimen is 50% of TDD as basal insulin and the remainder as multiple preprandial boluses of insulin, using a programmable insulin pump.