Documente Academic
Documente Profesional
Documente Cultură
GuidelinesforRoutineGlucoseControlinHospital
2012
1
Contents
Introduction Page3
Section1MethodologyandProcess Page5
Section2Whatglucosetargetshouldbeaimedforinacutemyocardialinfarction? Page6
Section3Whatglucosetargetshouldbeaimedforinacutestroke? Page8
Section4Whatareappropriateglucosetargetsforpatientsingeneralhospital Page9
wards?
Section5Whatspecialmeasuresneedtobeundertakenforpeopleonenteralor Page11
parenteralnutrition?
Section6Howissteroidinducedhyperglycaemiabestmanaged? Page13
Section7Whatistheoptimalmeansofachievingandmaintainingglycaemic Page15
controlinhospitalisedpatientswhoarenotcriticallyill??
Section8Howshouldpatientsoninsulinpumptherapybemanagedinhospital? Page16
Section9Whatisappropriateglucosecontrolinendoflifesituations? Page18
Section10Atwhatlevelishyperglycaemiainhospitalpredictiveofdiabetesand Page20
howshouldpatientswithnewlydiscoveredhyperglycaemiabefollowed
up?
Section11Whatistheroleofaspecialistdiabetesinpatientteam? Page22
Section12Whatroutinemeasuresshouldbeundertakenforpeoplewith Page23
diabetesadmittedtohospital?
Appendices Page24
Contributors Page59
Glossary Page60
References Page61
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Introduction
Diabetesisestimatedtoaffect7.4%oftheAustralianpopulation1,andisincreasingannuallyby0.8%2.People
withdiabeteshaveahigherutilisationofbothprimaryandtertiaryhealthservices.In200405,9%ofall
hospitaladmissionswererecordedashavingdiabetes3.Thisislikelytobeanunderestimateasclinicalaudits
fromAustraliaandoverseashavefoundhospitalratesofdiabetesof1125%49andfurthermore,manycases
areundiagnosedatthetime10.Australiandataindicatethattheproportionofpeoplewithdiabetesasa
diagnosisinhospitalhasbeenincreasing,witha35%increaseinnumbersbetween200001and2004053.
Theyalsohavelongerlengthsofhospitalstay,beingabout2dayslongerthanpeoplewithoutdiabetes3,9.The
AustralianInstituteofHealthandWelfarehasestimatedthecostofdiabetestohospitalservicesin200405
was$371M3.
Diabetesandhyperglycaemiahasbeenshowninanumberofobservationalstudiestobeassociatedwith
pooreroutcomesandaremarkersofmorbidityandmortality.Reasonsfortheincreasedmorbidityand
mortalitymayberelatedtopoorimmuneresponse,delayedhealing,inflammationandthrombosisassociated
withhyperglycaemiaaswellasahigherrateofcomorbidconditionsinthispatientgroup11.
Independentofdiabetes,hyperglycaemiaperseisalsoassociatedwithworsehospitaloutcomes.Thisisthe
casewhetherthepersonhasdiabetesornot,buttherelationshipisstrongerforpeoplewhodonothave
diabetes.Therelationshipbetweenhyperglycaemiaandadversehospitaloutcomes,inparticularmortality,
hasbeenclearlydemonstratedinmanydifferenthospitalsettings,includingmyocardialinfarction,stroke,
generalmedicalandsurgicalwards,trauma,cardiothoracicsurgery,TPN,intensivecare,andemergency
admissions.Forhyperglycaemicpeoplewhoarenotknowntohavediabetes,itisunclearifthehigher
mortalityisduetothehyperglycaemia,orifthehyperglycaemiaisbutamarkerofunderlyingcriticalillness.
Mostofthehighqualitystudiesdemonstratingbenefitoftightglycaemiccontrolhavecomefromcriticalcare
situations,andeventhesehaveproducedconflictingresults.
Forpatientswithhyperglycaemiathatisnewlydiscoveredinhospital,thereisahighprobabilityof
undiagnoseddiabetes,orfuturediabetes.However,atpresentfollowupisoftenhaphazard,andthe
opportunityforearlydiagnosisandtreatmentofdiabetesandtherebypreventionofacuteandlongterm
complicationsmaybemissed.
Theaimofthisdocumentistoprovideguidanceforthemanagementofhyperglycaemiainarangeofhospital
situations.TheADShasfocusedonthemanagementofhyperglycaemiainpatientswithmyocardialinfarction
andstroke,ongeneralhospitalwards,receivingenteralandparenteralnutrition,withsteroidinducedor
exacerbatedhyperglycaemia,andinendoflifesituations.Theoptimalmeansofachievingtightcontrol,the
roleofthespecialistinpatientdiabetesteam,inpatientmanagementofinsulinpumptherapy,andgeneral
measuresfordiabetesmanagementhavealsobeenexamined.Wealsoprovideguidanceforthefollowupof
patientswithnewlydiscoveredhyperglycaemia.Therecommendationswerebasedonevidenceobtained
fromsystematicreviewswheretrialshadbeenperformed;otherwisetheyweremadebyconsensus.
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Itisnottheintentionoftheseguidelinestodealwithscreeningfordiabetes,themanagementofdiabetic
emergenciessuchasdiabeticketoacidosis,hyperglycaemichyperosmolarstate,andhypoglycaemia,nordo
theycoverpaediatrics,obstetricsorintensivecare.Otherwisetheyshouldprovideguidanceforthe
managementofpatientswithhyperglycaemiainthemajorityofhospitalwards,andarecomplementarytothe
AustralianDiabetesSocietyPerioperativeDiabetesManagementGuidelines.
Wesoughttoachieveconcordanceinourrecommendationtoasingletargetglucoselevelforthemajorityof
clinicalsituations,althoughtherearesomedifferencesinthelimiteddatafordifferentscenarios.Theoverall
recommendationisthatformosthospitalpatientswithhyperglycaemia,treatmentshouldbeinstitutedto
achieveandmaintainbloodglucose(BG)levelsbelow10mmol/L,butbecauseofthepotentialdangersof
hypoglycaemia,treatmentshouldnotaimtolowerglucoselevelsbelow5mmol/L.
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Section1: MethodologyandProcess
Systematicreviewswereconductedtoprovidethebestpossibleevidencebasefortherecommendations.
PICOsearchesoftheCochraneDatabaseforSystematicReviews,andPubmedClinicalQuerieswere
undertaken.Systematicreviews,metaanalysesandexistingguidelinesrelatingtoourquestionswere
reviewedbyamemberoftheWritingGroup,andsummarised(Appendix1).Keycitedarticleswerealso
reviewed.Wheresystematicreviewswerenotavailable,generalsearchesoftheliteraturewereundertaken.
TheevidencewasdiscussedinanADSworkshopcomprisinganexpertpanelofEndocrinologistsandDiabetes
Educators,heldinJuly2011.Atthisworkshop,recommendationsforeachsectionoftheguidelines,and
overallrecommendationswereagreedupon.Wheretherewaslittleornoevidence,thenthecommittee
reliedonexperience,judgmentandconsensustomaketheirrecommendations.Issuesarisingfromthe
discussion,forwhichthereisnoevidencebase,areincludedaspracticepoints.TheWritingGroupdraftedthis
document,whichwascirculatedforfurtherfeedbackfromtheparticipantsoftheWorkshop,andotherswho
wereunabletoattend.
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Section2: WhatGlucoseTargetShouldbeAimedforinAcuteMyocardialInfarction?
HyperglycaemiaandCardiacMortality
Hyperglycaemiaiscommonwithmyocardialinfarction.Datafromnumerousobservationalstudiesshowa
clearandconsistentassociationbetweentheinitialadmissionglucoselevelandinfarctoutcomes,inparticular
mortality.AmetaanalysisbyCapesetal12showedthatamongstpatientswithoutdiabetes,thosewithan
admissionbloodglucoselevel(BGL)6.18.0mmol/Lhada3.9fold(95%CI2.95.4)higherriskofdeaththan
thosewithlowerBGL.Forpatientswithdiabetes,thosewithaBGL1011.0mmol/Lhada1.7fold(95%CI1.2
2.4)increasedriskofdeath.Themajorityofstudiesinthispublicationwereperformedintheprethrombolytic
era,butnewerpublicationsshowsimilarresults(Appendix2,Table2.1).Virtuallyallhaveshownadose
relationshipandaglucosethresholdforincreasedmortalityofaround68mmol/L.Inaddition,thereare
observationaldatademonstratingarelationshipbetweenglucoselevelsinthefirst24hoursaftermyocardial
infarctionandmortality(Appendix2,table2.2).Theseindicatethatpersistenthyperglycaemia,evenifmild,is
alsoassociatedwithincreasedmortalityfollowingmyocardialinfarction.
Hypoglycaemia
Moststudieshaveconcentratedontherelationshipbetweenhyperglycaemiaandincreasedmortality.There
arealsosomedatathathypoglycaemiaisassociatedwithadverseoutcomes,withaUshapedrelationship
beingdescribedinseveralobservationalstudies15,23,25.Theincreasedriskwasseeninpatientswithadmission
BGLsrangingfrom<3.3to<7mmol/L.IntheDIGAMIStudywheretherewasactiveloweringofglucose,there
wasnoincreaseinmortalityorothermajoroutcomesamongstsubjectswhodevelopedhypoglycaemia<3
mmol/L,afteradjustmentforconfoundingvariables31.
ClinicalTrialDataandExistingRecommendations
Fivesystematicreviewswithspecificanalysis(insomecasessubanalysis)ofwhethertightglucosecontrolin
myocardialinfarctionimprovessurvivalwereidentified3236.Oneoldersystematicreviewwhichpredateda
numberofthemorerecenttrialswithnegativeresults,foundareductioninmortalitywithtightglucose
control32.Amorerecentreviewsuggestedthattightglycaemiccontrolcanreducemortalitybutdidnotmake
thisconclusiononthebasisofametaanalysis35,whilstanotheronedecidedthattheevidenceis
inconclusive34.Tworecenthighqualitysystematicreviewsconcludedthattightglycaemiccontroldidnot
reducemortality33,36,butoneincludedcardiacconditionsotherthanmyocardialinfarction.
Fouroftherandomisedcontrolledstudiesidentifiedinthesystematicreviewshadsetspecificglucosetargets
fortheirintervention(Appendix2,Table2.4)28,31,44,48.Therewasimprovementinsurvivalintheintensive
treatmentarmonlyintheoldestofthesestudies,wheretheglucosetargetwas710mmol/L31.Ithasbeen
postulatedthatthefailuretodemonstrateaneffectinthemorerecentstudiesmaybeduetoi)failureto
6
achievealargeenoughdifferentialinglucoselevelsbetweenthearmsofthestudy,ii)glucoselevelsinthe
controlarmbeingonlyminimallyelevated,iii)theadventofmoderntreatmentsforAMI(PTCA,thrombolysis,
antiplatelettherapy,betablockade,statintherapy),overwhelminganybenefitofglucosecontrol53.
Existingguidelinescoveringglucosecontrolinmyocardialinfarctionhavegivendiverserecommendations
(Appendix2,Table2.5)5457.Twoofthe4guidelinesdidnothavespecificrecommendationsformyocardial
infarction,butencompassedmyocardialinfarctionwithinbroaderguidelinesforhospitalglucosecontrol55,57.
TwooftheguidelinesrecommendedtargetBGs<10mmol/L55,56,onerecommendednormallevels54,and
onerecommendedagainsttightcontrol57.
Conclusions
Observationaldataindicateaclearassociationbetweenhyperglycaemiaandmortalityinmyocardial
infarction.However,onlyoneRCTofpatientswithmyocardialinfarctionhasshownabenefitofglycaemic
control,withaglucosetargetof710mmol/L.Intheotherstudies,nomortalitybenefitoftightcontrolwas
seen.Despitethis,mostprofessionalorganizationshaverecommendedaglucosetargetof<10mmol/L,
providedthatthiscanbeachievedsafely.
RecommendationsandPracticePoints
1. Patientsadmittedtohospitalwithmyocardialinfarctionwhohavehyperglycaemia,shouldbetreated
toachieveandmaintainglucoselevelslessthan10mmol/L.
2. Hypoglycaemiamustbeavoided.Itwouldbeprudenttoavoidtreatmentwhichlowerstheglucose
below5mmol/L.
3. Insulininfusiontherapymayallowfortightertargetsbutthisrequiresfrequentmonitoringandhigh
levelstafftraining.
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Section3: WhatGlucoseTargetShouldbeAimedforinAcuteStroke
HyperglycaemiaandStrokeMortality
Datafromnumerousobservationalstudiesshowanassociationbetweeninitialglucoselevelsandoutcomesof
stroke,inparticularmortality.AnothermetaanalysisbyCapesetalshowedthatamongstpatientswithout
diabetes,thosewithanadmissionBGL6.18.0mmol/Lhada3.07fold(95%CI2.503.79)higherriskofdeath
thanthosewithlowerBGL58.Therewasnoincreaseinriskamongstpatientswithdiabetesattheselevels(RR
1.3,95%CI0.493.43)increasedriskofdeath.Mortalityfromhaemorrhagicstrokemortalitywasnot
associatedwithadmissionhyperglycaemia.Morerecentpublicationsshowsimilarresults(Appendix3,Table
3.1).Observationaldataalsoindicatethatthereisarelationshipbetweenglucoselevelsduringthefirst24
hoursafterstrokeandmortalityorinfarctsize(Appendix3,Table3.2).
ClinicalTrialDataandExistingRecommendations
The3systematicreviewsexaminingstudiesoftightglucosecontrolinstrokecametodivergentconclusions
(Appendix3,Table3.3)36,75,76.Althoughnoneofthestudiesrevieweddemonstratedabenefitofglucose
control,onereviewrecommendedinsulintherapyifglucoselevelsexceed10mmol/L75.Therewere7
randomisedcontrolledtrialsoftightglycaemiccontrolforstroke.Onehadalargesamplesizebutwas
discontinuedearlyduetoslowrecruitmentandfailedtodemonstrateabenefitofglucosecontrol78.Mostof
theothertrialsweremoreofapilotnature(Appendix3,Table3.4).AnadditionalrecentAustralianstudy
wheretherewasaglucosecontroltargetof48demonstrateda16%reductioninmortalitywiththe
interventionarm85.Howeverglucosecontrolwasonlyoneof3factorsintheinterventionpackage(theothers
beingmanagementofswallowingandfever),anditisdifficulttodeterminethecontributionofglucosecontrol
totheoutcome.Thisstudyhadnotbeenincludedinanyoftheabovesystematicreviews.
Twosetsofstrokeguidelineswhichprovidedsomerecommendationsregardingglucosecontrolwere
identified(Appendix3,Table3.4).BothsuggestedaimingtokeepBGsbelowalevelaround10mmol/L,but
admitthattheevidenceforthisisweak.
Conclusions
Observationaldataindicateaclearassociationbetweenhyperglycaemiaandmortalityinacutethrombotic
stroke.Thereisalackofclinicaltrialevidenceregardingappropriateglucosetargetsinstroke,andthe
recommendationismadeonthebasisofextrapolationfromotherclinicalsituations,andconsensus.
RecommendationsandPracticePoints
1. Patientsadmittedtohospitalwithacutethromboticstrokewhohavehyperglycaemia,shouldbe
treatedtoachieveandmaintainglucoselevelslessthan10mmol/L.
2. Hypoglycaemiamustbeavoided,andthereforeitwouldbeprudenttoavoidtreatmentwhichlowers
theglucosebelow5mmol/L.
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Section4: WhatareAppropriateGlucoseTargetsforPatientsinGeneralHospitalWards?
HyperglycaemiaandComplicationsinGeneralHospitalWards
Anumberofobservationalstudieshavedemonstratedanassociationbetweenglucoselevelsandadverse
outcomesinpatientsingeneralhospitalwards.Thesehaveshownahigherriskofadverseoutcomesabovea
randomglucoselevelof812.2mmol/L(Appendix4,Table4.1).Theadverseoutcomesincludeinfection,
mortality,andlongerlengthofstay.Thereisalsoadoserelationshipbetweenglucoselevelsandmortality9193.
Therelationshipbetweenhyperglycaemiaandmortalityinthegeneralwardsismuchstrongeramongthose
withnewlydiscoveredhyperglycaemiathanamongthosewithknowndiabetes.
SystematicReviewsandExistingGuidelines
Threesystematicreviewshaveexaminedclinicaltrialsoftightglycaemiccontroloutsideoftheintensivecare
situation,andnotspecificallyfocusingonmyocardialinfarctionorstroke(Appendix4,Table4.2).Moststudies
includedinthesereviewswereintheperioperativecontext,orincludedsubjectswithmyocardialinfarction.
Thefindingshavebeenmixed,withonereviewfindingareductioninmortalitywithtightglycaemiccontrol
withcardiacsurgery94,onefindingnobenefitinthenonICUorperioperativesettings36,andathirdfindinga
reductionininfectionrateonly95.Thereisarecentstudyingeneralsurgicalpatientswhichfoundthattreating
toapremealglucosetargetof<7.8mmol/Lwithbasal,bolusandsupplementalinsulinresultedinbetter
glycaemiccontrolandfewerwoundinfectionsandtotalcomplicationsthanusingslidingscaleinsulinwiththe
sametarget104.Howeverthisstudywasdesignedtocomparethe2insulinregimes,ratherthantheeffectof
treatingtotheirtarget.Notrialshaveastheirprimaryobjective,examinedtheeffectoftreatingtospecific
glucosetargetsingeneralmedicalwards.
Threeexistingguidelinesforglucosecontrolinnoncriticallyillhospitalpatientshaverecommendedglucose
levelsbelow10mmol/L(Appendix4,Table4.3)55,105,107.Afourthguidelinemaintainsthatthereisnoevidence
forstrictcontrolinnonICUpatients106.TheAmericanAssociationofClinicalEndocrinologists/American
DiabetesAssociationandEndocrineSocietyofAmericaguidelinesalsorecommendpremealglucoselevelsof
3.97.8mmol/L,withoutgivingtherationalefordifferentpremealandrandomglucosetargets55,107.The
caveatthattheseshouldonlybethetargetsiftheycanbesafelyachievedhasalsobeenstated.
Conclusions
Astheevidenceislimited,ourrecommendationsarebasedonexistingguidelinesandextrapolationsfrom
otherclinicalsituations.Havingthesameglucosetargetsasformyocardialinfarctionandstrokewas
consideredimportantforuniformityacrossthehospital,andtoavoidconfusion.Althoughonewouldnot
regardglucoselevelsasbeinginthehypoglycaemicrangeuntiltheyarebelow4mmol/L,activeintervention
9
shouldnotaimtoreducetheglucoselevelsbelow5mmol/L,whichallowsforanaddedmarginofsafety.If
aimingfortightglycaemiccontrol,frequentglucosetestingisrequired.
RecommendationsandPracticePoints
1. Mostpatientsingeneralhospitalwardswithhyperglycaemiashouldbetreatedtoachieveand
maintainglucoselevelslessthan10mmol/L.
2. Hypoglycaemiamustbeavoided.Itwouldbeprudenttoavoidtreatmentwhichlowerstheglucose
below5mmol/L.
3. Toachievetightglucosecontrolsafely,frequentglucosemonitoringisrecommended
10
Section5: WhatSpecialMeasuresNeedtobeUndertakenforPeopleonEnteralor
ParenteralNutrition?
HyperglycaemiaandEnteralandParenteralFeeding
Hyperglycaemiaisacommonoccurrenceinpatientsreceivingnutritionalsupporteitherintheformofenteral
orparenteralnutrition.Thespecificeffectofhyperglycaemiaonclinicaloutcomesinpatientsreceiving
nutritionsupporthasonlybeenreportedbyoneobservationalstudy.Aretrospectivestudyof111patients
receivingtotalparenteralnutrition(TPN)foundthatincreasedbloodglucoselevelswereassociatedwithan
increasedriskofcardiaccomplications,infection,sepsis,acuterenalfailureanddeath91.ThosereceivingTPN
withmeanglucoselevels>9.1mmol/lhada10foldgreaterriskofmortalitythanthosewithmeanglucose
levels6.9mmol/l.Thisassociationwasindependentofage,sexandpresenceofpreexistingdiabetes.This
addsfurtherweighttotheoverwhelmingevidenceofaclearrelationshipbetweenhighbloodglucoselevels
andadverseoutcomesincriticallyillorhospitalisedpatients,asreviewedintheearliersectionsofthis
guideline.
Amajorgoalinthemanagementofpatientswithdiabetesreceivingnutritionalsupportistheachievementof
goodglycaemiccontrol,avoidingbothhyperglycaemiaandhypoglycaemia,withtheirassociatedrisksoffluid
imbalanceanddehydration,ketoacidosisandhyperosmolarcoma,infectionandneurologicalevents.
However,howbesttoachievegoodglycaemiccontrolinthesepatientsremainsunclear.Acriticalfactorfor
considerationiswherethepatientwillbecaredfor:intheICUorgeneralward.Otherimportant
considerationsincludethemethodofnutritionaltherapy(enteralvsparenteral)andcompositionofthefeeds
particularlycarbohydrate/dextrosecontent.Ingeneral,diabeticenteralformulas(lowcarbohydratehigh
monounsaturatedfattyacidformulas)arepreferabletostandardhighcarbohydrateformulasinpatientswith
diabetes107.ClosemonitoringofBGLsandreviewofdiabetesmanagementisessentialwhen
enteral/parenteralfeedsceaseandoralintakeresumes.
ClinicalTrials
Nostudiesinvestigatingtheeffectsoforalglucoseloweringagentsonbloodglucoselevelsandoutcomesin
patientsreceivingenteralorparenteralnutritionwereidentified.Thereare2studies,bothofpoorqualityand
athighriskofbias,whichhaveinvestigatedtheeffectsofdifferentinsulinregimensinpatientsreceiving
enteralnutrition(Appendix5,Table5.1),butnoneinthesituationofparenteralnutrition.Onecomparedthe
effectsofslidingscaleinsulintoslidingscaleinsulinandregularsubcutaneousglargineinsulin,showingno
differencesinbloodglucoselevels,adverseoutcomesorlengthofstay108.However,asignificantproportionof
thepatientsintheslidingscalealonegroupalsoreceivedNPHinsulinduringfollowup.Thissuggeststhata
basalinsulinontopofacorrectionalinsulinregimen,hasaroleinachievingadequateglycaemiccontrolin
patientsreceivingenteralnutrition.Asecond(nonrandomized)pilotstudywitharetrospectivecontrolgroup
foundthatabasalbolusinsulinprotocolachievedlowermeanglucoselevelsthanavariabledosepreprandial
11
insulinregime,attheexpenseofasmallincreaseinhypoglycaemia109.Thenurseledinsulinprotocolwas
implementedintheICUsettingwhichlimitsitsgeneralisability.
Conclusions
Onthebalanceofthelimitedevidence,insulintherapyislikelytobethemosteffectiveagentforimmediate
controlofbloodglucoselevelsinpatientsreceivingenteralandparenteralnutritionalsupport.The
recommendationsmadearebasedonexperienceandconsensus.
RecommendationsandPracticePoints
1. Individualisednutritionalplansshouldbeprovidedasinsulintherapywilldependonthenatureofthe
feedingcycle.
2. Slidingscaleinsulinshouldnotbeusedalonetooptimizeglucosecontrolinpatientsreceivingenteral
orparenteralnutrition.
3. Insulintherapyshouldincluderegularbasalinsulin(intermediateorlongactinginsulin)withprandial
andcorrectionalinsulinifrequired.
4. PerformBGtesting46hourly.WithbolusenteralorparenteralnutritionperformBGtestingbefore
eachbolusisgiven.
6. Patientswithunstablemetaboliccontrolorvariableparenteralfeedingmaybenefitfroman
intravenousinsulininfusiontherapy.
7. Closeliaisonwiththedietitianorteammanagingtheenteralorparenteralnutritioniscritical
particularlyifcalorieintakeischanging,asinsulindoseswillneedtobeadjusted.
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Section6: HowisSteroidInducedHyperglycaemiaBestManaged?
Prevalenceandriskfactors
Hyperglycaemia is common amongst inpatients who are receiving glucocorticoids (GC), with reported
incidencesof6471%110,111.Riskfactorsfordevelopmentofhyperglycaemiaamongstinpatientsincludeapre
existing diagnosisof diabetes110,112, higher HbA1c113, increasingage111, steroid dose114, and family history of
diabetes115,116.
ThereislittledataontemporalBGprofileofindividualsreceivingGC.Anopenprospectiveobservationaltrial
performed on acute hospital wards examined the interstitial glucose profiles of pts admitted with COPD
treated with at least prednisone 20mg/day as compared to pts with COPD, not known to have diabetes,
admittedforanotherindicationwhodidnot receive GC117. Patients receiving GCinthemorning hadhigher
BGLsintheafternoonandevening,ascomparedtothosenotreceivingGCs(withthegreatestelevationseen
in those with known diabetes). A rise in fasting glucose is also seen when extremely high dose GC (e.g.
methylprednisone2501000mg/day)areadministered113.Basedonambulatorydata,theeffectofGConBG
profile is rapid, with a change seen within 23 hours of administration of GC118,119. This is also rapidly
reversible,inthatlowerglucoselevelsareseenonGCfreedaysinpatientswhoreceivealternatedayGC120.
ScreeningfordevelopmentofhyperglycaemiaandmonitoringinthosewithDM
PriortoorupontheinitiationofGC,itisprudenttoexcludethepresenceofundiagnoseddiabetesthrough
measurement of serum glucose (see section 11). Screening for development of steroidinduced
hyperglycaemiabyafternoonfingerprickBGassessmentislikelytodetectthedevelopmentofmostcasesof
hyperglycaemia112, and twice daily GC induced hyperglycaemia should still be detected. Reliance on fasting
glucoseisinadequate.Ifhyperglycaemiaisdetected,BGmonitoringshouldoccurasperthegeneraldiabetes
protocol.
Managementofglucocorticoidinducedhyperglycaemia
TherearenoprospectivetrialsontheuseofanyantidiabeticmedicationforthemanagementofGCrelated
hyperglycaemia.ThelimitedobservationaldataareoutlinedinAppendix6,Table6.2.Sulphonylureashavea
limited role in the treatment of steroidinduced hyperglycaemia in hospital. There are reports of
thiazolidinedione use in the setting of organ transplantation, but these agents are also unsuitable for most
patients in hospital. The management of new onset diabetes after transplantation has been addressed in
otherguidelines140andwillnotbefurtherdiscussedinthisdocument.
Althoughtherearenotrialsofitsuseinsteroidinducedhyperglycaemia,insulinisconsideredtobetheagent
of choice for the management of steroidinduced hyperglycaemia in hospital. Benefits provided by insulin
include greater dose flexibility, more rapid onset of action and titration and that there is usually no dose
ceiling as compared to other glucose lowering agents. Insulin dose requirements will always need to be
individualised,andrequirepreemptivetitrationastheGCdoseisadjusted,usuallyonadailybasis.Theinsulin
13
regimen should predominantly target postprandial control, and with morning GC administration, the
afternoon hyperglycaemia. The use of isophane insulin for management of steroidinduced hyperglycaemia
hasbeenadvocated,withtheinitialdosedeterminedaccordingtoGCdoseandpatientweight124,139.Isophane
typeinsulincanbesupplementedwithultraquickinsulinanaloguewithmeals139.Withtwice,thriceor4times
adayGCregimens,isophaneinsulintwicedailywithprandialrapidactinganaloguecanbeinitiated.Aregime
that controlled glycaemia on previous occasions can be reinitiated, e.g. when cyclical GCs are required, as
longastherehasbeennomajorintervalchangeinweightorrenalfunction.Forthosewithpreexistinginsulin
requiringdiabetes,apreemptiveincreaseininsulinwillberequired,andfurtheradjustmentbasedonblood
glucoseresponse.
RecommendationsandPracticePoints
1. Inpatientsreceivingglucocorticoids,undiagnoseddiabetesshouldbeexcluded.Thosefreeofdiabetes
should be screened for the development of hyperglycaemia by random blood glucose monitoring
performedintheafternoonfollowingmorningadministrationofGC.
2. Hyperglycaemiaisbestmanagedwithinsulin:basalinsulinasisophanetypeinsulin,andrapidacting
analoguewithmealsasrequired.
3. In individuals already on insulin the likely need for increased insulin should be recognised. Dose
requirementsneedtobeindividualisedandrequiredailyreview.
14
Section7: WhatistheOptimalMeansofAchievingandMaintainingGlycaemicControlin
HospitalisedPatientswhoarenotCriticallyIll?
Thissectionexaminestheoptimalmethodsforachievingandmaintaininggoodroutineglycaemiccontrolin
hospital.Itdoesnotdiscusstheuseofinsulininfusiontherapy,orperioperativemanagement.Forthelatter,
wereferthereadertotheAustralianDiabetesSocietyPerioperativeDiabetesManagementGuidelines141.
Thereisapaucityofdatainthenoncriticallyillpatientgroupastothebestmethodofmaintainingglycaemic
control.Thisgroupofpatientsdiffersgreatlyfromthosecriticallyillastheyareofteneating.Intensiveinsulin
therapyhasbeenshowntobebeneficialinacriticallyillpatientpopulation,buttherehavebeennostudies
evaluatingoutcomesingeneralmedicalwards.Themainadverseeventwithintensivesubcutaneousinsulin
therapyishypoglycaemiawhichcanbequitesevere.
Intensiveinsulintherapyrequiresfrequentmonitoringandshouldnotjustbereactivetochangesinglucose
loads,e.g.food.Itsapplicationrequiresaspecificskillsetforstafftomaintain.Traditionallyslidingscaleshave
beenusedtomaintainbloodglucoselevelsinnoncriticalhospitalizedpatients.Thismethodofinjectingaset
doseofinsulinatsettimesisoftenreactivetohighlevelsofbloodglucose.BGsoftenfluctuatefromhighto
low,whichcanpotentiallybedetrimental.Slidingscaleadministrationofinsulinisnotrecommended,and
Americanguidelinesrecommendthataninsulinregimenwithbasal,nutritionalandsupplemental(correction)
componentsbeutilizedforhospitalisedpatientswithdiabetesorstresshyperglycaemia142.
Therearefewstudiesthathaveexamineddifferentsubcutaneousinsulinregimensinnoncriticalhospitalised
patients(Appendix7).Moststudieshavemoderatetohighriskofbiasandoutcomemeasureshavebeen
inconsistentbetweenthedifferentstudies.Basalbolusregimenshavebeenshowntobesuperiortosliding
scaleregimensforglucosecontrol102,104,andslidingscaleinsulinalonehasbeennomoreeffectivethan
continuationofthepatientsusualdiabetesmedication101.Effectiveuseofbasalbolusinsulinrequires
frequentandregularbloodglucosemonitoring(atleast4andpreferably68timesdaily).Basedonclinical
expertise,currentpracticesandthelimitedliterature,thefollowingconsensusrecommendationsweremade.
RecommendationsandPracticePoints
1. Slidingscaleinsulinshouldnotbeusedtooptimiseglucosecontrolintheinpatientgeneralmedicalor
surgicalsetting.
2. Oralhypoglycaemicagentsorpremixedinsulincanbeusedincertainstablehospitalisedpatientswho
areeatingregularly.Supplementalinsulinshouldbewrittenupinaddition.
3. Insulintherapyinhospitalisedpatientsshouldotherwiseconsistofabasalinsulin,prandialand
supplementalinsulin.
15
Section8: HowShouldPatientsonInsulinPumpTherapybeManagedinHospital?
ContinuousSubcutaneousInsulinInfusionTherapyinHospital
Continuoussubcutaneousinsulininfusion(CSII)orinsulinpumptherapyisusedinthemanagementofgrowing
numbersofpatientswithType1diabetesinAustralia.Anecdotalreportssuggestthatpatientsestablishedon
CSIIusuallyprefertocontinueontheirpumpsduringhospitaladmissions.Hospitalhealthcareproviderswill
increasinglybefacedwiththeissueofhowtomanagesuchinpatients.Anumberofpublicationshavedetailed
guidelinesregardinginpatientmanagementofpatientspreviouslyestablishedonCSII144147. Whilstthereare
no data from randomised trials available, observational reports indicate that patients admitted to hospital
continued on CSII who are managed with bestpractice consensus protocols fare at least as well as those
changedovertosubcutaneousinsulininjectionsandmanagedbytheendocrinologyteam.Thedataregarding
hypoglycaemiaisconflictingwithonestudyindicatingalowerincidenceinthoseinpatientscontinuedonCSII
whichwasnot confirmedwitha subsequentstudy148,149. Acaveatis that thesereportshavestemmedfrom
tertiary academic medical centres in the United States and their applicability to a spectrum of hospitals
(includingcommunityhospitals)inAustraliaisyettobedetermined.Therecommendationsbelowarebased
uponaconsensusopinion.
ManagementofCSIIinHospital
General recommendations for CSII therapy in hospital are outlined in Appendix 8, Table 8.1. In appropriate
circumstances, CSII maybethe preferredmethodofinsulindelivery.However,device operatingmenusand
programsvarynotonlyaccordingtothemanufacturerbutalsofrommodeltomodel.Itishighlyunlikelythat
nonspecialised medical and nursing staff will be familiar with the operation of all available devices. We
thereforerecommendthatCSIItherapyisbecontinuedinhospitalonlyinthosesituationswherethepatient
(or guardian) has the ability to safely selfmanage their insulin dosing and the pump. The competency
requirementsareoutlinedinAppendix8,Table8.2.IfthesecriteriaarenotmetCSIImustbesubstitutedwith
eitherasubcutaneousinsulinregimenoranintravenousinsulininfusion.ContraindicationstoCSIItherapyare
listedinAppendix8,Table8.3.AllaspectsofCSIImanagementshouldbedocumented(Appendix8,Table8.4)
anditisrecommendedthattheEndocrineteambeinvolved.
CSIIandSurgery
Surgery itself is not an absolute contraindication to continuation of CSII. If CSII is to be continued intra
operatively this decision must be made in conjunction with the anaesthetist, surgeon/proceduralist, and
endocrinologyteamwith thedocumentedconsent ofthepatientortheirguardian.CSIIandan intravenous
insulininfusionshouldnotbeusedsimultaneouslyforanyextendedperiod150.Thesituationsappropriatefor
intraoperativeCSIIorforitssubstitutionwithanintravenousinsulininfusionareoutlinedinAppendix8,Table
8.5. When CSII is being used intraoperatively, it is important for there is a protocol for its management
(Appendix8,Table8.6.).AppropriateoverlapandtimingisimportantwhenswitchingapatientfromCSIIto
insulininfusionormultiplesubcutaneousinsulininjections,andviceversa(Table8.6.).
16
RecommendationsandPracticePoints
1. Ingeneral,CSIIshouldbecontinuedinhospitalwherethepatientcancompetentlyandsafelyself
managethepumpandselfdosing.
2. Detailsofpumptherapyshouldbedocumented,andsupportedbytheendocrineteam
3. CSIImaybecontinuedforshortoperativeproceduresifthoseresponsibleforthepatients
intraoperativecarearecomfortablewithitsuse.
17
Section9: WhatisAppropriateGlucoseControlinEndofLifeSituations?
DiabetesandEndofLife
For patients with diabetes and advanced disease limiting their life expectancy there is no body of evidence
availableregardingtheimpactoftightglycaemiccontrolonoutcomes.Lifelimitingdiseaseincludes,butisnot
limited to, cancer and includes any disease process such as advanced dementia, end stage cardiac and
respiratory failure, which is incurable and significantly shortens the patients life expectancy. As the patient
with diabetes approaches the end of their life the guidelines regarding glucose monitoring and glycaemic
targets detailed earlier in this document may no longer be appropriate with a potential for discomfort,
inconvenience and significant morbidity relating to hypoglycaemia. Tight glycaemic control is questionable
benefit and the avoidance of longterm complications is no longer relevant. Conversely it is important to
maintain a level of glycaemia to prevent hyperglycaemia associated thirst, dehydration, polyuria associated
urinaryfrequency,alteredconsciousstateandsymptomatichypoglycaemia.Treatmentregimensneedtobe
individualisedaccordingtothepatientscircumstances.
Palliativecareisdefinedasmedicalorcomfortcarethatreducestheseverityofadiseaseorslowsitsprogress
rather than providing a cure. Currow et al151 have described 4 phases in the end of life pathway: Stable,
unstable, deteriorating, and terminal (see Appendix 9, Table 9.1 for details). Palliative patients may be
admitted to hospital for management of an acute illness, either intercurrent or related to their primary
underlying disorder or for terminal care. There is an absence of level I data though there are a number of
valuableconsensusbasedguidelinesaddressingtheglobalmanagementofpalliativepatientswithdiabetes151
153
.Thefollowingrepresentsaconsensusofopinionintheabsenceofasuitableevidencebase,andisinpart
basedonthe2010GuidelinesforManagingDiabetesattheEndofLife152.Thisconsensusdocumentfocuses
on the inpatient management of hyperglycaemia in those patients with diabetes deemed as requiring
palliative care. As management should be individualised to each patients needs this document provides
general principles for the inpatient management of palliative care patients with diabetes and detailed
protocolscannotbeprovided.
GlucoseManagementinEndofLifeSituations
Glucosemanagementduringinpatientadmissionswilldependonthetypeofdiabetesandthephaseofthe
endoflifepathway(seeAppendix9,Table9.2fordetails).Ingeneral,intheearlierstagesofendoflife,the
persons usual diabetes medication would be continued, with adjustments based on the many situational
factorswhichwouldaffectglycaemicstability(Appendix9,Table9.3).Thedecisiontosimplifyandrationalise
treatment regimes and targets would need to be made on an individual basis. As the person progresses
throughthephasesofendoflife,theemphasisshiftstowardsmaintenanceofcomfort,withcorresponding
reductionsinmedicationandglucosetesting,andsomeliberalisationoffoodrestriction.Thisdoesnotimplya
nihilisticapproachinthemetabolicmanagementofpalliativepatients.Avoidanceofmarkedhyperglycaemiais
stillrelevant,particularlyinhospital,toavoidsymptomsofhyperglycaemia,andimprovewoundhealingand
18
resistance to infection. Hypoglycaemia must also be avoided. With type 1 diabetes, ketoacidosis is likely to
precipitatedeath,soitshouldbepreventeduntiladecisionismadetowithdrawalltreatmentintheterminal
phase. Therefore until then, some glucose testing and insulin administration may remain necessary. It is
reasonabletocontinueoninsulinpumptherapyinthosepatientsestablishedonthesedevices.
The views of the patient and their family need to be determined. They may require advice and counseling
regardingthemanagementofthepatientsglucoselevelsasmanyyearsmayhavebeenspentwhereglucose
levelshavebeendiligentlymaintainedinatargetrange.Therealisationthatlongtermsurvivalisnolongera
viable proposition and that maintenance of tight glycaemic control is of dubious value and could even
adverselyimpactqualityoflifecanbeconfronting.Ultimatelythedecisionofthepatientandtheirfamilywill
takeprecedence.Thestatusofthepatientmaybeevolvingcontinuouslyrequiringtheongoingreassessment
ofglycaemicmanagementstrategiesbythemedicalteam.
RecommendationsandPracticePoints
1. Palliative care patients may still benefit from a level of glucose control in hospital so diabetes
treatmentremainsrelevant.
2. Thelevelofinterventionwouldgenerallybelessintensivethanforotherhospitalpatients,andneeds
tobeindividualised,dependingonthephaseofendoflife,andothersituationalfactors.
19
Section10: At What Level is Hyperglycaemia in Hospital Predictive of Diabetes and How
ShouldPatientswithNewlyDiscoveredHyperglycaemiabeFollowedup?
StressHyperglycaemia
Patientswithaknownhistoryofdiabetescommonlyhavehyperglycaemiainhospital,butpatientswithouta
historyofdiabetesmayalsobefoundtohaveelevatedbloodglucoselevels.Hyperglycaemiainpatientsnot
knowntohavediabetesmaybesecondarytostressortoundiagnoseddiabetes.Itisoftendifficultto
distinguishthecauseofhyperglycaemiainashorthospitalstay.
Stresshyperglycaemiamostcommonlyoccursinpatientswithacuteorcriticalillnessandismorelikelyto
occurinamorecriticallyillpatient.Hyperglycaemiaispostulatedtobemediatedthroughcytokines,the
sympatheticnervoussystemandthehypothalamicpituitaryadrenalaxis155.Itisnotclearwhetherpatients
whomanifeststresshyperglycaemiahaveanunderlyingimpairmentintheirglucosemetabolism,butinthe
longterm,inpatienthyperglycaemiamayheraldundiagnoseddiabetesorthedevelopmentofdiabetesinthe
future.Theprevalenceofundiagnoseddiabetesvariesindifferentinpatientsettingsandcanbeupto60%
(Appendix10,table10.1).Itisimportanttodiagnosepatientswithdiabetesearlytoensureappropriate
management,bothlifestyleandmedicationtopreventthedevelopmentoflongtermcomplications.
Thereislimitedliteraturetoguidethelevelofhyperglycaemiapredictiveofdiabetesortosuggestan
appropriatealgorithmfordetectionofdiabetesintheacutehospitalsetting.TheAmericanAssociationof
ClinicalEndocrinologists/AmericanDiabetesAssociationconsensusrecommendationsdefinesaBSL
>7.8mmol/LasinpatienthyperglycaemiaandsuggestanHbA1cmayassistindiagnosisofdiabetes.HbA1c
>6.5%(48mmol/mol)isstronglysuggestiveofunderlyingdiabetes55,160.However,thereisconsiderable
heterogeneityamongststudieslookingatpredictorsofdiabetesininpatientpopulations(Appendix10,table
10.1).Differentglucosevalueshavebeenusedtodefinehyperglycaemia.HbA1clevelsusedtodefinea
diagnosisofdiabetesandthepopulationsstudiedhavealsobeenquitevariable.WhilstHbA1chasnotbeen
ratifiedforthegeneraldiagnosisofdiabetesinAustralia,thereisnodoubtthatforapatientwith
hyperglycaemia,itisastrongindicatorofunderlyingdiabetes.
Whilstinhospital,patientswithnewlydiagnoseddiabetesshouldbereferredtotheSpecialistDiabetes
InpatientTeam(section12)ortheEndocrineTeamformanagement.Irrespectiveofwhetherdiabetesis
definitivelydiagnosedinhospital,patientswithinpatienthyperglycaemiashouldreceivefollowuptoensure
thatthediagnosisisclarified,andappropriatecounselingandmanagementinstituted.Notificationofthe
generalpractitionerisvitaltothisprocess.
Asuggestedalgorithmfortheapproachforthediagnosisandfollowupofaninpatientwithnewlydiscovered
hyperglycaemiaisgiveninAppendix11,Figure11.1.
20
RecommendationsandPracticePoints
1. Allinpatientswithnewlydiscoveredhyperglycaemia(randomplasmaglucose>7.8mmol/L)should
haveanHbA1cperformed.
2. Allinpatientswhoarenewlydiagnosedwithdiabetesshouldbemanagedappropriatelyfordiabetes.If
thereisdiabetesexpertiseavailable,anearlyreferralshouldbemade.
3. Allpatientswithabnormalglucosemetabolismdetectedinhospitalshouldhaveadequatefollowup
arranged,andthefindingsshouldbecommunicatedtotheusualcarepractitioner.
21
Section11: WhatistheRoleofaSpecialistInpatientDiabetesTeam?
Improvingglycaemiccontrolhasbeenshowntoreducetheriskofadverseoutcomesassociatedwith
hyperglycaemia,buttheevidencefortheseclinicalbenefitshavebeenobtainedinandlimitedtospecific
individualclinicalunits.Translatingtheseimprovedoutcomestoawholehospitalismorechallengingand
requiresadifferentapproach.Ratherthanfocusingonimprovedclinicaloutcomes,oronspecificblood
glucosetargets,hospitalwideapproacheshavefocusedonreducingthedifferenceinlengthofstayforpeople
withdiabetesbyimprovingoveralldiabetesmanagement.Thedriversforthisapproacharenotsomuchan
improvementinqualityofcareorclinicaloutcomes,butratherreductionsinassociatedcostsandimproved
bedutilisation.Thefactorscontributingtoincreasedlengthofstayandpooreroutcomesassociatedwith
diabetesthatarepotentiallymodifiableincludebloodglucosecontrol,inappropriatediabetesmanagement
anddelayedinvolvementofspecialistdiabetesservices.
Differentapproachestothisproblemhavebeenutilised,withvaryinglevelsofevidencetosupportthe
intervention.Thesevaryfromthetraditionalconsultativeservice,tosystematichospitalwidediabetes
programmes,tothenewerconceptoftheSpecialistDiabetesInpatientManagementTeam(Appendix11,
table11.1).Therehasnowbeenonerandomisedcontrolledtrial164andanumberofcomparativestudies
whichhavedemonstratedimprovedoutcomeswiththelatterapproach(Appendix11,Table11.2).
TheseteamsusuallycomprisededicatedDiabetesInpatientSpecialistNurses(DISN),usuallyledbya
consultantindiabetes.Theroleofsuchteamshasincludedimprovingdiabetesmanagementexpertise
throughoutthehospital,thedevelopmentandimplementationofdiabetesmanagementprotocols,direct
managementofdiabeteswithspecificreferralcriteria,wardliaison,troubleshooting,managementadvice,and
dischargeplanning(Appendix11,Table11.3).DISNsarecurrentlyinvolvedin3050%ofUKhospitals171,with
DiabetesUKrecommendingaratioofoneDiabetesDISNforevery300beds172.TheNHS(UK)hasadoptedthis
approachtoimprovediabetesinpatientmanagementthroughthewholehealthsystem,resultingin
reductionsinadverseoutcomesandlengthofhospitalstay9.InAustralia,theintroductionofSpecialist
DiabetesInpatientManagementTeamswillrequireadditionalresources,butthelongtermeconomic
argumentiscompelling.Theliteraturesuggeststhathospitalswhichhaveintroducedtheseteamshave
realisedshorterlengthsofstayandsignificantcostsavings165,166,167,170.Healthadministratorsneedtoinvestin
suchteamswhichshouldresultinbetterinpatientdiabetescare,shorterlengthsofhospitalstay,andcost
savingstothehealthsystem.Forwardplanningisalsoneededforthetrainingofthespecialisedworkforce
requiredforDiabetesInpatientManagementTeams.
Recommendation
1. HospitalsshouldconsidertheintroductionofSpecialistDiabetesInpatientManagementTeams
22
Section12: What Routine Measures Should be Undertaken for People with Diabetes
AdmittedtoHospital?
Effectiveinpatientdiabetesmanagementshouldbeprovidedearlyandcontinuouslythroughoutthehospital
admission.Tosupportoptimalglycaemiccontrolinhospitalanddiabetesmanagementafterdischarge,itis
importanttohaveestablishedroutineprocessesandprotocolsforthecareofpeoplewithdiabetesinhospital.
Theserecommendationsaregenerallybasedongoodgeneralhospitalpractice,experience,andcommon
sense.Generalrecommendationsinclude:clearidentificationofdiabetesinthemedicalrecord,bloodglucose
monitoring,ahypoglycaemiamanagementprotocol,HbA1ctesting,amultidisciplinaryteamapproach,
dieteticassessment,diabetesselfmanagementeducationwhenappropriate,anddischargeplanning142.
Insulinisacommonsourceofmedicationerror171,172,andmustbeminimisedbymechanismssuchasstaff
education,pharmacistoversight,anddedicatedinsulinprescriptioncharts173.
BloodGlucoseMonitoring
Wheretightglycaemiccontrolisdesired,andparticularlyforpatientsoninsulin,itisimportantforblood
glucosemonitoringtooccurbeforeandaftermeals.Thisiscriticaltofacilitateappropriateadjustmentstothe
patientsinsulindosage,andmonitorforhypoglycaemia.Additionaltestingatbedtimeandovernightisoften
alsohelpful.Forstablepatients,orthosewheretightglucosecontrolisnotanaim,testingcanbereduced
accordingly.
DischargePlanningandDiabetesEducation
Whilstthisdocumentfocusesonthemanagementinhospital,itisimportanttotaketheopportunityto
improvethepostdischargemanagementofdiabetesaswell.Liaisonwiththegeneralpractitionerisan
importantcomponentofthis.Notonlymightthisimprovepatientoutcomes,butitmayreducetheneedfor
readmissiontohospital.Thevariousteammembersparticipatingininpatientmanagementalsohavearolein
promotingandfacilitatingbetterdiabetescarepostdischarge(Appendix12,Table12.1).Appropriatediabetes
educationisacriticalcomponentofinpatientpatientcareanddischargeplanning.Afocusonthecontinuityof
carewhere thepatientisthecentralmemberinthemanagementofdiabetesisimportant,andtheirfamily
membersmayneedtobebroughtintothediscussion.
RecommendationsandPracticePoints
1. Ensureclearprocessesandprotocolsareimplementedinthehospitalforroutinediabetescare.
2. Ensuredischargeplanningwhichfacilitatesoptimallongtermdiabetesmanagement.
23
Appendices
Appendix1:SearchMethodologyofSystematicReviews
Table1.1.PICOsearchquestionsandsearchtermsusedforeachofthechapters.
Question SearchTerms
Whatglucosetargetshouldbeaimedforinacute hyperglyc(a)emia,diabetes,intensiveglucosecontrol,tightglucosecontrol,intensiveglyc(a)emic
myocardialinfarction? control,tightglyc(a)emiccontrol,myocardialinfarction,acutecoronarysyndrome,withthe
outcomesofmortalityordeath.
Whatglucosetargetshouldbeaimedforinacute hyperglyc(a)emia,diabetes,intensiveglucosecontrol,tightglucosecontrol,intensiveglyc(a)emic
stroke? control,tightglyc(a)emiccontrol,myocardialinfarction,stroke,cerebrovascularaccident,withthe
outcomesofmortalityordeath.
Whatareappropriateglucosetargetsforpatientsin intensiveglucosecontrol,tightglucosecontrol,intensiveglyc(a)emiccontrol,tightglyc(a)emic
generalhospitalwards? control,hospital,surgery,medicine
Whatspecialmeasuresneedtobeundertakenfor Diabetesand(enteralnutritionorparenteralnutrition)
peopleonenteral+parenteralnutrition?
Howissteroidinducedhyperglycaemiabest (MetforminorsulphonylureaorincretinsorDipeptidylPeptidaseIVInhibitorsorthiazolidinediones
managed? orinsulin)and(glucocorticoidsorprednisone)and(hyperglycaemiaordiabetes)
Whatistheoptimalmeansofachievingroutine hyperglyc(a)emia,diabetes,intensiveglucosecontrol,bloodglucose/sugarcontrol,intensive
glucosecontrolinhospital? glyc(a)emiccontrol,tightglyc(a)emiccontrol,hospital,inpatient
Howshouldpatientsoninsulinpumptherapybe diabetes,guidelines,hyperglyc(a)emia,hypoglyc(a)emia,hospitaladmission,acutecare,inpatient
managedinhospital? care,perioperativemanagement,CSII,insulinpump,insulinpumptherapy,IPT
Whatisappropriateglucosecontrolinendoflife diabetes,guidelines,hyperglyc(a)emia,hypoglyc(a)emia,hospitaladmission,inpatientcare,endof
situations life,palliativecare,terminalillness,advancedcancer,hospice,insulin,oralhypoglyc(a)emicagents,
slidingscale,bloodglucose,therapy,andmanagement
Howshouldpatientswithnewlydiscovered hyperglyc(a)emia,diabetes,intensiveglucosecontrol,bloodglucose/sugarcontrol,intensive
hyperglycaemiabefollowedup? glyc(a)emiccontrol,tightglyc(a)emiccontrol,hospital,inpatient
Whatistheroleofaspecialistdiabetesinpatient Diabetes,hospital,inpatient
team?
Whatroutinemeasuresshouldbeundertakenfor Consensusonly
peoplewithdiabetesadmittedtohospital?
24
Appendix2:LiteraturereviewedforWhatGlucoseTargetShouldbeAimedforinAcuteMyocardialInfarction?
Table2.1.Recentstudiesexaminingtherelationshipbetweenadmissionglucoselevelsandmortalityfollowingmyocardialinfarction
25
22
2009 (random) mortalityonly,fastingBGLassociatedwith database
5.6mmol/L bothinpatientand6monthmortality.
(fasting)
Ishihara 3750 Within48hrs Yes 7mmol/L Ushapedcurveforpatientswithdiabetes, Cohortstudy
23
2009 ofAMI increasedmortalityifBGL<7or>11mmol/L
Dziewiercz 763 NonSTEMI Yes 5mmol/L Relationshipstrongerfornondiabetic Analysisof
24
2009 treated subjects database
conservatively
25
Goyal2009 30536 CREATEECLA Yes 7.8mmol/L Hypoglycaemia<3.3alsopredicted Posthocanalysisof
andOASIS6 mortality clinicaltrialcohorts
cohorts
DeMulder 1185 Both Yes 11mmol/L Eachmmol/Lincreasecorrespondedtoa7% Cohortstudy
26
2010 preinvasive increasedmortality(adjustedHR1.07,95%
andPTCAeras CI1.041.10)
Timmer 4176 Nondiabetic Yes 8.2mmol/L 30dayand1yearmortalityassessed.U Cohortstudy
27
2011 STEMI shapedcurveformortalitywithincreased
mortalityforthosewithBGL6.9mmol/L
26
Table2.2.Observationaldataofarelationshipbetweenaverageglucoselevelsorglucoselevelsachievedinthefirst24hoursaftermyocardial
infarctionandmortality.
27
Table2.3.Systematicreviewsofrandomizedcontrolledtrialsoftightglucosecontrolinmyocardialinfarction,wheretheprimaryoutcomewas
death.
Table2.4.Randomisedcontrolledtrialsofmyocardialinfarctionwithaspecificglucosetarget.
28
Trial Subjects EntryCriteria InsulinRegimen Glucose Primary Secondary Comments
Target Outcome Findings
DIGAMI, 620 Myocardialinfarct Variablerate 710 Reducedone Greatestbenefit Amongstfirst327subjects,blood
Malmberg andadmissionBG glucoseinsulin mmol/L yearmortalityin topatientswith glucoseat24hourslowerininsulin
31
1995 , >11.0mmol/L. solutionforat insulininfusion lowpremorbid thanincontrolsubjects(9.22.9vs
51 least24hrs. group(18.6%vs cardiovascular 124.4mmol/L).Insulingroup
1997
26.1%, riskprofile. receivedregularsubcutaneousinsulin
p=0.027). afterdischarge,whichmayhave
contributedtobetteroutcomes.
GIPS,van 940 Within24hrsofST20%glucose 711 Nosignificant MedianBGat16hours7.7mmol/Lfor
derHorst segmentelevation potassium mmol/L. reductionin30 GIKgroupand8.1mmol/Lforcontrols
48
2003 infarct(allhad solutionat daymortality (NS).
PTCA). 3mls/kg/hrwith (4.8%vs5.8%).
insulinat
variablerate.
DIGAMI2, 1253 Myocardialinfarct Variablerate 710 Noreductionin BGat24hoursininsulintreated
Malmberg andeitherknown glucoseinsulin mmol/L mortalitywith groupsonly0.9mmol/Llowerthanfor
44
2005 type2diabetesor solutionforat insulininfusion. conventionaltreatmentgroup
admissionBG>11.0 least24hrs. (9.13.0and9.12.8vs103.6
mmol/L. mmol/L,p=0.0001)
HI5, 240 Myocardialinfarct Variablerate 410 Noreductionin Mortalityhigher Mean24hourBGininsulintreated
Cheung withknown insulinwith5% mmol/L mortalitywith insubjectswith grouponly0.7mmol/Llowerthanfor
28
2006 diabetesor dextrose80 insulininfusion. mean24hour conventionaltreatmentgroup
admissionBG7.8 mls/hr. bloodglucose (8.32.2vs9.02.8mmol/L,NS)
mmol/L. level>8.0
mmol/L.
Othertrialsofinsulinglucosetherapywheretherewerenoglucosetargetswereexcludedfromconsideration:ECLA(1998)45,POLGIK(1999)46,
CREATEECLA(2005)47,GIPSII(2006)52
Table2.5.Guidelinesregardingglucosecontrolinmyocardialinfarction
30
Appendix3:LiteraturereviewedforWhatGlucoseTargetShouldbeAimedforinAcuteStroke?
Table3.1.Recentstudiesexaminingtherelationshipbetweenadmissionglucoselevelandstrokeoutcomes.
32
Table3.2.Studiesexaminingtherelationshipbetweenmeanglucoselevelsandstrokeoutcomes:
NIHSS=NationalInstitutesofHealthStrokeScale,BI=BarthelIndex,mRS=modifiedRankinScore
33
Table3.3.Systematicreviewsofrandomizedcontrolledtrialsoftightglucosecontrolinstroke,wheretheprimaryoutcomewasdeathorameasure
ofdisability.
RCTscomparing 82
Bellolio CochraneStroke Vinychuk2005 , 1296 Nodifferenceindeathor Increased
76 GroupTrials intensivelymonitored 77 disabilityanddependence(OR hypoglycaemiawith
2011 Walters2006 ,Gray
Register,CENTRAL, insulintherapyversus 1.00,95%CI0.78to1.28)or
usualcareinadultpatients
78
2007 ,Staszewski intervention.Some
MEDLINE,EMBASE, finalneurologicaldeficit(SMD
withacuteischaemic 2007*,Bruno2008 ,
80 studiesinthisreview
CINAHL,Science 0.12,95%CI0.23to0.00).
stroke. 83 werenotdesignedto
CitationIndex,Web Kreisel2009 ,
assessneuro
ofScience,Scopus Johnston2009
84
outcomes.
Bold=studiesofstrokeonly,*Unpublished
Table3.4.Randomisedcontrolledtrialsofstrokewithaspecificglucosetarget.
34
Trial Subjects EntryCriteria Insulin Glucose Glucose Primary Secondary Comments Hypos
Regimen Target Achieved Outcome Findings
Vinychuk 128 Within24 Glucose <7 Diabetes:7 Improvemen 4armstostudy Notreported
82
2005 hoursof potassiu mmol/L vs11.2 tinNHISS
ischaemic minsulin mmol/Lat comparedto
strokeonset, infusion 1224hrs
admissionBG Nodiabetes:
716mmol/L 5.8vs8.1
mmol/L
Walters 25 Within24 Variable 58 Intarget 1deathinsulin Apilotstudy 1ininsulin
77
2006 hoursof rate mmol/L 87%ofthe group,0in group,0in
ischaemic insulin timevs71% controlgroup controls
strokeonset, infusion ofthetime
admissionBG (p<0.001)
820mmol/L
GISTUK, 933 Within24 Glucose 47 GKIgroup Noreduction Noreduction Trialdiscontinued 41.2%GKI
Gray hoursof potassiu mmol/L 0.57mmol/L indeathat inresidual earlyduetoslow patientshadBG
78
2007 strokeonset, minsulin lower 90dayswith disabilityor recruitment.BG <4mmol/Land
admissionBG infusion (p<0.001) GKI functional dropped 15.7%required
617mmol/L recovery spontaneouslyin rescueiv
controlgroup. glucose
Bruno 46 Within12 Variable <7.2 7.4vs10.5 Diffin 2deathinsulin Apilotstudy 35%vs13%had
80
2008 hoursof rate mmol/L mmol/L glucose group,0in hypos<3.3
cerebral insulin achieved controlgroup
infarctandBG infusion
8.3mmol/L for72hrs
Kreisel 40 Within24 Variable 4.46.1 6.5vs8.0 Diffin Nodifference Notpoweredtodetect 25vs2hypo
83
2009 hoursof rate mmol/L mmol/L, glucose indeathor differenceindeath events(p<0.05)
ischaemic insulin p<0.0005 achieved functional anddisability
strokeonset infusion outcome
Johnston 74 Within12 Variable 3.96.1 6.2vs8.4 Diffin Nodifference 3armstostudy 30%vs4%had
84
2009 hoursof rate mmol/L mmol/L glucose indeathor Notpoweredtodetect atleastone
cerebral insulin achieved functional differenceindeath hypo
infarctandBG infusion outcome anddisability
6.1mmol/L
35
Middleton 1126 Within48 Variable 48 7.0vs6.8 Differencein Nodifference Interventionwas Notreported.
85
2011 hoursof rate mmol/L mmol/L, mortalityor inBarthel packageofglucose,
acutestroke insulin orlocal p=0.02 dependency index,but fever,andswallowing
infusionif guidelin (Notesmall 42%vs58% higherSF36 management.Not
BG>=11 esonce difference (p=0.002) PhysicalHealth possibletodetermine
mmol/Lif insulin only) Scorein contributionofglucose
diabetes, infusion intervention control.
>=16for comme
non nced
diabetics,
upto72
hours
Table3.4.Guidelinesregardingglucosecontrolinstroke
36
Appendix4:LiteratureReviewedforQuestionWhatareAppropriateGlucoseTargetsforPatientsinGeneralHospitalWards?
Table4.1.Observationalstudiesexaminingtherelationshipbetweenhyperglycaemiaandoutcomesinhospitaloutsideofthesituationsof
intensivecare,myocardialinfarctionandstroke.
Table4.2.Systematicreviewsofstudiesexaminingtrialsoftightglycaemiccontroloutsideoftheintensivecaresetting,andnotspecifically
focusingonmyocardialinfarctionorstroke
37
Review SelectionQuestion Studies Total Result/Conclusion Comment
subjects
Haga Effectsoftightversus 3studies:Groban200242,Lazar 686 48%reductioninmortality(OR
201194 normalglycaemiccontrol,peri 200496,Ingels200697 0.52,95%CI0.30.91,p=0.02).
andpostoperatively,inpatients Maybesomebenefittotight
undergoingcardiacsurgery. glycaemiccontrolduringandafter
cardiacsurgery.
Kansagara RCTsusinginsulintoachieve 9nonICUstudies:Malmberg NonICU: NonICUsetting:noreductionin Notrialsin
201136 strictglycaemiccontrol. 199531,VanderHorst200341, 2677 shorttermmortality(RR1.0, generalmedical
Subanalysis:NonICUstudies Butterworth2005,Li2006, 95%CI0.941.07). wards
Subanalysis:Perioperative Cheung200628,Oksanen200750, Perioperative:noreductionin Perioperative
Azevedo200779,Yang200981, shorttermmortality. studiesmostly
5perioperativestudies:Smith poorquality
200243,Lazar200439,Butterworth RRhypoglycaemia
200598,Li200699,Barcellos2007100 6.0,95%CI4.06
8.87,p<0.001).
Murad Observationalorrandomized 19studies:RCTsMalmberg Variedfor Noassociationbetweenintensive Inclusionof
201295 studiesthatcomparedthe 199531,Dickerson2003101,vander different glucosecontrolandriskofdeath, observational
effectofintensiveglycaemic Horst200348,Malmberg200531, analyses myocardialinfarctionorstroke. studiesis
28 77
controltoacontrolgroup Cheung2006 ,Walters2006 , Associationwithreducedriskof questionable.
seekinglessaggressive Umpierrez2007102,Umpierrez infection(RR0.41,95%CI0.21
normalization 2009103,Umpierrez2011104 0.77).Trendtoincreased
ofglycaemiclevels.Intensive hypoglycaemia.
caresettingexcluded.
38
Table4.3.Existingguidelinesforglucosetargetsinnoncriticallyillpatientsinhospital.
Formajorityofnoncriticallyillpatients,premeal<7.8mmol/L,random<10mmol/L,aslong
asthiscanbesafelyachieved.
EndocrineSociety,2012107 Recommendpremealtarget<7.8mmol/L,randomtarget<10mmol/L,butmodifyaccordingto
clinicalstatus.ReassesstherapyifBGvaluesfallbelow5.6mmol/L.ModifytherapywhenBG
valuesare<3.9mmol/L.
39
Appendix5:LiteratureReviewedforQuestionWhatisthebestmethodtomaintainglycaemiccontrolinahospitalizedpatientwhoisreceiving
parenteralorenteralnutrition?
Table5.1.Clinicaltrialsofglucosecontrolamongpatientsreceivingenteralorparenteralfeeding.
40
Appendix6:LiteraturereviewedfortheQuestionHowissteroidinducedhyperglycaemiabestmanaged?
Table6.1.Incidenceofsteroidinducedhyperglycaemia.
41
Table6.2.Evidenceregardingtheeffectivenessofantidiabeticmedicationinthemanagementofsteroidinducedhyperglycaemia.
43
Appendix7:LiteratureReviewedforQuestionWhatisthebestmethodtomaintainglycaemiccontrolinahospitalizedpatientwhoisnot
criticallyill?
Table7.1.Randomisedcontrolledtrialscomparinginsulinregimesforglucosecontrolinhospital.
44
managementof characteristicssame. p<0.001,mean hypoglycaemia.Nodifference hypoglycaemic
generalmedical Unrestrictededucational glucose insecondaryendpoints(LOS agentson
patientswithtype2 eventfromSanofiAventis throughout andmortality).Significant admission.
diabetes. hospitalstay differenceintheunitsof Slidingscalenot
p<0.001. insulinused. appropriate
comparator.
Umpierrez 130subjects. Mediumriskofbias.Selection III Nodifference Noeffect.Bothregimens Tertiaryhospital.
2009103 Randomisedtrial bias,randomisationprocess betweenthe equallyaseffectivein Similarpatient
comparingregimens unclear.Informationbias, treatment loweringmeanBGsandlead populationand
withdetemirand openlabelstudy.Inclusion groups,p=NS tosimilarratesof treatingteams.
aspartversusneutral andexclusioncriteriadetailed. hypoglycaemia. Differenceis
protaminehagedorn Baselinecharacteristicsthe BG<140mg/dLwasachieved ceasingalloral
andregularin same.FinancedbyNovo in45%ofBBIgroupand48% hypoglycaemic
medicalpatients Nordisk(disclosedandhadno insplitmixedgroup. agentson
withtype2diabetes. influenceonstudydesign). admission.
Umpierrez 211subjects. Mediumriskofbias. II Appropriately Largeeffect.BBIbetterthan Tertiaryhospital.
2011 Randomisedtrialof Computergenerated powered. SSIintreatinghyperglycaemia. Similarpatient
(RABBIT2 basalbolusinsulin randomisation.Openlabel. FBGp=0.037, Significantdifferencebetween populationand
Surgery)104 therapycomparedto Inclusionandexclusioncriteria meanBG groupsinregardsglycaemic treatingteams.
slidingscaleinsulin detailed.Baseline p<0.001,BG control,p<0.001,lowermean Differenceis
intheinpatient characteristicsthesame. <140mg/dL dailyBGandFPG.More ceasingalloral
managementof Unrestrictededucational p<0.001. hypoglycaemiainBBIgroup. hypoglycaemic
patientswithtype2 eventfromSanofiAventis Secondary Differenceinsecondary agentson
diabetesundergoing outcomes endpointsfavourBBI,with admission.
generalsurgery p=0.003,wound reducedwoundinfectionsand Slidingscalenot
infection ICUstay.NodifferenceinLOS appropriate
p=0.05. ormortality.Significant comparator.
differenceinunitsofinsulin
used.
45
Appendix8:HowShouldPatientsonInsulinPumpTherapybeManagedinHospital?
Table8.1.Generalrecommendationsfordiabeticpatientswhocontinuecontinuoussubcutaneousinsulininfusiontherapyinhospital.
CSIItherapyistobecontinuedinhospitalonlyinthosesituationswherethepatientortheirguardianhavetheabilitytoselfmanagetheirinsulin
dosingandthepump(buttonpushingandsetchanges)safely.
CSIIshouldneversubstituteforanintravenousinsulininfusiontotreatpatientswithdiabeticketoacidosis.
Inametabolicallystablepatient,whoisabletoeat,CSIImaybemoreappropriatethananintravenousinsulininfusionorabasal+topupinjection
regimen.
RegardlessastowhetherCSIIistobecontinuedorceasedduringthepatientshospitalizationitisstronglyrecommendedthatanendocrineservice
consultation(ifavailable)isobtainedforallpatientsatthetimeofadmission.Theendocrinologistusuallyresponsibleforthecareofthepatient
shouldbenotifiedatthetimeofadmission.
Thepatientwillberesponsible(inconsultationwiththeendocrineteam)forsettingbasalrates,determiningbolusdosesadministeredwithmeals
ortocorrectelevatedglucoselevelsandforsetchanges.
ComprehensivedocumentationallaspectsofCSIImanagementisrequired.
CSIItherapymustbesubstitutedwitheitherasubcutaneousinsulinregimenoranintravenousinsulininfusionif:
1/Thepatientorguardianisnotabletodemonstratethattheyareabletosafelyandreliablymanagetheinsulinpump.
2/Asevereacuteillnessispresent.
3/AprocedureorinvestigationisplannedpotentiallyrenderingCSIItherapyineffectiveortheanaestheticstaffarenotconfident
regardingthemanagementofthepump.
4/Thereareconcernsregardingamalfunctioninthepump.
Shouldtherebeconcernsregardingthetechnicalfunctioningofthepumpmanufacturershelplineshouldbecontacted.
CSII therapy should never be discontinued without first ensuring the provision of insulin via an alternative route (IV infusion or subcutaneous
injection)
ThepatientsadmissiontohospitalshouldbeusedasanopportunitytoreviewallaspectsofCSIImanagementbytheEndocrinologyteam.
46
Table8.2.MinimumpatientcompetencyrequirementsforcontinuedinpatientCSIItherapy.
Abilitytooperatethemanagementmenuofthedevicetoalterbasalrates.
Ability to operate the management menu of the device to modify parameters of and operate the bolus calculator (including a basic level of
proficiencyincarbohydratecounting)
Abilitytoperformasetchangeandmanagelineocclusionsorleaksandhaverelevantsuppliestoimplementasetchange.
Table8.3.ContraindicationstocontinuedinpatientCSIItherapy.
Patientisunabletodemonstrateabasiclevelofcompetencyintheoperationoftheirinsulinpump.
Impairedorfluctuatingconsciousstate.
Majorpsychiatricdisorder(psychosis)
Severeacuteillness(includingdiabeticketoacidosis)requiringaninsulininfusion
Lackofsupplies(infusionsets,batteriesandotherequipmentrequiredtocontinuethepatientonCSIItherapy)
Extensiveskininfectionsorinflammation.
Concernsregardingtechnicalmalfunctionofthepump.
Numerous radiological procedures (CT and MRI). The pump should be suspended and disconnected prior to the patient entering a CT or MRI
scanner.
Patientundergoinglengthyorcomplicatedsurgery,orseriousmedicalillnesslikelytobeaccompaniedbysignificantmetabolicdisturbance.
47
Table8.4.HospitaldocumentationrecommendedforinpatientscontinuingCSII.
ThemodelofthepumpanddurationofCSII.
Datecurrentpumppurchased.
Detailsofinsulindeliveryline.
Thenameoftheinsulininfusedwithanindicationthatitisbeingdeliveredviaapump.
Insulindeliveryparametersincludingbasalrates,insulintocarbohydrateratios,correctionfactors,durationofinsulinactionandglucosetargets.
Anychangestothepumpinsulindeliverysettingsshouldbeclearlydocumentedatthetimetheyareimplemented.Itshouldalsobedocumented
thatthesechangeshavebeenclearlyconveyedtoandconfirmedbythepatientortheirguardian.
Thedateandtimeofsetchanges.Afollowupfingerprickglucoseshouldbeperformed2hrslateranddocumented.
Fingerprickglucosereadings.Atleast4(premealandbedtime)andpreferably7(premeal,2hourpostmealandbedtime)fingerprickglucose
readingsarerecommended.Theseshouldbedocumentedontheglucosemonitoringchart.
Ketonereadings.Bloodketonesarepreferabletourinaryketonemeasurements.
A signed agreement with the patient that clearly documents the patients responsibilities with regard to inpatient CSII management is
recommended.
Table8.5.IntraoperativeconditionsappropriateforCSIIorswitchtotemporaryinsulininfusion
SituationsappropriateforintraoperativeCSII Indicationsforintraoperativeintravenousinsulininfusion
Procedureofshortduration(e.g.D&C). Prolonged and complicated procedure (eg coronary bypass
Medicalandanaestheticstaffthatarefamiliarwithpumps. surgery).
Patientawakeandalertintraoperatively. MedicalandanaestheticstaffunfamiliarwithCSII.
Patientmetabolicallystable. Patientcriticallyunwellandmetabolicallyunstable.
Patient alert and to resume eating shortly after completion of the Prolongedpostoperativerecoveryperiod.
procedure.
48
Table8.6.RecommendationsforperioperativemanagementofCSII.
Situation Recommendations
Preoperative Performasetchangeonthemorningorafternoonofthedaypriortotheprocedure.Ensurethattheinsertionsiteiswellawayfrom
theoperativefield.
Infastingpatientsconsiderinfusinginsulinatareducedtemporarybasalrateeg70%.
IVdextrose(eg5%at80ml/hr)shouldbeinfusedtopreventketosis.
Nobolusesarenecessaryunlesstheyareusedtocorrectelevatedglucoselevels.
Monitorglucoselevelsandketoneswithincreasedfrequencyasperthehospitalsestablishedprotocols.
IfCSIIistobecontinuedintraoperativelyconsentmustbeobtainedfromthepatientortheirguardian.
IfCSIIistobecontinuedintraoperativelyalabelwhichisclearlyvisiblemustbeattachedtothepatientstatingthattheyhaveType1
diabetesandareusinganinsulinpump.
Intraoperative EnsurethattheanaesthetistisawarethatCSIIistobecontinuedduringsurgeryandisabletodisconnectthepumpifnecessary.
Ensurethatthepumpisaccessibletotheanaesthetistintraoperatively.
Glucoselevelsshouldbemonitoredfrequently(atleasthourly)andketonesasdeterminedbytheanaesthetist.
IntheeventofanunexplainedelevationinglucoselevelsorfrankketosisanIVinsulininfusionshouldbecommencedandtheinsulin
pumpsuspendedanddisconnected.
Intheeventofintraoperativehypoglycaemia,thepumpshouldbesuspendedimmediatelyandabolusofIVdextroseadministered.
Oncehypoglycaemiahasbeenabolishedtheinsulinpumpcanberecommencedatareducedbasalrate.AlternativelytheIVdextrose
canbeinfusedatagreaterrate.Inthefaceofunstableglucoselevels,andananaesthetistwithlimitedCSIIexperience,CSIIshouldbe
ceasedandaformalIVinsulininfusioncommenced.
Bipolardiathermyiscontraindicated.Unipolardiathermycanbeused.
Ceasingand WhencommencingpatientsmanagedwithCSIIonasubcutaneousinsulinregimenthefirstinjection(s)shouldbegivenatthetime
Recommencing CSIIisceasedandshouldincludealongactinginsulinanalogue.
CSII Anintravenousinsulininfusionshouldbecommencedwithin2hoursofcessationofCSII.
InhospitalizedpatientswhereCSIIhasbeenceasedwiththepatientmanagedonaninsulininfusionormultipledailyinjections,when
recommencingCSIIispreferablethatCSIIberecommencedinthemorningandwiththeinsertionofanewline.
Inthosemanagedwithmultipledailyinjectionswhileaninpatient,iftheyareonalongactinganalogueadministeredintheevening,
halfthedoseshouldbegivenonthenightwithCSIIcommencedthenextmorning.
CSIIshouldberecommencedimmediatelypriortocessationofaninsulininfusion.
49
Appendix9:AppropriateGlucoseControlinEndofLifeSituations
Table9.1.Phasesofendoflifepathway
Phase Description
Stable Thepersonssymptomsareadequatelycontrolledontheirestablishedmanagementplanbutinterventionstomaintainsymptom
controlandqualityoflifehavebeenplanned.Thisphasemaylastforseveralyears.
Unstable Thepersondevelopsanewunexpectedproblemorarapidincreaseintheseverityofexistingproblems.
Deteriorating Thepersonsexistingsymptomsgraduallyworsenortheydevelopnewbutunexpectedproblems.
Terminal Deathislikelyinamatterofdaysandnoacuteinterventionisplannedorrequired.
Table9.2.Suggestedinpatientmanagementoftype1andtype2diabetesinthephasesoftheendoflifepathway
50
theinsulinregimene.g.singlebasal insulin injectionwithtopups currentinsulinregimenshouldbeimplementedifpossiblewithless
ofshortactinginsulinanaloguetomaintaincomfort.Lessfrequent frequentBGmonitoring(12perday).AimforBGsbetween5.015.0
BGmonitoring(12perday)andketonechecksarerecommended. mmol/L.Removefoodrestrictions.Reviewtheneedforanynon
AimforBGs between5.015.0mmol/L. Removefoodrestrictions. diabetesmedicationsexacerbatinghyperglycaemiaor
Review the need for any nondiabetes medications exacerbating hypoglycaemia.Ensurefollowupandsupportofthepatientpost
hyperglycaemia or hypoglycaemia. If patient is to be discharged discharge.
homefromhospital,considermodifyinginsulinregimenaimingfor
simplicity and minimisation of the risk for hypoglycaemia. Ensure
followupandsupportofthepatientpostdischarge.
Terminal Thepatientspreferencesorthoseoftheircarertakeprecedence. Theprimaryobjectiveistomaintaincomfort.Considerceasingall
Theprimaryobjectiveistomaintainpatientcomfort.Asingledaily glucosemonitoring.Considerceasingallinsulinandoral
injection of basal insulin administration may be required to hypoglycaemicagents.Ifseverehyperglycaemiaandthepatient
maintain comfort by addressing severe hyperglycaemia and to symptomaticfromhyperglycaemiaconsidercommencingadaily
preventfrankketoacidosis.Considerminimising/ceasingallglucose injectionofbasalinsulin.
and ketone monitoring after the appropriate discussion with the
patientortheircarer.
Table9.3.Factorspotentiallyinfluencingmanagementofglycaemia.
Anorexiaandweightloss.
Confusionandalteredconsciousstate.
Thestressresponsetopain,anxiety,infectionandunrelatedintercurrentillness.
Disturbanceinglucosemetabolismresultingfromsomemalignanttumours.
Useofcorticosteroidsandotherdiabetogenicmedications.
Metabolicderangementincludingrenalandhepaticdysfunction.
51
Appendix10:HowShouldPatientswithNewlyDiscoveredHyperglycaemiabeFollowedUp?
Table10.1.IncidenceofnewlydiagnoseddiabetesatvariousglucoseandHbA1cscreeningthresholds
Figure11.1.Suggestedapproachtodiagnosisofdiabetesandfollowupofinpatientwithnewlydiscoveredhyperglycaemia.
53
Elevatedrandomblood
glucose>7.8mmol/L
DetermineHbA1c
6.5%* <6.5%
(48mmol/mol) (48mmol/mol)
#
Manageasdiabetes oralGTTasan
outpatientorrepeat
Earlyreferralto HbA1c
inpatient
specialistdiabetes
teamifavailable #
EnsureappropriatecommunicationtotheGP
Appropriate
outpatientfollow
*Internationalexpertcommittee
up
54
Appendix11:TheSpecialistDiabetesInpatientManagementTeam.
Table11.1.Hospitalapproachestodiabetesmanagement
Table11.2.StudiesexaminingeffectivenessofSpecialistDiabetesInpatientTeams
55
2001165 analysisofdiabetic specialistnurse amongstmedicalpatientsand8to5days(p<0.001)in beddaysoverone hospital
admissionspreand surgicalpatients year
postintervention
Sampson Retrospective 14722 Diabetes Meanexcessbeddaysfordiabetesadmissions Estimated700bed SingleUK
2006166 analysisofdiabetic inpatient reducedfrom1.9daysto1.2daysafterintroduction dayssavedper teaching
admissionspreand specialistnurse oftheservice 1000inpatients hospital
postintervention service withdiabetes
Newton Randomchartaudit Not Diabetesclinical Reductioninmeanglucoselevelsfrom9.8mmol/Lto Estimatedsavingof SingleUS
2006167 preandpost reporte nursespecialist, 8.4mmol/L(p<0.0001).ReductioninLOSforpatients $2.2Mperyearfor tertiary
intervention d Diabetesnurse withdiabetesfrom6.010.32to5.750.38days thehospital care
casemanagers, (p=0.01). hospital
medicaldirector
Courtney Prospectivestudy 452 Diabetes Reductioninmedicationerrorsfrommedian6to4 6wards
2007168 comparingdiabetic SpecialistNurse (p<0.01). inUK
admissionswith withprescribing ReductioninLOSfrommedianfrom9to7days general
interventionvs rights (p<0.05) hospital
historicalcontrols
Flanagan Retrospective 28,016 5specialist LOSfellfrom8.3018to7.70.10(p=0.002).Effect SingleUK
2008169 analysisofdiabetic nurses, predominantlyinmedicalpatients. teaching
admissionspreand consultantand Emergencyadmissionsfellfrom9.70.2to9.20.2 hospital
postintervention specialty (p<0.001).
registrar Nochangeinelectiveadmissions.
Brooks Retrospectiveaudit 1140 Endocrinologist, ReductioninaverageLOSforallpatientswithdiabetes Estimatedcost SingleUK
2011170 diabetesnurse from9.39to3.76days. saving132,500 district
specialist,junior NochangeinaverageLOSforpatientswithprimary over3months hospital
doctor diagnosisofdiabetes
Table11.3.TheroleoftheSpecialistDiabetesInpatientTeam
Improvingdiabetesmanagementexpertisethroughoutthehospital,
Developmentandimplementationofspecificdiabetesmanagementprotocols,
Directmanagementofdiabeteswithspecificreferralcriteria,
Wardliaison,troubleshooting,managementadvice,
Dischargeplanning,
56
Appendix12:WhatRoutineMeasuresShouldbeUndertakenforPeoplewithDiabetesAdmittedtoHospital?
Table12.1:Roleofvariousteammembersinensuringoptimalroutinediabetescareinhospitalandafterdischarge.
Provideclinicalleadershipandcontinuing Qualifiedprofessionalsare"ADEACredentialledDiabetesEducators"176.Ifavailable,
stablecareinanenvironmentoftransitional theservicesofadiabeteseducatorareusefulintheearlystagesandacontinuing
androtatingmedical,nursingandallied liaisoncanbeestablished.
healthworkforce.
Reportbacktothediabetesteamifinput
shouldbeofferedtothereferringunit.
LiaisewithDiabetesTeamregardingchanges Providedieteticinterventionrecommendationsthatincludeconsistencyindayto
indietparticularlyinthesituationofenteral daycarbohydrateintake,substitutionofsucrosecontainingfoods,usualprotein
andparenteralnutrition. intake,cardioprotectivenutritioninterventions,weightmanagementstrategies,
regularphysicalactivity
AboriginalHealth Providingculturallyappropriateandpracticalsupportandcounselingforongoing
Worker care,thusimprovingpatientunderstandingandadherencetotreatmentprograms.
57
ContributorstotheADSGuidelinesforRoutineGlucoseControlinHospital
WritingParty
A/ProfNWahCheung MsKristineHeels*
DrDavidChipps DrDavidONeal
MsShirleyCornelius* DrJenniferWong
DrBarbaraDepczynski A/ProfSophiaZoungas
*RepresentingAustralianDiabetesEducatorsAssociation
ExpertConsultativePanelandAdditionalContributors
DrShirleyElkassaby DrMargaretLayton
AworkshopwiththeExpertConsultativePanelwasheldwithsupportfromtheNationalDiabetesServices
SchemeinJuly2012.
58
GLOSSARYOFTERMSUSEDRELATINGTOINSULIN
Slidingscaleinsulin Theprescriptionofinsulingiveninavariabledosedependingon
theglucoselevelatthetime.Oftenthisisthesoleinsulin
prescribed.
Supplementalinsulin Theadministrationofvariabledoseinsulintocorrect
hyperglycaemia,giveninconjunctionwithappropriateadjustments
tothepatientsscheduledantidiabetictherapy.
Correctionalinsulin Thistermisusedinterchangeablywithsupplementalinsulin
Basalinsulin Intermediateorlongactinginsulinprovidingbackgroundinsulin(eg
Protaphane,HumulinNPH,Lantus,Levemir)
Prandialinsulin Rapidactinginsulingivenatmealtimes(egNovorapid,
Humalog,Apidra)
Basalbolusinsulin Insulinregimecomprisingthecombinationofabasalinsulinwith
multipledailydosesofprandialinsulin
Ispohaneinsulin Intermediateactinginsulin(egProtaphane,HumulinNPH)
Continuoussubcutaneousinsulin Insulinadministeredbycontinuoussubcutaneousinfusionviaan
infusion(CSII) patientselfmanagedinsulinpump
59
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