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Canadian Diabetes Association
Clinical Practice Guidelines
In-Hospital Management of Diabetes
Dr.Saeid Khezer
Family physician
Kurdistan / Duhok
guidelines.diabetes.ca | 1-800-BANTING (226-8464) | diabetes.ca
Copyright © 2013 Canadian Diabetes Association
CONTINUE pre-hospital diabetes regimen if
appropriate, otherwise …
USE insulin as the treatment of choice
DO NOT use sliding scale insulin alone
DO use BASAL + BOLUS + CORRECTION insulin
regimen
AVOID hypoglycemia
2013In-hospital Management Checklist
guidelines.diabetes.ca | 1-800-BANTING (226-8464) | diabetes.ca
Copyright © 2013 Canadian Diabetes Association
• Approximately 1/3 of
in-patients have been
found to have
hyperglycemia
• Many have pre-
existing diabetes prior
to admission
Hyperglycemia
In-hospital Hyperglycemia is Common
guidelines.diabetes.ca | 1-800-BANTING (226-8464) | diabetes.ca
Copyright © 2013 Canadian Diabetes Association
Hyperglycemia
Decreased immune
function, wound healing,
increased oxidative stress
Acute Illness
Increased stress hormones, use of glucocorticoids,
decreased level of activity
Inzucchi SE. NEJM 2006;355;1903
Hyperglycemia and Acute Ilness
guidelines.diabetes.ca | 1-800-BANTING (226-8464) | diabetes.ca
Copyright © 2013 Canadian Diabetes Association
Hyperglycemia
Increases risks
of postoperative
infections and
delirium
Prolonged
hospital stay,
resource
utilization
Increased renal
dysfunction and
renal allograft
rejection in
transplant
Adverse Effects of Hyperglycemia
guidelines.diabetes.ca | 1-800-BANTING (226-8464) | diabetes.ca
Copyright © 2013 Canadian Diabetes Association
Patient Type Glucose Target
(mmol/L)
Therapy of
choice
Non-critically ill Fasting 5-8
Random <10
Pre-hospital
regimen OR
basal-bolus-
correction
Critically ill 8-10 IV insulin infusion
CABG intraop 5.5-10 IV insulin infusion
Other periop 5-10 As appropriate
CABG = coronary artery bypass graft; IV = intravenous; Intraop = intraoperative;
periop = perioperative
In-hospital Glycemic Targets
guidelines.diabetes.ca | 1-800-BANTING (226-8464) | diabetes.ca
Copyright © 2013 Canadian Diabetes Association
In the absence of routine
insulin, sliding scale insulin
regimen (bolus insulin on a prn
basis) is purely reactive rather
than proactive and allows for
hyperglycemia to occur before
responding
BG (mmol/L) Bolus insulin (U)
<4 Call MD
4.1 – 10.0 0
10.1 – 13.0 2
13.1 – 16.0 4
16.1 – 19.0 6
>19.0 Call MD
Queale WS. et al. Arch Int Med 1997;157
Sliding Scale Alone is Inefficient
guidelines.diabetes.ca | 1-800-BANTING (226-8464) | diabetes.ca
Copyright © 2013 Canadian Diabetes Association
4.0
10.0
Breakfast Lunch Dinner Bedtime
BG (mmol/L) Bolus insulin (U)
< 4 Call MD
4.1 – 10.0 0
10.1 – 13.0 2
13.1 – 16.0 4
16.1 – 19.0 6
> 19.0 Call MD
6.0
Bolus insulin QID
14.0
6.0
16.5
3.0
Sliding Scale alone
What do you do?
What do you do?
What do you do?
What do you do?
+4 U
0 U 0 U
+6 U
QID: four times daily; SSI: sliding-scale insulin; BG: blood glucose
Sliding Scale Insulin Alone Results in
Variable Glucose ControlBG (mmol/L)
guidelines.diabetes.ca | 1-800-BANTING (226-8464) | diabetes.ca
Copyright © 2013 Canadian Diabetes Association
Use BASAL + BOLUS + CORRECTION
In-hospital circumstances may
warrant temporarily holding
other antihyperglycemic
medications (eg. renal or
hepatic impairment)
Insulin = treatment of choice
BASAL + BOLUS +
CORRECTION
Insu
lin
BOLUS + CORRECTION
BASAL
Breakfast Lunch Dinner
guidelines.diabetes.ca | 1-800-BANTING (226-8464) | diabetes.ca
Copyright © 2013 Canadian Diabetes Association
BASAL + BOLUS + CORRECTION Results in
Smoother Glycemic Control
4.0
10.0
Breakfast Lunch Dinner Bedtime
BG (mmol/L) Bolus insulin (U)
< 4 Call MD
4.1 – 10.0 0
10.1 – 13.0 2
13.1 – 16.0 4
16.1 – 19.0 6
> 19.0 Call MD
6.0
12.0
6.0
Correctional Insulin AC meals
What do
you do?
What do you do?
What do
you do?
6+2 U
6+0 U
6U 6U
What do you do?
6+0 U
6.0
ROUTINE Bolus insulin
Basal
insulin6U
18 U
Routine Basal
guidelines.diabetes.ca | 1-800-BANTING (226-8464) | diabetes.ca
Copyright © 2013 Canadian Diabetes Association
*
*
ŧŧ
†
†
RABBIT 2 RABBIT 2 Surgery
Adapted from: Umpierrez GE, et al. Diabetes Care 2007;30:2181-86.
Adapted from: Umpierrez GE, et al. Diabetes Care 2011;34:256-61.
Basal-Bolus (BBI) Regimen Achieves Better
Control than Sliding Scale (SSI) Alone
Blo
od
glu
co
se
(m
mo
l/L
)
¶
¶
¶
**
*
Admit 1 2 3 4 5 6 7 8 9 10
Duration of treatment (days)
5.6
6.7
7.8
8.9
10.0
11.1
12.2
13.3
*p < 0.01; ¶p < 0.05.
¶
SSI
BBI
1Randomi
-zation2 3 4 5 6 7 8 9
Duration of treatment (days)
6.7
7.8
8.9
10.0
11.1
13.3
*p < 0.001, ŧp = 0.02, †p = 0.01
SSI
BBI
guidelines.diabetes.ca | 1-800-BANTING (226-8464) | diabetes.ca
Copyright © 2013 Canadian Diabetes Association
• Protocols for hypoglycemia avoidance, recognition
and management should be implemented with
nursing-initiated treatment
• Patients at risk of hypoglycemia should have ready
access to an appropriate source of glucose at all
times
• Insulin protocols and order sets may be used to
improve adherence to optimal insulin use and
glycemic control
Avoid Hypoglycemia
guidelines.diabetes.ca | 1-800-BANTING (226-8464) | diabetes.ca
Copyright © 2013 Canadian Diabetes Association
1. Provided that their medical conditions, dietary
intake, and glycemic control are acceptable, people
with diabetes should be maintained on their pre-
hospitalization oral anti-hyperglycemic agents or
insulin regimens [Grade D, Consensus]
Recommendation 1
guidelines.diabetes.ca | 1-800-BANTING (226-8464) | diabetes.ca
Copyright © 2013 Canadian Diabetes Association
Recommendation 2
2. For hospitalized patients with diabetes treated with
insulin, a proactive approach that includes basal,
bolus, and correction (supplemental) insulin,
along with pattern management, should be used to
reduce adverse events and improve glycemic
control, instead of the reactive sliding-scale
insulin approach that uses only short- or rapid-acting
insulin [Grade B, Level 2]
guidelines.diabetes.ca | 1-800-BANTING (226-8464) | diabetes.ca
Copyright © 2013 Canadian Diabetes Association
3. For the majority of non critically ill patients treated
with insulin, pre-meal BG targets should be 5.0 to
8.0 mmol/L in conjunction with random BG values
<10.0 mmol/L, as long as these targets can be
safely achieved [Grade D, consensus]
4. For most medical/surgical critically ill patients
with hyperglycemia, a continuous IV insulin
infusion should be used to maintain glucose levels
between 8.0-10.0 mmol/L [Grade D, consensus]
2013
2013
Recommendations 3 and 4
guidelines.diabetes.ca | 1-800-BANTING (226-8464) | diabetes.ca
Copyright © 2013 Canadian Diabetes Association
5. To maintain intraoperative glycemic levels between
5.5-10.0 mmol/L for patients with diabetes
undergoing CABG, a continuous IV insulin infusion
protocol administered by trained staff, [Grade C, Level 3]
should be used
6. Perioperative glycemic levels should be maintained
between 5.0-10.0 mmol/L for most other surgical
situations, with appropriate protocol and trained staff
to ensure safe and effective implementation of
therapy and to minimize the likelihood of
hypoglycemia [Grade D, Consensus]
2013
Recommendations 5 and 6
guidelines.diabetes.ca | 1-800-BANTING (226-8464) | diabetes.ca
Copyright © 2013 Canadian Diabetes Association
7. In hospitalized patients, hypoglycemia should be
avoided:
– Protocols for hypoglycemia avoidance, recognition
and management should be implemented with nurse
–initiated treatment, including glucagon for severe
hypoglycemia when IV access is not readily available [Grade D, consensus]
– Patients at risk of hypoglycemia should have ready
access to an appropriate source of glucose (oral or
IV) at all times, particularly when NPO or during
diagnostic procedures [Grade D, Consensus]
2013Recommendation 7
guidelines.diabetes.ca | 1-800-BANTING (226-8464) | diabetes.ca
Copyright © 2013 Canadian Diabetes Association
8. Healthcare professional education, insulin
protocols and order sets may be used to improve
adherence to optimal insulin use and glycemic
control [Grade C, Level 3]
9. Measures to assess, monitor, and improve
glycemic control within the inpatient setting should
be implemented, as well as diabetes-specific
discharge planning [Grade D, Consensus]
2013Recommendation 8 and 9
guidelines.diabetes.ca | 1-800-BANTING (226-8464) | diabetes.ca
Copyright © 2013 Canadian Diabetes Association
CDA Clinical Practice Guidelines
http://guidelines.diabetes.ca – for professionals
1-800-BANTING (226-8464)
http://diabetes.ca – for patients
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