Diabetes mellitus; Hyperglycemia

Diabetes mellitus; Hyperglycemia - Acute

Definition  

Individualized management of patients with known diabetes, and patients with hyperglycemia not known to have diabetes, to meet glycemic goals while preventing hypoglycemia

 

 

Monitoring of glycemic status in hospitalized patients with known diabetes or hospitalized patients receiving therapy associated with a high risk of hyperglycemia  

* Glucose measurement, blood: For noncritically ill patients, random glucose levels <180 mg/dL to 200 mg/dL and fasting glucose levels <126 mg/dL are reasonable. For critically ill surgical patients, blood glucose levels <140 mg/dL (ideally as close as possible to 110 mg/dL) are recommended and critically ill nonsurgical patients should maintain a blood glucose measurement <140 mg/dL .

 

Evaluation of glycemic status in patients with known diabetes upon admission to the hospital  

* Hemoglobin A1c measurement

 

Medical History  

* Past medical history of Heart disease

* Poor glycemic control

* Hypertension

 

Tests  

 

Monitoring of glycemic status in hospitalized patients with known diabetes or hospitalized patients receiving therapy associated with a high risk of hyperglycemia  

* Glucose measurement, blood: For noncritically ill patients, random glucose levels <180 mg/dL to 200 mg/dL and fasting glucose levels <126 mg/dL are reasonable. For critically ill surgical patients, blood glucose levels <140 mg/dL (ideally as close as possible to 110 mg/dL) are recommended and critically ill nonsurgical patients should maintain a blood glucose measurement <140 mg/dL .

 

Evaluation of glycemic status in patients with known diabetes upon admission to the hospital  

* Hemoglobin A1c measurement

 

Treatment  

 

Drug Therapy  

 

Subcutaneous insulin for noncritically ill hospitalized patients with type 2 diabetes mellitus  

 

INSULIN  

Adults (using insulin at home): Continue the subcutaneous regimen used at home; adjust as needed based on glucose levels

Adults (not using insulin previously): Usual daily requirement is 0.4 to 1 unit/kg/day subcutaneously; adjust as needed based on glucose levels

 

Subcutaneous insulin for noncritically ill hospitalized patients with type 1 diabetes mellitus  

 

INSULIN  

Adults (who are eating): Continue the same subcutaneous basal insulin regimen used at home; adjust subcutaneous prandial insulin as needed based on patient situation and glucose levels

Adults (newly diagnosed diabetes): Usual daily requirement is 0.5 to 0.7 units/kg/day subcutaneously; administer half of the daily dose as basal insulin and the other half as prandial insulin and adjust as needed based on glucose levels

 

Premeal supplemental subcutaneous insulin in noncritically ill hospitalized patients  

 

INSULIN  

Adults (requiring ?40 units of insulin/day): Premeal blood glucose (PBG) 150 to 199 mg/dL, 1 unit of additional insulin subcutaneously; PBG 200 to 249 mg/dL, 2 units of additional insulin subcutaneously; PBG 250 to 299 mg/dL, 3 units of additional insulin subcutaneously; PBG 300 to 349 mg/dL, 4 units of additional insulin subcutaneously; PBG >349 mg/dL, 5 units of additional insulin subcutaneously

Adults (requiring 40 to 80 units of insulin/day): PBG 150 to 199 mg/dL, 1 unit of additional insulin subcutaneously; PBG 200 to 249 mg/dL, 3 units of additional insulin subcutaneously; PBG 250 to 299 mg/dL, 5 units of additional insulin subcutaneously; PBG 300 to 349 mg/dL, 7 units of additional insulin subcutaneously; PBG >349 mg/dL, 8 units of additional insulin subcutaneously

Adults (requiring >80 units of insulin/day): PBG 150 to 199 mg/dL, 2 units of additional insulin subcutaneously; PBG 200 to 249 mg/dL, 4 units of additional insulin subcutaneously; PBG 250 to 299 mg/dL, 7 units of additional insulin subcutaneously; PBG 300 to 349 mg/dL, 10 units of additional insulin subcutaneously; PBG >349 mg/dL, 12 units of additional insulin subcutaneously

 

 

Blood glucose level less than 60 mg/dL in noncritically ill hospitalized patients on subcutaneous insulin  

 

DEXTROSE  

Adults (who can tolerate oral intake): Give 15 g of fast-acting carbohydrate (4 ounces of fruit juice or non-diet soda, 8 ounces of nonfat milk, or 3 to 4 glucose tablets); test blood glucose (BG) every 15 minutes, repeat fast-acting carbohydrate if BG <80 mg/dL

Adults (who cannot tolerate oral intake): Give 25 mL of dextrose 50% solution IV push; test BG every 15 minutes, repeat dextrose administration if BG <80 mg/dL

 

 

Intravenous insulin infusion for critically ill hospitalized patients  

 

INSULIN  

Adults: Initiate IV insulin infusion according to the appropriate algorithm when blood glucose (BG) ?70 mg/dL or BG >120 mg/dL in surgical patients who have taken an oral hypoglycemic within 24 hours. Standard drip concentration is 100 units/100 mL 0.9% NaCl for administration with infusion device .

Adult algorithm changes: Algorithm failure is defined as BG outside the goal range (usually 80 to 180 mg/dL), and BG does not change by at least 60 mg/dL within 1 hour. Movement to a lower algorithm is indicated for 2 consecutive BG levels <70 mg/dL. Monitor capillary BG every 1 hour until within goal range for 4 hours, then every 2 hours for 4 hours, then every 4 hours if stable .

Adults algorithm 1 (initial infusion for most patients): BG 70 to 109 mg/dL, 0.2 unit/hr; BG 110 to 119 mg/dL, 0.5 unit/hr; BG 120 to 149 mg/dL, 1 unit/hr; BG 150 to 179 mg/dL, 1.5 units/hr; BG 180 to 209 mg/dL, 2 units/hr; BG 210 to 239 mg/dL, 2 units/hr; BG 240 to 269 mg/dL, 3 units/hr; BG 270 to 299 mg/dL, 3 units/hr; BG 300 to 329 mg/dL, 4 units/hr; BG 330 to 359 mg/dL, 4 units/hr; BG >360 mg/dL, 6 units/hr

Adults algorithm 2 (failure of algorithm 1, or initial infusion for patients receiving corticosteroids, requiring more than 80 units/day as an outpatient, or status post coronary artery bypass graft, solid organ transplant, or islet cell transplant): BG 70 to 109 mg/dL, 0.5 unit/hr; BG 110 to 119 mg/dL, 1 unit/hr; BG 120 to149 mg/dL, 1.5 units/hr; BG 150 to 179 mg/dL, 2 units/hr; BG 180 to 209 mg/dL, 3 units/hr; BG 210 to 239 mg/dL, 4 units/hr; BG 240 to 269 mg/dL, 5 units/hr; BG 270 to 299 mg/dL, 6 units/hr; BG 300 to 329 mg/dL, 7 units/hr; BG 330 to 359 mg/dL, 8 units/hr; BG >360 mg/dL, 12 units/hr

Adults algorithm 3 (failure of algorithm 2; or authorization from endocrine service): BG 70 to 109 mg/dL, 1 unit/hr; BG 110 to 119 mg/dL, 2 units/hr; BG 120 to149 mg/dL, 3 units/hr; BG 150 to 179 mg/dL, 4 units/hr; BG 180 to 209 mg/dL, 5 units/hr; BG 210 to 239 mg/dL, 6 units/hr; BG 240 to 269 mg/dL, 8 units/hr; BG 270 to 299 mg/dL, 10 units/hr; BG 300 to 329 mg/dL, 12 units/hr; BG 330 to 359 mg/dL, 14 units/hr; BG >360 mg/dL, 16 units/hr

Adults algorithm 4 (failure of algorithm 3): BG 70 to 109 mg/dL, 1.5 units/hr; BG 110 to 119 mg/dL, 3 units/hr; BG 120 to 149 mg/dL, 5 units/hr; BG 150 to 179 mg/dL, 7 units/hr; BG 180 to 209 mg/dL, 9 units/hr; BG 210 to 239 mg/dL, 12 units/hr; BG 240 to 269 mg/dL, 16 units/hr; BG 270 to 299 mg/dL, 20 units/hr; BG 300 to 329 mg/dL, 24 units/hr; BG >330 mg/dL, 28 units/hr

 

DEXTROSE  

Adults: 100 to 200 mL/hr of dextrose 5% solution OR 100 to 200 mL/hr of dextrose 5% solution/normal saline (1:2) OR equivalent (eg, total parenteral nutrition, enteral feeding)

 

Blood glucose level less than 60 mg/dL in critically ill hospitalized patients on intravenous insulin  

 

DEXTROSE  

Adults (awake): Discontinue insulin infusion and give 25 mL 50% dextrose solution (D50W) IV; check blood glucose (BG) every 20 min and repeat dextrose administration if BG <60 mg/dL; resume insulin infusion with lower algorithm when BG>70 mg/dL on 2 consecutive tests

Adults (not awake): Stop insulin infusion and give 50 mL D50W IV; check BG every 20 min and give 25 mL D50W if BG <60 mg/dL; resume insulin infusion with lower algorithm when BG>70 mg/dL on 2 consecutive tests

 

Pregnant women with known diabetes during active labor  

 

DEXTROSE  

Adult (blood glucose <80 mg/dL): 2.55 mg/kg/min 10% dextrose solution IV

Adult (blood glucose 81 to 100 mg/dL): 1.275 mg/kg/min 10% dextrose solution IV

 

SODIUM CHLORIDE  

Adult (blood glucose 101 to 140 mg/dL): IV saline infusion without glucose

 

SODIUM CHLORIDE - INSULIN  

Adult (blood glucose >140 mg/dL without administration of insulin): IV saline infusion with hourly insulin administration

 

Procedural Therapy  

 

Hospitalized patients with diabetes mellitus  

* Referral to dietetics service

 

Non-Procedural Therapy  

 

Hospitalized patients with diabetes mellitus  

* Patient Education