II. Complications: Uncontrolled Blood Glucose

  1. Decreased survival
  2. Increased cardiac or Cerebral Infarction
  3. Increased infectious disease
  4. Post-surgical Hyperglycemia correlates to complications
    1. Diabetes Mellitus confers 2 relatve risk complication
    2. BG >200 mg/dl confers >3 Relative Risk complication
    3. BG >250 mg/dl confers >12 Relative Risk complication
    4. (2002) Amer J Cardiol [PubMed]

III. Approach: Emergency Department

  1. Exclude Diabetic Ketoacidosis (DKA)
    1. Serum beta hydroxybutyrate increased AND
    2. Significant Metabolic Acidosis with Anion Gap
  2. Exclude Hyperosmolar Hyperglycemic State (HHS)
    1. Significant Hyperglycemia (typically >1000 mg/dl) AND
    2. Severely hyperosmolar AND
    3. Neurologic deficit (e.g. Altered Level of Consciousness, focal weakness or sensory deficit, Seizure, coma)
  3. Once DKA and HHS are excluded, most Hyperglycemia (<600 mg/dl) in DM2 does not require emergent lowering
    1. Driver (2016) Ann Emerg Med 86(6): 697-705 +PMID:27353284 [PubMed]
  4. Protocol
    1. Glucose detectable on Glucometer (<500-600 mg/dl)
      1. See Nutrition in Diabetes Mellitus
      2. See Carbohydrate Count
      3. Increase Insulin (e.g. 3 units)
        1. See Insulin Dosing
      4. Discharge home with close follow-up
    2. Glucose undetectable on Glucometer (>600 mg/dl)
      1. Lower Glucose in ED to level that will consistently be readable on Glucometer (<400-500 mg/dl)
      2. Administer 1-2 Liters of Lactated Ringers
      3. Administer IV Insulin (e.g. 10 units)
      4. Monitor Glucose and Potassium
      5. When Glucose detectable, educate, adjust Insulin and discharge home with follow-up (as above)
  5. References
    1. Orman and Willis in Herbert (2017) EM:Rap 17(7):8-9

IV. Approach: Hospital

  1. Evaluate status on hospitalization
    1. Check Fasting Blood Glucose
    2. Hemoglobin A1C on admission
  2. Hospitalized Blood Glucose control in non-ICU patients
    1. Glucose monitoring
      1. Oral medications: once daily Blood Glucose (random Glucose is acceptable)
      2. Insulin: At meals and at bedtime (4 times daily)
    2. Non-ICU Blood Glucose goal: <180 mg/dl (<140 mg/dl preprandial)
      1. Modify protocol immediately if Blood Glucose below 70 mg/dl
    3. Continue home Glucose management protocol if possible
      1. Avoid Thiazolidinediones in cardiovascular disease (especially if part of admission indications)
      2. Avoid Metformin in declining Renal Function, if Intravenous Contrast dye used, or if Lactic Acidosis
  3. Hospitalized Blood Glucose control in ICU
    1. Very tight Glucose control in critically ill patients is associated with worse outcomes
      1. Finfer (2009) N Engl J Med 360(13): 1283-97 [PubMed]
    2. Monitor Blood Glucose every 4 hours depending on status
      1. For patients who are eating meals, following the non-ICU protocol above
    3. ICU goal Blood Glucose: 140-180 mg/dl
      1. Modify protocol immediately if Blood Glucose below 70 mg/dl
      2. Treat Hypoglycemia with D50 IV

V. Protocol: Complete Insulin Orders

  1. Basal Insulin: Long acting Insulin (e.g. Lantus, NPH)
    1. Do not adjust Lantus for oral intake
    2. NPH may require adjustment if covering mealtime
  2. Bolus Insulin: Lispro, Aspart
    1. Cover meals, snacks with units per carbohydrate
    2. See Insulin Adjustment with Carbohydrate Counting
  3. Hypoglycemia Management
  4. Hyperglycemia coverage: Sliding scale coverage
    1. Cover as units per Glucose 50 mg/dl over 150 mg/dl
    2. Adjust per condition (low dose scale versus high dose scale)
    3. See Correctional Insulin Dosing (Insulin Sliding Scale)

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