Ch16 In-HospitalManagement

Canadian Diabetes Association
Clinical Practice Guidelines
In-Hospital Management of Diabetes
Chapter 16
Robyn Houlden, Sara Capes,

Maureen Clement, David Miller
In-hospital Management Checklist 2013
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
guidelines.diabetes.ca | 1-800-BANTING (226-8464) | diabetes.ca

Copyright 2013 Canadian Diabetes Association
In-hospital Hyperglycemia is Common
Approximately 1/3 of
in-patients have been
found to have
Hyperglycemia
hyperglycemia
Many have pre-

existing diabetes prior
to admission

Hyperglycemia and Acute Ilness
Hyperglycemia
Increased stress Decreased

hormones, use of immune
glucocorticoids, function, wound
decreased level of healing,
activity increased
oxidative stress
Acute Illness
Inzucchi SE. NEJM 2006;355;1903

Adverse Effects of Hyperglycemia
Hyperglycemia
Increases risks Prolonged Increased renal

of postoperative hospital stay, dysfunction and
infections and resource renal allograft
delirium utilization rejection in
transplant

In-hospital Glycemic Targets
Patient Type Glucose Target Therapy of
(mmol/L) choice
Non-critically ill Fasting 5-8 Pre-hospital
regimen OR
Random <10 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

Sliding Scale Alone is Inefficient
BG Bolus insulin In the absence of routine
(mmol/L) (U)
<4 Call MD insulin, sliding scale insulin
4.1 10.0 0 regimen (bolus insulin on a prn
10.1 2 basis) is purely reactive rather
13.0
13.1 16.0 4
than proactive and allows for
16.1 6 hyperglycemia to occur before
19.0
responding
>19.0 Call MD
Queale WS. et al. Arch Int Med 1997;157

Sliding Scale Insulin Alone Results in
Variable Glucose Control
BG (mmol/L) 16.5 What do you do?
What do you do?
+6 U
14.0 +4 U
Sliding Scale alone
BG Bolus
(mmol/L) insulin
10.0 (U)
<4 Call MD
4.1 10.0 0
10.1 2
13.0
6.0 6.0
4.0 What do you do? What do you do? 13.1 16.0 4
16.1 6
0U 0U 19.0
3.0
Breakfast Lunch Dinner Bedtime > 19.0 Call MD
Bolus insulin QID

QID: four times daily; SSI: sliding-scale insulin; BG: blood glucose
Use BASAL + BOLUS + CORRECTION
BOLUS + CORRECTION In-hospital circumstances may

warrant temporarily holding
other antihyperglycemic
medications (eg. renal or
Insulin
hepatic impairment)
Insulin = treatment of choice

BASAL + BOLUS +
BASAL
CORRECTION
Breakfast Lunch Dinner

BASAL + BOLUS + CORRECTION Results in
Smoother Glycemic Control
6+2 U
What do you do? Correctional Insulin AC
12.0 meals
BG (mmol/L) Bolus
insulin (U)
10.0 <4 Call MD
6+0 U
What do
What do 4.1 10.0 0
you do?
you do? 10.1 2
13.0
6.0 6.0 6.0
What do you do? 13.1 16.0 4
4.0 18 U
6+0 U 16.1 6
19.0
Breakfast Lunch Dinner Bedtime > 19.0 Call MD
6U 6U 6U Basal
insulin
ROUTINE Bolus insulin Routine Basal
Basal-Bolus (BBI) Regimen Achieves Better
Control than Sliding Scale (SSI) Alone
RABBIT 2 RABBIT 2 Surgery
13.3 13.3
*
Blood glucose (mmol/L)
12.2
11.1
*
11.1 *
* SSI * SSI

10.0
10.0

8.9 8.9
7.8
7.8
6.7
*p < 0.01; p < 0.05. BBI *p < 0.001, p = 0.02, p = 0.01 BBI
5.6 6.7
Admit 1 2 3 4 5 6 7 8 9 10 Randomi 1 2 3 4 5 6 7 8 9
-zation
Duration of treatment (days) Duration of treatment (days)
Adapted from: Umpierrez GE, et al. Diabetes Care 2007;30:2181-86.

Adapted from: Umpierrez GE, et al. Diabetes Care 2011;34:256-61.

Avoid Hypoglycemia
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

Recommendation 1
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 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]

Recommendations 3 and 4
3. For the majority of non critically ill patients treated
with insulin, pre-meal BG targets should be 5.0 to
2013 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
2013 infusion should be used to maintain glucose levels
between 8.0-10.0 mmol/L [Grade D, consensus]

Recommendations 5 and 6
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
2013
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]
Recommendation 7 2013
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]
Recommendation 8 and 9 2013
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]

CDA Clinical Practice Guidelines
http://guidelines.diabetes.ca for professionals
1-800-BANTING (226-8464)
http://diabetes.ca for patients


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Canadian Diabetes Association

Clinical Practice Guidelines

In-Hospital Management of Diabetes

Robyn Houlden, Sara Capes,

CONTINUE pre-hospital diabetes regimen if

guidelines.diabetes.ca | 1-800-BANTING (226-8464) | diabetes.ca

Many have pre-

guidelines.diabetes.ca | 1-800-BANTING (226-8464) | diabetes.ca

Increased stress Decreased

guidelines.diabetes.ca | 1-800-BANTING (226-8464) | diabetes.ca

Increases risks Prolonged Increased renal

guidelines.diabetes.ca | 1-800-BANTING (226-8464) | diabetes.ca

Critically ill 8-10 IV insulin infusion

CABG intraop 5.5-10 IV insulin infusion

Other periop 5-10 As appropriate

guidelines.diabetes.ca | 1-800-BANTING (226-8464) | diabetes.ca

Queale WS. et al. Arch Int Med 1997;157

guidelines.diabetes.ca | 1-800-BANTING (226-8464) | diabetes.ca

Bolus insulin QID

BOLUS + CORRECTION In-hospital circumstances may

Insulin = treatment of choice

guidelines.diabetes.ca | 1-800-BANTING (226-8464) | diabetes.ca

Adapted from: Umpierrez GE, et al. Diabetes Care 2007;30:2181-86.

guidelines.diabetes.ca | 1-800-BANTING (226-8464) | diabetes.ca

guidelines.diabetes.ca | 1-800-BANTING (226-8464) | diabetes.ca

guidelines.diabetes.ca | 1-800-BANTING (226-8464) | diabetes.ca

guidelines.diabetes.ca | 1-800-BANTING (226-8464) | diabetes.ca

4. For most medical/surgical critically ill patients

between 8.0-10.0 mmol/L [Grade D, consensus]

guidelines.diabetes.ca | 1-800-BANTING (226-8464) | diabetes.ca

6. Perioperative glycemic levels should be maintained

7. In hospitalized patients, hypoglycemia should be

Patients at risk of hypoglycemia should have ready

8. Healthcare professional education, insulin

9. Measures to assess, monitor, and improve glycemic

guidelines.diabetes.ca | 1-800-BANTING (226-8464) | diabetes.ca

http://guidelines.diabetes.ca for professionals

http://diabetes.ca for patients

guidelines.diabetes.ca | 1-800-BANTING (226-8464) | diabetes.ca

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