Selecting a Treatment Regimen
ÎAll patients with diabetes admitted to the hospital should have their diabetes clearly identified in the medical record. (E)
ÎAll patients with diabetes should have an order for blood glucose monitoring, with results available to all members of the health care team. (E)
Goals for Blood Glucose Levels Critically Ill Patients
ÎInsulin therapy should be initiated for treatment of persistent hyperglycemia starting at a threshold of no greater than < 180 mg/dL (10 mmol/L). Once insulin therapy is started, a glucose range of 140-180 mg/dL (7.8-10 mmol/L) is recommended for the majority of critically ill patients. (A)
ÎMore stringent goals, such as 110-140 mg/dL (6.1-7.8 mmol/L) may be appropriate for selected patients, as long as this can be achieved without significant hypoglycemia. (C)
ÎCritically ill patients require an intravenous insulin protocol that has demonstrated efficacy and safety in achieving the desired glucose range without increasing risk for severe hypoglycemia. (E)
Noncritically Ill Patients
ÎThere is no clear evidence for specific blood glucose goals. If treated with insulin, the premeal blood glucose target should generally be < 140 mg/dL (7.8 mmol/L) with random blood glucose < 180 mg/dL (10.0 mmol/L) are reasonable, as long as these targets can be safely achieved. More stringent targets may be appropriate in stable patients with previous tight glycemic control. Less stringent targets may be appropriate in those with severe comorbidites. (E)
ÎScheduled subcutaneous insulin with basal, nutritional, and correction components is the preferred method for achieving and maintaining glucose control in noncritically ill patients. (C)
ÎGlucose monitoring should be initiated in any patient not known to be diabetic who receives therapy associated with high risk for hyperglycemia, including high-dose glucocorticoid therapy, initiation of enteral or parenteral nutrition, or other medications such as octreotide or immunosuppressive medications. (B) If hyperglycemia is documented and persistent, consider treating such patients to the same glycemic goals as patients with known diabetes. (E)
ÎA hypoglycemia management protocol should be adopted and implemented by each hospital or hospital system. A plan for treating hypoglycemia should be established for each patient. Episodes of hypoglycemia in the hospital should be documented in the medial record and tracked. (E)
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