What are the implications for an inpatient with hyperglycemia (elevated blood glucose)?

From the Guidelines

For an inpatient with hyperglycemia, immediate intervention is necessary to reduce the risk of morbidity, mortality, and impaired quality of life, with a target glucose range of 140-180 mg/dL, as recommended by the most recent and highest quality study 1.

Key Considerations

• Hyperglycemia is a common finding among hospitalized patients, with an estimated prevalence of around 40% 1.
• Poorly controlled hyperglycemia is associated with increased morbidity, mortality, and costs, as well as poor immune response, increased cardiovascular events, thrombosis, inflammatory changes, delayed healing, and other problems 1.
• The American College of Physicians recommends a target blood glucose level of 7.8 to 11.1 mmol/L (140 to 200 mg/dL) if insulin therapy is used in SICU/MICU patients, with a weak recommendation and moderate-quality evidence 1.
• The American Diabetes Association recommends a target range of 100-180 mg/dL (5.6-10.0 mmol/L) for noncritically ill patients with “new” hyperglycemia, as well as people with known diabetes prior to admission, with individualized glycemic targets based on clinical status, risk of hypoglycemia, and presence of diabetes complications 1.

Management Strategies

• Insulin therapy is the preferred agent to manage hyperglycemia and diabetes in the hospital, with continuous insulin infusion in the ICU and rational use of basal-bolus or basal plus supplement regimens in non-ICU settings 1.
• Noninsulin regimens with the use of dipeptidyl peptidase 4 inhibitors alone or in combination with basal insulin may be an alternative to basal-bolus regimens in elderly patients 1.
• Smooth transition of care to the outpatient setting is facilitated by providing oral and written instructions regarding timing and dosing of insulin, as well as education in basic skills for home management 1.

Monitoring and Evaluation

• Check glucose every 1-2 hours initially, then every 4-6 hours once stable, to monitor the effectiveness of insulin therapy and adjust the regimen as needed.
• Evaluate for precipitating causes such as infection, medication non-adherence, or new-onset diabetes, and monitor for electrolyte abnormalities, particularly potassium, as insulin therapy can cause hypokalemia.

From the FDA Drug Label

Hyperglycemia, diabetic ketoacidosis, or hyperosmolar coma may develop if the patient takes less Humulin R U-100 than needed to control blood glucose levels This could be due to increases in insulin demand during illness or infection, neglect of diet, omission or improper administration of prescribed insulin doses or use of drugs that affect glucose metabolism or insulin sensitivity. Early signs of diabetic ketoacidosis include glycosuria and ketonuria Polydipsia, polyuria, loss of appetite, fatigue, dry skin, abdominal pain, nausea and vomiting and compensatory tachypnea come on gradually, usually over a period of some hours or days, in conjunction with hyperglycemia and ketonemia. Severe sustained hyperglycemia may result in hyperosmolar coma or death

The implications for an inpatient with hyperglycemia (elevated blood glucose) are:

• Diabetic ketoacidosis or hyperosmolar coma may develop if blood glucose levels are not controlled
• Increased risk of serious complications, such as hyperosmolar coma or death, if left untreated
• Close monitoring of blood glucose levels and adjustment of insulin doses may be necessary to prevent complications
• Medical assistance should be obtained immediately if symptoms of diabetic ketoacidosis or hyperosmolar coma occur 2
• Hyperglycemia can be caused by omitting insulin, eating more than the meal plan suggests, developing a fever or infection, or other stressful situations 2

From the Research

Implications of Hyperglycemia in Inpatients

The implications of hyperglycemia in inpatients are numerous and can lead to serious complications. Some of the key implications include:

• Increased risk of infections, diabetic ketoacidosis, hyperosmolar hyperglycemic state, dehydration, electrolyte imbalances, and lengthened hospitalization 3
• Greater risk of antibiotic use and increased morbidity and mortality 3
• Metabolic derangements due to insulin deficiency, which can be aggravated by insulin counteracting hormones and hypertonic dehydration 4
• Increased risk of hospital complications, such as hypoglycemia, when blood glucose levels are not properly controlled 5

Complications Associated with Hyperglycemia

Some of the complications associated with hyperglycemia in inpatients include:

• Diabetic ketoacidosis (DKA) and hyperosmolar hyperglycemic syndrome (HHS), which are life-threatening conditions that require timely identification and treatment 6
• Fluid and electrolyte disorders, such as dehydration and electrolyte imbalances, which can lead to shock and further complications 7
• Neurologic changes, such as cerebral edema and hypokalaemia, which can occur in patients with hyperosmolar hyperglycemic nonketotic coma (HHNK) 7

Management of Hyperglycemia

The management of hyperglycemia in inpatients involves:

• Aggressive administration of intravenous fluids with appropriate replacement of electrolytes, particularly potassium 6
• Administration of insulin, usually via an intravenous insulin infusion, to control hyperglycemia and prevent further complications 6, 4, 5
• Careful monitoring by experienced physicians to prevent premature termination of intravenous insulin therapy and insufficient timing or dosing of subcutaneous insulin 6
• Individualized glycemic targets, which may vary depending on the patient's condition and characteristics 5