How to manage hyperglycemia in a patient hospitalized for an ankle fracture?

Management of Hyperglycemia in Patients Hospitalized for Ankle Fracture

For patients hospitalized with an ankle fracture and hyperglycemia, implement a basal-bolus insulin regimen with a target glucose range of 140-180 mg/dL to optimize glycemic control, promote wound healing, and reduce complications. 1, 2

Initial Assessment

• Determine if the patient has known diabetes or stress hyperglycemia (characterized by elevated blood glucose with HbA1c <6.5%) 3
• Measure HbA1c at admission to guide treatment decisions and post-discharge management 1, 2
• Monitor blood glucose before meals if eating, or every 4-6 hours if NPO 1
• Assess renal and hepatic function as insulin requirements may need adjustment in patients with impairment 4

Inpatient Glycemic Management

For Patients with Known Diabetes

• Type 1 Diabetes or Type 2 Diabetes on Multiple Daily Injections:

  • Resume previous insulin regimen with basal (long-acting) and bolus (rapid-acting) components, adjusting doses based on inpatient glucose readings 3
  • Follow up based on HbA1c: <8% (consult treating physician in one month), 8-9% (diabetologist consultation), >9% (consider specialized service) 3

• Type 2 Diabetes on Oral Antidiabetics (OADs) Only:

  • Temporarily discontinue oral agents and implement basal-bolus insulin during hospitalization 3, 1
  • For HbA1c >9% or persistent hyperglycemia >11 mmol/L (2 g/L), maintain basal-bolus insulin and request diabetologist consultation 3

• Type 2 Diabetes on OADs and Insulin:

  • Resume previous treatment if HbA1c <8% after 48 hours (if renal clearance >30 mL/min for OADs, >60 mL/min for metformin) 3
  • For HbA1c 8-9%, resume OADs and maintain basal insulin 3

For Stress Hyperglycemia (HbA1c <6.5%)

• Implement insulin therapy during hospitalization and taper based on capillary glucose readings 3
• No treatment necessary upon discharge, but monitor fasting glucose at one month, then annually 3
• Inform the patient that 60% of stress hyperglycemia patients develop diabetes within one year 3

For Newly Diagnosed Diabetes

• Initiate hygieno-dietary measures with dietician assistance 3
• Request diabetologist consultation for potential OAD initiation 3
• Schedule follow-up with primary physician at one month 3

Insulin Regimen Implementation

• Avoid sliding scale insulin alone as it's ineffective for glycemic control 2
• Implement a basal-bolus-correction regimen for patients with good nutritional intake 1
• Use basal insulin plus correction insulin for patients with poor or no oral intake 1
• For severe hyperglycemia (>400 mg/dL), consider initial IV insulin infusion until stabilized 2
• Monitor for hypoglycemia (glucose <70 mg/dL) and have a treatment protocol in place 1

Perioperative Considerations for Ankle Fracture

• Continue glucose monitoring before and after surgical repair of the ankle fracture 5
• Early glycemic control is associated with better outcomes and appears protective regardless of subsequent glucose levels 6
• Hyperglycemia increases infection risk through impaired host defenses, including decreased polymorphonuclear leukocyte mobilization and phagocytic activity 7

Discharge Planning

• Transition to an appropriate outpatient diabetes regimen 1-2 days before discharge 2
• If oral medications were suspended during hospitalization, establish a protocol to resume them 1-2 days before discharge 1
• For patients with HbA1c >10%, discharge with a basal-bolus regimen or previous oral agents plus 80% of the inpatient basal insulin dose 1

Patient Education

• Provide basic education about diabetes, blood glucose monitoring, and medication administration 3
• Explain the relationship between glycemic control and fracture healing 8
• Inform patients about hypoglycemia symptoms and management, especially if on insulin or sulfonylureas 3
• Emphasize the importance of follow-up with primary care physician or diabetologist 3

Common Pitfalls to Avoid

• Relying solely on sliding scale insulin without basal insulin is ineffective and should be avoided 2
• Overly aggressive glucose targets (<140 mg/dL) increase hypoglycemia risk without additional benefit 2
• Failing to provide diabetes education during hospitalization can lead to medication errors and side effects, particularly hypoglycemia 3
• Neglecting to monitor electrolytes, particularly in patients with renal impairment 2