Diabetic diet For Type 1 diabetics there will always be a need for insulin injections throughout their life. However, both Type 1 and Type 2 diabetics can see dramatic effects on their blood sugars through controlling their diet, and some Type 2 diabetics can fully control the disease by dietary modification.
Glycemic targets for people with pre-existing diabetes who are in the critical care setting have not been firmly established. Early trials showed that achieving normoglycemia 4.
However, subsequent trials in mixed populations of critically ill patients did not show a benefit of targeting BG levels of 4.
A meta-analysis of trials of intensive insulin therapy in the ICU setting suggested benefit of intensive insulin therapy in surgical patients, but not in medical patients Furthermore, intensive insulin therapy has been associated with an increased risk of hypoglycemia in the ICU setting The use of insulin infusion protocols with proven efficacy and safety minimizes the risk of hypoglycemia 35— Role of Intravenous Insulin There are few occasions when intravenous insulin is required, as most people with type 1 or type 2 diabetes admitted to general medical wards can be treated with subcutaneous insulin.
Intravenous insulin, however, may be appropriate for people who are critically ill with appropriate BG targetspeople who are not eating and in those with hyperglycemia and metabolic decompensation e.
The evidence to date suggests there is no benefit to intravenous insulin over subcutaneous insulin post-acute stroke 3, Health-care staff education is a critical component of the implementation of an intravenous insulin infusion protocol.
Several published insulin infusion protocols appear to be both safe and effective, with low rates of hypoglycemia; however, most of these protocols have only been validated in the ICU setting, where the nurse-to-patient ratio is higher than on medical and surgical wards 3, BG determinations can be performed every 1 to 2 hours until BG has stabilized.
With the exception of the treatment of hyperglycemic emergencies e. DKA and HHSconsideration should be given to concurrently providing people receiving intravenous insulin with some form of glucose e.
Transition from IV insulin to SC insulin therapy Hospitalized people with type 1 and type 2 diabetes may be transitioned to scheduled subcutaneous insulin therapy from intravenous insulin.
Short- or rapid- or fast-acting insulin can be administered 1 to 2 hours before discontinuation of the intravenous insulin to maintain effective blood levels of insulin. If intermediate- or long-acting insulin is used, it can be given 2 to 3 hours prior to intravenous insulin discontinuation.
People without a history of diabetes, who have hyperglycemia requiring more than 2 units of intravenous insulin per hour, likely require insulin therapy and can be considered for transition to scheduled subcutaneous insulin therapy. The initial dose and distribution of subcutaneous insulin at the time of transition can be determined by extrapolating the intravenous insulin requirement over the preceding 6- to 8-hour period to a hour period.
Dividing the total daily dose as a combination of basal and bolus insulin has been demonstrated to be safe and efficacious in medically ill patients 40, Perioperative glycemic control The management of individuals with diabetes at the time of surgery poses a number of challenges. Acute hyperglycemia is common secondary to the physiological stress associated with surgery.
Pre-existing diabetes-related complications and comorbidities may also influence clinical outcomes. Acute hyperglycemia has been shown to adversely affect immune function 42 and wound healing 43 in animal models.
Observational studies have shown that hyperglycemia increases the risk of postoperative infections 44,45renal allograft rejection 46and is associated with increased health-care resource utilization Cardiovascular surgery In people undergoing coronary artery bypass grafting CABGa pre-existing diagnosis of diabetes has been identified as a risk factor for postoperative sternal wound infections, delirium, renal dysfunction, respiratory insufficiency and prolonged hospital stays 48— Intraoperative hyperglycemia during cardiopulmonary bypass has been associated with increased morbidity and mortality rates in individuals with and without diabetes 51— A systematic review of randomized controlled trials supports the use of intravenous insulin infusion targeting a blood glucose of 5.
This was demonstrated by a marked reduction in surgical site infections odds ratio 0. Minor and moderate surgery The perioperative glycemic targets for minor or moderate surgeries are less clear.
Older studies comparing different methods of achieving glycemic control during minor and moderate surgeries did not demonstrate any adverse effects of maintaining perioperative BG levels between 5.
Attention has been placed on the relationship between postoperative hyperglycemia and surgical site infections. While the association was well documented, the impact and risks of intensive management was less clear. The risk of hypoglycemia was increased but there was no increased risk of stroke or death.
The included studies looked at the intraoperative and immediate postoperative period and used intravenous insulin to achieve intensive targets. The included studies were mostly cardiac and gastrointestinal and were found to have a moderate risk of bias Rapid institution of perioperative glucose control must be carefully considered in patients with poorly controlled type 2 diabetes undergoing monocular phacoemulsification cataract surgery with moderate to severe nonproliferative diabetic retinopathy because of the possible increased risk of postoperative progression of retinopathy and maculopathy The outcome of vitrectomy, however, does not appear to be influenced by perioperative control Given the data supporting tighter perioperative glycemic control during major surgeries and the compelling data showing the adverse effects of hyperglycemia, it is reasonable to target glycemic levels between 5.
The best way to achieve these targets in the postoperative patient is with a basal bolus insulin regimen 61, This approach has been shown to reduce postoperative complications, including wound infections. Despite this knowledge, surgical patients are often treated with correction supplemental rapid-acting insulin alone 63 which may not adequately control BG.Abstract.
The American Diabetes Association (ADA) “Standards of Medical Care in Diabetes” includes ADA’s current clinical practice recommendations and is intended to provide the components of diabetes care, general treatment goals and guidelines, and tools to evaluate quality of care. Glycemic Control in the Non-Critically Ill Patient.
A number of studies have demonstrated that inpatient hyperglycemia is associated with increased morbidity and mortality in noncritically ill hospitalized people (1,28,29).However, due to a paucity of randomized controlled trials on the benefits and risks of “conventional” vs.
“tight” glycemic control . Centers for Medicare & Medicaid Services. Medicare program; hospital inpatient prospective payment systems for acute care hospitals and the long-term care hospital prospective payment system and fiscal year rates; hospitals’ resident caps for graduate medical education payment purposes; quality reporting requirements for .
Glycemic Control in the Hospitalized Patient: A Comprehensive Clinical Guide is a unique, practical resource for health care providers dealing with hyperglycemia in the inpatient setting. As part of its goal to support a culture of patient safety and quality improvement in the Nation's health care system, the Agency for Healthcare Research and Quality (AHRQ) sponsored the development of patient safety culture assessment tools for hospitals, nursing homes, ambulatory outpatient medical offices, community pharmacies, and ambulatory surgery centers.
ASSESSMENT OF GLYCEMIC CONTROL. Patient self-monitoring of blood glucose (SMBG) and A1C are available to health care providers and patients to assess the effectiveness and safety of a management plan on glycemic control.