Adapted from BMJ 24 June 17 Managing adults with diabetes in hospital during an acute illness by Tahseen Chowdhury, Hannah Cheston and Anne Claydon.
Around one in five inpatient beds are occupied by someone who has diabetes. As patients, one in ten will have a severe hypo in hospital and in any one week, one in four will have an error made regarding their medication.
Poorly managed hyperglycaemia in patients with an acute illness do worse, stay in hospital longer and can even cause death. Blood sugars can be harder to manage because of the ongoing illness, erratic eating habits, changes to liver and kidney function, and changing medication, particularly starting and stopping steroids and metformin. But here is no evidence that tight glycaemic control for hospital patients improves outcomes other than during cardiac surgery and liver transplantation.
The consensus is that blood glucose values between 6-10 mmol/L is probably optimal, given the need to prevent hypos, and that a range of 4-12 is acceptable.
The sorts of things that can cause high blood sugars in hospital are: sepsis, steroids, omission of insulin or oral hypoglycaemic medication, an overtreated hypo, stress and anxiety, surgery, a relative lack of insulin and long term poor glucose control.
In type one patients and type twos on insulin they should not stop their insulin even when fasted or when oral intake is poor. At the very least basal insulin needs to be continued. The DAFNE plan is that blood sugars over 11 should be corrected by 2-6 units of rapid acting insulin and levels checked every 2 hours. Correction doses are advised not to be given at intervals more than every 4 hours to reduce insulin stacking. Staff are advised to ASK THE PATIENT what they would normally do outside hospital.
Treatment for diabetic ketoacidosis should be initiated if the blood ketone level is 3mmol/L or above. In mild or moderate cases subcutaneous insulin may be used, but if severe, intravenous insulin will be needed.
When dealing with type two patients, where there is less risk of ketoacidosis, higher blood sugar levels may be acceptable over the short term. It is important to ask the patient if they are actually getting their correct medication. It is helpful to figure out exactly WHY the patient’s blood glucose is elevated, as this can be the clue to effective treatment, eg an ongoing urine infection.
Most hospitals have a diabetes liaison team and they can be particularly helpful in for instance surgical wards where staff may have less expertise in treating diabetic patients.
Insulin is sometimes required if a type two patient needs blood sugars stabilised promptly. Doses will need frequent review as the patient becomes more active and eats more as they improve and as their condition returns to their normal state.