This article originally posted 27 December, 2003 and appeared in Issue 187
Issue 187 Item 1: Need for More Aggressive in-Hospital Glucose Control
Blood glucose is often ignored by nurses and physicians who focus only on the reason for admission, not the underlying disease.
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A group of professional organizations, brought together by the American College of Endocrinology (ACE) and the American Association of Clinical Endocrinologists (AACE), issued a consensus statement yesterday, calling for more aggressive management of hyperglycemic patients in acute care settings.
Better control can help decrease length of stay and reduce morbidity and mortality, especially in diabetics admitted for cardiovascular conditions, according to the statement, issued at the Consensus Development Conference on Inpatient Diabetes and Metabolic Control. The report will be used to issue formal guidelines next year, said Donald Bergman, MD, FACE, president of the American Association of Clinical Endocrinologists, at a press briefing.
The guidelines will be the first to address short-term management of diabetes.
"The evidence has proved we need to do better," said Etie Moghissi, MD, FACP, FACE, cochair of the conference, at the briefing. "We need to get every patient's blood sugar as close to normal as possible," she added.
Overwhelmingly, the evidence showed that better control improves outcomes. For instance, a meta-analysis of 15 studies showed that hyperglycemia (blood glucose greater than 110 mg/dL) increased in-hospital death and congestive heart failure in diagnosed and undiagnosed heart attack patients.
Random blood glucose levels greater than 200 mg/dL in general medical and surgical patients was associated with an 18-fold increase in in-hospital death, a longer length of stay (almost double, at nine days), greater risk of infection, and need for later nursing home care.
For stroke patients, in-hospital death was higher when blood glucose was greater than 100 to 126 mg/dL, according to a meta-analysis of 26 studies.
Conversely, lowering blood glucose levels improved outcomes, according to the report. Cardiac surgery patients who were hyperglycemic and received intravenous insulin for the first three days after surgery had a 57% absolute reduction in risk of death. Deep chest wound infections were reduced by 66%, and length of stay was reduced by one day for each 50 mg/dL decrease in blood glucose.
Although it cost more to give intravenous insulin, the reduction in infections and length of stay produced a net savings of $680 per patient, according to the report.
The report suggested maximum blood glucose targets of 110 mg/dL for intensive care patients, and for noncritical patients, 110 mg/dL for preprandial and 180 mg/dL for maximal glucose.
Insulin is the only effective agent and should be given to patients regardless of what they took before admission, said the report.
Most physicians are often reluctant to use insulin or aggressively treat high blood glucose out of fear of lowering blood glucose too much.
Nathaniel Clark, MD, MS, RD, national vice president for clinical affairs at the American Diabetes Association, said he hoped the report and guidelines would be a wake-up call for hospitals and physicians. "The situation at this point in hospitals is that diabetes is really being ignored, and the reason for that is that relatively few people are admitted to the hospital because of their diabetes."
In addition to ACE and AACE, the conference was supported by the American Association of Diabetes Educators, the American Diabetes Association, the American Heart Association, the American Society of Anesthesiologists, the Society of Critical Care Medicine, the Society of Hospital Medicine, the Society of Thoracic Surgeons, and the Endocrine Society.
The ACE plans to hold a conference next summer or fall on how to implement the guidelines, said Dr. Bergman, who said the report is available at http://www.aace.com/pub/ICC/inpatientStatement.php.
Consensus Development Conference on Inpatient Diabetes and Metabolic Control. Presented Dec. 16, 2003.
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