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.
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.
