Insulin Therapy for the Management of Hyperglycemia in Hospitalized Patients

Abstract

It has long been established that hyperglycemia with or without a prior diagnosis of diabetes increases both mortality and disease-specific morbidity in hospitalized patients1–4 and that goal-directed insulin therapy can improve outcomes.5–9 During the past decade, since the widespread institutional adoption of intensified insulin protocols after the publication of a landmark trial,5,10 the pendulum in the inpatient diabetes literature has swung away from achieving intensive glucose control and toward more moderate and individualized glycemic targets.11,12 This change in clinical practice is the result of several factors, including challenges faced by hospitals to coordinate glycemic control across all levels of care,13,14 publication of negative prospective trials,15,16 revised recommendations from professional organizations,17,18 and increasing evidence on the deleterious effect of hypoglycemia.19–22 This article reviews the pathophysiology of hyperglycemia during illness, the mechanisms for increased complications and mortality due to hyperglycemia and hypoglycemia, beneficial mechanistic effects of insulin therapy and provides updated recommendations for the inpatient management of diabetes in the critical care setting and in the general medicine and surgical settings.23,24

Bases para realizar un protocolo de control glucémico

“…El seguimiento ideal en el control glucémico se realiza a través de glucometrías; pero sus frecuencias deben establecerse de manera individual, usualmente con intervalos cortos al inicio de infusiones de insulina y posteriormente según la necesidad (17) . En cuanto al tiempo, se utiliza en promedio máximo 3 minutos por glucometría y la oportuna medida correctiva; según lo estimado por el protocolo, garantizará la disminución de controles, el ahorro en tiempo y dinero.…”

Long-Acting Insulin on the Road to Recovery With Diabetic Ketoacidosis

“…Rebound hyperglycemia has the potential to increase the concentration of ketone bodies rather than decrease it, further delaying resolution of DKA and increasing length of stay in addition to increasing risk of mortality and morbidity. 8,9 Few published studies have examined the effect of long-acting insulin analogues in the treatment of DKA. The 3 studies examined here demonstrate relative safety and effectiveness in using a long-acting analogue during intravenous insulin infusion.…”

“…These are just a few of the changes that can eventually lead to increased risk of infection, impaired wound healing, multiple organ failure, prolonged hospital stay, and death. 4,8,9 The core treatment of DKA involves the administration of regular insulin via continuous intravenous infusion. This route is preferred because of the short half-life (7 minutes) and easy titration of regular intravenous insulin.…”

Slip sliding away: the need for continued discussion of the use of insulin sliding scale in hospitalized patients

“…The flaws of the use of RISS have been discussed in the medical literature for more than a decade [2,3]. Notable shortcomings include un-physiologic insulin replacement, failure to compartmentalize insulin as basal, nutritional and correction, and a "one-size fits all" solution to the complexity of insulin use in the hospital which pays little or no heed to issues of body weight, basal insulin requirements (derived from IV insulin drip rates), variable nutrition (oral/enteral and parenteral), and the counterinsulin effects of illness, inflammation, medications and glucotoxicity.…”