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SICK DAYS- SITUATIONS REQUIRING HOSPITALIZED CARE!

SITUATIONS REQUIRING HOSPITALIZED CARE

  • The NICE-SUGAR (Intensive versus conventional glucose in critically ill patients) trial compared intensive (81-108 mg/dL) with conventional glucose control using IV Insulin in 6104 intensive care unit patients.
  • At 90 days, intensively controlled patients had an increased absolute risk of death of 2.6%.
  • Significantly, more hypoglycemia was observed in intensively controlled group.

Recommendations:

  • Current recommendations call for critically ill patients to be started on IV Insulin therapy at a threshold of 180mg/dL.
  • A goal range of 140-180mg/dL is recommended for majority of patients.
  • More stringent goals may be considered for selected critically ill patients, but only if hypoglycemia can be avoided.
  • Scheduled SC insulin regimens with basal, nutritional and correction components are recommended for patients who are not critically ill.
  • Goals of less than 140mg/dL for fasting glucose and less than 180mg/dL for random glucose are recommended for non-critically ill patients.

  • Patients should monitor their blood glucose levels more frequently during the sick days because it is more common for illness to increase blood glucose values.
    • Patients with T1 DM should check their glucose and urine for ketones every 4 hours when sick.
    • Patients with T2 DM may also need to check for ketones when their blood glucose levels are greater than 300mg/dL.
    • Patients should continue to take their medications while sick.
    • T1 DM patients may require additional insulin coverage, and some with T2 DM who are currently on, or medication regimens may require insulin during an acute illness.
    • Patients should be advised to maintain their normal caloric intake and carbohydrate intake while ill as well as to drink plenty of non-caloric beverages to avoid dehydration.
    • When having difficulty eating a normal diet, patients may be advised to use non-diet beverages, soft drinks, broths, crackers, soup, and non-diet gelatins to provide normal caloric and carbohydrate intake and avoid hypoglycemia.
    • With proper management, patients can decrease their chances of illness-induced hospitalization, particularly Diabetic Ketoacidosis & Hyperosmolar Hyperglycemic State.

    Measurement of Blood Glucose Levels:

    Several methods can be used for measuring Blood glucose levels.

    • Arterial samples are usually 5mg/dL higher than capillary values and 10mg/greater than venous values.
    • When preparing an insulin infusion for a patient, several factors must be considered, insulin will absorb to glass and plastic, reducing the amount of insulin actually delivered by 20%-30%. Primarily, the tubing decreases the variability of insulin infused.
    • Therefore, when patients can be converted safely from infusion to needle and syringe therapy, the total daily dose should be reduced by 20%to 50% of the daily infusion amount.
    • When transferring someone from IV insulin drip to subcutaneous insulin, basal insulin should be administered several hours before the drip is discontinued to prevent loss of glycemic control.
    • IV drip protocols are institution specific.


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