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Cardio Diabetes Medicine 2017 273

Conscious patient, no Unconscious patients, at 5. Providing appropriate nutritional requirements
risk of aspiration risk for aspiration 6. Applying systems for eliminating or reducing
Repeat blood glucose Repeat blood glucose medication and treatment errors in hospitalized
test in 15-30 minutes to test in 15 30 minutes patients
evaluate treatment
If BG > 70 mg/dl on re- If glucose less than 70 1. Recognition of precipitating factors
peat, no further treat- mg, repeat treatment
ment. Repeat treatment This includes delay in the timing of meals or dos-
if < 70 mg/dl age of oral hypoglycemic agents or insulin; errors
in dosages administered; timing of the medication,
Provide the patient with Once patient stabilized,
a meal/ snack within 1 notify physician regard- particularly insulin; and the presence of a comorbid-
hour of last carbohydrate ing response to treat- ity, such as renal insufficiency, adrenal insufficien-
treatment ment, receive further cy, and pituitary insufficiency, which heightens the
orders/ monitoring pa- risk for hypoglycemia. Self-management by patients
rameters whose diabetes is well controlled as outpatients and
Strategies for Reducing Risk for who possess the capability of managing their insu-
lin regimen in the hospital, such as those who wear
Hypoglycemia in Noncritical Care Settings an insulin pump or who use multiple daily injections
• Avoidance of sliding – scale insulin alone of glargine and aspart or lispro, can be a means to
• Use caution in prescribing oral anti-hyperglyce- reduce hypoglycemia. 1,4
mic agents
2.Scheduled insulin therapy
• Modify outpatient insulin doses in patients treat- Although endocrinologists have been warning
ed with insulin prior to admission.
against its use for decades, the regular or rapid-act-
ing analog insulin sliding scale without basal insulin
Standardize Insulin Therapy to Reduce replacement remains a common method of attempt-
Errors ing to control hyperglycemia in the hospital.Usually,
• Single insulin infusion concentration out of concern for hypoglycemia, no basal insulin is
• Single insulin infusion protocol given, and prandial insulin is given only if the pre-
meal blood glucose is elevated. Predictably, this ap-
• Guidelines for transitions: IV to SC
proach does not work. If no insulin is given before a
• Guidelines for special situations meal, the blood glucose level rises substantially and
• Enteral nutrition remains elevated at the time of the next meal. Then,
• Parenteral nutrition a large dose of regular, lispro, or aspart insulin is
given, which could cause hypoglycemia, particularly
• Patient transportation and other handoffs if administered at bedtime without a meal. Standard
• Hypoglycemia: BG <70 mg/dL insulin sliding scales are ineffective, carry the risk
of hyperglycemia and hypoglycemia, and generally
Prevention should be avoided.
Balancing glycemic control by preventing hyperglyce-
mia and hypoglycemia is key for providing optimum 3.Inpatient use of oral agents
care of individuals with diabetes. The inpatient team Oral agents should not be used by inpatients who
can prevent or reduce hypoglycemic events by are too ill to maintain adequate caloric intake or who
1. Recognizing precipitating factors or triggering are on NPO status because of illness or planned pro-
events; cedures. Secretagogues can cause hypoglycemia,
alpha glucosidase inhibitors are ineffective without
2. Ordering appropriate scheduled insulin or anti-di- carbohydrate intake, and metformin puts patients at
abetic oral agents;
risk who are renal compromised or in heart failure.
3. Monitoring blood glucose at the bedside; Thiazolidinediones (TZDs) should be discontinued
in patients with Class III or Class IV heart disease,
4. Educating patients, family, friends, and staff although the lingering effects of TZDs last several
about symptom recognition and appropriate weeks. 5
treatment;
A common error in this population of patients is the

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