Hospital Management of Hyperglycemia

For decades, a precept was passed down by academic physicians to trainees and staff as a guideline for inpatient care of patients with diabetes. That bit of wisdom held that it is best to “keep the patient a little sweet.” The Diabetes Control and Complications Trial1 and the U.K. Prospective Diabetes Study2 showed the ability of intensified control to reduce microvascular complications of diabetes. Despite the increased risk of hypoglycemia, these trials changed practice patterns in ambulatory settings in favor of intensification of diabetes therapy. Among hospitalized patients, a relationship of adverse outcomes to hyperglycemia was suggested by many observational studies that reported on mortality,3–7 infectious complications,8–11 length of stay,12 and other findings. Nevertheless, hospitalization continued to be seen by many practitioners as just a brief interlude during which tight glycemic control was risky and also irrelevant to the long-term well-being of patients with diabetes.Two randomized, prospective trials using intravenous insulin therapy now have revolutionized our thinking about inpatient care of diabetes and hyperglycemia by showing the ability of intensive insulin treatment of critically ill hospitalized patients to reduce mortality without increasing morbidity due to hypoglycemia.13,14 The first study called for initiation of an infusion of glucose and insulin in the setting of myocardial infarction and aimed at a target glucose of 126–180 mg/dl.13,15,16 The second used intravenous insulin infusion in the surgical intensive care unit to achieve a target glucose of 80–110 mg/dl.14,17 Control of hyperglycemia or insulin therapy per se hypothetically might reduce risks for hospitalized patients by correcting mechanisms of injury such as neutrophil dysfunction, abnormal activation of cytokines and the inflammatory pathway, cardiac reperfusion injury, endothelial dysfunction, thrombotic tendency, catabolism, and hyperglycemia-induced oxidative stress with …