BOSTONPatients hospitalized for treatment of cancer or other medical conditions who are diabetic or become diabetic need aggressive glycemic control, MiKaela Olsen, RN, MSN, OCN, said at the Oncology Nursing Society 31st Annual Congress (abstract 69).
"Often, doctors do not really listen when you tell them the patient's blood glucose levels are 200 or 250 mg/dL, but the consequences can be severe. One blood glucose level greater than 220 mg/dL results in a 5.8 times increase in nosocomial infection rates. Two hours of hyperglycemia results in impaired white cell function for weeks. And a blood glucose greater than 200 mg/dL in a hospitalized patient causes increased morbidity and mortality," said Ms. Olsen, an oncology nurse specialist at Johns Hopkins Hospital.
Ms. Olsen noted that rapid growth in the incidence of diabetes is forcing practice changes. "If you haven't had them happen in your institution, you will," she said. "They will be mandated at the bedside. And we often are not prepared to deal with diabetics, since the management of diabetes in the hospital is generally considered secondary in importance to the admitting problem, for example, cancer." She also pointed out that oncology providers often lack knowledge about the most up-to-date management of diabetes, such as current research showing major benefits of tight glycemic control in the ICU setting.
Ms. Olsen said that at least one-third of patients admitted to the hospital either have a diagnosis of diabetes at entry or will be found to have high glucose levels during their stay. She reviewed the new American Diabetes Association criteria for the diagnosis of diabetes: a casual plasma glucose of 200 mg/dL or higher, fasting plasma glucose of 126 mg/dL or higher (lowered from 140 mg/dL in the previous guidelines), or a 2-hour glucose of 200 mg/dL or higher during an oral glucose tolerance test.
"It is amazing how many patients are being harmed or even killed because people do not know that a type I diabetic has to have exogenous insulin. Without exogenous insulin, the patient will develop diabetic ketoacidosis within hours, which is potentially lethal," Ms. Olsen said. She also warned that the longer patients have type II diabetes, the more they will begin to look like type I patients and need exogenous insulin.
Tight Control in the ICU
Intervention studies have shown improved outcomes with intensive glycemic control. Ms. Olsen described work by Van den Berghe et al documenting a significant reduction in mortality and morbidity, including sepsis and blood transfusion use, with tight glycemic control (80 to 110 mg/dL) vs conventional control (180 to 200 mg/dL) (N Engl J Med 345:1359-1367, 2001).
She also noted American Association of Clinical Endocrinologists guidelines that recommend maintaining ICU patients' blood glucose levels at less than 110 mg/dL. "Outside the critical care setting, the pre-meal glucose should be not more than 110 mg/dL; and the maximum glucose 2 hours postprandial should not exceed 180 mg/dL," she said.