Manual of Clinical Nutrition

Diabetes Mellitus

Manual of Clinical Nutrition Management III- 25 Copyright © 2013 Compass Group, Inc.

DIABETES MELLITUS: CONSIDERATIONS FOR ACUTE ILLNESS

Monitoring
Achieving stringent glycemic control during concurrent illness (eg, acute illness, trauma, or surgery) may
reduce mortality and morbidity in the hospital setting (1). Therefore, targeting glucose control in the hospital
setting has the potential for improved mortality, morbidity, and health care outcomes (1).

During acute illness, records should be kept of blood glucose levels and ketone tests as well as weight loss,
temperature, insulin dose and time given, and any other medications that were given (1).

Individuals with diabetes must be appropriately monitored for diabetic ketoacidosis (acidosis accompanied
by the accumulation of ketone bodies in the tissues and fluids). Although diabetic ketoacidosis occurs most
often in people with type 1 diabetes, people with type 2 diabetes can develop ketoacidosis during illness. Ill
patients with type 1 diabetes should check urine ketones and blood glucose every 3 to 4 hours, more
frequently if the blood glucose level is high or if the patient is pregnant. If patients with type 1 diabetes have
blood glucose levels that are higher than 240 mg/dL two times in a row, the urine or blood should be tested
for ketones. Blood glucose readings >240 mg/dL and moderate to large amounts of ketones are a danger
signal for diabetic ketoacidosis. Patients with diabetic ketoacidosis (DKA) require additional insulin and
immediate management of fluids and electrolytes (2). Persons with type 2 diabetes are vulnerable to
hyperosmolar hyperglycemic nonketotic state (HHS) (3). This condition presents with a glucose of > 600
mg/dL, serum osmolality > 320 mOsm, serum bicarbonate > 15 mEq/L along with lethargy and possible coma
(3). Ketones in the urine and blood are trace or absent because the presence of some insulin inhibits lipolysis.
Patients should be immediately managed with intravenous fluids, electrolyte management and insulin (3).

Approaches for the Hospital Setting
Guidelines for patients with type 1 or type 2 diabetes mellitus:

1. Contact physician when vomiting or diarrhea continues for 3 to 4 hours (1).


2. For insulin-requiring patients or patients who are pregnant, test urine for ketones. Contact physician
   when test shows a moderate to large amount of ketones (1,2).


3. For diabetic critical-care patients, contact physician when blood glucose level remains above 180 mg/dL
   even after supplemental insulin (as arranged with physician). In critically ill patients insulin therapy
   should be initiated for treatment of persistant hyperglycemia starting at a threshold of no greater than
   180 mg/dL (1). Once insulin therapy is started, a glucose range of 140 to 180 mg/dL is recommended for
   the majority of critically ill patients (1). Critical-care patients will usually require intravenous insulin
   protocol that has demonstrated efficacy and safety in achieving desired glucose range without increasing
   risk for hypglycemia (1).


4. For diabetic noncritically ill patients there is no clear evidence for specific blood glucose goals (1). If
   treated with insulin, the premeal blood glucose levels should generally be < 140 mg/dL with random
   blood glucose < 180 mg/dL provided these targets can be safely achieved without risking hypoglycemia
   (1). More stringent targets may be appropriate in stable patients with previous tight control. Less
   stringent targets may be appropriate in those with severe comorbidities (1).


5. Contact physician when signs of ketoacidosis—dehydration, drowsiness, abdominal or chest pain,
   difficulty breathing, sunken eyes, or fruity breath—are present (2).


6. Contact physician when temperature is greater than 100ºF or when the patient is unable to take fluids for
   3 to 4 hours (1).


7. The patient should avoid physical exertion and rest at a comfortable room temperature.

Management
Medication: The patient should take insulin or oral glucose-lowering medication regardless of the ability to
eat normal amounts (1). During acute illness, an associated increase in levels of counterregulatory hormones
may increase insulin requirements (1). Scheduled prandial insulin doses should be given in relation to meals
and should be adjusted according to point-of-care glucose levels. The traditional sliding-scale insulin
regimens are ineffective and not recommended (1). For people with type 2 diabetes who normally do not
need insulin, the presence of infection may necessitate short-term use of insulin. Records should be kept of
blood glucose levels and ketone tests as well as weight loss, temperature, insulin dose and time given, and any
other medicines that were given (1). The patient should follow the physician’s instructions for changing the
insulin or medication regimen.