Manejo Paciente Diabetico En Urgencias

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Literature review current through: Jan 2013. | This topic last updated: may 24, 2012.
INTRODUCTION — Patients with type 1 or type 2 diabetes mellitus are frequently admitted to a hospital, usually for treatment of conditions other than the diabetes [1,2]. In one study, 25 percent of patients withtype 1 diabetes and 30 percent with type 2 diabetes had a hospital admission during one year; patients with higher values for hemoglobin A1C (A1C) were at highest risk for admission [2]. The prevalence of diabetes rises with increasing age, as does the prevalence of other diseases; both factors increase the likelihood that an older person admitted to a hospital will have diabetes.
Much of what wasformerly done in hospital, including many surgical procedures, complex diagnostic testing, or treatment of community-acquired infections, is now done in a clinic or at home. However, the presence of diabetes might precipitate admission of a patient who would otherwise be treated as an outpatient [3]. Whether in hospital or not, glycemic control is likely to become unstable in these patientsbecause of the stress of the illness or procedure, the concomitant changes in dietary intake and physical activity, and the frequent interruption of the patient's usual antihyperglycemic regimen.
Once in the hospital, the length of stay and cost are greater for patients with diabetes than for those without it [1,4]. Efficient treatment of diabetes in hospital may be an important factor in limiting thecosts of care. However, as mentioned below, firm data on optimal in-hospital treatment are sparse.
The treatment of patients with diabetes who are admitted to the general medical wards of the hospital for a procedure or intercurrent illness is reviewed here. The treatment of hyperglycemia in critically ill patients, the perioperative management of diabetes, and the treatment of complications ofthe diabetes itself, such as diabetic ketoacidosis, are discussed separately. (See "Glycemic control and intensive insulin therapy in critical illness" and "Perioperative management of diabetes mellitus" and"Treatment of diabetic ketoacidosis and hyperosmolar hyperglycemic state in adults" and "Management of hypoglycemia during treatment of diabetes mellitus".)
GOALS IN THE HOSPITAL SETTING — Themain goals in patients with diabetes needing hospitalization are to minimize disruption of the metabolic state, prevent an untoward result, and return the patient to a stable glycemic balance as quickly as possible. These goals are not always easy to achieve. On the one hand, the stress of the acute illness tends to raise blood glucose concentrations. On the other hand, the anorexia that oftenaccompanies illness or the need for fasting before a procedure tends to do the opposite. Because the net effect of these countervailing forces is not easily predictable in a given patient, the target blood glucose concentration is usually higher than when the patient is stable.
Uncertainty regarding goal blood glucose concentration is compounded by the paucity of controlled trials on the benefitsand risks of "loose" or "tight" glycemic control in hospitalized patients, with the exception of patients who are critically ill or have had an acute myocardial infarction (MI). (See "Glycemic control and intensive insulin therapy in critical illness" and "Glycemic control for acute myocardial infarction in patients with and without diabetes mellitus".)
In general, the goals are to:
* Avoidhypoglycemia
* Avoid severe hyperglycemia, volume depletion, and electrolyte abnormalities
* Ensure adequate nutrition
* Assess patient educational needs and address deficiencies
Critical to achieving these goals is the frequent measurement of glucose, often in capillary blood, with a method that is known to be reliable. (See "Blood glucose self-monitoring in management of adults with...