Glycemic chaos (not glycemic control) still the rule for inpatient care

Abstract

Diabetes is one of the most common diagnoses in hospitalized patients. A third of all persons admitted to urban general hospitals have glucose levels qualifying them for the diagnosis of diabetes, and a third of these hyperglycemic patients have not previously been diagnosed with diabetes. The impact of hyperglycemia on the mortality rate of hospitalized patients has been increasingly appreciated. Extensive evidence from observational studies indicates that hyperglycemia in patients with or without a history of diabetes is a marker of a poor clinical outcome. In addition, the results of prospective randomized trials in patients with critical illness or those undergoing coronary bypass surgery suggest that aggressive glycemic control improves clinical outcomes including reductions in: a) shortand long-term mortality, b) multiorgan failure and systemic infection, and c) length of hospitalization. The importance of glycemic control is not limited to patients in critical care areas but may also apply to patients admitted to general surgical and medical wards. The development of hyperglycemia in such patients with or without a history of diabetes has been associated with prolonged hospital stay, infection, disability after hospital discharge, and death. In general-surgical patients, serum glucose 220 mg/dL on postoperative day 1 has been shown to be a sensitive, albeit nonspecific, predictor of the development of serious postoperative hospital-acquired infection. A retrospective review of 1886 admissions to a community hospital in Atlanta, Georgia, found an 18-fold increase in mortality in hyperglycemic patients without a history of diabetes and a 2.5-fold increase in mortality in patients with known diabetes compared with controls. A meta-analysis of 26 studies identified an association of admission glucose 110 mg/dL with the increased mortality of patients hospitalized for acute stroke. More recently, hyperglycemia on admission was also shown to be independently associated with adverse outcomes in patients with community acquired pneumonia. In view of the increasing evidence supporting better glycemic control in the hospital, the American Association of Clinical Endocrinologists (AACE) in late 2003 convened a consensus conference on the inpatient with diabetes, cosponsored or supported by other prominent professional organizations, including the Society of Hospital Medicine (SHM). An expert panel agreed on and pubE D I T O R I A L