Approach

Distinguishing between type 1 diabetes mellitus, type 2 diabetes mellitus, and new-onset hyperglycaemia can help establish a clear plan for glycaemic control during hospital admission. Patients with newly discovered hyperglycaemia have been shown to have a significantly higher in-hospital mortality than patients who have a history of diabetes or people with normoglycaemia.[33] Vigilance is needed for detecting ketoacidosis in patients with type 1 diabetes. See Diabetic ketoacidosis.

Insulin therapy is the standard practice for management of patients in the hospital with hyperglycaemia due to its effectiveness and flexible dosing.[4] Hospitalised patients often experience fluctuating insulin sensitivity and insulin secretion due to acute illness, stress, infections, drugs, or organ dysfunction. Nutritional intake is frequently unreliable due to nausea, procedures, or surgical fasting, and drug regimens often require adjustment. For example, outpatient oral agents may need to be withheld due to factors such as: renal impairment or intravenous contrast use (e.g., metformin), heart failure exacerbations (e.g., thiazolidinediones), or nil by mouth (NBM) status (e.g., sulfonylureas).

​In both critical care and non-critical care settings, glycaemic targets should be individualised based on the patient's clinical status and the resources available.[1]​​[34] Both hyperglycaemia and hypoglycaemia are associated with higher mortality, independent of known history of diabetes.[3][21]​​​

Management strategy and goals are similar across medical and surgical patients. However, hypoglycaemia is common problem in medical patients and is linked to worse outcomes in this group.[26] The principles of glucose management in patients with newly detected hyperglycaemia remain the same as those for patients with established diabetes. A key priority in inpatient glycaemic management is avoiding hypoglycaemia while maintaining safe glucose control.

Goals of glycaemic control

It is now well recognised that inpatient hyperglycaemia is not merely a transient response to illness or stress, but a condition that requires active management. Several large trials have investigated optimal glycaemic targets for critically ill patients, with mixed results. While early studies supported tight glycaemic control in the intensive care unit (ICU), later research raised concerns about increased mortality and hypoglycaemia associated with intensive insulin therapy.[35][36][37]

Once therapy for hyperglycaemia (whether it is hyperglycaemia due to newly diagnosed diabetes or stress hyperglycaemia or hyperglycaemia related to diabetes prior to admission) is initiated, the American Diabetes Association (ADA) recommends:[1]

  • Target glucose levels of 7.8 to 10.0 mmol/L (140-180 mg/dL) for most critically ill patients.

    • More stringent individualised glycaemic goals for selected critically ill individuals, if achievable without significant hypoglycaemia.

  • Target glucose levels of 5.6 to 10.0 mmol/L (100-180 mg/dL) for non-critically ill patients, if achievable without significant hypoglycaemia.

    • Glycaemic levels up to 13.9 mmol/L (250 mg/dL) may be acceptable in selected populations (e.g., terminally ill individuals with short life expectancy, advanced kidney failure [and/or on dialysis], high risk for hypoglycaemia, and/or labile glycaemic excursions).

The Endocrine Society recommends the same target glucose range of 5.6 to 10.0 mmol/L (100-180 mg/dL) for non-critically ill patients who are being treated for hyperglycaemia.[4]

The Canadian Diabetes Association recommends target glucose levels between 6.0 and 10.0 mmol/L (108 and 180 mg/dL) for most critically ill hospitalised patients.[2] For the majority of non-critically ill hospitalised people with diabetes, preprandial blood glucose targets should be 5.0 to 8.0 mmol/L (90-144 mg/dL) in conjunction with random blood glucose values <10.0 mmol/L (<180 mg/dL), as long as these targets can be safely achieved.[2]

The Joint British Diabetes Societies for Inpatient Care (JBDS-IP) recommends an inpatient glycaemic target of 6.0 to 10.0 mmol/L (108-180 mg/dL) for acutely ill individuals.[29] However, it emphasises that targets should be individualised. For some hospitalised individuals who are well, a more relaxed target of 3.9 to 10.0 mmol/L (54-180 mg/dL) may be acceptable (e.g., in otherwise fit, well adults awaiting elective surgical procedures).[29]

Day-to-day decisions regarding treatment goals should be guided by clinical judgement and ongoing assessment of the patient’s condition, including trends in glucose levels, severity of illness, nutritional status, and the use of drugs that affect glucose (e.g., glucocorticoids).[1]

Glucose monitoring in hospitalised patients

In hospitalised patients with diabetes who are eating, capillary blood glucose (CBG) monitoring should be conducted before meals. For those who are not eating, glucose monitoring is recommended every 4-6 hours.[1] When intravenous insulin therapy is used, more frequent CBG monitoring - typically every 30 minutes to 2 hours - is required to ensure safe and effective management.[1] It should be noted that CBG glucose metres are less accurate and precise than laboratory-based glucose analysers. Best practice recommends confirming any CBG glucose result that is inconsistent with the patient's clinical presentation by repeating the test, and if the discrepancy persists, by sending a sample for laboratory measurement, especially in cases of asymptomatic hypoglycaemia.[1]

Although CBG remains the standard for inpatient glucose monitoring, emerging research has explored the use of ambulatory continuous glucose monitoring (CGM) in non-critically ill hospital patients. Initial studies on one such device suggest that it may help to reduce both hyperglycaemia and hypoglycaemia in non-ICU settings.[38] Several CGM devices have been approved for hospital use in Europe (most sample glucose through the intravascular route, and one through the subcutaneous route) and in the US (intravascular route). Real-time CGM has been shown to lower the incidence of hypoglycaemia, although it may increase nursing workload.[39] During the coronavirus disease 2019 (COVID-19) pandemic, there was increasing utilisation of ambulatory CGM devices in the hospital setting. Inpatient data suggest that CGM devices offer accuracy comparable to CBG testing in many situations, with the added benefit of enhanced detection and prevention of glycaemic excursions.[40][41][42][43]

According to the Endocrine Society, CGM initiation in the inpatient setting is recommended for select non-critically ill patients at high risk of hypoglycaemia, using a hybrid approach that combines CGM with periodical confirmatory CBG testing to validate CGM accuracy.[4][44]​ Patients at high risk for hypoglycaemia who might benefit from the initiation of inpatient CGM include (but are not limited to):[4]

  • Those with impaired awareness of hypoglycaemia

  • Individuals aged ≥65 years

  • Individuals with a body mass index ≤27 kg/m²

  • Total daily dose of insulin ≥0.6 units/kg

  • History of stage ≥3 chronic kidney disease (estimated glomerular filtration rate < 60 mL/min/1.73 m²), liver failure, cerebrovascular accident, active malignancy, pancreatic disorders, congestive heart failure, or infection

  • History of pre-admission hypoglycaemia or hypoglycaemia occurring during a recent or current hospitalisation

This recommendation does not apply to situations in which CGM may not be accurate, including in patients with extensive skin infections, hypoperfusion, or hypovolaemia or those receiving vasoactive or pressor therapy. In addition, some drugs can cause inaccurate CGM readings (e.g., paracetamol >4 g/day, dopamine, vitamin C, hydroxycarbamide).[4] It is important to note that inpatient CGM use is not currently US Food and Drug Administration (FDA) approved but is allowed under enforcement discretion and was utilised with emergency use authorisation during the COVID-19 pandemic.[44] For patients already using personal CGM devices, the Endocrine Society recommends continuing their use during hospitalisation.[44] This continuation should also follow the hybrid approach, combining CGM with periodical CBG testing to ensure accuracy.[44] The FDA’s enforcement discretion similarly applies here.[44]

​The ADA supports the continued use of CGM during hospitalisation (particularly for people with type 1 or type 2 diabetes treated with intensive insulin therapy and at increased risk for hypoglycaemia while hospitalised) alongside confirmatory CBG testing, provided that adequate resources and staff training are available.[1] However, it does not recommend initiating CGM use during hospitalisation, noting that the initiation of new CGM devices in this setting has not received FDA approval.[1]

Guide to wearable diabetes technology: ​Patient Safety Learning: diabetes - what the tech? poster (June 2024) Opens in new window

Management of uncontrolled hyperglycaemia (blood glucose levels >7.8 mmol/L [>140 mg/dL]) in hospitalised patients

Critically ill patients

ADA and American Association of Clinical Endocrinology (AACE) guidelines recommend continuous intravenous insulin infusion as the most effective approach for achieving targeted glycaemic control while minimising the risk of hypoglycaemia in critically ill patients.[1][3][21] Subcutaneous insulin and oral antidiabetic drugs should be discontinued during intravenous insulin therapy. Reassessment should be performed once the patient is stable, tolerating oral intake, and transitioning off intravenous insulin.

The ADA recommends bedside blood glucose monitoring every 30 minutes to 2 hours for patients receiving intravenous insulin.[1] Patients may require concurrent glucose infusion to maintain glucose balance and prevent hypoglycaemia, particularly if they are not eating or have limited oral intake.

Intravenous insulin infusions should be administered using validated written or computerised protocols that allow for predefined adjustments in the insulin infusion rate based on glycaemic fluctuations and immediate past and current insulin infusion rates. For patients receiving insulin infusions in the ICU, standardised computerised protocols are increasingly used to streamline care.[1] These protocols facilitate nursing processes, improve efficiency, and have been shown to reduce glucose variability.[45] A variety of protocols, including the Yale Insulin Infusion Protocol, are available, and though few have been compared directly, outcomes across them are generally comparable.[1][3][21][35][46][47] Yale Insulin Infusion Protocol Opens in new window

Transition planning is important for patients receiving intravenous insulin; co-administration of a subcutaneous basal insulin analogue 2 hours before the intravenous infusion is discontinued can ease the shift from intravenous to subcutaneous insulin, reducing the risk of rebound hyperglycaemia.[1] For transitioning, the total daily dose of subcutaneous insulin may be calculated based on the insulin infusion rate during the prior 6-8 hours when stable glycaemic goals were achieved, based on prior home insulin dose, or following a weight-based approach.[1]

Patients with stable, non-critical illness

For non-critically ill patients with uncontrolled hyperglycaemia, management typically involves starting subcutaneous insulin and stopping oral antihyperglycaemic drugs. Subcutaneous insulin doses can then be adjusted as needed based on glucose levels and nutritional intake. Avoiding hypo- and hyperglycaemia is particularly important, as in some settings this has been associated with worse outcomes.[48]

The Endocrine Society recommends scheduled insulin therapy (using basal or basal-bolus regimens) as the preferred approach for glycaemic management in most adults hospitalised with non-critical illness and hyperglycaemia.[4]​ Sliding scale insulin alone is strongly discouraged in the inpatient setting, as it is less effective and associated with greater glucose variability.[1][49][50]

However, for adults without known diabetes who develop hyperglycaemia during hospitalisation, the Endocrine Society advises starting with correctional insulin alone (i.e., insulin given only in response to raised glucose) to maintain glucose targets between 5.6 and 10.0 mmol/L (100 and 180 mg/dL).[4] If hyperglycaemia persists - defined as two or more CBG blood glucose readings ≥10.0 mmol/L (≥180 mg/dL) within 24 hours - scheduled insulin therapy should then be added.[4]

In adults with diabetes previously treated with diet or non-insulin antihyperglycaemic agents, initial therapy may also begin with either correctional insulin or scheduled insulin.​[4] However, for patients showing persistent hyperglycaemia (≥2 CBG blood glucose readings ≥10.0 mmol/L [≥180 mg/dL] in 24 hours) while on correctional insulin alone, scheduled insulin should be initiated.[4] Scheduled insulin is also recommended for patients who present with admission blood glucose ≥10.0 mmol/L (≥180 mg/dL).[4]

For adults with insulin-treated diabetes prior to admission, the Endocrine Society recommends continuation of the home insulin regimen, modified based on nutritional intake and illness severity, with the goal of maintaining blood glucose levels within the 5.6 to 10.0 mmol/L (100-180 mg/dL) range.[4] Reductions in the dose of basal insulin (by 10% to 20%) at time of hospitalisation may be required for patients on basal heavy insulin regimens (defined as doses of basal insulin ≥0.6 to 1 unit/kg/day), in which basal insulin is being used inappropriately to cover meal-related excursions in blood glucose.[4] The ADA similarly recommends initiating or intensifying insulin or other glucose-lowering therapy for persistently raised blood glucose levels ≥10.0 mmol/L on two separate occasions within 24 hours.[1]

Insulin regimens

For patients previously on insulin therapy, the home total daily dose may be used as a guide to initiate inpatient insulin regimens. The basal-bolus strategy is preferred.

  • Basal insulin: can be long-acting (e.g., insulin glargine, insulin degludec) or intermediate-acting (e.g., insulin NPH [neutral protamine Hagedorn]). Second-generation basal insulins such as insulin glargine (300 units/mL) and insulin degludec (100 units/mL and 200 units/mL) provide more stable pharmacokinetics and lower glycaemic variability, and may be continued during hospitalisation.[51][52]

  • For long-acting regimens, half of the total daily dose is administered as basal insulin once or twice daily, and the other half as rapid-acting insulin in divided doses before meals.[49] Rapid-acting insulin should be withheld if the patient is not eating, but basal insulin should generally be continued.[49]

  • For intermediate-acting regimens, two-thirds of the daily dose is given in the morning (divided into two-thirds insulin NPH and one third fast-acting insulin), and one third in the evening (divided into half insulin NPH and half fast-acting insulin with the evening meal or at bedtime).

  • Use of fast-acting insulin at bedtime to correct hyperglycaemia is not recommended based on data from a randomised trial in patients with type 2 diabetes.[53]

  • The Endocrine Society and ADA encourage the continued use of closed-loop insulin pumps (automated insulin delivery [AID] systems) during hospitalisation, provided the patient is capable of independent device management and the institution has established protocols, supplies, training, and competency assessments in place.[1][44]

The authors of this topic do not recommend the use of sliding scale insulin alone in the majority of clinical circumstances. However, it may be used on occasion for 24 hours to determine the insulin requirements in some patients. Sliding scale insulin alone can be considered for patients hospitalised with non-critical illness and no history of diabetes with only mild hyperglycaemia >7.8 mmol/L but <10.0 mmol/L.[4]

Well-controlled pre-existing diabetes: stable non-critical illness

For hospitalised patients with diabetes who are clinically stable, have well-controlled blood glucose levels, and maintain consistent oral intake, continuation of their usual outpatient antidiabetic regimen may be appropriate.[34] However, inpatient management should be individualised based on comorbid conditions, risk of hypoglycaemia, and the potential for fasting (NBM) status. Insulin remains the preferred form of treatment for most inpatients, particularly those with hyperglycaemia or unpredictable oral intake.

Type 1 diabetes:

Patients admitted to the hospital who have well-controlled blood glucose levels can continue taking their usual insulin regimen if meal consumption remains similar to home intake. The ADA recommends a basal and correction insulin regimen for all hospitalised patients with type 1 diabetes, regardless of oral intake status, with prandial insulin added if the patient is eating.[1] Mealtime insulin doses may need to be adjusted depending on food intake.

Type 2 diabetes:

There is no strong evidence to suggest whether patients with type 2 diabetes should continue oral antidiabetic drugs during hospitalisation (when able). Most patients are switched to a basal-bolus insulin regimen, especially in the presence of hyperglycaemia or unpredictable oral intake. However, for patients with well-controlled glycaemic levels who are eating consistently and have no contraindications, continuation of oral agents may be considered if it is unlikely that the patient will be made NBM.

  • Metformin should be used with caution due to its contraindications (including renal impairment, acute heart failure, and contrast imaging), and it is often discontinued during hospitalisation. However, recent large observational studies suggest it may be safely continued in select, clinically stable patients.[54][55]

  • Thiazolidinediones are not recommended in patients presenting with fluid overload or heart failure due to their risk of exacerbating volume retention.

  • Sodium-glucose cotransporter-2 (SGLT2) inhibitors should be discontinued on admission due to the risk of euglycaemic DKA, particularly in surgical patients; they should be stopped 3 days prior to elective procedures (4 days for ertugliflozin).[1][56] Despite these concerns, the use of SGLT2 inhibitors in the hospital setting remains a subject of active investigation, with emerging data suggesting benefit in select populations.[57] The ADA recommends that patients with type 2 diabetes hospitalised with heart failure be started or continued on an SGLT2 inhibitor after recovery from the acute illness, provided there are no contraindications.[1]

  • In select patients with type 2 diabetes and mild hyperglycaemia, the Endocrine Society suggests that a dipeptidyl peptidase-4 (DPP-4) inhibitor with correctional insulin or scheduled insulin therapy can be used. This approach is appropriate for patients with recent haemoglobin A1c (HbA1c) <58 mmol/mol (<7.5%), blood glucose consistently <10.0 mmol/L (<180 mg/dL), and, if previously insulin-treated, a total daily dose <0.6 units/kg/day. Patients whose blood glucose levels remain persistently raised while on a DPP-4 inhibitor should be transitioned to scheduled insulin. These recommendations do not apply to patients with type 1 diabetes or insulin-dependent forms of diabetes. For any new therapy initiated during hospitalisation with plans for outpatient continuation, clinicians should discuss cost and patient preference before discharge.[4]

  • Drugs with hypoglycaemic effects (e.g., sulfonylureas, meglitinides) may be difficult to dose accurately in the setting of variable nutrition and feeding status and are generally not recommended.

Perioperative glycaemic management

For adults with diabetes scheduled to undergo elective surgery, the Endocrine Society recommends aiming for a preoperative HbA1c of 63.9 mmol/mol (<8%) and maintaining blood glucose levels between 5.6 and 10.0 mmol/L (100 and 180 mg/dL).[4] These recommendations apply only to patients undergoing elective procedures where there is sufficient time to optimise glucose control in advance. Blood glucose levels should be within the target range during the 1-4 hours prior to surgery. Clinicians should also be aware that factors such as anaemia, haemoglobinopathies, chronic kidney disease, alcohol use, certain drug, and significant glucose variability can affect HbA1c readings and should be considered when assessing glycaemic control.[4]

Patients admitted for minor elective surgery who take oral antidiabetic drugs may continue these agents if the procedure is short and the patient is expected to resume eating later the same day. For longer, more complicated procedures, oral drugs are usually discontinued in favour of starting subcutaneous basal-bolus insulin given subcutaneously starting on the day of surgery.

While acknowledging that limited data are available on the perioperative use of glucagon-like peptide-1 (GLP-1) receptor agonists, a 2024 multisociety clinical practice guidance, endorsed by the American Society of Anesthesiologists (ASA) and other specialty groups, recommends a shared decision-making approach between anaesthesia, surgical, and prescribing teams.[58]​ This includes assessing individual risk factors for delayed gastric emptying and aspiration, such as being in a dose escalation phase, use of higher-dose or weekly formulations, presence of gastrointestinal symptoms (e.g., nausea, vomiting, abdominal pain, constipation), or comorbidities like gastroparesis or Parkinson’s disease. For patients without raised risk, GLP-1 receptor agonist therapy may be continued perioperatively.[58] In patients with increased risk, discontinuation should be considered, with the ASA recommending holding daily formulations on the day of surgery and weekly formulations at least 7 days prior to elective procedures.​[58][59]​​ Preoperative risk mitigation strategies - such as a 24-hour pre-procedure liquid diet, use of gastric ultrasound when available, or anaesthesia adjustments like rapid sequence induction - may further reduce aspiration risk.[58] The ADA similarly advises that perioperative decisions be individualised based on factors including the indication for therapy (e.g., diabetes vs. obesity), current glycaemic control, surgical urgency, type of anaesthesia, and institutional resources.[1] If withholding a GLP-1 receptor agonist (or a dual glucose-dependent insulinotropic polypeptide [GIP]/GLP-1 receptor agonist) is expected to worsen glycaemic outcomes, the ADA recommends considering alternative perioperative glycaemic management, such as insulin therapy.[1]

For patients using insulin before hospitalisation, the dose of intermediate-acting insulin is reduced by 30% to 50% the evening before surgery. True basal insulins such as insulin glargine or insulin degludec can usually be given at or close to their routine dose. Rapid-acting insulins are held while the patient is not eating.

Long and complicated surgical procedures may require intravenous insulin infusion to maintain optimal glucose control and there are a number of algorithms available. In converting stable post-surgical patients from intravenous insulin to subcutaneous basal-bolus regimens, the total daily intravenous dose can be reduced by 20%. Fifty percent of that total is then administered as long-acting insulin once or twice daily, with the other 50% divided into two or three premeal injections. Co-administration of a subcutaneous basal insulin analogue 2 hours before the intravenous infusion is discontinued can ease the shift from intravenous to subcutaneous insulin, reducing the risk of rebound hyperglycaemia.[1]

Management of hypoglycaemia

Patients at increased risk of hypoglycaemia include those with reduced nutritional intake, malnutrition, renal or hepatic impairment, heart failure, malignancy, infection, sepsis, older age, and cognitive impairment.[1][3]​​[21]​​

Compared with sliding scale insulin, basal-bolus insulin is more frequently associated with hypoglycaemia.[26][34]​ Insulin-induced hypoglycaemia can lead to neuroglycopenia. Hypoglycaemia is associated with worse outcomes, especially in ICU patients. Sedation or beta-blocker use may mask symptoms of neuroglycopenia, and counter-regulatory responses can be impaired. Additionally, changes in corticosteroid dosing, reductions in intravenous glucose or parenteral nutrition, or alterations in oral nutritional intake may contribute to hypoglycaemia. Oral insulin secretagogues (sulfonylureas or meglitinides) may also precipitate hypoglycaemia.

The ADA and the AACE recommend reassessing the insulin regimen when the patient's blood glucose falls below 5.6 mmol/L (100 mg/dL), and modifying the regimen if glucose drops below 3.9 mmol/L (70 mg/dL).[1][3]​​​[21]​​

To prevent hypoglycaemia, frequent glucose monitoring and timely treatment modifications - such as promptly reducing insulin infusion rates - are essential. Mild hypoglycaemia in patients capable of oral intake can be managed with oral glucose or fruit juice. For severe or refractory hypoglycaemia, or in patients unable to take orally, 50% glucose should be given intravenously with close glucose monitoring for the next hour. Some clinicians prefer lower concentrations (10% or 20% glucose) to reduce the risk of post-treatment hyperglycaemia or tissue injury from extravasation.[60]​ Alternatively, intramuscular glucagon can be given. Newer glucagon formulations are available in some countries; see Emerging treatments.

Supportive care

In all patients, adequate nutrition and fluid replacement should be ensured. Enteral nutrition or total parenteral nutrition (TPN) may be required in patients with diabetes who are not eating:[1]

  • If TPN is used, insulin can be added directly to the TPN solution - particularly if more than 20 units of correctional insulin have been needed in the previous 24 hours - or administered as a separate intravenous infusion. A starting insulin dose of 1 unit of neutral human insulin per 10 g of glucose is recommended, with daily adjustments as needed.

  • For individuals receiving enteral nutrition, insulin orders should address basal, prandial, and correctional needs. Most adults already receiving basal insulin should continue their usual dose. The prandial insulin component can be estimated at 1 unit per 10-15 g of carbohydrate delivered by the feeding formula. Insulin selection and timing should match the feeding schedule: for continuous enteral feeds, options include insulin NPH every 8-12 hours or neutral insulin every 6 hours, given their longer duration of action. For bolus enteral feedings, rapid-acting or neutral insulin should be administered before each feed, with correctional insulin added as needed.

  • Because continuous enteral or parenteral feeding creates a constant postprandial state, attempting to lower glucose below 7.8 mmol/L (140 mg/dL) significantly increases the risk of hypoglycaemia. Frequent insulin dose adjustments are necessary, and correctional insulin may be given every 6 hours (neutral insulin) or every 4 hours (rapid-acting insulin), depending on the regimen. In the event of enteral nutrition interruption, glucose-containing intravenous fluids should be started immediately, particularly in individuals with type 1 diabetes, to prevent hypoglycaemia and reduce the risk of diabetic ketoacidosis. Basal insulin must be continued in patients with type 1 diabetes, regardless of nutritional status.

Patients on intravenous insulin may require concurrent glucose infusion to maintain glucose balance and prevent hypoglycaemia, particularly if they are not eating or have limited glucose intake.

Electrolytes should be monitored and corrected as required. Potassium should be added to intravenous fluids according to local ward protocols to prevent or treat hypokalaemia.

Discharge and follow-up

Measurement of HbA1c is valuable in determining the plan at discharge. A high HbA1c indicates poor pre-existing glycaemic control and suggests the need for intensified or modified antidiabetic therapy (e.g., starting insulin or maximising oral agents).[3][33]

A wide range of therapy is available for long-term diabetes management. Some patients may need to continue taking insulin at home until complete recovery allows a transition to other drugs.[34]

Patients without known diabetes should receive outpatient follow-up to reassess glucose levels and determine the need for ongoing treatment or diagnostic evaluation.

Children

One randomised trial involving paediatric patients undergoing cardiac surgery found that tight glycaemic control, targeting blood glucose levels of 4.4 to 6.1 mmol/L (80-110 mg/dL), did not significantly affect infection rates, mortality, length of hospital stay, or measures of organ failure, compared with standard care.[61] In another trial of critically ill paediatric patients (excluding those undergoing cardiac surgery) with hyperglycaemia, those in the tight glycaemic control group (blood glucose targets 4.4 to 6.1 mmol/L [80-110 mg/dL]) experienced higher rates of healthcare-associated infections and significantly higher rates of severe hypoglycaemia compared with those maintained at higher blood glucose targets (8.3 to 10.0 mmol/L [150-180 mg/dL]). There were no significant differences in mortality, measures of organ failure, or ventilator-free days between the groups. Due to the lack of benefit and increased risk of harm, the trial was stopped early.[62]

Where available, a paediatric endocrinologist should be consulted when managing hospitalised children with diabetes, especially those who are critically ill.

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