Endo Exam 3: DKA Student

Who should get an A1c on admission?

All admitted patients with diabetes, or patients with random BG >140 mg/dL, if no A1c from the past 3 months exists

When should insulin be started in the hospital?

BG 180 mg/dL or higher

What is the ICU glucose goal (ADA 2026)?

140-80 mg/dL for most patients

What is the noncritically ill glucose goal (ADA 2026)?

100 to 180 mg/dL, if achievable without significant hypoglycemia

Which patients can have a higher glucose goal, up to 250 mg/dL?

Terminally ill or short life expectancy, advanced CKD with or without dialysis, high hypoglycemia risk, labile glucose

What were the NICE-SUGAR intensive and conventional targets?

Intensive 80-110 mg/dL, conventional 140-180 mg/dL

What did NICE-SUGAR find about intensive control?

Significantly higher mortality, severe hypoglycemia 6.8% vs. 0.5% with conventional control, no significant difference in length of stay

How is inpatient hyperglycemia defined?

BG >140 mg/dL

What outcomes are linked to hyperglycemia?

Higher morbidity and mortality, more infections, longer hospital and ICU stays

What are the causes of inpatient hyperglycemia?

Nutrition status, organ dysfunction, stress hyperglycemia in critical illness, surgery, medications

Why do NPO patients still need glucose coverage?

Enteral feeds or TPN can raise glucose, and dextrose in TPN is a major cause

What triggers stress hyperglycemia?

Hypoxia, hemorrhage, sepsis, surgery

What mechanisms drive stress hyperglycemia?

Increased cortisol, glucagon, gluconeogenesis, glycogenolysis, catecholamines, insulin resistance

Which medications raise glucose?

Glucocorticoids, fluoroquinolones, calcineurin inhibitors, beta blockers, atypical antipsychotics

How is hypoglycemia defined, and what is its main concern?

BG <70 mg/dL, associated with increased mortality

What are the common inpatient causes of hypoglycemia?

Insulin dosing or administration errors, improper prescribing of other glucose-lowering drugs, poor follow-up after a first episode, kidney failure, sudden steroid dose reduction, reduced oral intake or vomiting

What is the inpatient monitoring frequency when a patient is eating?

Point-of-care BG before meals

What is the inpatient monitoring frequency when a patient is not eating?

Every 4 to 6 hours

How often should BG be checked on IV insulin?

Every 30 minutes to 2 hours

What must hospitals have for BG under 70 mg/dL?

A standardized hypoglycemia protocol, with every episode documented including the cause and what helped

Treatment for an asymptomatic, responsive patient who can swallow and is not NPO?

15-20 g oral carbohydrate (tablet, juice, or gel), slow onset

Treatment for an asymptomatic, responsive patient who is NPO?

50% dextrose 50 mL (25 g) IV push

Treatment for a symptomatic or nonresponsive patient?

50% dextrose 50 mL (25 g) IV push, fast onset, preferred route

Treatment when there is no IV access?

Glucagon 1 mg IM, an option but not commonly used due to cost and sometimes not stocked

What is the preferred treatment for hospitalized patients with hyperglycemia?

Insulin

What is the most effective ICU insulin regimen?

Continuous IV regular insulin, fast onset and offset, requires constant glucose monitoring

What is the preferred floor insulin regimen?

Scheduled subcutaneous insulin

When is basal or basal plus correctional bolus preferred?

Poor oral intake or NPO patients

Is sliding scale insulin as monotherapy recommended?

Strongly discouraged, it can be used only as correction on top of basal and bolus

What must be in place if sliding scale insulin is used?

A hypoglycemia protocol, per ADA 2026

When should continuous IV insulin be used outside DKA?

Hyperglycemic patients who are NPO or have BG 180 mg/dL or higher, critically ill patients on continuous TPN

Where is continuous IV insulin typically limited?

ICU or higher-acuity units, due to monitoring and nursing needs

Which oral agents should be avoided while inpatient?

Metformin, meglitinides and sulfonylureas (especially glyburide and glimepiride), SGLT-2 inhibitors

When can oral agents be continued inpatient?

Only if the patient is stable, eating a normal diet, and not in the ICU

How is short-acting steroid hyperglycemia managed (for example, prednisone)?

NPH insulin given with the steroid, on top of daily basal-bolus or oral agents

How is long-acting, multidose, or continuous steroid hyperglycemia managed (for example, dexamethasone)?

Long-acting insulin

How should higher steroid doses be handled?

Increase prandial and correctional insulin

Why is continuous IV insulin preferred for critically ill patients?

It can achieve specific goals and avoid hypoglycemia, not because it is easier or cheaper

What is the A1c goal before elective surgery?

<8%, whenever possible

What is the BG goal within 4 hours of surgery?

How often should BG be monitored while NPO?

100-180 mg/dL

Every 2 to 4 hours

What happens to metformin on the day of surgery?

When should SGLT-2 inhibitors be stopped before surgery?

Hold it

3-4 days before surgery

When should other oral agents be held?

The morning of surgery or procedure

How should home insulin be adjusted for surgery?

50% of NPH dose, 75 to 80% of long-acting analog dose, adjust pump basal rates

How long can surgical stress hyperglycemia last?

9-21 days after surgery

What does PC’s chart suggest about his glucose risk while NPO?

Which home meds for PC should not be restarted while acutely ill?

Hypoglycemia risk from NPO status, not hyperglycemia

Metformin and glipizide

Why should PC stay on the IV drip for now, not switch to SC meal insulin?

What raises PC’s glucose in the ICU?

He is acutely ill and NPO, so IV insulin continues until stable

IV dexamethasone

What are the steps to convert an IV insulin drip to SC insulin?

Sum units over the last 6 hours of the drip, multiply by 4 for total daily dose, take 60 to 80% of TDD, split 50% basal and 50% bolus, divide bolus by 3 for meals

What is the overlap rule for IV to SC insulin?

Continue IV insulin for at least 2 to 4 hours after starting SC insulin, per the inpatient lecture (see discrepancy card)

How should insulin-naive patients start SC insulin?

0.3-0.6 units/kg/day

How should insulin-experienced patients transition?

Usually return to their prior home regimen