3. Don’t forget to watch potassium in patients with diabetic ketoacidosis (DKA).
A patient with a normal level of potassium, or even a high one, at baseline can encounter a problem with plummeting levels, says Bruce Mitchell, MD, director of hospital medicine services at Emory Hospital Midtown and assistant professor of hospital medicine at Emory University in Atlanta.
“Once you start insulin and correcting the hyperosmolality, the potassium shifts,” says Dr. Mitchell, who has a particular interest in endocrinology, “so it can become abnormally low fairly quickly.
“You start the insulin and fluids; then all of a sudden that person’s potassium is drastically abnormal and they’re coding,” he says. “It’s important to make sure your hospital’s diabetic ketoacidosis protocol includes frequent potassium checks.”
4. Be sure to wait long enough before rechecking TSH after a medication change.
It takes several weeks before thyroid medication dose changes start to show their effects, says Jeffrey Greenwald, MD, a hospitalist at Massachusetts General with expertise in endocrinology. Guidelines published in 2012 by the American Association of Clinical Endocrinologists and the American Thyroid Association recommend rechecking TSH within four to eight weeks.3
“It bears reminding that [for] patients who have recently changed their thyroid medication dose, you need to wait several weeks before you recheck their TSH. That’s another reason why the TSH can be somewhat difficult to interpret. There’s a tendency that I have seen, too, if the TSH is high and they’re on thyroid replacement, to want to adjust the dose while they’re in the hospital, which is probably not the time to do it.”—Jeffrey Greenwald, MD, hospitalist, Massachusetts General, Boston
“It bears reminding that [for] patients who have recently changed their thyroid medication dose, you need to wait several weeks before you recheck their TSH,” he says. “That’s another reason why the TSH can be somewhat difficult to interpret.
“There’s a tendency that I have seen, too, if the TSH is high and they’re on thyroid replacement, to want to adjust the dose while they’re in the hospital, which is probably not the time to do it.”
5. When administering insulin, factor in soon-to-arrive meals and give prandial insulin as needed.
If patients with diabetes are receiving insulin in the hospital, even if their glucose is in the normal range, they will need insulin if they’re about to have a carb-loaded breakfast, says Jose Florez, MD, PhD, an endocrinologist at Massachusetts General and associate professor of medicine at Harvard Medical School in Boston.
“A person with a glucose of 98 who is about to eat pancakes needs standing short-acting insulin regardless of the fingerstick,” Dr. Florez says. “A person with a glucose of 250 who is about to eat needs both the correction insulin and the amount needed to handle the impending carbohydrate load.”
“The person not only needs to correct what the glucose is at the moment, but they also need to account for the impending carbohydrate intake,” he says.
Dr. Anderson says he always cautions those caring for hospitalized diabetic patients against using the “sliding-scale philosophy”—marked by set amounts of long-acting insulin and set amounts of carbohydrate intake—because it’s overly formulaic for that setting.
“It leads to really variable glucoses,” he says, “and usually not good control.”
6. Giving isotonic fluids to someone who has fixed water retention or hypertonic urine can worsen the problem.
This can stem from an incomplete or incorrect evaluation of hyponatremia, which is a common problem in hospitalized patients. When hyponatremia is present, the first order of business should be to exclude pseudohyponatremia and confirm that it’s hypotonic hyponatremia.
