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es-cgm-contraindication-check

This skill checks for contraindications or sources of inaccuracy that may affect continuous glucose monitoring (CGM) reliability in hospitalized adults. It is triggered when clinicians ask, “Are there factors that could make CGM unreliable?” or when assessing for skin infection, hypoperfusion, hypovolemia, vasoactive/pressor therapy, or medications such as acetaminophen >4 g/day, dopamine, vitamin C, or hydroxyurea.

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Check for CGM contraindications or inaccuracies

STEP 1 — Gather Information

Collect data on skin integrity (extensive infection or lesions), signs of hypoperfusion (e.g., cool extremities, delayed capillary refill), hypovolemia (orthostatic hypotension, low urine output), current vasoactive or pressor therapy (e.g., norepinephrine, epinephrine, dopamine infusion), and medication list focusing on acetaminophen >4 g/day, dopamine, vitamin C supplements, or hydroxyurea.

STEP 2 — Rule In / Rule Out

If any of the following are present: extensive skin infection, hypoperfusion, hypovolemia, vasoactive/pressor therapy, acetaminophen >4 g/day, dopamine, vitamin C, or hydroxyurea → rule in (CGM may be inaccurate); otherwise → rule out (CGM likely accurate).

STEP 3 — Classify or Stratify

Classify CGM as unreliable when any rule‑in factor is present; classify as reliable when no rule‑in factors are identified.

STEP 4 — Decide

If CGM is unreliable, do not use CGM readings for insulin dosing adjustments; rely on point‑of‑care blood glucose (POC‑BG) monitoring. If CGM is reliable, proceed with real‑time CGM use accompanied by confirmatory POC‑BG checks before making insulin adjustments.

Clinical Guardrails / Mimics / Pitfalls

Do not assume CGM accuracy in critically ill patients (this guideline applies to noncritical care). Do not overlook transient hypotensive episodes that may intermittently affect perfusion. Remember that even without listed factors, CGM still requires POC‑BG calibration for safety. Never rely solely on CGM for insulin decisions without confirmatory POC‑BG. Check for over‑the‑counter acetaminophen contributions to total daily dose.

Concrete Clinical Example

A 68‑year‑old admitted for pneumonia is started on norepinephrine 0.1 µg/kg/min for septic shock and takes acetaminophen 1 g every 6 hours (total 4 g/day) plus an extra 500 mg PRN for fever. The skill identifies vasoactive pressor therapy and acetaminophen >4 g/day → classifies CGM as unreliable → directs the team to use POC‑BG for all insulin adjustments.

Source: Management of Hyperglycemia in Hospitalized Adult Patients in Non-Critical Care Settings: An Endocrine Society Clinical Practice Guideline, Endocrine Society, 2022, DOI: 10.1210/clinem/dgac278

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