DO NOT USE FOR CLINICAL PRACTICE
Please use current guidelines available on the UHNM intranet for patient treatment
Please use current guidelines available on the UHNM intranet for patient treatment
RECOGNITION AND ASSESSMENT
- Blood glucose persistently >12 mmol/L
- For symptoms and signs, investigations and guideline to use, see Hyperglycaemia: triage guideline
Appropriate patients
- Patients with blood glucose persistently >12 mmol/L with:
- mild/no dehydration
- no metabolic acidosis nor severe dehydration
- nil-by-mouth or long starvation period anticipated (e.g. ≥2 missed meals)
- If capillary blood ketones ≥ 3mmol/L or urinary ketones> 2, follow Diabetic ketoacidosis (DKA) or Hyperosmolar hyperglycaemic state (HHS) guideline
- for advice on which of DKA or HHS guideline to follow, go to Hyperglycaemia: Triage
- Severe illness with need to achieve good glycaemic control e.g. sepsis
- Vomiting (not DKA)
Important points to consider
- Patients with type 1 diabetes require insulin even if not eating
Investigations
- Blood glucose (capillary)
- if persistently high, check venous blood glucose
GENERAL MANAGEMENT
- Treat cause
- Refer to diabetes team
DELIVERY OF FLUID AND INSULIN
Never give single doses of insulin
- Deliver insulin and IV fluid simultaneously
- only via a set incorporating anti-reflux valves through single cannula
- see IV Insulin & Fluid via one cannula guideline
- Do not use ordinary 3-way taps
- Use IVAC pump to control IV fluid infusion rate and to alert when fluid bag needs replacing
- Never give single doses of insulin e.g. Actrapid®
- leads to large swings in glucose
FLUID
- In patients with heart failure, exercise caution with fluid administration
- Consider clinical haemodynamic state and U&E before deciding on type and rate at which IV fluids are prescribed
Amount of fluid
- Set fluid replacement rate to deliver patient’s hourly fluid requirement. This can vary between 83-125 mL/hr (Estimate maintenance volume - see IV fluid maintenance guideline)
- If patient requires additional resuscitation fluid, give via other arm
- see Fluid resuscitation guideline
Choice of Fluid
- NEVER add potassium chloride to infusion bags
- Ideal fluid of choice to be co-administered with Variable Rate Insulin Infusion (VRII) is pre-mixed bag (500 mL) of sodium chloride 0.45% with glucose 5% and potassium chloride:
- If above fluid is not available, use the following:
- if blood glucose ≥14.0 mmol/L, use pre-mixed bag (500 mL) of sodium chloride 0.9% with potassium chloride
- if blood glucose <14.0 mmol/L, use pre-mixed bag (500 mL) of glucose 5% with potassium chloride
Potassium: amount in premixed bag
- Serum K+ >5.5 mmol/L: do not use potassium in the first bag of fluid
- Serum K+ 3.6-5.5 mmol/L: use pre-mixed bag (500 mL) of chosen fluid with 10 mmol of potassium
- Serum K+ 3.0-3.5 mmol/L: use premixed bag (500 mL) of chosen fluid with 20 mmol of potassium in 500 mL
- Serum potassium <3.0 mmol/L: seek more senior help
INSULIN
Previous Insulin regimen
- If patient taking long-acting insulin e.g. glargine (Lantus®), detemir (Levemir®) or deguldec (Tresiba®), continue this
- advise nurse to administer alongside IV insulin
- If patient on insulin pump subcutaneous (CSII), discontinue pump
- contact diabetes team or consultant in charge of patient
IV insulin delivery and infusion
- Use BD micro-fine insulin hypodermic syringes to accurately dose and draw insulin
- do not use ordinary syringe
- 50 units soluble insulin (Actrapid or Humulin S) diluted to 50 mL with sodium chloride 0.9% in 50 mL syringe
- Luer-lok through a spiral or long line delivered by syringe driver pump (so each mL equates to 1 unit of insulin)
Variable rate insulin infusion (VRII)
- Infuse insulin at a variable rate to maintain blood glucose 6-10 mmol/L (acceptable range 4-12 mmol/L)
- Measure capillary blood glucose initially and every hour
- adjust insulin infusion rate accordingly
- Use initial capillary blood glucose to choose insulin infusion rate
MONITOR
- Measure capillary blood glucose initially and every hour
- adjust insulin infusion rate accordingly
- To choose insulin infusion rate, use rate adjuster
Glucose not falling
- If blood glucose remains >12 mmol/L for 3 consecutive readings and is not dropping by ≥3 mmol/L/hr, increase rate of insulin infusion by 1 unit/hr until target achieved.
- When blood glucose falls below 12 mmol/L, use rate adjuster
Potassium Monitoring
- Check serum K+ after first bag of fluid has run through
- then check serum K+ 4-6 hr after start of infusion depending on rate
- If serum K+ remains 3.6-5.5 mmol/L, check U&E daily
- If serum K+ is <3.5 mmol/L or >5.5 mmol/L, adjust fluid. See Choice of fluid
- check and adjust K+ after each bag until serum K+ is 3.6-5.5 mmol/L
- then check U&E daily
CONVERSION FROM IV INSULIN
- Once patient biochemically stabilised and able to eat and drink, convert to maintenance regimen
- decide oral hypoglycaemic agents or SC insulin
- ask diabetes team advice
Oral hypoglycaemic agents
- Once patient ready to eat and drink, recommence oral hypoglycaemic agents
- If food intake likely to be reduced, be prepared to withhold or reduce sulphonylureas
- Recommence metformin only if eGFR is >30 mL/min/1.73 m2
SC insulin
- Transition from IV to SC insulin should take place when the next meal-related SC insulin dose is due e.g. with breakfast or lunch
- If already on insulin, continue fixed-rate infusion for 30-60 min after SC insulin administration in conjunction with a meal
- If delay in obtaining diabetes team support, the following is guidance for insulin therapy
Previously using SC insulin dose
- Restart usual insulin
- increasing previous dose by 10-20% for first 2-3 days
Insulin naïve patients
- In patient new to insulin, insulin requirements will fall initially as resistance falls
- ensure close supervision during this period
- Caution in patients with low or high BMI as dosing requirement and insulin sensitivity may vary
- Daily insulin requirement is 0.3-0.5 units/kg
- in elderly, renal failure (CKD stage 4 & 5), severe hepatic failure or newly diagnosed type-1 diabetes, use 0.3 units/kg
- all other adult patients, use 0.5 units/kg
- e.g. in a 60 kg patient, total starting dose of insulin is either 18 units or 30 units over 24 hr
- Give 50% of the total dose as long-acting analogue (glargine, detemir or degludec) SC before evening meal or before bedtime
Either
- Divide the remaining 50% into 3 equal doses of quick-acting insulin (Novorapid®, Humalog® or Apidra®) SC
- to be given before breakfast, lunch and evening meal
Or
- If twice daily pre-mixed insulin regime to be used - 2/3 of total dose can be given before breakfast and 1/3 before evening meal
Adjusting SC insulin regimen
- Once patient using SC insulin regimen, adjust doses to achieve target range of 6-11 mmol/L
- if using soluble insulin before breakfast, lunch and dinner, plus isophane at 2200 hr, use Table as guide to insulin adjustment, raising or lowering appropriate insulin by 2-4 units
- if patient usually using insulin analogue (e.g. lispro/aspart +/- glargine/detemir), additional isophane may be needed - discuss with diabetes team
DISCHARGE AND FOLLOW-UP
- Encourage early mobilisation
- Continue prophylactic LMWH until day of discharge (unless contraindicated)
- Check diabetes team have made appropriate follow-up arrangements or refer to diabetes team for out-patient review
- If patient new to insulin, prescribe needles for insulin pens, lancets and sharps guard