RECOGNITION AND ASSESSMENT
- 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
- If long starvation period anticipated (e.g. ≥2 missed meals)
- If capillary blood ketones > 3 mmol/L or urinary ketones > 2 mmol/L, follow DKA or 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
- 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 )
- 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 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
- Do not use potassium in the first bag of fluid
- Use pre-mixed bag (500 mL) of chosen fluid with10 mmol of potassium
- Use premixed bag (500 mL) of chosen fluid with 20 mmol of potassium in 500 mL
- 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 (pH >7.3, capillary ketones <6 mmol/L) and able to eat and drink, convert to SC insulin regimen
- decide oral hypoglycaemic agents or SC insulin
- if in doubt, 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 and 5), severe hepatic failure or newly diagnosed type-1 diabetes, use 0.3 units/kg
- all other adult patients, use 0.5 units/kg
- 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
© 2022 The Bedside Clinical Guidelines Partnership.
Created by University Hospital North Midlands and Keele University School of Computing and Mathematics.
Research and development team: James Mitchell, Ed de Quincey, Charles Pantin, Naveed Mustfa