1. health and fitness
2. disease
3. diabetes

1
WEST HERTFORDSHIRE HOSPITALS NHS TRUST
GUIDELINES FOR
HOSPITAL MANAGEMENT OF ADULT PATIENTS
WITH DIABETES MELLITUS
Author
Division
Department
Version number
Ratified/Endorsed:
Ratified Date
Review Date
E-mail address of Manager
Source of Evidence (If applicable)
Key Words (To aid searching)
2007/217
Department of Diabetes
Medicine
Dept of Endocrinology and Diabetes
4
Medical Director/Drug & Therapeutics Cttee
March 2007
March 2009
Colin.Johnston@whht.nhs.uk
Multiple
Diabetes Mellitus Management of Adult
Patients
2
WEST HERTFORDSHIRE HOSPITALS NHS TRUST
GUIDELINES FOR HOSPITAL MANAGEMENT OF
DIABETES MELLITUS IN ADULT PATIENTS
CONTENTS
1.
2.
3.
4.
Introduction
Diabetes Team WGH and HHGH
Diagnostic criteria
Referral of patients to Diabetes Team
4.1. Ward referrals to Medical Team
4.2. Referrals to Diabetes Specialist Nurse
5. Monitoring of diabetes in hospital – blood glucose and IV insulin charts
6. Intravenous insulin therapy
7. Commencing subcutaneous insulin
8. Diabetic Ketoacidosis
9. Severe Hyperglycaemia +/- Ketosis (HONK)
10. Management of hypoglycaemia in hospital
11. Diabetes and Hyperglycaemia in acute coronary syndrome and myocardial
infarction (DIGAMI)
12. Thrombolysis and secondary prevention in patients with diabetes
13. Diabetes and CVA
14. Diabetes and Surgery
15. Guidelines for advice to patients with diabetes using a bowel preparation
• Insulin-treated diabetes
• Tablet-treated diabetes
16. Diabetes and radiological procedures
17. Metformin and iodine-based contrast
18. Diabetes and pregnancy
18.1. Antenatal counselling
18.2. Screening and management of gestational diabetes – guidelines for blood
glucose testing in all pregnancies
18.3. Management of insulin-treated diabetes during labour (including gestational
diabetic patients on insulin)
18.4. Emergency management of acute hypoglycaemia in pregnant patients on
insulin
18.5. Guidelines for post-natal diabetes follow-up
19. Management of incidental newly diagnosed diabetes
20. Management of diabetic leg and foot ulceration
21. Management of acute Charcot joint
22. Care of the Dying Pathway
Appendix 1 – DSN referral from WGH intranet site
Appendix 2 – Advice sheet for patients with diabetes undergoing bowel preparation
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1. INTRODUCTION
Diabetes Mellitus is a common condition affecting 2 to 3% of the UK population, the incidence being
higher in older patients and those of Asian and African Caribbean background. There is now a large
evidence base for the management of diabetes, which has been reflected in our guidelines. These have
been developed for the use of medical staff in secondary care to enable us to deliver a consistently high
quality service to patients with diabetes mellitus attending our hospital.
Diabetes is a complex metabolic disorder associated with a high risk for cardiac and systemic vascular
disease. It is often associated with hypertension and dyslipidaemia. Patients may have coexisting
diabetes-related complications such as retinopathy, renal disease or neuropathy, which can increase
anaesthetic risk and co-morbidity. These factors should always be borne in mind when assessing the
patient with diabetes.
The National Service framework launched in 2002 sets out standards of care embracing a self-care
model designed around the needs of the person with diabetes and encouraging patient autonomy.
One in ten hospital beds is occupied by a person with diabetes. Patients with diabetes tend to have
longer hospital stays than those with normal glucose tolerance. In many patients diabetes is diagnosed
for the first time when they are admitted to hospital and it is therefore important to be able to identify
patients with a raised blood glucose and confirm the diagnosis of diabetes.
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2. DIABETES MULTIDISCIPLINARY TEAM
Consultant Physicians:
Dr Colin Johnston (HHGH)
01442 287083
Dr Chantal Kong (HHGH)
01442 287083
Dr Michael Clements (WGH)
01923 217696
Dr Arla Ogilvie (WGH)
01923 217287
Dr Amin Mir (Care of the Elderly WGH)
01923 217818
Diabetes Nurse Specialists:
Hemel Hempstead General Hospital
Tessa Judge bleep 2033
Clare Stratton bleep 2033
Emma Rhodes bleep 2033
Caroline Harris Bleep 2034
DSN direct line: 01442 287482
Switchboard: 0845 402 4331
Watford General Hospital
Emily Rodway bleep 1030(Mon – Fri)
Christine Feben bleep 1031 (Wed – Fri)
Wendy Liberty bleep 1032 (Mon – Wed)
Sharon Carter bleep 1033 (Mon – Wed)
Phyllis Renehan, Community DSN contact no 07785250726 (not to be given to patients)
Switchboard: 0845 402 4332
Diabetes Centre, DSN direct line: 01923 217553
Podiatrists:
Susannah Howard (Watford General Hospital – Tue and Wed am x3197)
Peter Smith (Hemel Hempstead General Hospital – x2641)
St Albans Foot Health Service 01727 829 405
Dietitians:
Joan Pollack (WGH) x3521
Ward referrals (WGH) x3519
HHGH x2566 bleep 2948
St Albans Hospital covered by Diabetes Team at HHGH
Mount Vernon Hospital covered by Diabetes Team at WGH
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3. Diagnostic criteria
The diagnosis of diabetes is made either by:
1. Fasting blood glucose >/=7 mmol/L
OR
2. Random glucose > 11 mmol/L with associated hyperglycaemic symptoms
If the patient is asymptomatic, blood glucose should be repeated.
Diabetes should only be diagnosed on a laboratory glucose measurement. A capillary blood
glucose (BM) is insufficient to confirm the diagnosis.
•
HbA1c cannot be used as a diagnostic test and is a measure of long-term glycaemic
control useful only in the monitoring of confirmed diabetes.
•
Glucose tolerance test (OGTT): This test is rarely necessary in hospital. A fasting glucose is
usually sufficient. It may be necessary in the following circumstances where the diagnosis of
diabetes is in doubt:
1. Impaired fasting glucose between 6.1 and 6.9 mmol/L.
2. Raised random glucose on one occasion with normal fasting glucose
A laboratory blood glucose is measured fasting and at two hours following a 75g oral glucose
load.
Interpretation of Oral Glucose Tolerance Test:
Two hour blood glucose <7.8 mmol/L = normal
>7.8 but <11.0 mmol/L = impaired glucose tolerance
>11.0mmol/L = diabetes mellitus
Fasting blood glucose >6.1 to 6.9 mmol/L = impaired fasting glucose
Fasting blood glucose >/=7mmol/L = diabetes mellitus
If you have any doubt about the interpretation of a patient’s results, please contact a member of
the diabetes medical team.
If a new diagnosis of diabetes is made in a hospital patient, the medical team caring for that patient must:
•
•
Inform the patient of the diagnosis and the need for follow-up by their General Practitioner
upon discharge from hospital
Inform the General Practitioner of the diagnosis and need for follow-up upon discharge from
hospital
It is not necessary for all patients with newly diagnosed Type 2 diabetes to be seen by the diabetes
team. It is however essential to refer all patients with newly diagnosed Type 1 diabetes and those
admitted with hyperglycaemic emergencies or diabetes-related complications to the diabetes team on an
urgent basis.
Further guidance on those patients who require inpatient review of their diabetes management is set out
in Section 4.
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4. GUIDELINES FOR REFERRAL OF INPATIENTS TO
THE DIABETES TEAM
4.1 INPATIENT REFERRALS
Not all patients with diabetes need to be referred to the Diabetes Team. The following high risk patients
need to be referred and reviewed as soon as possible:
MEDICAL REVIEW
Send an inpatient referral form AND discuss urgent cases personally with the Specialist Registrar (SpR)
or consultant
•
•
•
•
•
•
•
All patients with newly diagnosed Type 1 diabetes
All patients admitted with diabetic ketoacidosis (DKA), hyperosmolar non-ketotic state (HONK) or
severe hyperglycaemia.
All patients admitted due to complications of their diabetes
All patients with diabetes who have ulceration or sepsis of the foot or leg
Patients admitted with myocardial infarction or Troponin-T positive acute coronary syndrome who
have a blood glucose >11 mmol/L should be referred to the diabetes specialist nurse and
commenced on insulin according to the DIGAMI protocol. If there is any doubt as to whether the
patient should continue insulin or not this should be discussed with a member of the medical
diabetes team
Patients with Type 1 or Type 2 diabetes who have ongoing poor control requiring review of their
current diabetes regime or, in the case of Type 2 diabetes, possible conversion to insulin.
Patients with Type 1 diabetes admitted for a surgical procedure, particularly if known diabetesrelated complications.
DIABETES SPECIALIST NURSE REVIEW
Use DSN referral form located on intranet if not on ward
•
•
•
All patients listed above.
All patients requiring education and advice or where insulin therapy has been initiated should be
referred directly to the diabetes specialist nurses (using the DSN referral form which is available
on the intranet under Department).
All patients admitted with MI or acute coronary syndrome who have known diabetes (regardless
of glucose level on admission) or have a blood glucose >11.0 mmol/L. They will usually need
insulin.
If you think a patient may require outpatient review and follow-up send a direct written
referral to the Consultant. The Trust inpatient referral form can be used for this purpose.
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4.2 REFERRAL TO DIABETES SPECIALIST NURSING TEAM
Who to refer?
All newly diagnosed Type 1 patients – these patients should also be referred directly to a consultant
diabetologist.
All patients admitted with DKA, HONK – also refer to consultant diabetologist.
All patients admitted with a severe hypoglycaemic event.
All patients with Type 2 diabetes requiring conversion to insulin therapy.
All patients admitted with myocardial infarctions that also have diabetes or a random plasma glucose
greater than 11.0 mmol/L.
Any patients admitted due to diabetic complications including foot ulcers.
Patients on insulin requiring enteral feeding
How to refer to the DSN:
Referrals will be accepted from all qualified nursing and medical staff.
Only written referrals with all mandatory sections completed will be accepted (see overleaf)
Please fax referrals to 7673 (WGH) or 2381 (HHGH), or hand deliver to DSN.
It is not appropriate to refer patients on the day of discharge as we cannot guarantee that they will be
seen that day.
NB Refer as early as possible (allow at least 3 days for patients starting insulin)
Points to remember:
Ward referrals are for patient education and advice.
Decisions regarding changes in medication must be made by a member of the patient’s own medical
team or referred to one of the diabetes consultants at the request of the admitting consultant.
All patients requiring referral to a DSN should also be referred to a dietitian.
Patients with new Type 2 diabetes that do not require insulin will be invited to Type 2 group education if
appropriate (Hemel ext. 2482, Watford ext. 3553). These patients do not routinely need to be seen by a
DSN.
Please note these are only guidelines. The diabetes specialist nurses are
willing to be contacted if staff wish to discuss a patient’s diabetes care.
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5. MONITORING OF DIABETES
Ward Diabetes Chart
Most patients with diabetes requiring admission to hospital will need capillary glucose monitoring. The
frequency of monitoring should be clearly indicated to the nursing team by the medical staff. In stable
patients who are otherwise well with good glycaemic control, blood glucose recording may be taken once
or twice daily.
Patients who are unwell and/or requiring frequent changes to their medication will need to be monitored
more frequently, usually four times daily (pre-meals and 10pm).
Patients on intravenous sliding scale will usually need hourly or two-hourly glucose monitoring.
Patients with diabetes admitted to hospital need frequent review and often need adjustments to their
medication. If you require advice, please contact a member of the diabetes team.
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GLUCOSE MONITORING CHART FOR PATIENTS ON AN INTRAVENOUS INSULIN
INFUSION
(to be used in conjunction with WHHT Guidelines at http://wghintra01/dp/default.htm)
Consultant ____________________________
Ward
Patient details
Addressogram label
____________________________
PLEASE MONITOR BLOOD GLUCOSE EVERY _____________ HOURS
BLOOD GLUCOSE MONITORING
Date
Time (24h
clock)
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Blood glucose
(mmol/l)
INSULIN INFUSION RATE
IV insulin rate
units/hr
Nurse’s
signature
10
BLOOD GLUCOSE MONITORING
Date
Time (24h
clock)
2007/217
Blood glucose
(mmol/l)
INSULIN INFUSION RATE
IV insulin rate
units/hr
Nurse’s
signature
11
6. INTRAVENOUS INSULIN THERAPY – SLIDING SCALE
THIS REGIME IS NOT SUITABLE FOR PATIENTS
WITH DKA, HONK OR MI
Patients with diabetes who are ill and unable to eat or drink require intravenous insulin AND intravenous
fluids with potassium replacement (unless serum K+ is raised). Fluid replacement should be given at a
rate appropriate to the clinical condition of the patient and may need to be reduced in renal or cardiac
failure. Insulin should never be given as a stand alone infusion.
Most patients who are eating and drinking normally do not need IV insulin but may need revision of their
anti diabetic therapy. Patients with Type2 diabetes which is uncontrolled on oral agents may need insulin
temporarily during acute illness, infection or perioperatively.
IV Fluids: MUST be given through an infusion pump.
•
•
•
0.9% Sodium Chloride may be used initially where the blood glucose is >/= 15 mmol/L. Use 5%
Glucose and continue with this once blood glucose falls below 15 mmol/L.
If blood glucose </= 15 mmol/L use 5% glucose.
Infusion rate of 100 to 125 mls/hour is adequate in stable patients.
IV Potassium:
• Serum potassium ≥ 4 mmol/L use 20 mmols Potassium Chloride to 1 litre 5% Glucose or 0.9%
Sodium Chloride.
• Serum potassium < 4 mmol/L use 40 mmols Potassium Chloride to 1 litre 5% Glucose or 0.9%
Sodium Chloride.
IV Insulin:
Set up infusion pump containing Human Actrapid 50 units in 50mls of 0.9% Sodium Chloride
(i.e. 1 unit/ml) and infuse at following rate: Infusion regime should be written up in the intravenous
section of the drug chart.
Blood glucose (mmol/L)
<4.0
4.1 – 7.0
7.1 – 10.0
10.1 – 15.0
15.1 – 20.0
>20.0
Actrapid dose units/hr (mls/hr)
* Stop infusion for 15 mins. Change to and
continue 10% Glucose. Restart at
0.5unit/hr
1
2
3
4
6
AND CALL DOCTOR
Monitoring patients:
•
The above sliding scale is a starting point only and should be revised regularly by the medical
team responsible. Insulin doses should be adjusted if blood glucose levels are consistently rising
or falling. Seek advice from the Diabetes Team if necessary
•
Capillary blood glucose should be measured and recorded hourly and insulin doses adjusted
according to the sliding scale above. A doctor may reduce the frequency of testing to 2 or 4
hourly, when the clinical conditions and insulin requirements are stable.
•
ONLY stop the insulin infusion temporarily if the blood glucose drops below 4mmol/l. Change
the IV fluids to 10% Glucose and continue insulin at 0.5 unit/hr. Check blood glucose after 10 to
15 mins as above.
•
Once the patient is eating and drinking, IV insulin sliding scale should be stopped and
subcutaneous insulin or oral agents given as appropriate.
•
When transferring a patient from intravenous insulin by sliding scale to conventional
subcutaneous insulin regime, give the first dose of the subcutaneous insulin, continue the IV
insulin infusion for 15 minute after the first injection before stopping.
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•
If you have any concerns please discuss with a member of the diabetes team.
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7. COMMENCING SUBCUTANEOUS INSULIN FOR PATIENTS
PREVIOUSLY ON IV SLIDING SCALE BUT NOW
EATING AND DRINKING
SC Insulin should be prescribed using the variable prescription part of the drug chart.
Suggested SC insulin regimes are either:1.
Basal bolus regime – Fast acting insulin, e.g. Actrapid, given three times daily
before meals, long acting insulin e.g. Insulatard at 2200 hours.
Estimate average IV units/hour for the previous 3-4 hours = X. Dose of short acting insulin
(Actrapid) pre meals = 4X. Doses of long acting insulin (Insulatard) = 8X. Eg. if on 2 units per
hour IV doses would be 8:8:8:16 units.
or:2.
BD mixed insulin, e.g. Human Mixtard 30 0.4-0.6 units/Kg per day in divided
doses usually two-thirds am and one-third pm.
THESE DOSES SHOULD BE REVIEWED AND ADJUSTED DAILY AS REQUIRED. ONCE
ONLY DOSES OF INSULIN TO BE PRESCRIBED ON THE FRONT OF MAIN
PRESCRIPTION CHART.
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8. DIABETIC KETOACIDOSIS IN ADULT PATIENTS
Diabetic Ketoacidosis (DKA) is due to insulin deficiency and is usually, but not always,
associated with hyperglycaemia. Consider in any diabetic patient who is unwell. The main
treatment is intravenous insulin which needs to be continued at a dose of at least 3 units per hour
until the acidosis resolves.
Diagnosis:
Degree of Ketoacidosis
Mild
Moderate
Severe
Blood pH
7.25 – 7.34
7.0 – 7.24
<7.0
Serum bicarbonate (mmol/L)
15 – 20
10 – 14.9
<10
Associated with ketonuria (if urine ketones not present consider other causes of metabolic acidosis)
N.B:
•
•
Blood glucose may be <10 mmol/L in patients with protracted vomiting, alcoholics and
malnourished.
The blood glucose level does NOT correlate with the severity of ketoacidosis.
Immediate investigations:
• Urea & electrolytes
• Plasma glucose
• Arterial blood gas (venous blood if ABG unobtainable)
• Urine dipstick for ketones
• Full blood count
Identify cause:
• ECG
• Chest x-ray
• Culture of blood, urine, sputum as clinically indicated
Treatment is aimed at correcting dehydration, electrolyte imbalance, hyperglycaemia and any
underlying precipitating event.
Treatment:
• Admit to HDU/ITU if severe DKA or patient drowsy
• Assess hydration and clinical status of patient. Institute appropriate supportive measures.
• Oxygen as required
• Airway protection, if compromised
• NG tube if drowsy, severe vomiting or known gastroparesis
• Central venous line if shocked, oliguric, drowsy, cardiac or renal failure. Aim for CVP 5 - 10.
• Prophylactic subcutaneous Heparin (LMW).
• Monitor ECG
• Urinary catheter ONLY if ill, hypotensive, renal impairment or oliguric.
INTRAVENOUS FLUIDS:
Rate of administration of fluids is determined by the clinical state of the patient. Clinical assessment of
hydration is imperative in determining the rate of fluid administration.
Suggested starting regime:
• 0.9% Sodium Chloride – NO POTASSIUM CHLORIDE IN FIRST BAG until Us & Es known.
Severely dehydrated patients will need 250 – 500mls per hour. Well-hydrated patients
may only require 1 litre 8-hourly.
• If serum sodium >150 mmol/L, consider use 0.45% Sodium Chloride.
•
• Once blood glucose <15 mmol/L, change I.V. fluids from 0.9% Sodium Chloride to 5%
Glucose and CONTINUE WITH THIS. DO NOT REVERT TO 0.9% Sodium Chloride BUT
ADJUST INSULIN TO CONTROL BLOOD GLUCOSE.
2007/217
•
15
If blood glucose <10 mmol/L with persistent ketonuria, consider changing fluids to 10%
Glucose and continue until ketosis resolved.
POTASSIUM – intravenous:
• Urgent lab potassium required
• Await potassium result before replacing
• Potassium on presentation may be low, normal or high, but will fall on correction of acidosis with
insulin and fluids.
Guide:
• Serum potassium (K+) >5.5 mmol/L – no potassium in IV infusion bag – repeat Us & Es
one hour
• Potassium K+ 4.0 – 5.5 mmol/L – 20mmol Potassium Chloride per litre IV infusion bag
• K+ 3.5 – 3.9 mmol/L – 40mmol Potassium Chloride per litre IV infusion bag
Repeat serum Potassium and bicarbonate every 4 to 6 hours until acidosis corrected.
•
K+ < 3.5 mmol/L – infuse Potassium Chloride at 20 mmol/hour ( 40 mmol Potassium
Chloride in 500ml 0.9% sodium chloride) in a separate IV infusion via infusion pump.
Monitor ECG. Check serum potassium in 3 to 4 hours
INSULIN – intravenous:
• If any delay in obtaining insulin pump, give 10 units fast acting insulin IM stat
• Set up syringe infusion pump containing Human Actrapid 50 units in 50mls 0.9% Sodium
Chloride (i.e. 1 unit/ml).
• Administer insulin IV.
(A) If severe ketoacidosis or moderate with blood glucose >20 mmol/L commence insulin
at 6 units/hr, reduce to 3 units/hr when blood glucose lower than 20 and acidosis only
mild (pH 7.25 or above, bicarbonate 15 or above).
(B) If moderate ketoacidosis and blood glucose <20 mmol/hr or mild ketoacidosis
commence at 3 units/hr
• Monitor capillary glucose hourly (2 hourly after 24 – 48hrs if stable and ketosis is
resolving).
•
•
•
•
Review insulin dose regularly. Increase insulin infusion rate if glucose trend is rising.
Continue IV insulin until ketoacidosis resolved (Bicarb >20) and patient is eating and drinking
normally.
If ketoacidosis slow to resolve change fluid to 10% glucose with same potassium and
increase insulin infusion.
Start subcutaneous insulin when ketoacidosis resolved and patient eating and drinking
normally. Continue IV infusion for 15 minutes after giving the first subcutenous injection with
insulin analogues (Novorapid – Lispro) infusion can be stopped immediately.
BICARBONATE:
The use of bicarbonate in DKA is controversial and should NOT be used in uncomplicated
diabetic ketoacidosis. Acidosis will resolve with the above regime.
Bicarbonate may be indicated if:
• Blood pH < 7.0 not responding after 1 – 2 hours of above therapy or severely compromised
patient with co-existing lactic acidosis, unresponsive to initial treatment. BICARBONATE
SHOULD NOT BE GIVEN WITHOUT DISCUSSING WITH CONSULTANT IN CHARGE OR
DIABETES MEDICAL TEAM.
• If bicarbonate is deemed necessary,
Dose: 500 mls of 1.4% sodium bicarbonate IV over 2 hours
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ALL patients admitted with Diabetic Ketoacidosis MUST be referred to:
•
•
Diabetes medical team
Diabetes specialist nurse
•
Dietician
AS SOON AS POSSIBLE
DIABETIC KETOACIDOSIS IS PREVENTABLE
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9. MANAGEMENT OF HYPEROSMOLAR NON KETOTIC
HYPERGLYCAEMIA
(HONK)
Occurs most frequently in older patients with Type 2 diabetes
Hyperosmolar non ketotic hyperglycaemia (HONK) is characterised by:
•
•
•
Severe hyperglycaemia
Dehydration and pre-renal uremia
Ketosis is either absent or mild
Precipitating factors:
•
•
•
•
May be first presentation of new type 2 diabetes
Underlying infections
High-dose steroids
MI, vomiting, CVA or other medical illness
Clinical presentation:
Consider in any adult patient with unexplained drowsiness, focal neurology, dehydration or shock. May
have associated vomiting, confusion. High mortality (30%).
Complications:
Rhabdomyolysis, high risk of venous thromboembolism, lactic acidosis, hypertriglyceridaemia,
dehydration and renal failure, cerebral oedema (particularly if rapid over-correction of hyperglycaemia
and hyperosmolality).
Diagnosis:
Serum osmolality >320 mosm/kg (2 x (sodium + potassium) + urea + glucose)
Urine ketones negative to +
Plasma glucose 40 – 100 mmol/L
Standard bicarbonate usually >15 mmol/L
Total body water deficit often 6 – 8 litres
Management:
SLOW correction of the high osmolality by no more than 5 mOsm/kg/hr. Rapid over-correction may
precipitate cerebral oedema or central pontine myelinolysis and increase mortality.
Investigations:
Blood glucose
Urine dipsticks
Us & Es
Arterial blood gas
Serum bicarbonate
Urine and serum osmolality
Amylase
Glucose
Creatine kinase
Blood cultures, urine culture and other cultures as indicated
ECG, chest xray
CT brain scan +/- lumbar puncture as clinically indicated
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N.B.: Patient may have a pseudohyponatraemia due to hyperglycaemia and/or hypertriglyceridaemia
– every 3mmol increase in glucose will artificially lower the sodium by 1 mmol/L depending on laboratory
assay.
Management:
•
•
•
•
•
•
•
•
Good general care of unconscious patient
Prompt resuscitation and treatment of underlying causes
Transfer to high-dependency or ITU
ECG monitor, oxygen
Urinary catheter if appropriate
CVP line
Nasogastric tube as indicated
Treat underlying precipitating medical cause, particularly infection
IV fluids (Typical deficit 6 – 8 L)
o IV 0.9%Sodium Chloride
o 0.45% Sodium Chloride if serum sodium Na >160 mmol/L
o Often need 4 – 6L in the first 24 hours. Titrate fluids to clinical condition of patient, CVP,
cardiac, renal status and serum osmolality.
IV Potassium
o KCL supplements if Serum Potassium <3.5 mmol/L – use Potassium Chloride 40 mmol/L
IV infusion
o Serum Potassium level 3.5 to 5 mmol/L –use Potassium Chloride 20 mmol/L IV infusion
IV Insulin
In HONK, I.V. insulin may not be needed as blood glucose will fall with rehydration alone.
Where insulin is used do not exceed 2 units per hour and monitor blood glucose hourly.
•
•
•
•
IV insulin: 50 units Actrapid in 50 mls of 0.9% Sodium Chloride via syringe pump driver
Aim is for SLOW correction of hyperglycaemia
Do not reduce osmolality by more than 5 mOsm/hr
IV fluids should be changed to 5% Glucose when blood glucose <15 mmol/L and continue with
glucose containing fluids.
Anti-coagulants:
The majority of patients will require formal anticoagulation with therapeutic doses of LMW heparin due to
high risk of venous thromboembolic disease.
Monitoring:
•
•
•
•
•
Hourly capillary blood glucose (laboratory measurement if meter reading high).
Hourly urine output.
Us & Es and serum osmolality 2-hourly initially, thereafter 4- to 6-hourly according to clinical
status.
Accurate fluid balance.
Same day referral to diabetes medical team.
Long term management of diabetes:
•
•
Most patients do not require long-term insulin therapy and are usually managed on oral agents
and diet by discharge.
Oral agents should only be started once the patient is well and eating and drinking normally.
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10. PROTOCOL FOR THE MANAGEMENT OF
ACUTE HYPOGLYCAEMIA
IN ADULT PATIENTS WITH DIABETES MELLITUS
Please see updated Hypoglycaemia Guidelines on the Intranet
Protocol for the Management of Acute Hypoglycaemia in Adult Patients
with Diabetes Mellitus ID # 2010 182
October 2010
>> Click here to view the protocol
20
21
11. MANAGEMENT OF DIABETES AND HYPERGLYCAEMIA IN
MYOCARDIAL INFARCTION OR ACUTE CORONARY SYNDROME
(GLUCOSE/POTASSIUM/INSULIN INFUSION)
The DIGAMI Study in 1997 showed that three-year mortality was reduced by 11% in those patients with
diabetes and raised blood glucose treated for 24 hours with IV insulin, potassium and glucose followed
by a three-month basal bolus insulin regime as compared with those who were treated with conventional
treatment.
•
All patients with suspected myocardial infarction or acute coronary syndrome should have a
random blood glucose measured.
•
All patients with established diabetes, regardless of the blood glucose at the time of
admission, should be treated according to the protocol below with intravenous
glucose/potassium/insulin infusion.
•
Patients who are not known to be diabetic but have a blood glucose reading > 11 mmol/L should
be considered as having diabetes and be treated with IV glucose/potassium/insulin infusion as
below.
Patients should ideally be admitted and managed in the coronary care unit. If this is not possible patients
being managed in other medical wards should still receive IV glucose/potassium/insulin with appropriate
monitoring according to this protocol. Please ensure at the time of discharge that all patients have a
follow-up appointment with the diabetes specialist nurse and consultant diabetologist.
On Admission:
• Measure laboratory glucose
• Baseline HbA1c (helps differentiate stress hyperglycaemia from diabetes)
• Stop all oral hypoglycaemics
• Commence IV glucose/potassium/insulin according to protocol
• NEVER give insulin as a stand-alone infusion. Must be given with IV fluids
and usually potassium.
IV Fluids:
500mls of 5% Glucose containing 40mmols of Potassium Chloride and infuse at 30mls per hour
controlled by an intravenous infusion pump.
The amount of Potassium Chloride will need to be reduced in patients with a raised serum potassium.
Discuss with on-call medical Specialist Registrar.
IV Insulin Infusion:
50 units of Actrapid in 50mls of 0.9% Sodium Chloride via infusion pump. Adjust infusion according to
blood glucose.
Blood glucose (mmol/L)
<4.0
4.1 – 7.0
7.1 – 10.0
10.1 – 15.0
15.1 – 20.0
>20.0
Actrapid units/hour(mls/hr)
Stop infusion for 15 mins. Change fluids to and
continue 10% glucose with 20 mmol of KCL,
infusion at 0.5unit/hr
1
2
3
4
6
AND CALL DOCTOR
Monitoring:
•
2007/217
Whilst on intravenous infusion therapy, patients should avoid eating and drinking foods
and drinks with a high carbohydrate content.
22
•
•
•
Aim for blood glucose level of 7 to 11 mmol/L.
Check blood glucose hourly and adjust insulin.
Measure plasma protein six-hourly to ensure values >4 mmol/L
N.B.
IV regime should be continued for 24 to 48 hours ONLY and should then change to subcutaneous
insulin if the patient is stable from the cardiovascular point of view and is eating and drinking normally.
I.V. glucose/potassium/insulin infusion should only be continued beyond 48 hours where the patient
remains unstable or is unable to eat and drink normally.
Conversion from IV to Subcutaneous Insulin Regime:
•
Patients who are able and willing to manage an insulin regime (see below) should be given this
treatment for three months after myocardial infarction – contact specialist nurses
•
A minority of patients may have such significant co-morbidity or difficult personal circumstances
that insulin would not be appropriate. These patients should be offered the simplest oral
hypoglycaemic therapy which affords satisfactory glycaemic control but ideally sulphonylureas
should be avoided.
Patients should be referred as soon as possible to the diabetes team to ensure that that the
decision regarding continuing insulin is made. If the patient is continuing insulin therapy the
patient should be referred for an appointment in the diabetes clinic.
•
Suggested insulin regimes :
•
Basal bolus multidose injection:
Actrapid (or Novorapid/Humalog) 4 to 8 units Three times a day before meals
and
basal insulin 6 to 10 units at 10pm
(dosage calculated according to patient’s weight and insulin requirements).
•
Twice daily pre-mix regime if patient unable or unwilling to manage a multidose basal bolus
regime:
Human Mixtard 30, Humulin M3
dose calculated as 0.3 units/kg body weight divided as:
2/3 of total dose before breakfast;
1/3 of total dose before evening meal
IF THERE IS ANY UNCERTAINTY ABOUT WHETHER THE PATIENT HAS DIABETES OR STRESS
HYPERGLYCAEMIA, THE DECISION ABOUT WHETHER OR NOT TO CONTINUE INSULIN SHOULD
BE DISCUSSED WITH THE DIABETES MEDICAL TEAM
ALL DIABETIC PATIENTS WITH MI OR ACUTE CORONARY SYNDROME SHOULD BE REFERRED
TO THE DIABETES SPECIALIST NURSES AND TO THE DIETITIAN.
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12. THROMBOLYTIC THERAPY AND SECONDARY PREVENTION
IN PATIENTS WITH DIABETES AND CORONARY DISEASE
Patients with diabetes have a higher incidence of coronary events and a poorer prognosis.
They derive as much, if not more, benefit from thrombolytic therapy and secondary preventive
measures than those without diabetes.
Thrombolytic therapy:
This should be given to all patients with diabetes who fulfil the ECG and diagnostic criteria for
thrombolytic therapy.
Patients with proliferative retinopathy should be offered thrombolytic therapy provided there has
been no recent history of acute bleeding with visual loss. If in doubt discuss with Medical or
Ophthalmology Consultant on call.
Secondary prevention:
•
Aspirin should be given to all if no contraindication. Recommended dose 300mg stat
then 75 to 150mg daily.
•
Betablockers and ACE inhibitors should be commenced if no contraindication
•
Statins should be commenced in all patients with established coronary disease.
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24
13. MANAGEMENT OF DIABETES DURING CEREBROVASCULAR
ACCIDENT
There are no controlled studies to provide definite evidence that good glycaemic control with insulin
alters outcome in cerebrovascular event but there is increasing circumstantial evidence in favour.
•
•
Hyperglycaemia is well recognised as a poor prognostic sign within CVA.
There is in vitro an animal work to indicate improvement in cerebral perfusion and recovery with
good glycaemic control.
Recommendations:
Treat as per protocol for management of myocardial infarction
•
•
•
•
•
Measure blood glucose in all.
All those with established diabetes or patients with a random blood glucose >11should be
commenced on insulin, glucose and potassium infusion following the same protocol as MI.
This should continue for 24-48 hours and subcutaneous insulin therapy should be considered for
those remaining hyperglycaemic.
The need for long term insulin therapy should be reviewed by the diabetes team.
For those with proven cerebral infarction aspirin and statin should be prescribed in addition to
their anti hyperglycaemic agents.
On Admission:
•
•
•
•
•
Measure laboratory glucose
Baseline HbA1c (helps differentiate stress hyperglycaemia from diabetes)
Stop all oral hypoglycaemics
Commence IV glucose /potassium /insulin according to protocol.
NEVER give insulin as a stand-alone infusion. Must be given with I.V. fluids and usually
potassium.
IV Fluids:
500mls of 5% Glucose containing 40mmols of Potassium Chloride and infuse at 30mls per hour
controlled by an intravenous infusion pump.
The amount of Potassium Chloride will need to be reduced in patients with a raised serum potassium.
Discuss with on-call medical Specialist Registrar.
IV Insulin Infusion:
50 units of Actrapid in 50mls of 0.9% Sodium Chloride via infusion pump. Adjust infusion according to
blood glucose.
Blood glucose (mmol/L)
<4.0
4.1 – 7.0
7.1 – 10.0
10.1 – 15.0
15.1 – 20.0
>20.0
2007/217
Actrapid units/hour (mls/hr)
Stop infusion for 15 mins. Change fluids to
and continue 10% glucose with 20 mmol of
KCL, infusion at 0.5unit/hr
1
2
3
4
6
AND CALL DOCTOR
25
Monitoring:
•
Whilst on intravenous insulin infusion therapy, patients should avoid eating and drinking foods
and drinks with a high carbohydrate content.
•
Aim for blood glucose level of 7 to 11 mmol/L.
•
Check blood glucose hourly and adjust insulin.
• Measure plasma potassium six-hourly to ensure values >4 mmol/L.
N.B.
I.V. regime should be continued for 24 to 48 hours ONLY and should then change to subcutaneous
insulin if the patient is stable from the cardiovascular point of view and is eating and drinking normally.
IV glucose/potassium/insulin infusion should only be continued beyond 48 hours where the patient
remains unstable or is unable to eat and drink normally.
Conversion from IV to Subcutaneous Insulin Regime:
•
Patients should be referred as soon as possible to the diabetes team to ensure that the decision
regarding continuing insulin is made. If the patient is on insulin they should be referred for an
appointment within the diabetes clinic as soon as possible.
Suggested insulin regimes:
•
Basal bolus multidose injection:
Actrapid (or Novorapid/Humalog) 4 to 8 units three times a day before meals
and
basal insulin 6 to 10 units at 10 p.m.
(dosage calculated according to patient’s weight and insulin requirements).
•
Twice daily pre-mix regime if patient unable or unwilling to manage a multidose basal bolus
regime:
Human Mixtard 30, Humulin M3
dose calculated as 0.3 units/kg body weight divided as:
2/3 of total dose before breakfast
1/3 of total dose before evening meal
IF THERE IS ANY UNCERTAINTY ABOUT WHETHER THE PATIENT HAS DIABETES OR STRESS
HYPERGLYCAEMIA, THE DECISION ABOUT WHETHER OR NOT TO CONTINUE INSULIN SHOULD
BE DISCUSSED WITH THE DIABETES MEDICAL TEAM
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14. MANAGEMENT OF DIABETES DURING SURGERY
Surgical stress stimulates secretion of counterregulatory hormones and inhibits insulin
secretion. In insulin-deficient patients this may cause dangerous hyperglycaemia and ketosis.
The other major risk in surgery is that of hypoglycaemia. KEY AIM IS TO BE SAFE, KEEPING
BLOOD GLUCOSE LEVELS BETWEEN 4 – 10 MMOL/L.
Management will depend on whether or not patient is insulin treated and on the nature and
duration of surgery. All patients should ideally have their glycaemic control optimised preoperatively.
Do not cancel patients with hyperglycaemia from theatre list without prior discussion
with a member of the Diabetes Team. Glucose levels can easily be corrected with
insulin.
Patients with peripheral vascular disease and peripheral neuropathy are at higher risk of
pressure ulcers and need pressure relief, especially for heels, pre and postoperatively. Always
examine feet preoperatively.
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DIABETES AND SURGERY
•
•
•
All patients
Liaise between anaesthetist,
surgeons & Diabetes Team
Optimise glycaemic control
Perform ancillary
investigations: U&Es, ECG,
CXR
Patient not treated with insulin
Insulin-treated patients
Day/Minor surgery
• Operate in morning if possible
• Patient should be advised not to
drive into hospital
Morning list
• Try and ensure patient is early
on list
• Patient should have usual insulin
regime night before
• Delay am insulin and give with
first meal (adjust if necessary,
possible quick-acting only)
• Insert IV cannula (and start
glucose/insulin infusion if delay
or procedure prolonged)
• Give usual evening insulin and
food
Major surgery or poor glycaemic
control
•
•
•
•
•
•
•
•
•
Afternoon list
• Give small dose of quick-acting
insulin with breakfast and start IV
glucose and insulin infusion midmorning
• Following op, insulin dose may
have to be reduced with evening
meal
• Patient may need to stay in
overnight
2007/217
•
Admit 24 – 48 hrs before
surgery.
Operate in morning if possible.
Stop oral agents on morning of
operation in Type 2 patients.
Stabilise control if necessary
preop using s/c insulin sliding
scale (see refs) or IV insulin.
Start IV insulin and glucose from
midnight – see over.
Monitor capillary glucose 1 to 2
hourly.
Restart s/c insulin with first postop meal & discontinue IV insulin
15 to 30 mins later.
Monitor BMs 4 - 6 hrly, pre
meals and 10pm.
If control is unstable, refer to
Diabetes team for advice.
Patients with Type 2 diabetes on
high dose oral agents pre op
may require to be treated with
insulin
for
several
weeks
following surgery to facilitate
good diabetes control and
promote wound healing.
Minor surgery and/or good
glycaemic control (fasting glucose
<8mmol/l or random
glucose<10mmol/l)
• Admit day before surgery.
• Operate in morning if
possible.
• Omit breakfast and oral
agents if applicable.
• Long-acting drugs should be
stopped at least 48 hrs
before surgery.
• Avoid IV Glucose. Use 0.9%
Sodium Chloride.
• Measure
blood
glucose
preop & 2 hourly postop.
• Restart oral agents with first
postoperative meal.
• If unstable, transfer to
insulin sliding scale (s/c or
IV).
• Return to oral agents when
control stable.
• If control remains unstable,
refer to Diabetes Team.
28
PERIOPERATIVE INSULIN REGIMES
Patients who are nil by mouth, or not yet eating and drinking as usual, will need:
I.V. insulin / glucose/ potassium infusion
Which must be given using a one-way valve system and an intravenous infusion pump.
Insulin
•
•
50 units Actrapid in 50ml 0.9% Sodium Chloride via infusion pump.
Rate adjusted to blood glucose as per sliding scale.
Check capillary glucose 1 to 2 hourly.
Never given insulin as a stand alone infusion. IV fluids are always needed.
Capillary glucose
(mmol/L)
<4
4.1 – 7.0
7.1 – 10.0
10.1 – 15.0
15.1 – 20
Actrapid units/hr
(ml/hr)
0.5 – stop infusion for 15 mins. Change fluids
and continue with 10% Glucose
1.0
2.0
4.0
6.0
and call Doctor
IV Fluids
1) Well, clinically stable patient: use 500ml 5% glucose with 10 mmols Potassium Chloride (KCL) at
100 ml/hr
2) In patients undergoing emergency surgery and those who have other medical problems, the type
and rate of fluid administration and potassium supplementation depends on the clinical state of the
patient.
In patients who are well and are eating and drinking normally, but whose diabetes control is poor on
their usual therapy (consistently > 10 mmols), subcutaneous insulin can continue to be used but it
is best to use a 4xdaily regime short acting insulin before meals, basal insulin at night. Advice on
dose should be immediately available from the diabetes team or the specialist nurses.
An alternative regime for patients nil by mouth who are clinically stable:
I.V. Glucose – Potassium – Insulin (GKI) single infusion
•
•
•
Add 10 units Actrapid to 500 mls of 10% glucose with 10 mmols Potassium chloride
(10:10:10 rule)
Infuse at 100 mls/hr (over 5 hours)
Check capillary glucose 1 to 2 hourly. Aim for 5 – 10 mmol/L
If glucose consistently > 11 mmol/L and increasing, change entire infusion to contain 20 units of
Actrapid.
If glucose consistently less than 5 mmol/L and decreasing, change entire infusion to contain 5
units Actrapid.
IV fluids and insulin should be continued until patient is well and eating normally. Continue
infusion to overlap first scheduled insulin injection by 15 minutes.
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15a. GUIDELINES FOR ADVISING INSULIN-TREATED
PATIENTS WITH DIABETES
USING A BOWEL PREPARATION
2 days before:
Patients may be on low residue diet i.e. chicken, white bread, white rice, etc. Insulin treatment may need to
be reduced if blood glucose levels are low.
Day before procedure:
The patient will follow the low residue, liquid diet as per leaflet and will use a bowel preparation such as
Picolax or Fleet as advised.
Advise the patient to:
•
Reduce all doses of insulin by a Third
•
Aim to keep all blood glucose levels above 4 mmol/L during the day and above 7 mmol/L before
bed, by having sugary drinks such as Lucozade, lemonade, squash or clear fruit juice (e.g. apple juice or
strained orange juice, it should not be a red fruit juice) if necessary.
•
If blood glucose levels fall below 4 mmol/L advice should be given to take 50 mls Lucozade or 3 Glucose
tablets and then recheck their blood glucose level after 15 minutes to ensure blood glucose level is above
4 mmol/L. If not, repeat 50 mls of Lucozade or 3 Glucose tablets every 15 minutes until blood glucose
level rises above 4 mmol/L.
•
Maintain a blood glucose level above 7 mmol/L before bed by taking extra carbohydrate in the form of
fluid, such as Lucozade, lemonade, squash or clear fruit juice (as above) before bed.
•
Monitor blood glucose levels pre meal and before bed.
o If blood glucose levels remain below 4 mmol/L on two consecutive tests, reduce insulin dose to 50%
of usual dose at next injection, together with more fluid carbohydrate.
o If blood glucose levels still remain below 4 mmol/L, consider further reductions of insulin together with
more fluid carbohydrate.
If the patient calls with persistent blood glucose levels below 4 mmol/L, contact the Diabetes Medical Team (or
diabetes specialist nurse if doctor unavailable).
Day of procedure – patient on a.m. list:
Ideally patients should be first on morning list
Advise patient to:
•
Follow diet and bowel preparation instructions as per dietary leaflet
•
Not to take insulin before coming to the hospital but to bring their monitoring equipment and insulin
with them.
•
Test blood glucose level before leaving home and ensure above 4 mmol/L. If blood glucose levels fall
below 4 mmol/L advise should be to take 50 mls of Lucozade or 3 Glucose tablets and then recheck their
blood glucose level after 15 minutes to ensure blood glucose level is above 4 mmol/L. If not, repeat having
50 mls of Lucozade or 3 Glucose tablets every 15 minutes until blood glucose level rises above 4 mmol/L.
•
After the procedure, they should eat and drink as soon as possible and recommence their usual insulin. If
a patient on twice daily insulin undergoes the investigation and is unable to eat and drink before 10am,
they will require some soluble short-acting insulin with their lunch instead of usual insulin.
o If blood glucose level is between 4 – 10 mmol/L, give 6 units of Actrapid Insulin.
o If blood glucose level is above 10mmol/L, give 10 units of Actrapid insulin.
o Take usual mixed insulin before evening meal.
Make sure blood glucose level is above 4 mmol/L before patient is discharged home.
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30
Day of procedure – patient on p.m. list:
If patient is on the afternoon list:
Advise patient to:
•
Request first appointment on afternoon list
•
Follow diet and bowel preparation instructions as per dietary leaflet.
•
Bring their monitoring equipment and insulin with them to the hospital.
•
Reduce morning dose of insulin by a third and to continue to take liquid carbohydrate, such as
Lucozade, lemonade, squash or clear fruit juice (as above).
•
Test blood glucose level 1 to 2 hourly during morning and ensure above 4 mmol/L. If blood glucose
levels fall below 4 mmol/L advice should be to take 50 mls of Lucozade or 3 Glucose tablets and then
recheck their blood glucose level after 15 minutes to ensure blood glucose level is above 4 mmol/L. If not,
repeat having 50 mls of Lucozade or 3 Glucose tablets every 15 minutes until blood glucose level rises
above 4 mmol/L.
•
Patients on 4 times daily insulin regime should reduce their lunchtime dose of insulin by half and
continue to take liquid carbohydrate, such as Lucozade, lemonade, squash or clear fruit juice.
•
Eat and drink as soon as possible after the procedure and recommence usual insulin with evening meal.
Make sure blood glucose level is above 4 mmol/L before patient is discharged home.
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15b. GUIDELINES FOR ADVISING TABLET TREATED
PATIENTS WITH DIABETES
USING A BOWEL PREPARATION
Day before Examination
The patient will follow a low residue liquid diet as per diet leaflet and will use bowel preparation such as
Picolax or Fleet as advised.
Advise the patient to:
•
Take normal dose of diabetic tablets.
•
If monitoring blood glucose levels, they should be advised to test pre meal and before bed and aim to
keep all blood glucose levels above 4 mmol/L during the day and above 7mmol/L before bed by
having sugary drinks such as Lucozade, lemonade, squash or clear fruit juice (e.g. apple juice or strained
orange juice, it should not be a red fruit juice).
•
If blood glucose levels fall below 4 mmol/L advise should be given to take 50 mls Lucozade or 3 Glucose
tablets and then recheck their blood glucose level after 15 minutes to ensure blood glucose level is above
4 mmol/L. If not, repeat having 50 mls of Lucozade or 3 Glucose tablets every 15 minutes until blood
glucose level rises above 4 mmol/L.
Day of Examination
The patient should be first on list where possible.
Advise all patients to:
•
Follow diet and bowel preparation instructions as per dietary leaflet
•
Omit morning diabetes tablets
•
Bring their monitoring equipment and diabetes tablets with them to the hospital
•
If monitoring blood glucose levels, they should be advised to test before leaving home and ensure that
their blood glucose level is above 4 mmol/L. If not, advice should be given to take 50 mls of Lucozade
and then recheck their blood glucose level 15 minutes later to ensure blood glucose level above 4mmol/L.
If not, repeat having 50 mls of Lucozade every 15 minutes until blood glucose level rises above 4mmol/L.
•
After the procedure, they should eat and drink as soon as possible and take their usual Diabetes
medication.
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16. PATIENTS WITH DIABETES UNDERGOING
RADIOLOGICAL PROCEDURES
•
Inform x-ray department on x-ray request form that patient has diabetes.
Indicate current treatment. Do not use abbreviations.
•
For procedures involving bowel preparation, e.g. colonoscopy, please see
separate guideline (Section 14).
•
For procedures requiring an overnight fast an early appointment should be offered to
patients with diabetes. Patients on tablets should omit them on the day of the
procedure but should be instructed to bring them with them. Usual treatment can
continue once the procedure is finished.
•
Patients on insulin will need advice regarding dose adjustment and should be
advised to contact the diabetes specialist nurse in advance for guidance
•
Patients on Metformin undergoing iodine-based contrast procedures should be
advised to stop the Metformin on the day of the procedure and recommence the
tablets 48 hours later (see Section 16).
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17. DIABETIC PATIENTS ON METFORMIN UNDERGOING
RADIOLOGICAL PROCEDURES
WITH IODINE-BASED CONTRAST
Common radiological procedures using iodine-based contrast include peripheral arterial
angiography, coronary angiography, intravenous pyelography (IVP). There is a risk of provoking
renal impairment due to contrast nephropathy and impaired renal function from the iodine load. This
information applies to iodine-based contrast investigation only and does not apply to MRI and
Nuclear Medicine scans.
Recommendation:
Patients on Metformin:
•
It is recommended that Metformin be discontinued on the day of the procedure and for 48
hours thereafter.
•
Ensure adequate hydration prior to and following the radiological investigation.
Patients with known renal impairment:
•
In general Metformin should not be prescribed to patients with a creatinine level >150
umol/L.
•
Risk of deterioration in renal function. Monitor Us & Es for 48 to 72 hours after
contrast procedure as renal function may deteriorate further.
•
Liaise with diabetes team/renal physician if necessary.
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34
SECTION 18 – DIABETES AND PREGNANCY
Diabetes/Obstetric team:
Dr M R Clements MD FRCP, Consultant Physician
Dr C Johnston MD FRCP, Consultant Physician
Mr R J Sheridan MD FRCOG, Consultant Obstetrician
Mr F A Boret MRCOG, Consultant Obstetrician
Mr F A Sanusi MRCOG, Consultant Obstetrician
Caroline Duncombe, Diabetes Specialist Midwife
Chris Feben, Diabetes Specialist Nurse
Michele Ramos-Gonzalez, Midwife, Delivery Suite
Steve Wigg, Midwife, Fetal Day Assessment Unit
Caroline Harris, Diabetes Specialist Nurse
18.1. ANTENATAL COUNSELLING
This should be offered to all diabetic patients of child-bearing age.
If planning for a pregnancy, the following should be covered:
1. Importance of control re pregnancy outcome and foetal abnormalities
2. Request HbA1c – results should be <7%, ideally <6.5%
3. Teach blood glucose monitoring with written and verbal instructions
4. Advise intensive monitoring as appropriate:
pre-prandial and pre-bed 1st day
1 hour post-prandial 2nd day
Values: pre-prandial <5.5 mmol/L
1 hour post-prandial 5.5 –8.0 mmol/L
5. For those on oral therapy consider swapping to insulin before conception
6. For those on Twice daily insulin regime, need to consider Four times daily (basal bolus) regime.
7. Patients should commence on folic acid 5mg daily.
8. Patients on Metformin will usually remain on this preparation prior to conception The decision to
continue Metformin during pregnancy should be taken in conjunction with the diabetes team.
9. Teach urine testing to ketodiastix (to ensure patient can use these during pregnancy as required).
10. Give contact telephone number of diabetes specialist nurse.
11. Offer follow-up as appropriate – with diabetes specialist nurse and/or joint ante-natal clinic
Literature Given:
Lilly/Roche leaflet
No. 18 Diabetes and Pregnancy
No.17 Diabetes developed in pregnancy (for gestational only)
Novo leaflet Diabetes and Planning a Family
Pregnancy sheets
Documentation:
Update diabetes specialist nurse record card
2007/217
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Update medical notes as appropriate
2007/217
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18.2 SCREENING AND MANAGEMENT OF GESTATIONAL DIABETES
(Diabetes first diagnosed in pregnancy)
GUIDELINES FOR BLOOD GLUCOSE TESTING IN ALL PREGNANCIES
These guidelines describe the recommended routine biochemical screening of all pregnancies for the
presence of diabetes. They do not absolve the clinician from the responsibility of checking for diabetes at any
other time in pregnancy when the clinical condition of the mother suggests the possibility.
At booking:
In addition to the normal booking bloods, blood should be taken from all women for glucose measurement
(2ml grey top fluoride bottle) and documented on the form for antenatal blood investigations. Blood sugar can
be taken either fasting (more than 2 hours after food) or non-fasting (within 2 hours of food), but this must be
recorded.
At each antenatal visit:
Urine should be tested at each antenatal visit. Whenever glycosuria (1+ or more) is detected then a plasma
glucose sample should be taken, either fasting or non-fasting, however many times this happens. The result of
any plasma glucose estimation can only be properly interpreted if the timing in relation to last food and drink is
known, and therefore this must always be recorded.
At 28 weeks gestation:
A timed blood sample for plasma glucose should be taken from all women, either fasting or non-fasting.
RESULTS:
All plasma glucose tests, where possible, will be taken in the community by either the GP or midwife and
documented accordingly in the patient’s pregnancy record. A copy of all plasma glucose results will be
returned to:
The fetal day assessment unit (FDAU) for the Watford site
The Antenatal Clinic (ANC) in Hemel Hempstead or St. Albans
They will then be assessed as to whether a glucose tolerance test (GTT) or further action is needed, and the
women contacted accordingly. No action will need to be taken by the community midwife or GP on these
results – this will hopefully prevent duplication of work.
Risk factors for diabetes in pregnancy:
Previously, routine screening for diabetes in pregnancy was carried out on the basis of whether the patient
had pre-existing risk factors (obesity, family history of diabetes in a first degree relative, patient birth weight
>4.5kg, age >30 years, previous history of IGT or GDM, recurrent UTI or candidiasis, habitual abortion,
unexplained stillbirth, congenital abnormality, large-for-dates baby, pre-eclampsia and polyhydramnios). This
method has limited reliability and does not need to be considered in making a judgement at booking and 28
weeks gestation because all patients are going to be biochemically screened with timed blood glucose
measurements.
However, the presence of these risk factors may be a relevant consideration in deciding whether to test for
diabetes at other times in the pregnancy if the clinical condition of the mother suggests this diagnosis.
Situations where a standard 75g oral GTT test is indicated:
a) Plasma glucose ≥ 6.1mmol/L in the fasting state or more than two hours after food (=fasting)
b) Plasma glucose ≥ 7.0mmol/L within two hours of food (=non fasting).
Gestational diabetes is defined as ANY abnormality of glucose tolerance first recognised in pregnancy.
It is therefore a heterogeneous condition. The diagnosis applies to any of the abnormalities of glucose
tolerance tabulated overleaf:
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37
Interpretation of 75g carbohydrate oral glucose tolerance test (OGTT) in pregnancy (modified WHO
criteria)
Gestational diabetes
Normal
LABORATORY PLASMA GLUCOSE (mmol/L)
Fasting:
2 hours:
≥ 6.1
≥ 7.8
≤ 6.0
< 7.8
If a timed random plasma glucose concentration exceeds 11mmol/L then an oral GTT is not necessary and
the patient should be referred to the Combined Antenatal Clinic, as they will need to start home plasma
glucose monitoring to assess the need for insulin therapy.
Management of women with an abnormal 75g oral GTT
1. Women with an abnormal GTT (at either fasting or 2 hours) will need to be referred to:
•
WGH site: the Combined ANC (1st and 3rd Friday each month)
•
HHGH/SACH sites: the Diabetic Specialist Midwife (07990 562096) or the Combined
ANC (1st and 3rd Tuesday each month)
2. They will be taught how to carry out home capillary blood glucose monitoring, with a view to
maintaining their capillary blood glucose:
•
<5.5 mmol/L in the pre-prandial state
•
<8.0 mmol/L 2 hours post-prandially
3. Dietary advice will be given, including redistribution of meals to ensure a regular intake of
carbohydrate across the day and restriction of saturated fat and sugar. Obese women will be advised
to reduce their energy intake to between 1500-1800 calories per day. This hypo-caloric diet may be
sufficient to lower the plasma glucose into the normal range and avoid the need for insulin.
4. If the plasma glucose measurements predominantly exceed either of the targets on diet alone, then
insulin therapy should be considered. Obstetric management will be individualised so that most
patients can continue to 40 weeks gestation whenever possible.
Post partum management :
Insulin therapy should be stopped immediately post-partum in all patients who were not given treatment with
insulin before pregnancy unless specified by a medical member of the diabetes team.
The diabetes specialist nurses should be informed of all pregnant women with diabetes admitted to Watford
Maternity Unit on 01923 217553.
These women must always be seen by a DSN before discharge and if possible by a member of the Diabetes
Medical Team.
Postnatal follow-up:
All women should have an appointment arranged to see a diabetes specialist nurse or midwife three months
post-delivery to discuss blood results and educate as needed re: contraception, further pregnancies, diabetes
management, blood pressure and thyroid function check.
For those patients that wish to have their follow-up diabetes care at Watford General:
Six week post-natal oral GTT in Fetal Day Assessment Unit to be arranged prior to discharge
Three-month appointment with Diabetes Specialist Nurse required (01923 217553).
For women who wish to have their follow-up diabetes care in Hemel Hempstead or St Albans:
An appointment will be arranged for 2-3 months postnatal directly with the Diabetic Specialist
Midwife/Nurse: 01442 287399 (HHGH).
A fasting blood glucose will be arranged prior to the appointment.
Consider OGTT if fasting blood glucose >6.0 mmol
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38
References:
Brown CJ et al (1966)
Report of the Pregnancy and Neonatal Care Group
Diabetic Medicine Vol. 13 S43-S53
International Diabetes Federation
(1998)
Guidelines for Diabetes Care – A Desktop Guide for
Type 1. Pregnancy and Contraception in Women
with Diabetes pp. 29-30
European Diabetes Policy Group
International Diabetes Federation
(1998-99)
Guidelines for Diabetes Care – A Desktop Guide for
Type 2. Pregnancy and Contraception in Women
with Type 2 Diabetes pp. 30-31
European Diabetes Policy Group
Metzger BE, Coustan DR (Eds)
(1998)
Summary and recommendations of the Fourth
International Workshop-Conference on Gestational
Diabetes Mellitus
Diabetes Care 21 (Suppl. 2) B161-167
Diabetes UK Website
(October 2003)
Care recommendations: recommendations for the
Management of pregnant women with diabetes
(including gestational diabetes)
American Diabetes Association
Clinical Practice Recommendations
(Jan 2002)
Gestational Diabetes Mellitus (ADA)
Diabetes Care 25 (Suppl 1) S94-96, 2002
Scott DA et al (Oct 2002)
Screening for gestational diabetes: a systematic
review and economic evaluation. Health Technology
Assessment Vol 6 (11) 2002
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18.3 MANAGEMENT OF INSULIN DEPENDENT DIABETES
DURING LABOUR
(Including gestational diabetic patients on insulin)
Induction and spontaneous labour – insulin therapy
1.
Usual morning insulin and breakfast should be taken. Normal regimen to continue until in established
labour. When in established labour, or if admitted in labour, start sliding scale insulin and glucose
intravenous infusion as described in paragraph 2.
Transfer to Delivery Suite should take place prior to commencement of sliding scale
2.
When labour is established, set up a sliding scale insulin/glucose infusion as follows:
a) 500ml 10% Glucose containing 10mmol Potassium Chloride– infuse at a rate of 60ml/hour (ie over
eight hours).
b) Prepare an insulin infusion by adding 50 units of Actrapid insulin to 49.5ml of 0.9% Sodium
Chloride in a 50ml syringe. Mix thoroughly. Mount in a 50ml syringe driver, which is kept on
Delivery Suite.
c) Use a Y-can or 3 way tap to connect the insulin and glucose infusions. Check the blood glucose
from the fingers of the other arm using a capillary blood glucose meter.
3.
Adjust the insulin infusion rate according to the blood glucose at hourly intervals.
Blood glucose (mmol/L)
(by capillary blood glucose meter)
0 - 2.9
3.0 - 3.9
4.0 - 5.9
6.0 - 7.9
8.0 - 9.9
10.0 - 11.9
>12.0 (call doctor)
Insulin infusion rate
(ml/hr = units/hr)
0
0.5
1.0
2.0
2.5
3.0
4.0
The purpose of the above schedule is to keep the blood glucose stable between 4.0 and 8.0mmol/L. This
regimen can be continued indefinitely after delivery until the woman is ready to eat, when she can return to
her normal pre-pregnancy insulin regimen and dosage.
For patients with gestational diabetes the above regime is stopped immediately post delivery and replaced
with 0.9% Sodium Chloride infusion if required. Sub-cutaneous insulin will not be recommenced unless preplanned by the medical team and documented in the notes. The patient should be advised to continue to
self-record her blood glucose for 48 hours as she did in the ante-natal period.)
A sliding scale insulin/glucose infusion may be indicated prior to labour if:
• Vomiting occurs
• Capillary blood glucose is > 9.0 mmol/L on more than one occasion
• Hypoglycaemia occurs on more than one occasion
Other considerations:
Continuous electronic fetal monitoring (CTG) is recommended throughout labour (hypoglycaemia
can cause fetal bradycardia).
The Consultant Obstetrician on call should be informed when a diabetic woman is in labour. The risk of
shoulder dystocia should always be a consideration.
If labour is induced the paediatrician should attend the delivery in case of immature fetal lung
development.
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Corticosteroids (e.g. betamethasone) and Beta2 agonists (e.g. salbutamol)
These should only be given to pregnant women with diabetes on the instructions of the obstetric consultant
on call. Pre and post meal / 4-hourly blood glucose monitoring will be required. Insulin doses may need to be
adjusted accordingly and a sliding scale insulin/glucose regime may be indicated.
Caesarean section for women on insulin before pregnancy:
Elective Caesarean Section
1.
2.
3.
Fast from midnight and omit morning insulin
***Inform the diabetic team
Admit At 08.00. Record capillary blood glucose, then set up a sliding scale insulin/glucose infusion as
described in section 18.3. Follow the same infusion rate protocol.
Emergency Caesarean Section
4.
5.
Record capillary blood glucose on admission, and continue to monitor this at hourly intervals.
As soon as it is established that the woman is fit for surgery and is going to be taken to theatre,
proceed as line 2*** above.
A Paediatrician need not be at the delivery if maternal diabetes is the only complication, but should see the
baby as soon as possible after the birth. Capillary blood glucose monitoring for the baby should be performed
at 2, 4 and 8 hours if there are no signs of hypoglycaemia, and more frequently if hypoglycaemia is detected
and treatment required.
Caesarean section in patients with gestational diabetes:
For women with gestational diabetes who only started insulin therapy during pregnancy:
(i)
Fast from midnight and omit morning insulin
(ii)
Admit at 08.00. Record capillary blood glucose.
(iii)
Set up a standard IV Infusion with 0.9% Sodium Chloride 1litre 8-hourly
(iv)
Sliding scale insulin/glucose infusion will not be required unless the blood glucose is above 8mmol/L.
(v)
If this is the case, inform the diabetic team and proceed as for elective Caesarian section line 2***
above
(vi)
An infusion containing glucose should not be administered in the absence of insulin
Postnatal:
Breastfeeding
Diabetic mothers intending to breastfeed may need to increase their carbohydrate intake. Capillary blood
glucose levels should be tested before and after feeding to establish whether the blood glucose drops
significantly. This can be discontinued when the mother feels confident. Allow blood glucose levels to run
slightly higher than usual for a few weeks (6-12mmol/L) until a routine is established. Please contact the
diabetes team re. Insulin dose. In general, insulin is reduced to pre-pregnancy levels, although it may be
necessary to decrease the dose further.
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18.4 GUIDELINES FOR THE EMERGENCY MANAGEMENT OF ACUTE
HYPOGLYCAEMIA IN PREGNANT PATIENTS ON
TREATMENT WITH INSULIN
Background
Patients with diabetes in pregnancy are commonly managed with intensive insulin regimens designed to
maintain tight blood glucose control between 4.0 and 7.0mmol/L. Blood glucose values lower than this are to
be avoided. Values <2.5mmol/L may cause clinical symptoms of hypoglycaemia, but pregnant mothers often
have impaired awareness of these symptoms, which may reduce their ability to respond appropriately. Severe
hypoglycaemia may cause loss of consciousness and fitting, and is therefore a potentially life-threatening
situation which must be treated promptly and rigorously.
Midwives and junior medical staff should familiarise themselves with the following management guidelines. All
episodes of minor hypoglycaemia should be notified to the diabetes team (contact numbers below) within 24
hours, so that the patient can be reviewed. All episodes of severe hypoglycaemia must be notified to a senior
member of the medical or obstetric team immediately (see below).
The diabetic emergency treatment pack should be readily accessible and contain the following:1. 50ml IV (50%) Glucose
2. 19 gauge intravenous cannula
3. 0.9% Sodium Chloride flush with syringe and needle
4. Small bottle of Lucozade
5. Glucagen (Glucagon 1mg) for IM injection
6. Vygon
Management of symptomatic hypoglycaemia when patient is conscious and able to
cooperate:
•
Check capillary blood glucose concentration immediately using ward glucometer and record
result.
•
Choose one of the quick acting carbohydrates followed by one of the slow acting
carbohydrates:
Quick acting carbohydrate
Slow acting carbohydrate
3 Glucose tablets
A slice of bread
1 small glass of sugary drink
e.g. Lucozade
A piece of fruit
2 teaspoons of sugar in a glass of water
or a cup of tea
A couple of biscuits
2 teaspoons jam or honey
Next meal
After 10 – 15 minutes, re-check blood glucose. If <4 mmol/L repeat above, rechecking glucose every
15 minutes until fully recovered and blood glucose >4 mmol/L .
Continue to check blood glucose hourly until next meal.
Refer to the diabetes team as soon as possible (i.e. same day or beginning of next working day).
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Management of severe hypoglycaemia - patient unconscious or fitting:
•
Summon immediate medical and midwifery assistance.
•
Observe vital signs – Ensure safe position – Commence facial oxygen at 6L/min.
•
Obtain quality controlled glucometer and diabetic emergency treatment pack.
•
Check capillary blood glucose concentration and repeat every 15 minutes until patient fully
recovered and glucose >4 mmol/L.
•
Obtain IV access.
•
*Administer either:
. Glucogen *(glucagon 1mg) intramuscularly, or
. 20ml 50% Glucose IV, repeated if patient not responded within 5 mins
• When patient fully conscious – give long acting carbohydrate.
• Commence IV infusion of 500ml 10% Glucose containing 10mmol Potassium Chloride and 10 units
Actrapid insulin in the bag and run at 100ml/hr until next meal.
• Once fully recovered, check blood glucose hourly until next meal. Aim for blood glucose 58mmol/L following hypoglycaemic episode.
• Discontinue drip at next meal and resume normal insulin and eating pattern.
•
Inform senior member of medical staff immediately for review of insulin dosage (see below).
•
Establish cause of hypoglycaemia.
Notes:
i.
All patients with type 1 diabetes to have IV access for 24-hours post-partum.
ii.
All staff on maternity wards to be aware of location of Elite blood glucose meter and emergency
diabetic treatment pack.
iii.
*Glucogen is likely to be ineffective within 24 hours of delivery. In this situation always use 50% IV
Glucose.
iv.
Glucogen can only be used once in 24 hours. In the event of further hypoglycaemia always use 50%
Glucose IV.
IN THE EVENT OF SEVERE HYPOGLYCAEMIA INFORM ONE OF THE FOLLOWING SENIOR MEMBERS
OF STAFF, IN THIS ORDER OF PRIORITY, IMMEDIATELY:-
1. Diabetes Specialist Registrar, Bleep 1407 or 1465
2. Dr Clements (Consultant Physician), extension 7696, home tel 01923 267697
3. Dr Ogilvie (Consultant Physician), extension 7287 (mobile via switchboard)
4. The Obstetric Registrar to Mr Sheridan, bleep 1206
5. Mr Sheridan, Consultant Obstetrician (pager via switchboard)
6. The acute on-call Medical Registrar of the day, via switchboard
7. The acute on-call Obstetric Registrar of the day, via switchboard
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18.5 GUIDELINES FOR POSTNATAL DIABETES FOLLOW-UP
These are meant as a guide only and any queries should be directed to the Diabetes Team:
Dr Clements
Dr Ogilvie
Diabetes Specialist Registrar
Diabetes Specialist nurse
Diabetes Specialist midwife
Ext. 7696
Ext. 7287
Bleep 1407 or 1465
Ext 7553
Bleeps 1030/1031/1032/1033
07990 562096 (for Hemel Hempstead and St Albans follow up)
Post natal follow-up:
All women should have an appointment arranged to see a diabetes specialist nurse or midwife three months
post-delivery to discuss blood results and educate as needed re: contraception, further pregnancies, diabetes
management, blood pressure and thyroid function check.
Established diabetes: Type 1 or Type 2
These women must always be seen by a member of the Diabetes Medical Team and/or a Diabetes Specialist
Nurse (DSN) before discharge.
Three-month appointment to be made with a Diabetes Specialist Nurse or Midwife (See numbers above).
Appropriate follow up will be arranged from this appointment.
Gestational diabetes
These women must always be seen by a DSN before discharge and if possible by a member of the Diabetes
Medical Team.
For those patients that wish to have their follow-up diabetes care at Watford General:
Six week post-natal oral GTT in Fetal Day Assessment Unit to be arranged prior to discharge
Three-month appointment with Diabetes Specialist Nurse required (01923 217553).
For women who wish to have their follow-up diabetes care in Hemel Hempstead or St Albans:
An appointment will be arranged for 2-3 months postnatal directly with the Diabetic Specialist Midwife:
01442 287399.
A fasting blood glucose will be arranged prior to the appointment. GTT will be recommended if
glucose >6.0 mmol/L.
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19. INCIDENTAL DIAGNOSIS OF NEW DIABETES
Incidental new diagnosis of diabetes in Casualty:
Presentation:
Polyuria, polydipsia, blurred vision, weight loss, cutaneous sepsis or may be asymptomatic.
Diagnosis:
Random blood glucose >11.0 mmol/L with symptoms.
Examination should document:
•
•
•
•
•
Blood pressure lying and standing
Peripheral pulses
Lower limb reflexes, peripheral sensation
Examination of feet for infection, ulcers, Charcots
Visual acuity and fundoscopy
Initial investigations:
Finger prick blood glucose (record in notes)
Urine dipstick (record level of ketones in notes)
FBC, Us & Es, LFTs, lipids, HbA1c, TFTs, glucose (and copy result to GP)
Serum bicarbonate and arterial blood gas if ketonuria
Consider ECG, chest x-ray
Patient admission is necessary if:
• Not eating and drinking normally
• Nausea or vomiting
• Ketoacidosis (pH <7.35) or heavy ketonuria
• Other complicating problems
• Type 1 diabetes suspected and weekend/public holiday
Admission is not necessary if:
• Patient is otherwise well, no sepsis/ulcers
• Eating and drinking normally
Further management:
Depends on whether the patient is thought to have Type 1 or Type 2 diabetes and whether or not they are
well. All patients must be informed of their diagnosis and need for ongoing and long term care.
Type 1 diabetes:
• All patients will need to see the diabetes specialist nurse and dietitian to start insulin on same day or
following day.
• Referral to diabetes consultant for urgent outpatient follow-up.
• Admission will be necessary over weekends.
Type 2 diabetes:
• Most patients do NOT need to be referred to hospital diabetes team. If you are unsure and need
advice, contact diabetes team/DSN.
• It is good practice to notify the GP.
• Provide simple explanation of diabetes and need for follow-up. Ask to make appointment with GP as
soon as possible.
• If osmotic symptoms and blood glucose >15 mmol/L, consider starting Gliclazide 80mg Once daily in
patient of normal body mass. (Advise patient must inform DVLA)
• If overweight and blood glucose >15 mmol/L, normal renal/liver function, consider commencing
Metformin 500mg Twice daily.
• Advise to avoid sugar-containing food and drinks and will need more detailed dietary advice later.
• To return to A&E if unwell or not eating or drinking.
• Ensure patient understands plans for follow-up, i.e. GP or hospital.
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20. MANAGEMENT OF DIABETIC FOOT AND LEG ULCERATION
Diabetic foot ulcers are a major cause of morbidity and mortality and cause more amputations than any other
pathology. Currently there is not a nationally accepted protocol for the management of the diabetic foot.
Recognition of the condition and appropriate treatment however does reduce adverse outcomes. This
depends on a multidisciplinary approach.
Infections are usually more extensive than the initial appearance, every skin break in the diabetic foot is a
potential portal of entry for bacteria. Affected feet should be assessed for neuropathy and ischaemia.
•
•
•
All inpatients with diabetes AND a foot problem should be referred to the diabetes team.
If one foot has a problem the other foot is at risk too and must be examined
Infection is often underestimated as clinical signs may be reduced in patients with vascular
compromise.
MANAGEMENT:
Management of diabetic foot ulcers should be multidisciplinary and may require input from diabetes medical
team, diabetes specialist nurse, vascular surgeon, specialist orthopaedic team (if osteomyelitis), chiropodist,
and orthotics. Foot care, footwear and podiatry input are of paramount importance and should be addressed
prior to discharge from hospital.
1. Radiology
All affected feet should be x-rayed to detect:
o Underlying loss of bone density suggesting osteomyelitis
o any foreign body
o gas in the deep tissues indicating severe infection
o Charcot’s joint
2. Mechanical control
Bed rest facilitates wound healing. Avoidance of pressure can also be attained by e.g. crutches, wheelchairs,
orthotic assessment (need to offload neuropathic ulcers by casting once open wound has healed).
3. Wound control
Wound debridement and application of sterile and non-adherent dressings. This may require surgical
resection. Foreign bodies should be removed.
4. Vascular control
If evidence of (neuro)ischaemia or failure of ulcer to heal despite treatment, consider further investigation and
revascularisation.
5. Metabolic control
Ensure no systemic, metabolic or nutritional disturbance to retard healing. Wound healing and neutrophil
function is impaired by hyperglycaemia therefore tight glycaemic control is paramount. Some patients with
longstanding or severe ulcers may benefit from zinc and vitamin C supplements.
6. Educational control
Full explanation of condition and management plan.
7. Pain control
Use W.H.O. pain ladder. Initiate with simple analgesics. Many patients will require stronger narcotic
analgesics.
Neuropathic pain may respond to *Amitriptyline, Gabapentin, *Carbamazepine or other atypical agents and
often needs specialist hospital referral.
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* = unlicensed indication
8. Microbiological control
It is vital to send swabs for microbiology, culture and sensitivity without delay. Deep swabs or deep tissue
should be sent after debridement. Blood cultures should also be taken if there is evidence of systemic
infection clinically. There should be close consultation with the microbiology department and patients with
positive results should be treated with appropriate antibiotics until there is evidence of clinical and
microbiological cure.
The following are guidelines for empirical treatment prior to positive culture results which should allow specific
antibiotic treatment according to sensitivities.
“CLEAN” ULCER WITHOUT CELLULITIS:
Uniform practice on the place of antibiotics in the uninfected ulcer has not been established. Pay close
attention to swab results.
If no cellulitis, no discharge or radiological evidence of osteomyelitis treat with debridement, cleaning with
0.9% Sodium Chloride, dressings and regular inspection.
ULCER WITH LOCAL SIGNS OF INFECTION AND MILD CELLULITIS:
Treat with oral antibiotics. Regular (at least weekly) inspection and dressing of ulcer as above. Antibiotics
may need to be continued for 10 to 14 days or longer, according to clinical response.
Use:
AND
(AND
Co-amoxiclav (Augmentin) 375 to 625 mg tds (oral) or Ciprofloxacin 250-500mg bd (oral)
Flucloxacillin 500mg qds (oral)
Metronidazole 400mg tds (oral) if anaerobic infection suspected)
If Penicillin allergic patient:
Use:
AND
Ciprofloxacin 500mg bd (oral)
Erythromycin 500mg qds (oral) or Clindamycin 300mg qds (oral)
“CLEAN” ULCER WITH MRSA COLONISATION AND NO SIGNS OF INFECTION:
Use: Mupirocin 2% in ointment topical (if sensitive)
ULCER WITH MRSA PRESENT AND SIGNS OF INFECTION OR MILD CELLULITIS:
•
•
Use Mupirocin 2% ointment topically to wound AND oral antibiotics
Consult microbiologist for advice.
Use 2 of the following:
Sodium Fusidate 500mg tds (oral)
Rifampicin 300mg tds (oral)
Trimethoprim 200mg bd (oral)
Doxycycline 100mg daily (oral)
If fusidic acid or rifampicin used, liver function should ideally be monitored every 1 to 4 weeks
throughout treatment.
ULCER WITH SEVERE CELLULITIS:
Requires treatment with intravenous antibiotics:
Amoxicillin 1 gram tds (IV)
AND Flucloxacillin 1 gram qds (IV) OR Cefuroxime 1.5 gram tds (IV)
AND Metronidazole 400mg tds( orally)
In Penicillin allergic patient:
IV Ciprofloxacin 400mg bd (although oral is well absorbed if less severe infection)
2007/217
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AND IV Clindamycin 600mg qds or IV Erythromycin 500mg qds
AND Metronidazole 400mg tds (oral)
ULCER WITH SEVERE CELLULITIS AND MRSA INFECTION:
Teicoplanin 400mg 12 hourly for 3 doses then od (intravenous)
OR
Vancomycin 1g bd (dose adjust)(intravenous)
AND EITHER Sodium Fusidate 500mg tds (oral)
OR
Rifampicin 300mg tds (oral)
→ oral antibiotics once cellulitis resolving
OSTEOMYELITIS WITH OR WITHOUT ULCERATION:
Discuss with microbiologist. Take deep swab if ulcer present.
Use 2 of the following antibiotics:
Sodium fusidate 500mg tds (oral)
Clindamycin 300mg tds (oral)
Rifampicin 300mg tds (oral)
Ciprofloxacin 500mg bd (oral)
Treat for minimum of 6 weeks, usually 8 to 12 weeks. Need regular clinical review with specialist
podiatrist. Consider resection/amputation if no improvement.
Linezolid may be required for serious multi-resistant Gram positive infections (MRSA) and
Vancomycin resistant enterococci (VRE).
URGENT SURGICAL INTERVENTION REQUIRED IF:
•
•
•
•
Large area of infected sloughy tissue
Localised fluctuance and expression of pus
Crepitus and gas in soft tissues on x-ray
Purplish discoloration of skin indicating subcutaneous necrosis
N.B. In the neuroischaemic foot any debridement needs to be accompanied by an assessment of the arterial
perfusion of the foot so that healing can be maximised/ensured.
References:
Managing the Diabetic Foot. Edmonds M.E. and Foster A.V.M. Blackwell Sciences 2002
Management of Diabetic Foot Lesions. McCulloch D.K. and Horton L.D. UpToDate 2002
Guidelines for Empiric Antibiotic Therapy of Infected Foot Ulcers in Diabetic Patients. West Hertfordshire
Hospitals 2002
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21. MANAGEMENT OF ACUTE CHARCOT JOINT
This is a serious condition which, if unrecognised and untreated, causes collapse and deformity with
considerable long term morbidity and high risk for foot ulceration. Early diagnosis and treatment is essential.
Charcot usually involves midfoot, but may involve any part of foot or ankle. It may be difficult to differentiate
from osteomyelitis. Osteomyelitis is usually preceded by an ulcer and often affects the metatarsals and
calcaneum, whereas Charcot Joint more often affects the midfoot or ankle. The differential diagnosis includes
cellulitis, osteomyelitis or gout.
History:
•
•
•
Suspect if acute onset unilateral erythema, oedema and warmth.
Pain may or may not be present.
History of mild trauma.
Examination:
Document the following:
Site and description of cellulitis/ulcer/deformity
Reflexes, light touch, vibration, position sense, pain and temperature, 10g monofilament
Pulses femoral, popliteal, DP and PT
Document lying and standing BP
Investigations:
Us & Es, bone profile, CRP, urate, HbA1c, FBC, ESR, glucose
Foot x-ray (to include weight bearing view)
Isotope bone scan
MRI or white cell scan may be needed – Consultant decision only in consultation with radiologist.
Management:
Urgent referral to diabetes medical team.
Podiatry review same day if possible.
Urgent antibiotics if osteomyelitis is possible continue till excluded.
Optimise glycaemic control.
Radiology review. MRI scan may be required.
Review by orthopaedic foot surgeon with special interest.
Immobilisation non weight bearing cast for 1 month.
Then total contact cast or aircast with very gradual mobilisation.
Regular measurements of CRP and Alk phos at diagnosis and follow-up.
Pharmacological:
There is a limited evidence base for management of acute Charcot Joint and local protocols may vary.
Please seek urgent advice from Diabetes consultant. Pamidronate infusion under specialist supervision ONLY
may be appropriate (up to 6 infusions at 2 to 4 weekly intervals may be necessary). This is an unlicensed
indication.
Follow-up:
•
•
•
•
•
•
Regular clinical assessment by foot health services, usually in consultation with diabetes physician.
Footwear assessment moulded inserts etc.
Regular podiatry 2 to 4 weeks when discharged
Orthopaedic follow-up may be indicated
Repeat isotope bone scan at 3 months and 6 months
The affected joint must be relieved of all pressure from weight bearing by an offloading orthotic
appliance.
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G U ID E L IN E S F O R T H E M A N A G E M E N T O F D IA B E T E S
P A T IE N T S IN T H E D Y IN G P H A SE
IN SU L IN T R E AT E D
O N O N C E D A IL Y
L O N G A C T IN G
IN SU L IN
C O N T IN U E
O N T W IC E D A IL Y / F O U R
T IM E S D AIL Y IN SU L IN O R IV
IN SU L IN SL ID IN G SC A L E
C O N V E R T T H IS T O
G L A R G IN E / L E V E M IR O N CE
D A IL Y .
C A L C U L A T E 30% O F U SU A L
T O T A L D AIL Y IN SU L IN D O SE
(U N IT S).
M O N IT O R B L O O D
G L U C O SE O N C E
D A IL Y
M O N IT O R B L O O D
G L U C O SE O N C E D A IL Y
ORAL
H Y P O G L Y C A E M IC
AGENTS
ST O P O R A L M E D IC A T IO N
W H EN P T UN ABLE T O
SW A L L O W O R IF BL O O D
G L U C O SE < 8 M M O L S/L
D IE T
NO BLOOD
G L U C O SE
M O N IT O R IN G
R E Q U IR E D
N O B L O O D G L U C O SE
M O N IT O R IN G R E Q U IRE D
U N L E SS PT A PP E A R S
SY M P T O M A T IC
IF PT SY M PT O M A T IC A N D
B L O O D G L U C O SE
> 16M M O L /L , C O N SID E R
O N C E D A IL Y G L A R G IN E /
L E V E M IR . SU G G E ST E D
ST A R T IN G D O SE 10 U N IT S
IF B L O O D G L U C O SE < 8 M M O L S/L R E D U CE D O SA G E 10%
IF B L O O D G L U C O SE IS > 16 M M O L S/L IN C R E A SE D O SA G E B Y
10%
T H E A IM O F D IAB E T E S C A R E IS T O E N SU R E T H E P A T IE N T IS SY M P T O M F R E E .
W H E R E P O SSIB L E P A T IE N T S W ISH E S SH O U L D B E R E SP E C T E D W IT H R E G A R D S T O AL L A SP E C T S O F D IA B E T E S M A N A G E M E N T
P L E A SE C O N T A C T T H E P A L L IA T IV E C A R E T E A M O R D IA B E T E S SP .N U R SE S F O R A D V IC E
2007/217
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Appendix I
The DSN referral form can be found on the Intranet if not available on the ward.
On the home page, in ‘Departments then Documentation the click on ‘Diabetes Nurse Ward Referral Form’
The following page appears:
Trust Documentation
Click on the following link:
Search Database for required Policy/Pt Info Leaflet/Documents
The following page appears:
Use the form below to search for documents in this web containing specific words. The text search engine
will display a list of forms, policies, protocols, procedures or guidelines whose description, CMU, ratifier
and/or author contains your search criteria.
Entering search criteria
narrows your search, so
if you enter 'resus' in
the description field,
for example, only those
documents with 'resus'
in the database
description will be
displayed.
Document Type:
If the fields are left
blank all of the chosen
document type will be
displayed.
Ratified By:
All
Description:
CMU:
Written By:
Search
In ‘Description’ enter the word diabetes and you will be taken to the correct document.
2007/217
Appendix 2
51
If your test is in the morning do not take your morning insulin before leaving
home, but bring your insulin and blood glucose meter with you to the
hospital.
If your test is in the afternoon reduce morning dose by a third (if you take
insulin at lunchtime reduce it by half.)
You will then recommence your usual evening dose of insulin with your evening
meal
Advice Sheet For Patients with Diabetes
having
Bowel Preparation
If you are monitoring blood glucose levels, test before leaving home and make
sure that your blood glucose level is above 4mmol/l. If your blood glucose level
falls below this take 3 glucose tablets or 50 mls of Lucozade. After taking the
glucose tablets or drinking the Lucozade, repeat your blood glucose level
reading after 15 minutes, if your blood glucose level is still below 4 mmol/l take
3 more glucose tablets or 5 0mls Lucozade until blood glucose level is above 4
mmol/l.
Please inform the nursing staff of your hypoglycaemia on arrival at the
investigations unit.
After procedure you will be able to eat and drink as normal. You should be able
to take your normal dose of insulin once able to eat and drink, unless otherwise
directed. You should have a blood glucose level above 4 mmol/l before being
discharged.
If you have any queries please contact your diabetes nurses.
Hemel Hempstead & St Albans Hospital
01442 287482
Watford General Hospital
01923 217553
Or bleep Diabetes Nurses through switchboard
Page
4
2007/217
Page
1
Appendix 2
52
Tablet treated Patients with Diabetes
On the day before the examination
After the examination you will be able to eat and drink and take your usual
tablets.
Insulin treated Patients with Diabetes
Follow the advice on the diet leaflet, which explains what to eat and when to
take your bowel preparation.
On the day before the examination
Take your usual dose of diabetes tablets on the day before the examination,
unless you are otherwise directed.
Follow the advice on the diet leaflet, which explains what to eat and when to
take your bowel preparation.
On the day before the examination reduce each insulin dose by a third.
If you are monitoring blood glucose levels, test before meals and before going
to bed and aim to keep all blood glucose levels above 4mmol/l during the day
and above 7 mmol/l before bed by drinking lucozade, lemonade squash or
fruit juices such as apple or strained orange juice (but not red fruit juice)
If you are monitoring blood glucose levels, test before meals and before going
to bed and aim to keep all blood glucose levels above 4 mmol/l during the day
and above 7 mmol/l before bed by drinking Lucozade, lemonade, squash or
fruit juices such as apple or strained orange juice (but not red fruit juice).
If your blood glucose level falls below these levels take 3 glucose tablets or 50
mls of Lucozade. After taking the glucose tablets or drinking the Lucozade,
repeat your blood glucose level reading after 15 minutes, if your blood glucose
level is still below 4mmol/l take 3 more glucose tablets or 50 mls Lucozade
until blood glucose level is above 4mmol/l. If you have any queries please
contact the diabetes nurses.
If your blood glucose level falls below these levels take 3 glucose tablets or 50
mls of Lucozade. After taking the glucose tablets or drinking the Lucozade,
repeat your blood glucose level reading after 15 minutes, if your blood glucose
level is still below 4 mmol/l take 3 more glucose tablets or 50 mls Lucozade
until blood glucose level is above 4 mmol/l.
Any queries please contact the investigations unit or the diabetes nurses
On the day of the examination
Follow the advice on the preparation information leaflet. You should be on the
beginning of the examination list if at all possible.
On the day of the examination
Follow the advice on the diet leaflet.
Do not take your tablets before leaving home, but bring them with you to the
hospital, and bring your blood glucose meter.
If you are monitoring blood glucose levels, test before leaving home and make
sure that your blood glucose level is above 4 mmol/l. If not, take 3 glucose
tablets or 50 mls of Lucozade. After taking the glucose tablets or drinking the
Lucozade, repeat your blood glucose level reading after 15 minutes, if your
blood glucose level is still below 4 mmol/l take 3 more glucose tablets or 50
mls Lucozade until blood glucose level is above 4mmol/l. Any queries please
contact the Diabetes Nurses.
Please inform the nursing staff if you have had low blood glucose levels on
arrival at the endoscopy suite
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