CLINICAL GUIDELINE FOR THE MANAGEMENT OF HIGH BLOOD GLUCOSE LEVELS AND SICK DAYS ON AN INSULIN PUMP. 1. Aim/Purpose of this Guideline

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1 CLINICAL GUIDELINE FOR THE MANAGEMENT OF HIGH BLOOD GLUCOSE LEVELS AND SICK DAYS ON AN INSULIN PUMP. 1. Aim/Purpose of this Guideline 1.1. The purpose of this guideline is to give clear information and guidance for managing high blood glucose levels and sick days for Children/ Young people on an insulin pump. 2. The Guidance 2.1. When you are on an insulin pump, a high blood glucose must be taken seriously as insulin pumps deliver only short or rapid-acting insulin. Without any long-acting insulin in your body, blood glucose can rise quickly if the insulin flow is accidentally interrupted and a condition called diabetic ketoacidosis (DKA) can develop. DKA is a very serious condition which must be treated immediately. Therefore if your blood glucose level is 14mmol/l or more at any stage, whether well or unwell, you must follow the flow chart in Section Sick Day Rules Illness usually causes high blood glucose levels because of the production of stress hormones and because the body becomes resistant to insulin. However diarrhoea and vomiting can lower blood glucose levels causing hypoglycaemia. Rule 1: Test don t guess! When you are unwell, test your blood glucose level at least every 2 hours. You should also check your ketone levels with each blood test. Blood ketones are most accurate, but if you have a problem with your blood ketone meter you can check urine ketones. Ketones are produced when the body breaks down fat as a source of energy. This happens in people, with or without diabetes, when they don t eat. In people with diabetes, ketones can also be produced when there is a lack of insulin e.g. if your pump is not working, or during illness, when the body becomes resistant to insulin. Rule 2: Never stop your insulin, even when you are not eating. You are likely to need etra insulin when you are unwell. In rare cases where the blood glucose levels are low (below 4mmol/l), your insulin doses may need to be reduced in this case you should phone the emergency contact number to discuss this with one of the team. Rule 3: Eat regular carbohydrate foods to prevent starvation ketones. If you aren t able to eat normal foods you can try easily digestible foods such as soup, toast, jelly and ice-cream. Or you can have frequent sugary drinks. Rule 4: Drink plenty of etra non-sugary fluids in addition to the food or sugary fluids in Rule 3. This is because high blood glucose levels, fever, diarrhoea or vomiting can cause dehydration and stop your body clearing ketones. Page 1 of 11

2 Ketones are dangerous. They can make you feel unwell and cause diabetic ketoacidosis. Rule 5: If you have any of the following symptoms, check your blood ketones: vomiting (vomiting shouldn t be assumed to be due to a bug as ketones can cause vomiting) severe abdominal (tummy) pain breathlessness, or breath smells of acetone (pear drops or nail varnish remover) drowsy signs of dehydration e.g. dry tongue, sunken eyes, cold or blue fingers and toes Blood Ketones Interpretation Action (mmol/l) Less than 0.6 Normal Give normal insulin Slightly high doses, including normal correction dose if blood glucose greater than 8-10 mmol/l High Give sick day insulin Significant risk of developing diabetic ketoacidosis dose, instead of normal correction dose, if blood glucose greater than 14 mmol/l 3.0 or above Immediate risk of diabetic ketoacidosis Phone emergency contact number 2.3. Troubleshooting Where you are directed to troubleshoot the cause of the high blood glucose level, check the following: The Infusion Set Is the tubing primed or filled with insulin? Is there air or blood in the tubing? Did you remember to fill the cannula with insulin after inserting new set? Is the tubing connected to cartridge? Is the set connected to your body? Are there any leaks? Is the cannula dislodged or kinked? Has the infusion set been in longer than 2-3 days? Is there redness at the site? Is there discomfort at the site? Is there blood on/at the site? Page 2 of 11

3 The Insulin Pump Did you forget your last bolus? (review bolus history) Have you received any recent alarms? Has your battery run down? Is your cartridge/reservoir empty? Is the date and time correct? Are your basal rates programmed correctly? Do a pump self-test after checking your pump The Insulin Is your insulin epired/inactive? Is it cloudy or clumped? How long has your insulin been at room temperature? Did you leave your insulin in a warm location? How long has the insulin been in the cartridge and tubing? Was your insulin eposed to freezing temperatures? Page 3 of 11

4 2.4. Treating High Blood Glucose Levels Insulin Pump Therapy Is the blood glucose level 14 mmol/l or above? YES Check blood ketones NO Continue normal pump doses Blood ketones 2mmol/L or higher Blood ketones between 1 and 2mmol/L Blood ketones less than 1mmol/L Give a DOUBLE correction bolus by INJECTION with an insulin pen or syringe, not via the pump: - see Section 2.5 for how to work out correction dose. Phone emergency contact number to talk through the plan on : - 8am 8pm ask for Paediatric Diabetes Nurse - 8pm 8am ask for Paediatric Registrar Give a correction bolus using the pump. Try to identify the cause of the high blood glucose level (see Troubleshooting, Section 2.3) Repeat blood glucose and ketones in two hours Give a usual correction bolus of insulin by INJECTION with an insulin pen or syringe, not via the pump: - see Section 2.5 for how to work out the correction dose Change the insulin, infusion set and cartridge. Restart your pump (do not give a correction bolus via the pump at this stage). Drink plenty of liquids that contain no calories, for eample a glass of water every thirty minutes. Try to identify the cause of the high blood glucose level (see Troubleshooting, Section 2.3). Repeat blood glucose and ketones after 1 hour: if ketones rising: repeat correction dose using an insulin pen/syringe and phone the emergency contact number if you have not already done so. if ketones falling: repeat blood glucose and ketones in 1 hour then go back to the top of the chart. Page 4 of 11

5 2.5 Conversion to Insulin Injections from Insulin Pump How to calculate the correction dose or rapid-acting insulin to be given by injection: A. If you think the pump itself is still working and there is only a problem with the cannula or tubing: - you can put your blood glucose level into the pump and it will calculate your correction dose, which you can then give by injection. B. If there is a problem with the actual pump, then you can use the Insulin Sensitivity Factor (ISF) setting on your pump for that time of day to calculate the correction dose: - If you are unable to access the settings via your actual pump, then you will need to get this information from your last pump download on Diasend. If you are not using Diasend, you should have been advised to keep a regular written record of your pump settings. - Aim for a blood glucose of 8mmol/L and round the correction dose down to the nearest half unit. - The correction dose can be calculated using the formula: (Current blood glucose level in mmol/l 8) ISF - E.g. Blood glucose currently 18mmol/l and blood ketones 0.2mmol/l. The ISF on your pump for that time of day is 3mmol/l, which means that 1 unit of insulin will bring the blood glucose down by 3mmol/l. Using the formula to aim for a blood glucose of 8mmol/l: (18 8) 3 = 3.33 units: rounded down this would be 3 units - Remember, if your ketones are greater than 2mmol/L, you should give a DOUBLE correction dose by INJECTION with a pen or syringe. If you are likely to be back on your insulin pump within the net 12 hours, you can simply give regular rapid-acting insulin (e.g. Novorapid) to cover meals and snacks using the Insulin Carbohydrate Ratio (ICR) settings on your pump. You should check your blood glucose and ketone levels at least every 2 hours and follow the guidance on page 4 if your ketones are greater than 1mmol/l or your blood glucose levels are greater than 14mmol/l. If you are not going to be back on your insulin pump within 12 hours, in addition to the rapid-acting insulin mentioned in the previous paragraph, you will also need to give long-acting insulin (e.g. Lantus or Levemir), once daily until back on your pump. The dose of long-acting insulin can be calculated by adding up your basal rates over a 24 hour period. Remember, you probably decreased your pre-pump insulin dose by 25% on starting pump therapy, so you may need etra insulin whilst on injections. If your pump is not working, please contact the pump manufacturer who will arrange to supply another pump for you if it is within warranty. Page 5 of 11

6 3. Monitoring compliance and effectiveness Element to be monitored Lead Tool Frequency Reporting arrangements Acting on recommendations and Lead(s) Change in practice and lessons to be shared Compliance with guidance Diabetes team (Dr Katie Mallam) Audit If any problems identified, or minimum 3 yearly Diabetes team and Directorate Audit and Guidelines meeting Audit lead and diabetes team Required changes to practice will be identified and actioned within a specified time frame. A lead member of the team will be identified to take each change forward where appropriate. Lessons will be shared with all the relevant stakeholders Page 6 of 11

7 4. Equality and Diversity 4.1. This document complies with the Royal Cornwall Hospitals NHS Trust service Equality and Diversity statement Equality Impact Assessment The Initial Equality Impact Assessment Screening Form is at Appendi 2. Page 7 of 11

8 Appendi 1. Governance Information Document Title Date Issued/Approved: July 2015 Clinical guideline for the management of high blood glucose levels and sick day rules on an insulin pump. Date Valid From: July 2015 Date Valid To: July 2018 Directorate / Department responsible (author/owner): Paediatric Diabetes Team led by Dr Katie Mallam Contact details: Brief summary of contents Clear guidance for management of high blood glucose levels on an insulin pump. Includes flow diagram and sick day rules. Suggested Keywords: Target Audience Eecutive Director responsible for Policy: Date revised: 09/06/2015 This document replaces (eact title of previous version): Approval route (names of committees)/consultation: Divisional Manager confirming approval processes Diabetes Pump High blood glucose Sick RCHT PCH CFT KCCG Managing high blood glucose level on an insulin pump. Paediatric Diabetes Team Audit and guidelines meeting Name and Post Title of additional signatories Signature of Eecutive Director giving approval Publication Location (refer to Policy on Policies Approvals and Ratification): Document Library Folder/Sub Folder {Original Copy Signed} Internet & Intranet Intranet Only Paediatrics Page 8 of 11

9 Links to key eternal standards Related Documents: Training Need Identified? no Version Control Table Date Versio n No July 2012 V1.0 Initial Issue August 2013 October 2013 July 2015 V4.0 V2.0 Minor amendments V3.0 Re format only Summary of Changes Page 2: rule 5 wording and removed urine ketones from table, Page 4 flowchart changed, Page 5 conversion to injections changed. Changes Made by (Name and Job Title) Diabetes team- Dr. K. Mallam,Dr. S. Robertson, Anita Englan, Michelle Skewes, Pip Ali and Trish Shaw Diabetes team- Dr. K. Mallam,Dr. S. Robertson, Anita Englan, Michelle Skewes, Pip Ali and Trish Shaw Tabitha Fergus Deputy ward manger Dr Katie Mallam and the Paediatric Diabetes Team All or part of this document can be released under the Freedom of Information Act 2000 This document is to be retained for 10 years from the date of epiry. This document is only valid on the day of printing Controlled Document This document has been created following the Royal Cornwall Hospitals NHS Trust Policy on Document Production. It should not be altered in any way without the epress permission of the author or their Line Manager. Page 9 of 11

10 Appendi 2. Initial Equality Impact Assessment Form Name of the strategy / policy /proposal / service function to be assessed (hereafter referred to as policy) (Provide brief description): Clinical guideline for the management of high blood glucose levels on an insulin pump. Directorate and service area: Is this a new or eisting Policy? eisting Child health Name of individual completing Telephone: assessment: T. Fergus 1. Policy Aim* Who is the strategy / policy / proposal / service function aimed at? 2. Policy Objectives* Standardised practice. Clear guidance for management of high blood glucose levels on an insulin pump. Includes flow diagram and sick day rules. 3. Policy intended Outcomes* 4. *How will you measure the outcome? 5. Who is intended to benefit from the policy? 6a) Is consultation required with the workforce, equality groups, local interest groups etc. around this policy? Evidence based, standardised care. audit Children/young people and families. no b) If yes, have these *groups been consulted? C). Please list any groups who have been consulted about this procedure. 7. The Impact Please complete the following table. Are there concerns that the policy could have differential impact on: Equality Strands: Yes No Rationale for Assessment / Eisting Evidence Age Page 10 of 11

11 Se (male, female, transgender / gender reassignment) Race / Ethnic communities /groups Disability - learning disability, physical disability, sensory impairment and mental health problems Religion / other beliefs Marriage and civil partnership Pregnancy and maternity Seual Orientation, Biseual, Gay, heteroseual, Lesbian You will need to continue to a full Equality Impact Assessment if the following have been highlighted: You have ticked Yes in any column above and No consultation or evidence of there being consultation- this ecludes any policies which have been identified as not requiring consultation. or Major service redesign or development 8. Please indicate if a full equality analysis is recommended. Yes No 9. If you are not recommending a Full Impact assessment please eplain why. No negative aspects Signature of policy developer / lead manager / director T.fergus Date of completion and submission October 2013 Names and signatures of members carrying out the Screening Assessment Keep one copy and send a copy to the Human Rights, Equality and Inclusion Lead, c/o Royal Cornwall Hospitals NHS Trust, Human Resources Department, Knowledge Spa, Truro, Cornwall, TR1 3HD A summary of the results will be published on the Trust s web site. Signed T.Fergus Date 30/10/13 Page 11 of 11

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