This document is uncontrolled once printed. Please refer to the Trusts Intranet site for the most up to date version MANAGEMENT OF HYPOGLYCAEMIA IN ADULT PATIENTS NGH-GU-567 Document Reference Number: NGH-GU-567 Author: Dr J Rippin, Consultant Diabetic Physician Ratified By: CGG Date Ratified: May 2011 Date(s) Reviewed: May 2011 Next Review Date: December 2012 Responsibility for Review: Clinical Guidelines Group Contributors: Dr A Kilvert, Consultant Diabetic Physician Diabetes Specialist Nurses Medication Safety Pharmacist NGH-GU-567 Page 1 of 12
CONTENTS Section Page 1 Summary 3 2 Introduction 3 3 Target Group(s) or Disease Process(es) 3 4 Professional Group(s) 3 5 Clinical Guidelines [with subsections if required] 4 a) Causes b) Symptoms c) Initial Management d) Follow-up 6 Related Trust and or National Guidance 9 7 References/Bibliography 10 8 Guidance Development 10 9 Audit 10 10 Implementation & Training 10 11 Roles and Responsibilities 10 Appendices Appendix 1 Flow-chart 11 Appendix 2 Contents of Hypo Box 12 NGH-GU-567 Page 2 of 12
Management of Hypoglycaemia in Adult Patients These guidelines are based on national guidelines The Hospital Management of Hypoglycaemia in Adults with Diabetes Mellitus www.diabetes.nhs.uk 1. Summary These guidelines provide recommendations for treatment of hypoglycaemia. This is defined as blood glucose less than 4 mmol/l in a patient on blood glucose lowering treatment or blood glucose less than 3mmol/L in a patient on no medication. Treatment is based on assessment of the clinical severity (mild, moderate or severe.) The treatment recommendations are summarised in a flow chart (Appendix 1) 2. Introduction Hypoglycaemia is a common and potentially serious condition which usually occurs as a complication of treatment of diabetes mellitus. It may rarely occur as a result of an undiagnosed medical condition in people without diabetes e.g. Addison s disease, insulinoma, hypopituitarism, alcohol. 3. Target Groups Adult patients over 16 years with diabetes who have a capillary blood glucose less than 4 mmol/l with or without symptoms Adult patients not known to have diabetes and not on hypoglycaemic therapy who are found to have a blood glucose less than 3mmol/L. This requires laboratory confirmation but in a symptomatic patient treatment may be commenced while confirmation is awaited. 4. Professional Groups This guideline is for use by health care professionals caring for people with diabetes. This includes nursing, midwifery and medical staff, podiatrists, dietitians, Health Care Assistants and pharmacists and Assistant Practitioners. NGH-GU-567 Page 3 of 12
5. Clinical Guidelines A. Causes of hypoglycaemia in hospital patients Medical causes Inappropriate use of stat or PRN quick acting insulin Discontinuation of steroid therapy Recovery from acute illness Mobilisation after illness Major limb amputation Inappropriately timed diabetes medication in relation to food/enteral feed Incorrect insulin (dose or type) prescribed or administered Intravenous insulin infusion with or without glucose infusion Inadequate mixing of intermediate or mixed insulin Regular insulin doses administered in hospital when not taken at home Reduced carbohydrate intake Missed or delayed meals Reduced carbohydrate intake Altered timing of main meal (midday rather than evening) Lack of access to snacks Prolonged starvation time Vomiting Reduced appetite B. Symptoms of hypoglycaemia Adrenergic Sweating Palpitations Shaking Hunger Neuroglycopaenic Confusion Drowsiness Odd behaviour including aggression Speech difficulty Incoordination General Headache Nausea Patients with hypoglycaemia unawareness may not experience adrenergic symptoms NGH-GU-567 Page 4 of 12
C. Treatment of hypoglycaemia Recommendations depend on assessment of the severity of hypoglycaemia See appendix 1 for flow chart summarising the treatment options for each category of severity. Hypoglycaemic symptoms with blood glucose greater than 4.0mmol/L: 1. Seek alternative cause for symptoms 2 2. A small carbohydrate snack (1 medium banana, I slice of bread or 2 biscuits)can be given for symptomatic relief 3. If glucose rapidly falling repeat after 20 mins. Mild hypoglycaemia: patient conscious, orientated and able to swallow 1. Give 15-20g quick acting carbohydrate of the patient s choice where possible. Examples 150-200 ml pure fruit juice e.g. orange 90-120ml of original Lucozade (preferable in renal patients) 4-5 GlucoTabs (4g each) 5-7 Dextrosol tablets (3mg each) 3-4 heaped teaspoons of sugar dissolved in water 2. Repeat capillary blood glucose measurement 10-15 minutes later. If it is still less than 4.0mmol/L, repeat step 1 up to 3 times 3. If blood glucose remains less than 4mmol/L after 45 minutes or 3 cycles, contact a doctor. Consider 1mg of Glucagon IM or IV 10% glucose infusion at 100ml/hr. Volume should be determined by clinical circumstances NB glucagon is not suitable for patients starved / nil by mouth, in severe liver failure or after significant alcohol ingestion. May be less effective in patients prescribed sulphonylurea therapy 4. Once blood glucose is above 4mmol/L and the patient has recovered, give a long acting carbohydrate of the patient s choice where possible, taking into consideration any specific dietary requirements. Some examples are: Two biscuits One slice of bread 200-300ml milk (not soya) Normal meal if due (must contain carbohydrate) DO NOT omit insulin injection if due (dose review may be required) NGH-GU-567 Page 5 of 12
N.B. Patients given glucagon require a larger portion of long acting carbohydrate to replenish glycogen stores (double the suggested amount above) Patients using an insulin pump (continuous subcutaneous insulin infusion CSII) may not need a long acting carbohydrate 5. Document event in patient s notes. Ensure regular capillary blood glucose monitoring is continued for 24 to 48 hours. Ask the patient to continue this at home if they are to be discharged. Give hypoglycaemia education or refer to diabetes inpatient specialist nurse (DSN) Moderate hypoglycaemia: patient conscious but confused, disorientated, unable to cooperate or aggressive but able to swallow 1. If the patient is capable and cooperative, follow section above in its entirety. 2. If the patient is not capable and/or uncooperative, but is able to swallow give either 1.5-2 tubes GlucoGel / Dextrogel squeezed into the mouth between the teeth and gums or (if this is ineffective) give glucagon 1mg IM NB glucagon is not suitable for patients starved / nil by mouth, in severe liver failure or after significant alcohol ingestion. May be less effective in patients prescribed sulphonylurea therapy 3. Repeat capillary blood glucose levels after 10-15 minutes. If still less than 4.0mmol/L repeat steps 1 and/or 2 (up to 3 times) 4. If blood glucose level remains less than 4mmol/L after 45 minutes (or 3 cycles of above treatment), contact a doctor. Consider IV 10% glucose infusion at 100ml/hr. Volume should be determined by clinical circumstances 5. Once blood glucose is above 4.0mmol/L and the patient has recovered, give a long acting carbohydrate of the patient s choice where possible, taking into consideration any specific dietary requirements. Some examples are: Two biscuits One slice of bread/toast 200-300ml glass of milk (not soya) Normal meal if due (must contain carbohydrate) DO NOT omit insulin injection if due (dose review may be required) N.B. Patients given glucagon require a larger portion of long acting carbohydrate to replenish glycogen stores (double the suggested amount above) Patients using insulin pumps (continuous subcutaneous insulin infusion - CSII) may not need a long acting carbohydrate NGH-GU-567 Page 6 of 12
6. Document event in patient s notes. Ensure regular capillary blood glucose monitoring is continued for 24 to 48 hours. Ask the patient to continue this at home if they are to be discharged. Give hypoglycaemia education or refer to Diabetes Nurse. Severe hypoglycaemia: patient unconscious and/or having seizures and/or very aggressive 1. Check: Airway (and give oxygen) Breathing Circulation Disability (including GCS and blood glucose) Exposure (including temperature) If the patient has an insulin infusion in situ, stop immediately Fast bleep a doctor 2. If IV access available or can be swiftly be established, give 75-80ml of 20% glucose (over 10-15 minutes). Use ready to use 100ml small volume infusion if available. If an infusion pump is available use this, but if not readily available the infusion should not be delayed. Repeat capillary blood glucose measurement 10 minutes later. If it is still less than 4.0mmol/L, repeat glucose infusion If IV access not readily available, give glucagon 1mg IM (not suitable in patients starved / nil by mouth, in severe liver failure or after significant alcohol ingestion; may be less effective in patients prescribed sulphonylurea therapy. Not suitable for repeat use - effective only once until liver glycogen stores repleted) 3. Once blood glucose is above 4.0mmol/L and the patient has recovered, give a long acting carbohydrate of the patient s choice where possible, taking into consideration any specific dietary requirements. Some examples are: Two biscuits One slice of bread/toast 200-300ml glass of milk (not soya) Normal meal if due (must contain carbohydrate) DO NOT omit insulin injection if due (dose review may be required) N.B. Patients given glucagon require a larger portion of long acting carbohydrate to replenish glycogen stores (double the suggested amount above) Patients who use insulin pumps (CSII) may not need long acting carbohydrate If the patient became hypoglycaemic while on an IV insulin infusion, stop the insulin and check the capillary blood glucose every 30 minutes until above 3.5mmol/L, then re-start IV insulin after review of dose regimen NGH-GU-567 Page 7 of 12
4. Document event in patient s notes. Ensure regular capillary blood glucose monitoring is continued for 24 to 48 hours. Ask the patient to continue this at home if they are to be discharged. Give hypoglycaemia education or refer to Diabetes Nurse Adults who are nil by mouth 1. If the patient has a variable rate intravenous insulin infusion, adjust as per prescribed regimen, and seek medical advice 2. Treat as for severe hypoglycaemia (intravenous glucose or IM glucagon) 3. Once blood glucose is greater than 4mmol/L and the patient has recovered consider intravenous10% glucose at a rate of 100ml/hr until patient is no longer nil by mouth or has been reviewed by a doctor 4. Document event in patient s notes. Ensure regular capillary blood glucose monitoring is continued for 24 to 48 hours. Adults receiving enteral feeding Patients requiring total parenteral nutrition (TPN) should be referred to a dietitian/nutrition team and diabetes team for individual assessment. Risk factors for hypoglycaemia Blocked/displaced tube Change in feed regimen Enteral feed discontinued TPN or IV glucose discontinued Diabetes medication administered at an inappropriate time to feed Changes in medication that cause hyperglycaemia e.g. steroid therapy reduced/stopped Feed intolerance Vomiting Deterioration in renal function Severe hepatic dysfunction Treatment: to be administered via enteral feeding tube Do not administer these treatments via a TPN line. 1. Give 15-20g quick acting carbohydrate of the patient s choice where possible. Some examples are: 25ml original undiluted Ribena 50-70ml of Ensure Plus Juice or Fortijuice 3-4 heaped teaspoons of sugar dissolved in water NGH-GU-567 Page 8 of 12
2. Repeat capillary blood glucose measurement 10 to 15 minutes later. If it is still less than 4mmol/L, repeat step 1 up to 3 times 3. If blood glucose remains less than 4mmol/L after 45 minutes (or 3 cycles), consider IV 10% glucose infusion at 100ml/hr. Volume should be determined by clinical circumstances 4. Once blood glucose is above 4mmol/L and the patient has recovered, give a long acting carbohydrate. Some examples are Restart feed If bolus feeding, give additional bolus feed (read nutritional information and calculate amount required to give 20g of carbohydrate) 10% IV glucose at 100ml/hr. Volume should be determined by clinical circumstances DO NOT omit insulin injection if due (dose review may be required) 5. Document event in patient s notes. Ensure regular capillary blood glucose monitoring is continued for 24 to 48 hours. Ask the patient/carer to continue this at home if they are to be discharged. Give hypoglycaemia education or refer to Diabetes Nurse. Ensure patient has been referred to a dietitian. D. Follow-up 1. If the cause for hypoglycaemia is apparent, the patient has fully recovered, recurrence is not likely and there is no evidence of concurrent illness, s/he can usually be discharged. Consider referral to Diabetes Specialist Nurses or advise patient to contact their Diabetes Nurse. If awareness of hypoglycaemia is impaired, the patient should be advised not to drive. 2. If hypoglycaemia is due to sulphonylurea or long-acting insulin the risk of recurrent hypoglycaemia is high and the patient may need admission for ongoing observation, especially if s/he has renal failure or is elderly. Consider 10% glucose intravenous infusion if the patient is unable to take food by mouth. Monitor capillary blood glucose hourly initially. May need monitoring for 24-48hrs. 3. Admit for monitoring (and psychiatric assessment) if deliberate self harm suspected 4. If the patient is unable to eat omit mealtime insulin and continue background insulin only. If the patient normally takes twice daily insulin, reduce dose by 50%. Seek the advice of the Diabetes Team 6. Related Trust and/or National Guidance The Hospital Management of Hypoglycaemia in Adults with Diabetes Mellitus March 2010 www.diabetes.nhs.uk NPSA Patient Safety Alert 20. Promoting Safer Use of Injectable Medicines March 2007 Enteral Feeding (Adults). NGH-GU-480 Parenteral Nutrition (Adults). NGH-GU-203 Glucometers Point of Care Testing. NGH-CGG-GU-366 NGH-GU-567 Page 9 of 12
7. References/Bibliography This guideline reflects national guidance. The Hospital Management of Hypoglycaemia in Adults with Diabetes Mellitus www.diabetes.nhs.uk Further references can be found in the national publication 8. Guidance Development The guideline has been drawn up by Jonathan Rippin, consultant diabetologist, in line with national guidance and in consultation with Anne Kilvert, consultant diabetologist and Diabetes Specialist Nurses Eileen Richardson and Kathy Kerlogue. Pharmacist Karin Start has been consulted about parenteral treatment and hypokits. 20% Dextrose solution will now be stocked. 9. Audit The national guidelines include an audit form. The intention is to introduce this form so that the diabetes team can monitor the frequency and treatment of hypoglycaemia in inpatients 10. Implementation and Training There is ongoing training of ward nursing staff through the Diabetes Link Nurse program. The guidelines will be incorporated in the Think Glucose project being rolled out on all adult wards over the next 18 months 11. Roles and Responsibilities Staff group Ward manager Nursing staff Medical Staff Pharmacy Responsibility Ensure that a nurse trained in blood glucose monitoring and management of hypoglycaemia is available at all times Monitor use of Hypobox and ensure that it is restocked after use Monitor blood glucose and escalate results where appropriate. Treat hypoglycaemia promptly according to guidance Restock Hypobox after use Determine frequency of blood glucose monitoring Respond promptly to requests from nursing staff to treat hypoglycaemia if required To ensure appropriate medeications are stocked. NGH-GU-567 Page 10 of 12
Appendix 1 Symptoms of Hypoglycaemia: Algorithm for the Treatment of Hypoglycaemia in Adults with Diabetes in Hospital Adrenalin symptoms (may be absent): Sweating, shaking, palpitations, hunger, irritability or aggression Neurological: Poor concentration, altered behaviour, confusion, drowsiness, impaired speech or coordination; fitting Remember: Hypo symptoms can be very individual - listen to patient: if the they say they are low, they very probably are Hypoglycaemia is considered a blood glucose of less than 4mmol/L. (If blood glucose above 4 but symptoms of hypo give 2 biscuits for symptom relief) Mild Moderate Severe Patient conscious, orientated and able to swallow Patient conscious and able to swallow, but confused/disorientated or aggressive Patient unconscious/fitting or very aggressive or nil by mouth (NBM) Give 15-20g of quick-acting carbohydrate: 4-5 GucoTabs (4g/tab) or one GlucoJuice 59ml bottle or 1/3 bottle of Lucozade Test blood glucose after 10-15 minutes. If still less than 4mmol/L, repeat up to 3 times. If repeated three times, consider iv 10% Dextrose infusion at 100ml/hr* or 1mg Glucagon im. If capable and cooperative, give 15-20g of quick-acting carbohydrate as on the left. If not capable and cooperative but able to swallow, give 1.5-2 tubes of oral GlucoGel or 1mg Glucagon im if suitable (see right). Test blood glucose after 10-15 minutes. If still less than 4mmol/L, give15-20g of quick-acting carbohydrate up to three times. If blood glucose still less than 4mmol/L, consider iv 10% Dextrose at 100ml/hour*. Check ABC, stop iv insulin, fast bleep a doctor If iv access available or possible to achieve swiftly, give 75-80ml of 20% Dextrose, repeated up to 3 times. Alternatively, 1mg Glucagon im (not suitable for repeat hypo, if starved or NBM, in severe hepatic disease or after significant alcohol use) Blood glucose level should now be above 4mmol/L. Give 20g of long-acting carbohydrate, e.g. 2 biscuits or a slice of bread or next meal if due. If im Glucagon has been used, give 40g of long-acting carbohydrate (to replenish liver Glycogen stores). For enterally fed patients, restart feed or give bolus feed as per guideline or iv 10% glucose at 100ml/hr* Re-check blood glucose after 10-15 minutes. It should now be above 4mmol/L. Follow-up treatment as described on the left. If NBM, give 10% Dextrose infusion at 100ml/hr* until no longer NBM or reviewed by doctor. Do not omit subsequent doses of insulin; continue regular capillary blood glucose monitoring for 24-48 hours and give hypo education or refer to DSN. For enterally fed patients, see full guideline *In end-stage renal failure, heart failure: Take care re volume administered if giving 10% Dextrose (check not overloaded, especially if short of breath). NGH-GU-567 Page 11 of 12
Appendix 2 Contents of hypo box: GlucoTabs (4g of carbohydrate per tablet): One blister pack of 24 tablets GlucoJuice: (15g of carbohydrate per bottle): Three 59ml bottles GlugoGel: (10g of carbohydrate per tube): Two boxes with three tubes each Laminated algorithm for treatment of hypoglycaemia as in Appendix 1. NGH-GU-567 Page 12 of 12