Tayside Diabetes MCN Handbook - Management of Hyperglycaemia "out of hours"


 

 
High risk conditions associated with hyperglycaemia
 
Diabetic Ketoacidosis (DKA)
  • DKA can occur with or without hyperglycaemia
  • DKA can occur in patients with Type 2 diabetes in the context of acute illness, in secondary pancreatic failure and/or pancreatitis
  • Positive ketones in blood or urine signify a risk of DKA
 
Hyperosmolor non ketotic coma (HONK)
  • Hyperglycaemia (> 35mmol/L or ‘Hi’ on meter) and no ketones in blood or urine
  • Known or unknown Type 2 diabetes with acute illness e.g. infection, MI
  • History of using steroids, thiazides, phenytoin or beta-blocker
 
Assessment and management of hyperglycaemia
  • Check the clinical status e.g. is the patient well/unwell/vomiting/pyrexial etc.
  • Check the urine or blood for ketones
  •  Hyperglycaemia, with no evidence of ketonuria, in people who are otherwise not acutely unwell does not require emergency treatment to lower the blood glucose
  • Review the ‘usual’ diabetes management within the next 24 hours
  •  Increase the ‘usual’ insulin  or oral diabetes medication  if the blood glucose level has been elevated according to the recent record of control
 
Insulin management
  • If the person has been identified as being at high risk of DKA (i.e. unwell and/or ketones present in urine or blood,then extra insulin can be administered.
  • Suitable insulin preparations to prescribe for STAT dosing include soluble (e.g. Actrapid/Humulin S) or rapid acting insulin (e.g. Novorapid/Humalog/Apidra)
  • Calculate the STAT dose as 20% of total normal daily insulin dose e.g. assume total daily insulin dose is 40 units, administer 8 units of actrapid STAT
  • Recheck the blood glucose and ketones within 2 hours
  • Extra insulin doses can be given 2- 4 hourly if no improvement has occurred
  • Increase the ‘usual’ insulin if the recent record of blood glucose levels is elevated
 
Fluid intake
  • Increase the oral fluid intake to 150 mL water hourly to reduce the risk of dehydration associated with hyperglycaemia (NB caution with renal/cardiac failure)
 

Emergency hospital admission is required in the following situations:
 
Blood glucose >35mmol/L or ‘Hi’ with no urine ketones and/or
  • Problematic osmotic symptoms
  • Dehydration
OR
Moderate ketonuria or blood ketone level 1.5 mmol/L or greater and/or
  • Unable to tolerate oral intake
  • Abdominal pain
  • Breathlessness