1 diabetes in hospital prepared by [lynne gilks] [cnc diabetes education] [tamworth diabetes centre]...

1

Diabetes In HospitalPrepared by [Lynne Gilks][CNC Diabetes Education]

[Tamworth Diabetes Centre]

[Nov 2010]

Diabetes & hospitalisation

Issues to consider:

Type of Diabetes

Glycaemic control during hospitalisation

Managing fasting in the diabetic patient

Use of sliding scale insulin

Lack of basal insulin

Discharge planning

Follow up


Important to determine and document whether:

Type 1 diabetes

Type 2 diabetes

Type 2 insulin requiring


Admission necessary the day before surgery for thorough assessment if :

Type 1 DM

Type 2 DM insulin requiring

DM that is poorly controlled

Major surgical procedures

Patient is likely to be NBM for a prolonged period pre or post operatively


Optimal BGL prior to, during and after surgery will assist with wound healing, reduce the risk of post-operative complications (including infection) and shorten hospital time

Stress of anaesthetic and surgery tends to cause BGL to rise

An increase in diabetes treatment may be required for an extended period

Patient should be informed that medication/insulin doses should return to pre-operative doses as they recover and become more active

Monitor BLG 4 times per day or more frequently if appropriate


Blood glucose levels as close to normal as possible improves in-hospital morbidity & mortality rates. Demonstrated strong association between hospital hyperglycaemia and adverse clinical outcomes.

Aim for blood glucose levels 5 to 10 mmol/l

Never stop insulin in a Type 1 diabetic

Avoid routine use of sliding scale insulin as this destabilises diabetes in most patients.

Sliding scale insulin should only be used in limited circumstances


Insulin regimes should target prospective (anticipated BGL) rather than reactive retrospectively to previous BGL

It is better to adjust overall regime to prevent further rises in BGL

If at any stage diabetes management targets are not being met, contact medical team for review of patient


Oral Hypoglycaemic agents (OHA) which are started or increased during hospitalisation generally do not work quickly enough to control hyperglycaemia

Inpatients who have adequate diabetes control and have no contraindications (patient being acutely ill or renal impairment) OHAs can be continued

An insulin/glucose infusion would be used if the patient requires insulin and is fasted for a prolonged period of time (more than 6 hrs) or patient is very unstable


The frequency of BG monitoring needs to be assessed regularly

Notify Medical Officer if BGL is > 15 mmol/l on 2 consecutive readings or any BGL > 20 mmol/l

Check urine ketones in Type 1 patients if BGL is > 15 mmol/l or if the patient is very ill.

If ketones are present especially if large urinary ketones or blood ketones are >1.6 or ketoacidosis is suspected contact Medical Officer


Surgery:

Anaesthetic consult.

Advice regarding insulin regimes can be obtained by contacting Endocrinologist or Physician if necessary

Metformin should be ceased 48 hrs prior to surgery

Sulphonylureas need to be withheld on the day of surgery

Daonil, because of it’s long action, may need to be withheld the night before surgery

Management determined by BGL and whether the person is eating or not


All people with DM should have their BGL checked within 1 hr prior to going to theatre

Notify Anaesthetist if:

BGL is < 5 mmol/l

BGL is > 10 mmol/l

BGL should be done during surgery and immediately post-operatively

People with Type 1 DM are particularly at risk from ketosis. Notify Anaesthetist or Medical Officer if ketones are present in urine or blood


Before giving insulin to a person who is fasting ensure there is an IV glucose infusion in place, that is running

Ensure optimal hydration & electrolyte balance (dehydration increases BGL)

Operate early in the day (in Type 1 DM prolonged fasting predisposes to DKA)

In patients with gastro paresis allow longer period of fasting before surgery

All patients with Type 1 DM should be receiving some insulin at all times even when NBM

Most people with Type 2 DM will usually need insulin for major surgical procedures


Type of IV fluid given will depend on whether the person is receiving insulin, fasting or not and their BGL

Glucose infusion must be used if the patient has received insulin prior to or during surgery

Monitor BGL at least every 2 hrs- hrly if IV glucose/insulin infusion in situ


Check BGL on arrival at recovery

Then every 4 to 6 hrs

If on IV insulin/glucose infusion then hrly

Once stable and eating -before meals

All people with Type 1 DM require checks for ketones:

At least 8 hrly

If BGL > 15 mmol/l

If vomiting or generally unwell


Discharge planning should start at admission

Recommence anticipated discharge regime for at least 24 hrs prior to discharge

Patient should be advised of regime on discharge

Radiological Procedures

Book earliest possible appointment time to minimise problems for people with DM

Radiology Dept should be notified the patient has DM and their current treatment regime

Medication/ Insulin orders may be modified according the patient’s type of DM, medication/ insulin and time of procedure

Any dose reduction needs to be discussed with MO and the person with DM

Radiological procedures

Well controlled Type 2 DM on diet only or OHA

Omit morning dose of OHA if fasting is necessary

Metformin should be stopped 48 hrs prior to a procedure

Assess serum creatinine levels before restarting Metformin

Type 1 & 2 receiving insulin:

Individual advice based on insulin regime


BG monitoring equipment should be available

BG should be check before, during and after the procedure especially in patient feels unwell or hypoglycaemic

All patients with diabetes should bring with them:

some quick acting CHO in case of hypoglycaemic episode

Radiology Dept should have available:

Hypoglycaemia guideline, BG meter and hypo kit


Special precautions may be necessary for people having any radio contrast study which includes angiography, CT scan with enhancement, intravenous pyelography. Those most at risk:

Impaired renal function-GFR< 30ml per min

Dehydration or effective reduction in blood volume-eg CCF, Hypotension, septic shock or intensive diuretic therapy

Other nephrotoxic drugs or medications that may contribute to decreasing GFR-eg gentamicin, diuretics, ACE inhibitors, Angiotensin II receptor antagonists, NSAID, cyclo-oxygenase 2 inhibitors, cyclosporin, vancomycin, tacrolimus, amphotericin.


The following precautions may need to be considered by MO:

Stopping certain medications several days before the procedure-eg diuretics, NSAID

Hydration before, during and after the procedure


After the procedure:

Once eating and drinking recommence medication except for Metformin-check serum creatinine/GFR prior to restarting this

It may be necessary to reduce insulin dose if food intake is reduced. Discuss medication adjustment with MO or Diabetes Educator

Type 1 diabetes & insulin need

Type 1 Diabetics:

At diagnosis 80 to 90% of their beta cells have been destroyed by an autoimmune process

They become insulin deficient

Insulin deficiency results in:

-hyperglycaemic

-Osmotic diuresis leading to dehydration

-ketosis

-metabolic acidosis

-electrolyte loss

Insulin deficiency

Rapid acting

– Immediate onset, very short duration

– Novorapid, Humalog & Apidra

Short acting

-rapid onset and short duration

-Actrapid & Humulin R

Basal/bolus insulin

References

Guideline for the management of Diabetes during surgery, Diabetes Centre POW hospital

Hospitalisation, section 4 Diabetes Manual 7th edition A guide to Diabetes Management 2009

National Associations of Diabetes Centre Course for Nurses & Allied Health Professional

Significance of Hyperglycaemia for Hospitalised patients, N.Wah Cheung. Westmead Hospital

1 diabetes in hospital prepared by [lynne gilks] [cnc diabetes education] [tamworth diabetes centre]...

Documents