Optimal glycaemic control before and during pregnancy improves both maternal and fetal outcomes. This article summarizes the recently published guidelines on the management of glycaemic control in pregnant women with diabetes on obstetric wards and delivery units produced by the Joint British Diabetes Societies for Inpatient Care and available in full at www.diabetes.org.uk/joint-british-diabetes-society and https://abcd.care/joint-british-diabetes-societies-jbds-inpatient-care-group. Hyperglycaemia following steroid administration can be managed by variable rate intravenous insulin infusion (VRIII) or continuous subcutaneous insulin infusion (CSII) in women who are willing and able to safely self-manage insulin dose adjustment. All women with diabetes should have capillary blood glucose (CBG) measured hourly once they are in established labour. Those who are found to be higher than 7 mmol/l on two consecutive occasions should be started on VRIII. If general anaesthesia is used, CBG should be monitored every 30 min in the theatre. Both the VRIII and CSII rate should be reduced by at least 50% once the placenta is delivered. The insulin dose needed after delivery in insulin-treated Type 2 and Type 1 diabetes is usually 25% less than the doses needed at the end of first trimester. Additional snacks may be needed after delivery especially if breastfeeding. Stop all anti-diabetes medications after delivery in gestational diabetes. Continue to monitor CBG before and 1 h after meals for up to 24 h after delivery to pick up any pre-existing diabetes or new-onset diabetes in pregnancy. Women with Type 2 diabetes on oral treatment can continue to take metformin after birth.
This article summarises the Joint British Diabetes Societies for Inpatient Care guidelines on the management of glycaemia in pregnant women with diabetes on obstetric wards and delivery units, Joint British Diabetes Societies (JBDS) for Inpatient Care Group, ABCD (Diabetes Care) Ltd. The updated guideline offers two approaches -the traditional approach with tight glycaemic targets (4.0-7.0 mmol/L) and an updated pragmatic approach (5.
The National Diabetes Inpatient Audit for 2013 described insulin-related prescription errors in over 21% of patients each year from the beginning of data collection in 2010. Error rates have fallen year on year but remain unacceptably high, with significant variation between hospitals. Many of these issues were related to insulin prescribing.In 2014, the Joint British Diabetes Societies for Inpatient Care (JBDS) organised a competition for the 'best in class' current insulin prescription chart from hospitals in the UK. The aim was to identify safe and effective insulin charts, and make them available to the other clinical teams. A total of 41 Trusts submitted their insulin prescription charts, which were considered by an expert panel of independent judges against predefined criteria based on guidelines on the safe prescription of insulin from the UK National Patient Safety Agency.The charts from Nottingham University Hospitals won this competition, with East Sussex Healthcare, Worcestershire Royal Hospital and Western Sussex Hospitals as runners up. The competition identified areas of particular strength in the winning charts, which are available online (see Box 1).This article describes the background to the competition, with an account of the winning entry. The judging process highlighted a number of valuable mechanisms for improving insulin prescribing in UK hospitals. Br J Diabetes Vasc Dis 2015;15:135-138 Key words: Insulin, safety, prescription chart, award, competition The problemThe National Diabetes Inpatient Audit (NaDIA) for 2013 found that about 16% of acute hospital beds in the UK were occupied by someone with diabetes, 1 of whom 37% experienced at least one diabetes medication error, 22% at least one prescription error, 21% at least one insulin prescription error, and 22% at least one medication management error in their drug chart in the previous 7 days of admission. Inpatients whose drug chart had at least one medication error were twice as likely to have a hypoglycaemic episode compared to those whose drug chart had no errors. Alarmingly, 63 patients (0.4%) were reported to have developed diabetic ketoacidosis (DKA) after their admission to hospital. Higher rates of hypoglycaemia and DKA were thought to be linked to unsafe management of insulin. Most incidents of high or low blood glucose were due to failure to recognise trends in blood glucose levels and to alter the dose of insulin accordingly.Problems with insulin safety are not new, with previous findings of risks to patients associated with absent prescription, displaced documentation, use of abbreviations in prescribing, and illegible handwriting. 2 Between 2003 and 2009, the UK National Patient Safety Agency (NPSA) recorded more than 16,000 incidents involving insulin with 24% reporting harm to the patient and 18 with fatal or severe outcomes. 3 The Department of Health included maladministration of insulin in its 'never event list '. 4 There is a clear need for innovative approaches to reduce errors in the prescribing of insu...
Hyperosmolar Hyperglycaemic State (HHS) is a medical emergency associated with high mortality. It occurs less frequently than diabetic ketoacidosis (DKA), affects those with pre-existing/new type 2 diabetes mellitus and increasingly affecting children/younger adults. Mixed DKA/HHS may occur. The JBDS HHS care pathway consists of 3 themes (clinical assessment and monitoring, interventions, assessments and prevention of harm) and 5 phases of therapy (0-60 min, 1-6, 6-12, 12-24 and 24-72 h). Clinical features of HHS include marked hypovolaemia, osmolality ≥320 mOsm/kg using [(2×Na + ) + glucose+urea], marked hyperglycaemia ≥30 mmol/L, without significant ketonaemia (≤3.0 mmol/L), without significant acidosis (pH >7.3) and bicarbonate ≥15 mmol/L. Aims of the therapy are to improve clinical status/replace fluid losses by 24 h, gradual decline in osmolality (3.0-8.0 mOsm/kg/h to minimise the risk of neurological complications), blood glucose 10-15 mmol/L in the first 24 h, prevent hypoglycaemia/hypokalaemia and prevent harm (VTE, osmotic demyelination, fluid overload, foot ulceration). Underlying precipitants must be identified and treated. Interventions include: (1) intravenous (IV) 0.9% sodium chloride to restore circulating volume (fluid losses 100-220 ml/kg, caution in elderly), (2) fixed rate intravenous insulin infusion (FRIII) should be commenced once osmolality stops falling with fluid replacement unless there is ketonaemia (FRIII should be commenced at the same time as IV fluids). (3) glucose infusion (5% or 10%) should be started once glucose <14 mmol/L and (4) potassium replacement according to potassium levels. HHS resolution criteria are: osmolality <300 mOsm/kg, hypovolaemia corrected (urine output ≥0.5 ml/kg/h), cognitive status returned to pre-morbid state and blood glucose <15 mmol/L.
Aims: The aim of this study was to report on the practicality, feasibility and impact of implementing the National Institute for Health and Care Excellence (NICE) guidelines for the control of diabetes in women during labour and birth. Methods: We analysed case records of pregnant women with diabetes who delivered in the period between July 2014 and June 2015. The data were collected in relation to the availability of a plan in the notes, capillary blood glucose (CBG) monitoring, use of variable rate intravenous insulin infusion (VRIII), maintenance of CBG targets within 4-7 mmol/L, maternal hypoglycaemia during labour and neonatal hypoglycaemia. Results: Fifty-one women with diabetes delivered during this period. Only 45% of women were monitored by complete hourly CBGs until delivery. 27.4% of women had CBG ≥7 mmol/L but only 17.6% were started on VRIII. The VRIII group had a 22.2% incidence of minor maternal hypoglycaemia. Neonatal hypoglycaemia occurred in 47% of the babies. Conclusion: A CBG target of 4-7 mmol/L during labour and initiation of VRIII when levels are above this target in pregnant women with diabetes is difficult to achieve and is associated with some maternal hypoglycaemia. Repeat CBG measurements within half an hour and strict adherence to clear guidelines and protocols supported by more education and adequate staffing may improve results.Br J Diabetes 2017;17:ONLINE AHEAD OF PUBLICATION
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