Diabetes at the front door. A guideline for dealing with glucose related emergencies at the time of acute hospital admission from the Joint British Diabetes Society (JBDS) for Inpatient Care Group*

Abstract

People with diabetes account for nearly one-fifth of all inpatients in English and Welsh hospitals; of these, up to 90% are admitted as an emergency. Most are admitted for a reason other than diabetes with only 8% requiring admission for a diabetes-specific cause. Healthcare professionals working in emergency departments experience numerous clinical challenges, notwithstanding the need to know whether each individual with diabetes requires urgent admission. This document has been developed and written by experts in the field, and reviewed by the parent organizations of the Joint British Diabetes Societies for Inpatient Care-Diabetes UK, the Diabetes Inpatient Specialist Nurse Group and the Association of British Clinical Diabetologists. The document aims to support staff working in emergency departments and elsewhere by offering practical advice and tools for effective, appropriate and safe triage. Each section relates to the commonest diabetic specific emergencies and algorithms can be printed off to enable ease of access and use.

A Practical Guide for the Management of Steroid Induced Hyperglycaemia in the Hospital

“…HbA1c should be assessed in all people with previous DM in order to evaluate glycaemic control prior to GC initiation. In people who were not previously diagnosed with DM and who require relevant amounts of GCs (>20 mg prednisolone or equivalent) or who are at high risk to develop diabetes or SIHG (criteria see Figure 2), HbA1c should be assessed at admission [ 34 ]. This helps to distinguish whether a pre-existing unrecognized DM is present which would result in a more pronounced glycaemic excursion following GC therapy initiation.…”

Managing hyperglycaemia in inpatients

“…If the patient fulfils the diagnostic criteria for DKA (CBG >11.1 mmol/L; plasma ketones ≥3 mmol/L; pH <7.3 or bicarbonate <15 mmol/L), local DKA management protocols should be followed urgently. 5 If the patient is not in DKA, a variable rate insulin infusion (VRII) can be started to ensure rapid clearance of ketosis and reduce the risk of a hyperglycaemic emergency. Long-acting insulin should be continued even if the patient is unable to maintain oral intake.…”

“…Patients receiving nasogastric feeding who are hyperglycaemic despite metformin therapy should be considered for subcutaneous insulin therapy as nasogastric absorption of other oral hypoglycaemic agents is not reliable. 5 This should be given with the patient's usual pre-meal insulin dose if they are eating or given without the mealtime insulin dose if they are not eating but are hyperglycaemic. A minimum of 2-hourly CBG and ketone monitoring is required with a low threshold to switch to VRII if ketonaemia persists, the patient is unable to maintain adequate hydration or they are vomiting or are unwell.…”

“…If the patient is unfamiliar with DAFNE principles or unable to self-manage, give 2-6 units of NovoRapid if the CBG is >18 mmol/L (accepting that 1 unit of NovoRapid will lower CBGs by 3 mmol/L). 5,7 Repeat this after 4 hours if readings >18 mmol/L persist. If there is no improvement, then a VRII should be considered.…”

Artificial Pancreas Control Strategies Used for Type 1 Diabetes Control and Treatment: A Comprehensive Analysis

“…Sinclair et al [23] explained various recommendations in the areas of: clinical diagnosis, establishing management plans and glucose regulation, diabetes self-management education, nutritional therapy, physical activity, exercise and lifestyle modification, insulin treatments and regimens, use of technology in diabetes management, hypoglycemia, managing cardiovascular risk, management of microvascular risk, and inpatient management of T1DM and ketoacidosis. A comprehensive guideline for dealing with glucose-related emergencies in T1DM are summarized by Dhatariya et al [24].…”