Hypoglycaemia in Adults with Diabetes Clinical Guideline V5.0. March 2018

Transcription

1 March 2018 Page 1 of 11

2 Adult with Diabetes and blood glucose < 4 mmol/l Treatment as per Guideline: Nursing / Clinical Staff Patient reviewed as per guideline guidance notes: Nursing / Clinical Staff Nursing / Medical documentation completed: Nursing / Medical Staff Page 2 of 11

3 1. Aim/Purpose of this Guideline This guideline is for the management of Hypoglycaemia in Adults with Diabetes. It has been benchmarked against national guidance, to provide detailed guidance on the clinical management of hypoglycaemia in line with best practice guidelines. This guideline applies to all healthcare professionals involved in the treatment of hypoglycaemia 2. The Guidance Hypoglycaemia Hypoglycaemia (which literally means low sugar in the blood) occurs when the blood glucose falls below 4 mmol/l Symptoms of Hypoglycaemia May include one or more of the following: Sweating Hunger Pallor Headache Odd behaviour, confusion, aggression Weakness Drowsiness All episodes of hypoglycaemia i.e. glucose < 4mmol/l should be treated even if symptoms are not present Page 3 of 11

4 Initial Management of Hypoglycaemia (For patients who are enterally fed whilst nil by mouth see page 3) Is the peripheral blood glucose < 4 mmol/l Yes Peripheral blood glucose < 2.8 mmol/l a venous sample must be obtained as per policy (SoP for use of blood glucose meter ) (Do not wait for the result before treating) Hypoglycaemia management is not appropriate. BUT consider other reasons for symptoms and review soon as blood glucose may be dropping rapidly Is the patient conscious and able to swallow? 1. Inform medical staff Yes 2. Give grams of fast acting carbohydrate 15-20g eample is one of the following: mls pure fruit juice (not suitable for renal patients due to high potassium) mls Juice style (NOT milk based) supplement Drink (e.g. Fresubin Jucy Drink, Ensure Plus Juce or Fortijuce) 4-5 Glucotabs 3-4 heaped teaspoons of sugar dissolved in a non-milky drink mls of Lucozade Original or 3. If the patient is Nil By Mouth 1½ - 2 tubes of Glucose oral gel squeezed into the side of the mouth (not swallowed). Rubbing the cheek can aid absorption. 4. Repeat peripheral blood glucose in 10 minutes. N.B. only follow this process for 3 cycles (30-45 minutes) then seek medical review for Intravenous glucose / IM Glucagon treatment (see IV Glucose / IM Glucagon treatment bo) IV Glucose / IM Glucagon Treatment 1. Inform medical staff :CHECK ABCD/AVPU. If reduced CGS escalate as medical emergency. 2. Administer a total of 150 mls of 10% glucose IV (must be prescribed) over 15 mins via one of the following methods: - 50 mls of 10% glucose bolus every 5 minutes (check blood glucose between each dose) or mls of 10% glucose infusion over 15 minutes via infusion pump if available or 3. Glucagon 1mg s.c, or i.m. (must be prescribed) * Glucagon may be ineffective in episodes of hypo precipitated by the ingestion of alcohol 4. Repeat peripheral blood glucose in 10 minutes. If no improvement and CGS is reduced escalate as a medical emergency. Is the peripheral blood glucose< 4mmol/l Yes If the patient is conscious and not nil by mouth 1. Follow up with long acting carbohydrate i.e. 2 plain biscuits or 1 slice of toast or mls of milk (Double the amount if Glucagon used) Or 2. A meal with carbohydrate if the net meal is due. If the patient remains unconscious or is nil by mouth obtain medical review for detrose infusion Guidance tes Do not withhold insulin / medication. Once the hypoglycaemia has been treated as per the above guidelines, administer usual insulin / medication to prevent rebound hyperglycaemia. Intravenous Insulin Infusion is not a treatment for hypoglycaemia te that hypoglycaemia due to overdose of oral hypoglycaemics/insulin/ may be prolonged and may require prolonged detrose infusion Continue regular blood glucose monitoring for at least hours. Long term management - medical review of insulin / medication / cause of repeated episodes of hypoglycaemia. For further advice refer to Diabetes In-Patient Specialist Nurse via Maims/bleep 3825 or the Endocrine team Page 4 of 11

5 Initial Management of Hypoglycaemia Adult inpatients with Diabetes who are being ENTERALLY fed whilst nil by mouth and feeding tube in situ Is the peripheral blood glucose < 4 mmol/l Yes If the peripheral blood glucose < 2.8 mmol/l a venous sample must be obtained as per policy Clinical guideline for use of blood glucose meter (Do not wait for the result before treating) 1. Inform medical staff 2. Give grams of fast acting carbohydrate via the enteral feeding tube (by gravity use a purple syringe as per NPSA) g eample is one of the following mls Juice style (NOT milk based) Supplement Drink (Fresubin Jucy Drink, Ensure Plus Juce or Fortijuce) 3-4 heaped teaspoons of sugar dissolved in sterile water Then flush with 50mls of sterile water 3. Repeat peripheral blood glucose in 10 mins N.B. only follow this process for 3 cycles (30-45 minutes) then seek medical review for Intravenous glucose / IM Glucagon treatment (See IV Glucose / IM GlucagonTreatment Bo Opposite) Hypoglycaemia management is not appropriate. BUT consider other reasons for symptoms and review soon as blood glucose may be dropping rapidly IV Glucose / IM Glucagon Treatment 1. Inform medical staff: CHECK ABCD/AVPU. If reduced CGS escalate as medical emergency. 2. Administer a total of 150 mls of 10% glucose IV (must be prescribed) over 15 mins via one of the following methods: 50 mls of 10% glucose bolus every 5 minutes (check blood glucose between each dose) Or mls of 10% glucose infusion over 15 minutes via infusion pump if available Or 3. Glucagon 1mg s.c, or i.m. (must be prescribed) * Glucagon may be ineffective in episodes of hypo precipitated by the ingestion of alcohol Then 4. Repeat peripheral blood glucose in 10 minutes. If no improvement CGS is reduced escalate as a medical emergency. Is the peripheral blood glucose< 4mmol/l Yes 1. Follow up with long acting carbohydrate via enteral feeding tube: Restart Enteral feed or CC/BH give 100 mls of Milky Supplement drink (Fresubin Energy Drink, Ensure Plus Milk Shake Style, Fortisip) Guidance tes Do not use Oral Glucose Gel due to risk of aspiration Avoid using fizzy drinks or fruit juice as these can damage the tube Do not withhold insulin / medication. Once the hypoglycaemia has been treated as per the above guidelines, administer usual insulin / medication to prevent rebound hyperglycaemia. Continue regular blood glucose monitoring for at least hours. Long term management - medical review of insulin / medication / cause of repeated episodes of hypoglycaemia. Intravenous Insulin Infusion is not a treatment for hypoglycaemia te that prolonged hypoglycaemia may require prolonged detrose infusion For further advice refer to Diabetes In-Patient Specialist Nurse via Maims / bleep 3825 or the Endocrine team Page 5 of 11

6 3. Monitoring compliance and effectiveness Element to be monitored Lead Tool Frequency Reporting arrangements Acting on recommendations and Lead(s) Compliance Specialist Adult In-Patient Diabetes Team Patient Documentation Adult diabetes In-patients who are reviewed by the specialist diabetes team who have required management of Hypoglycaemia n compliance will be reported to the ward /area manager. Repeated non compliance will be reported via Dati Ward / Area managers will undertake subsequent recommendations and action planning for any or all deficiencies and recommendations within reasonable timeframes for their areas The Specialist Adult In-Patient Diabetes Team will undertake any trust wide recommendations and action planning for any or all deficiencies and recommendations within reasonable timeframes Change in practice and lessons to be shared Lesson learned or changes to practice will be shared with all the relevant stakeholders 4. Equality and Diversity 4.1. This document complies with the Royal Cornwall Hospitals NHS Trust service Equality and Diversity statement which can be found in the 'Equality, Diversity & Human Rights Policy' or the Equality and Diversity website Equality Impact Assessment The Initial Equality Impact Assessment Screening Form is at Appendi 2. Page 6 of 11

7 Appendi 1. Governance Information Document Title Date Issued/Approved: March 2018 Clinical Guideline For The Care Of People With Diabetes The Management Of Hypoglycaemia In Adults v5.0 Date Valid From: March 2018 Date for Review: March 2021 Directorate / Department responsible (author/owner): Amanda Veall Lead Clinical Nurse Specialist Diabetes Contact details: Brief summary of contents Treatment for hypoglycaemia in adults with diabetes Suggested Keywords: Target Audience Eecutive Director responsible for Policy: Date revised: 01/03/18 This document replaces (eact title of previous version): Approval route (names of committees)/consultation: Diabetes, hypoglycaemia, hypo RCHT CPFT KCCG Guideline For The Management Of Hypoglycaemia In Adults Endocrine Governance Committee Divisional Manager confirming approval processes Name and Post Title of additional signatories Signature of Eecutive Director giving approval Publication Location (refer to Policy on Policies Approvals and Ratification): Document Library Folder/Sub Folder Links to key eternal standards Roz Davies t Required {Original Copy Signed} Internet & Intranet Intranet Only Clinical/ Endocrine And Diabetes NSF Diabetes Standards 7 and 8 Diabetes UK 2017(on line) s-s3/ /hypoglycaemia%20new.pdf Page 7 of 11

8 JBDS 2013: (on line)the Hospital Management of Hypoglycaemia in Adults with Diabetes Mellitus (revised second addition) Adults_Revised.pdf Related Documents: Management of hyperglycaemia Training Need Identified? All User communication Update SIM team Version Control Table Date March April th August 2013 vember 2015 March 2018 Version V1.0 Initial Issue V2.0 V3.0 V4.0 V5 Summary of Changes Amendment to quantities of CHO and enterally fed patients in accordance with national guideline Review date due and amendment in line with National Guideline 2013 Review date due and amendment in line with the national guideline Review date due. Quantities of carbohydrates changed in line with national changes to sugary drinks Changes Made by (Name and Job Title) Amanda Veall Clinical Nurse Specialist Diabetes Amanda Veall Clinical Nurse Specialist Diabetes Amanda Veall Lead Clinical Nurse Specialist Diabetes Amanda Veall Lead Clinical Nurse ASpecialist Amanda Veall Diabetes Lead Clinical Nurse Specialist Diabetes All or part of this document can be released under the Freedom of Information Act 2000 This document is to be retained for 10 years from the date of epiry. This document is only valid on the day of printing Controlled Document This document has been created following the Royal Cornwall Hospitals NHS Trust Policy on Document Production. It should not be altered in any way without the epress permission of the author or their Line Manager. Page 8 of 11

9 Appendi 2.Initial Equality Impact Assessment Screening Form Clinical Guideline For The Care Of People With Diabetes The Management Of Hypoglycaemia In Adults Directorate and service area: Medicine and ED: Endocrine Name of individual completing assessment: Amanda Veall Is this a new or eisting Policy? Eisting Telephone Policy Aim* To provide detailed guidance on the clinical management of hypoglycaemia in line with best practice guidelines for all healthcare professionals working with RCH 2. Policy Objectives* To provide a consistent approach to the management of hypoglycaemia at RCH sites. To maintain patient safety and improve outcomes for patients eperiencing hypoglycaemia whilst inpatients at RCH sites 3. Policy intended Consistent management of hypoglycaemia at RCH sites. Outcomes* Prompt and safe management of hypoglycaemic episodes and follow up care. 4. *How will you measure the outcome? Audit Dati Reporting Review of nursing/ medical documentation as required 5. Who is intended to benefit from the policy? 6a Who did you consult with b). Please identify the groups who have been consulted about this procedure. What was the outcome of the consultation? All adults with diabetes who eperience hypoglycaemia in hospital at RCH sites. Workforce Patients Local groups Please record specific names of groups Diabetes Inpatient Specialist Nurses Diabetes Specialist Renal Nurse Consultant Endocrinologists Diabetes Dietician Proposed changes discussed and agreed Eternal organisations Other Page 9 of 11

10 7. The Impact Please complete the following table. If you are unsure/don t know if there is a negative impact you need to repeat the consultation step. Are there concerns that the policy could have differential impact on: Equality Strands: Yes Unsure Rationale for Assessment / Eisting Evidence Age Se (male, female, trans-gender / gender reassignment) Race / Ethnic communities /groups Disability - Learning disability, physical impairment, sensory impairment, mental health conditions and some long term health conditions. Religion / other beliefs Marriage and Civil partnership Pregnancy and maternity Seual Orientation, Biseual, Gay, heteroseual, Lesbian You will need to continue to a full Equality Impact Assessment if the following have been highlighted: You have ticked Yes in any column above and consultation or evidence of there being consultation- this ecludes any policies which have been identified as not requiring consultation. or Major this relates to service redesign or development 8. Please indicate if a full equality analysis is recommended. Yes 9. If you are not recommending a Full Impact assessment please eplain why. yes s ticked above Signature of policy developer / lead manager / director Date of completion and submission 01/03/18 Names and signatures of members carrying out the Screening Assessment Human Rights, Equality & Inclusion Lead Page 10 of 11

11 Keep one copy and send a copy to the Human Rights, Equality and Inclusion Lead c/o Royal Cornwall Hospitals NHS Trust, Human Resources Department, Knowledge Spa, Truro, Cornwall, TR1 3HD This EIA will not be uploaded to the Trust website without the signature of the Human Rights, Equality & Inclusion Lead. A summary of the results will be published on the Trust s web site. Signed Date 01/03/18 Page 11 of 11