TRUST CORE CLINICAL POLICY THE MANAGEMENT OF HYPOGLYCAEMIA IN ADULTS. Clinical Policies Group

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1 TRUST CORE CLINICAL POLICY THE MANAGEMENT OF HYPOGLYCAEMIA IN ADULTS APPROVAL Clinical Policies Group Date approved: 11 November 2013 EFFECTIVE FROM November 2013 DISTRIBUTION All clinical staff at Barts Health NHS Trust OWNER Chief Nurse Consultant Physician & Diabetologists Reader in Medicine and Honorary Consultant AUTHOR/FURTHER INFORMATION Physician Nurse Consultant Medicines Optimisation Pharmacist Joint British Diabetes Societies Inpatient Care EXTERNAL REFERENCES Group (2010) The management of hypoglycaemia in Adults with Diabetes Mellitus. Barts and The London guideline on Hypoglycaemia SUPERSEDED DOCUMENTS Newham University Hospital Hypoglycaemia Guideline Whipps Cross University Hospital Hypoglycaemia Guideline REVIEW DUE November 2016 KEYWORDS Diabetes, GTT INTRANET LOCATION(S) Guidelines/Trust-wide-policies.aspx CONSULTA TION Barts Health External Partners Diabetes Consultants Diabetes Nurse Specialists Emergency Department leads Acute Medicine Leads Diabetes and Renal General Manager CHL SCOPE OF APPLICATION and EXEMPTIONS All Trust clinical staff, working in whatever capacity Staff employed or contracted within Trust Premises by Partner Organisations For the groups listed, failure to comply with the policy may result in investigation and management action which may include formal action in line with the Trust's disciplinary or capability procedures for Trust employees, and other action in relation to organisations contracted to the Trust, which may result in the termination of a contract, assignment, placement, secondment or honorary arrangement. Page 1 of 11

2 TABLE OF CONTENTS ALGORITHM 1 FOR PATIENTS WHO ARE ABLE TO SWALLOW SAFELY... 3 ALGORITHM 2 PATIENTS WHO ARE NIL BY MOUTH OR WHO ARE NOT ABLE TO SWALLOW SAFELY INTRODUCTION BACKGROUND DEFINITION CLINICAL ASSESSMENT MANAGEMENT SPECIAL CIRCUMSTANCES... 7 ADULTS REQUIRING ENTERAL FEEDING... 7 ADULTS ON AN INTRAVENOUS INSULIN/GLUCOSE INFUSION... 7 USE OF GLUCOGEL CONTENTS OF HYPO BOX (ALL WARDS AND CERTAIN OUTPATIENT AREAS SUCH AS DIABETES CENTRES) REFERENCES MONITORING AND AUDIT... 9 PROCESSES... 9 OUTCOME MEASURES... 9 APPENDIX 1: CHANGE LOG APPENDIX 2: IMPACT ASSESSMENTS APPENDIX 3: WARD SIGNAGE Page 2 of 11

3 Algorithm 1 for patients who are able to swallow safely Capillary blood glucose level less than 4.0 mmol/l Give one of the following: ml Lucozade ml fruit juice teaspoons of sugar dissolved in a glass of water Glucogel may be used see Special circumstances (in full guideline) Recheck capillary blood glucose in minutes Repeat cycle. If capillary blood glucose not greater than 4.0 mmol/l after 2 cycles, then call doctor or site nurse practitioner Is capillary blood glucose greater than 4.0mmol/l? Yes No Give long acting carbohydrate: - 2 biscuits - half a sandwich - 1 piece of fruit ml milk OR next meal if due Do NOT omit next insulin dose but ask medical staff to review doses, particularly for night time insulin. Page 3 of 11

4 Algorithm 2 patients who are nil by mouth or who are not able to swallow safely Capillary blood glucose level less than 4.0 mmol/l Initiate treatment and call for emergency medical review Give either: - 75ml of 20% glucose IV over 5 minutes - OR 150ml 10% glucose IV over 5 minutes If IV access not available consider 1mg Glucagon IM. Repeat cycle. If capillary blood glucose not greater than 4.0 mmol/l after 2 cycles, then ask for senior medical review Recheck capillary blood glucose in minutes. Is capillary blood glucose greater than 4.0 mmol/l? Yes No If now able to swallow safely, give long acting carbohydrate as in Algorithm 1. If nil by mouth then consider 10% glucose at 100ml/hr and ask for medical review. Do NOT omit next insulin dose but ask medical staff to review doses, particularly for night time insulin. Page 4 of 11

5 THE MANAGEMENT OF HYPOGLYCAEMIA IN ADULTS 1 INTRODUCTION 1.1 This guideline is designed to be nurse-led initially (registered nurses Band 5 and above), but medical review at some stage will be needed in all circumstances. These guidelines are based on the national Joint British Diabetes Society (JBDS) The Hospital Management of Hypoglycaemia in Adults with Diabetes Mellitus (March 2010). 2 BACKGROUND 2.1 Hypoglycaemia is the most common side effect of insulin and sulphonylurea treatment, and poses a significant barrier to achieving appropriate glycaemic control. Metformin, thiazolidinediones, DPP-4 inhibitors and GLP-1 analogues are unlikely to cause significant hypoglycaemia without concurrent use of insulin or sulphonylureas. 3 DEFINITION 3.1 For the purposes of adult inpatients with diabetes in the general ward setting, hypoglycaemia is defined as capillary/ venous blood glucose less than 4.0 mmol/l. This is not applicable to antenatal patients, (please refer to Diabetes Antenatal trust guidelines on the intranet), paediatric patients or patients in the community. 4 CLINICAL ASSESSMENT 4.1 The symptoms of hypoglycaemia vary between individuals, but the common symptoms are summarised below (Deary et al. 1993). Table 1: The Edinburgh Hypoglycaemia Scale AUTONOMIC NEUROGLYCOPAENIC GENERAL MALAISE Sweating Confusion Headache Palpitations Drowsiness Nausea Shaking Odd behaviour Hunger Speech difficulty Incoordination 4.2 There are several risk factors for hypoglycaemia and are summarised in table 2. 5 MANAGEMENT 5.1 Patients experiencing hypoglycaemia require quick acting carbohydrate to return their blood glucose values to the normal range. This should then be followed up by a long acting carbohydrate as a snack or part of the next planned meal. Page 5 of 11

6 5.2 Hypoglycaemia should be confirmed with capillary blood glucose monitoring if possible, but if measurement is difficult (ie during a seizure) then treatment should not be delayed. After treatment of acute hypoglycaemia, consideration should be given about the cause of hypoglycaemia ie long acting insulin therapy or sulphonylurea treatment, as prolonged intravenous dextrose infusion may be required for some hours afterwards. Table 2: Risk factors for hypoglycaemia Medical issues Lifestyle issues Reduced CHO intake Tight glycaemic control Exercise Malabsorption Previous severe hypoglycaemia Long duration of diabetes Injection technique/lipohypertrophy Impaired hypoglycaemia awareness Preceding hypoglycaemia Hepatic dysfunction Renal impairment/ dialysis Inadequately treated previous hypoglycaemia Terminal illness Hypopituitarism, hypothyroidism, growth hormone deficiency, Addison s disease Increasing age Alcohol Early pregnancy Breast feeding Inadequate blood glucose monitoring Coeliac disease Concurrent drug therapy Warfarin, salicylates, fibrates Sulphonamides Quinine Monoamine oxidase inhibitors, serotonin reuptake inhibitors NSAIDs, probenacid Somatostatin analogues Tyrosine kinase inhibitors 5.3 The patient should be assessed as to whether they can swallow safely or are nil by mouth (NBM). Following this assessment, algorithm 1 or 2 should be followed as below. 5.4 After hypoglycaemia has occurred, medical staff or the diabetes specialist team should be informed. The cause of the hypoglycaemia should be established and documented, paying particular attention to the risk factors in Table 2. Treatment given for hypoglycaemia should be documented carefully in the nursing notes. Prescribed insulin or sulphonylurea doses should be reviewed. Medication should NOT be omitted, but it may be appropriate to reduce insulin doses by 10% or half/ stop sulphonylurea therapy. Usually this can be dealt with during working hours, but if the patient is due insulin with an evening meal or a night time insulin, the on call medical team should be asked to review the insulin/ sulphonylurea dosage. Page 6 of 11

7 6 SPECIAL CIRCUMSTANCES Adults requiring enteral feeding 6.1 For patients are requiring naso-gastric/jejunal or PEG feeding: 6.2 If capillary blood glucose (CBG) is <4.0 mmol/l, then give one of the following quick acting carbohydrates: 25ml original undiluted Ribena 3-4 heaped teaspoons of sugar dissolved in water 6.3 Repeat CBG after minutes, and if blood glucose <4.0 mmol/l then repeat the steps above up to 2 times. If blood glucose remains less than 4.0 mmol/l after 2 cycles then consider IV 10% glucose infusion at 100ml/hr. 6.4 If capillary blood glucose >4.0 mmol/hr then give long acting carbohydrate. Consider: restarting enteral feed or if bolus feeding then give additional bolus feed of 20g CHO OR IV 10% dextrose at 100ml/hr 6.5 Do not omit next insulin dose but medical staff will need to review doses. Document hypoglycaemia in patient s notes and any actions taken. 6.6 If a blocked or displaced nasogastric tube is suspected as the cause, then Algorithm 2 should be followed. Adults on an intravenous insulin/glucose infusion 6.7 If capillary blood glucose (CBG) mmol/l and asymptomatic, then stop insulin for 20 minutes and recheck glucose after 20 minutes. If CBG is >4.0 mmol/l, restart sliding scale but this will need to be adjusted. For the Barts & the London Diabetes chart, step down to the next sliding scale if possible. If CBG is still mmol/l after 20 minutes then follow the symptomatic pathway as below. 6.8 If symptomatic or capillary blood glucose <3.5 mmol/l then treat as per nil by mouth pathway ie increase 10% dextrose rate to deliver ml over 5 minutes, or if receiving 5% dextrose, disconnect IV 5% dextrose and give 20% dextrose as per protocol. Once capillary blood glucose >4.0 mmol/l then restart sliding scale. 6.9 Step down to the next IV sliding scale regimen (Barts and the London diabetes prescription chart only) or at Whipps Cross and Newham legacy sites, adjust the existing insulin infusion regime on pre-printed insulin sliding scale prescription. All three sites will be using a Barts Health Diabetes Drug Chart at some stage in the future If hypoglycaemia lasts for more than 20 minutes, please seek medical advice. Use of Glucogel 6.11 Glucogel (or other approved glucose gel) is generally not needed for the management of hypoglycaemia, and may be uncomfortable or difficult to administer but is appropriate in some circumstances. If the patient is confused but able to swallow, is not cooperating with oral treatment and IV access is not Page 7 of 11

8 readily available, then the use of Glucogel may be considered. It should be squeezed into the mouth between the teeth and gums ideally massaged into the gums. Each tube is 10g CHO, so tubes should be used. 7 CONTENTS OF HYPO BOX (ALL WARDS AND CERTAIN OUTPATIENT AREAS SUCH AS DIABETES CENTRES) Laminated copies of Algorithms 1 and 2 1 bottle Lucozade Energy Original and/or carton of fruit juice (500ml) 3 x vials (1 box) of Glucogel 20% Glucose solution 100ml (0.2g/ml) or 500ml for IV infusion (0.2g/ml) 10% Glucose solution 500ml for IV infusion (0.1g/ml) Glucagon 1mg for IM use [GlucaGen Hypokit should ideally be in the fridge but can be kept at no more than 25 C for 18 months. Laminated copy of For Hypoglycaemic Emergencies Only) (Appendix 3) 7.1 The contents should be kept in a phlebotomy tray or ideally in a prepared HypoBox, and should be clearly labelled for Hypoglycaemic Emergencies Only (please use Appendix 3). The tray should be kept in a clearly visible and predesignated area in the treatment room. All clinical staff should know the location of the hypo box. The hypo box items should be checked for expiry dates and that all contents are present at the start of every nursing shift, immediately after checking the Resuscitation trolley. The nurse in charge of the shift is responsible for ensuring that this is done. All the items can be ordered from Pharmacy, except Lucozade which should be ordered from the kitchens. 8 REFERENCES 8.1 Joint British Diabetes Societies Inpatient Care Group (2010). The managementof hypoglycaemia in Adults with Diabetes Mellitus. 8.2 Dreary IJ, Hepburn DA, Macleod KM, Frier BM (1993). Partitioning the symptoms of hypoglycaemia using multi-confirmatory factor analysis, Diabetologia 36: Page 8 of 11