Hyperglycaemia: Management of Preterm Infants in Neonatal Intensive Care

Transcription

1 1. Purpse Hyperglycaemia in preterm infants is likely due t a number f factrs (impaired insulin secretin, insulin resistance and immaturity f glucse hmestasis regulatin) 1,2. Hyperglycaemia has been assciated with increased mrtality and mrbidity in preterm infants (including IVH, NEC, infectin and retinpathy f prematurity) 3-5. Studies in adults suggest that using insulin t cntrl hyperglycaemia in critically ill patients is assciated with increased survival and decreased rates f sepsis 6. Hwever, it is nt yet clear whether insulin use imprves significant utcme in preterm infants. Evidence supprting varius management strategies is als pr. Despite this, the use f insulin t manage hyperglycaemia in preterm infants has becme rutine practice in ANZNN units 7. Given the lack f evidence t guide effective use, this guideline aims t highlight issues t cnsider when hyperglycaemia ccurs in preterm nenates and t prmte cnsistency f apprach in management. 2. Definitins Hyperglycaemia: True Bld Glucse (TBG) >10-12mml/L There is cntinued uncertainty as t what cnstitutes a level f hyperglycaemia that is likely t result in an adverse utcme and thus justifies specific interventin 7. It is unusual t see TBG levels abve 7mml/L in healthy term infants, thus many authrs have defined levels abve 8mml/L as hyperglycaemia 3,8, with interventin suggested at varius threshlds, ften arund 10-12mml/L. 3. Respnsibilities Staff caring fr preterm infants with hyperglycaemia shuld fllw this guideline. 4. Guideline 4.1 Indicatin fr initiating interventin: TBG >12mml/L fr mre than 6-12 hurs. This is an arbitrary definitin f significant hyperglycaemia as TBGs in preterm infants can vary significantly ver time, particularly in the first week f life 9. It may be reasnable t cntinue current management ver a lnger perid than 12 hurs if TBG <15mml/L and the infant is therwise stable (discuss with cnsultant). 4.2 Management Management ptins include the fllwing: Reduce glucse intake If infused glucse levels are high (>8-10mg/kg/min), reductin f glucse intake alne may be sufficient t decrease TBG t an acceptable level. The prcess includes the fllwing: change infusin slutins cntaining 10% glucse t nrmal r half nrmal saline (if cmpatible) befre decreasing ttal fluid intake r stpping parental nutritin d nt reduce glucse intake belw 5-6mml/kg/min (80ml/kg/day f 10% glucse r PN = 5.6mg/kg/min) as this is the minimum required t maintain adequate calric intake d nt reduce ttal fluid intake belw that required t maintain hydratin dcument glucse infusin rate n daily fluid chart fr all infants with hyperglycaemia cunt insulin infusin in daily ttal fluid intake. Uncntrlled dcument when printed Publicatin date (16/05/2017) Page 1 f 5

2 Glucse infusin rate (mg/kg/min) = %glucse X ml/kg/day 144 = %glucse X ml/h 6 X bdy wgt (kg) Breast milk/standard frmula is apprx 7% carbhydrate, LBW frmula apprx 8%, FEBM 10%. Resurce: nline calculatr (access via the fllwing website): Glycsuria alne shuld nt initiate reductin f glucse intake in the absence f significant hyperglycaemia as smtic diuresis and subsequent dehydratin is unlikely if TBG<12mml/L 10. Insulin Infusin Aim t nrmalise bld glucse levels (TBG t 4-10mml/L) whilst aviding hypglycaemia by cnsidering the fllwing: insulin infusin - starting dse: 0.05 units/kg/hur mid range dse adjust insulin rate gently (i.e. steps f units/kg/hur) with sufficient time between adjustments t mnitr effects (apprx 4 hurs) If feeds are stpped, r fluids changed, re-calculate glucse intake. Small adjustments f infusin and mre frequent TBG mnitring may be required If TBG drps sharply r HYPOglycaemia (TBG <2.6mml/L) ccurs, decrease insulin rate (e.g. halve it), rather than stpping cmpletely. Repeat TBG at mre frequent intervals until stable (e.g. hurly) If severe HYPOglycaemia (TBG <1.5mml/L), stp insulin infusin, give blus f 2ml/Kg f 10% glucse. Rarely glucagn may be cnsidered if there is n respnse (discuss with cnsultant). Maintenance infusin rate is likely t be less than that required t decrease TBG level. Sme infants are very sensitive t rapid changes in infusin rates with unpredictable respnses, thus care is needed when increasing infusin rates. 4.3 Mnitring Timing f TBGs: use the NISC Bld Gas Analyser t measure TBG test ne hur after starting infusin (nte: sme infants are sensitive t insulin and their TBGs drp quickly with the intrductin f insulin) nce stabilised, TBG can be tested 4-6 hrly check bld sugar levels mre frequently if: rate f administratin f infused insulin and/r maintenance glucse / feed is changed medicatin mixed with glucse and/r an insulin infusin is disrupted new infusin mix is cmmenced. Use f bld glucse mnitr and reagent strips t minimise test bld vlume is acceptable fr infants with hyperglycaemia wh are having frequent samples taken if TBGs are stable abve 4mml/L. All reagent strip levels <4mml/L shuld be cnfirmed with TBG. 4.4 Other infrmatin Variability f insulin infusate The insulin cncentratin in the infusin as it enters the infant may increase ver time as binding sites becme saturated because insulin binds t plastic syringes and lines 11,12. The methd f flushing and sitting lines is designed t prmte saturatin f binding sites and thus imprve stability f the slutin. Regular TBG mnitring als assists in preventing hypglycaemia, which is ptentially mre likely tward the end f a 24 hur perid as saturatin ccurs and infusate cncentratin increases. Uncntrlled dcument when printed Publicatin date (16/05/2017) Page 2 f 5

3 Fr mre infrmatin regarding insulin infusin, refer t IV medicatin manual: Insulin prtcl. Sepsis Sepsis is cmmnly assciated with hyperglycaemia, therefre when hyperglycaemia ccurs, infectin shuld be actively sught and treated as indicated. Persistent Hyperglycaemia Hyperglycaemia in preterm infants tends t be a transitry phenmenn and insulin treatment can be stpped after a few days. If hyperglycaemia persists mre than 2 weeks, cnsider alternative diagnses such as nenatal diabetes (1:400,000); investigatins include serum insulin, C-peptide and ketnes and urine ketnes8. Cnsult an Endcrinlgist after discussin with nenatal cnsultant. 5. Evaluatin, mnitring and reprting f cmpliance t this guideline Cmpliance t this guideline will be mnitred via clinical incident reprted thrugh Victrian Health Incident Management System (VHIMS). 6. References Online calculatr (access via the fllwing website): Evidence table: 7. Legislatin/Regulatins related t this guideline Nt applicable. 8. Appendices Appendix 1: Evidence Table:. PGP Disclaimer Statement The Ryal Wmen's Hspital Clinical Guidelines present statements f 'Best Practice' based n thrugh evaluatin f evidence and are intended fr health prfessinals nly. Fr practitiners utside the Wmen s this material is made available in gd faith as a resurce fr use by health prfessinals t draw n in develping their wn prtcls, guided by published medical evidence. In ding s, practitiners shuld themselves be familiar with the literature and make their wn interpretatins f it. Whilst appreciable care has been taken in the preparatin f clinical guidelines which appear n this web page, the Ryal Wmen's Hspital prvides these as a service nly and des nt warrant the accuracy f these guidelines. Any representatin implied r expressed cncerning the efficacy, apprpriateness r suitability f any treatment r prduct is expressly negated In view f the pssibility f human errr and / r advances in medical knwledge, the Ryal Wmen's Hspital cannt and des nt warrant that the infrmatin cntained in the guidelines is in every respect accurate r cmplete. Accrdingly, the Ryal Wmen's Hspital will nt be held respnsible r liable fr any errrs r missins that may be fund in any f the infrmatin at this site. Yu are encuraged t cnsult ther surces in rder t cnfirm the infrmatin cntained in any f the guidelines and, in the event that medical treatment is required, t take prfessinal, expert advice frm a legally qualified and apprpriately experienced medical practitiner. NOTE: Care shuld be taken when printing any clinical guideline frm this site. Updates t these guidelines will take place as necessary. It is therefre advised that regular visits t this site will be needed t access the mst current versin f these guidelines. Uncntrlled dcument when printed Publicatin date (16/05/2017) Page 3 f 5

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5 Appendix 1 Evidence Table in Nenatal Intensive Care Authr/s Title Surce 1. Mericq V. Prematurity and insulin sensitivity. Hrmne Research 2006;65 Suppl 3: Mitanchez-Mkhtari D, Lahlu N, Bth relative insulin resistance and defective Kieffer F, Magny JF, Rger M, Vyer islet beta-cell prcessing f prinsulin are M. respnsible fr transient hyperglycemia in extremely preterm infants. 3. Hall NJ, Peters M, Eatn S, Pierr A. Hyperglycemia is assciated with increased mrbidity and mrtality rates in nenates with necrtizing enterclitis. 4. Hays SP, Smith EOB, Sunehag AL. Hyperglycemia Is a Risk Factr fr Early Death and Mrbidity in Extremely Lw Birth- Weight Infants. 5. Manzni P, Castagnla E, Mstert M, Sala U, Gallett P, Gmirat G. 6. Van den Berghe G, Wuters PJ, Builln R, et al. Hyperglycaemia as a pssible marker f invasive fungal infectin in preterm nenates. Outcme benefit f intensive insulin therapy in the critically ill: Insulin dse versus glycemic cntrl. Survey f the management f nenatal hyperglycaemia in Australasia. Level f Evidence (1-1V) III-3 Cmments review Pediatrics 2004;113: Prspective cmparative Jurnal f Pediatric Surgery 2004;39: ; chrt Pediatrics 2006;118: chrt Acta Paediatrica 2006;95: Alsweiler JM, Kuschel CA, Blmfield FH. Jurnal f Paediatrics and Child Health 2007;43: Ogilvy-Stuart AL, Midgley P. Practical Nenatal Endcrinlgy Cambridge University Press; Hey E. Hyperglycaemia and the very preterm baby Seminars in Fetal and Nenatal Medicine 2005;10: Culthard MG, Hey EN Renal prcessing f glucse in well and sick Archives f Disease in Childhd nenates. Fetal & Nenatal Editin 11. Hewsn M, Nawadra V, Oliver J, Odgers C, Plummer J, Simmer K. 12. Fulria M, Friedberg MA, DuRant RH, Aschner JL. Insulin infusins in the nenatal unit: delivery variatin due t adsrptin. Effect f Flw Rate and Insulin Priming n the Recvery f Insulin Frm Micrbre Infusin Tubing. Case cntrl Crit Care Med 2003;31: II Prspective randmised 1999;81:F92-8. Jurnal f Paediatrics & Child Health 2000;36: Pediatrics 1998;102: survey text chrt chrt In-vitr In-vitr Uncntrlled dcument when printed Updated/Frmatted: (05/05/2016) Apprved by Clinical Directr Nenates 05/05/2016 Page 5 f 5