Guideline for the Management of Diabetes in Pregnancy

Guideline for the Management of Diabetes in Pregnancy INITIATED BY: Directorate of Obstetrics, Gynaecology & Sexual Health APPROVED BY: Integrated Business, Obstetrics, Gynaecology, Sexual Health & Patient Quality and Safety Group DATE APPROVED: 28/07/2016 VERSION: Three OPERATIONAL DATE: 01/08/2016 DATE FOR REVIEW: DISTRIBUTION: 3 years from date of approval or if any legislative or operational changes require Medical & Midwifery Staff of Cwm Taf University Health Board FREEDOM OF INFORMATION STATUS: Open

Guidelines Definition Clinical guidelines are systemically developed statements that assist clinicians and patients in making decisions about appropriate treatments for specific conditions. They allow deviation from a prescribed pathway according to the individual circumstances and where reasons can be clearly demonstrated and documented. Minor Amendments If a minor change is required to the document, which does not require a full review please identify the change below and update the version number. Type of change GTT Parameters Target BM Ranges All fluids in 500ml volumes Why change made Reflect NICE Reflect NICE To reduce errors Page number Date of change 2,9,12 01/08/16 6,8,9,15 01/08/16 5,13,15,16,18 01/08/2016 Version 1 to 1.1 Name of responsible person Related Guidelines Antenatal Corticosteroids Antenatal Care Induction of Labour Caesarean Section i

Contents Definition..1 Rationale..1 Glucose Tolerance Testing...2 Antenatal Care...3 Pre Existing Insulin Dependent Diabetes - Pre conception planning 4 - Antenatal Care..4 - Labour and Birth..5 - Elective Caesarean Section. 6 - Postnatal Management..7 Pre existing Non Insulin Dependent Diabetes - Antenatal Care 8 - Labour and Birth..8 - Elective Caesarean Section...8 Gestational Diabetes - Diagnosis and Antenatal Care..8 - Labour..8 - Following Birth...9 References..11 Appendices Oral Glucose Tolerance Testing. 12 Dextrose and Insulin Infusion Regime 13-14 Generic VRIII to be used for labour. 15 Dexamethasone Administration. 16 Trust Guideline for the Treatment of Hypoglycaemia.17 Flow Chart Showing the Use of VRIII in Pregnancy.18 ii

Definition Diabetes is a disorder of carbohydrate metabolism characterised by abnormally raised blood glucose. It is caused by a failure of the physiological systems that control glucose levels. These guidelines provide basic information on the management of pregnant women with diabetes. They will fall into 3 categories; - Pre existing insulin dependent diabetes which is present before conception and can worsen during pregnancy (usually Type one) - Pre existing non-insulin dependent diabetes (usually type 2) - Gestational diabetes, which is diagnosed for the first time during pregnancy (may or may not require insulin) The management of each of these will vary. This table should help explain the difference between Type One and Type Two Diabetes. Type 1 Diabetes Often diagnosed in childhood Not associated with excess body weight Often associated with higher than normal ketone levels at diagnosis Treated with insulin injections or insulin pump Cannot be controlled without taking insulin Type 2 Diabetes Usually diagnosed in over 30 year olds Often associated with excess body weight Often associated with high blood pressure and/or cholesterol levels at diagnosis Is usually treated initially without medication or with tablets Sometimes possible to come off diabetes medication Rationale Women with diabetes are at increased risk of complications during pregnancy, labour and birth, including; -Miscarriage -Hypertension in pregnancy -Fetal Macrosomia -Premature Birth - Stillbirth -Shoulder dystocia -Instrumental birth -Caesarean Section Women with pre-existing diabetes are at especially high risk of problems. Management during pregnancy, labour and birth will depend upon individual factors, but all women with diabetes should be considered to be high-risk patients. 1

Glucose Tolerance Testing Certain women are at a greater risk of developing gestational diabetes and should be offered a glucose tolerance test (GTT) at 28 weeks gestation (earlier if clinically indicated). The criteria is as follows; Glycosuria 1.1 mmol/ l (1+) or more on 2 subsequent antenatal visits or glycosuria 2.8 mmol/ l (++) in a fasting urine sample. Previous large baby > 4.5kg or > 90 th centile for gestational age. Mother, father or siblings with Type 1 or Type 2 diabetes. BMI 30 or more at booking Previous unexplained perinatal death Maternal polycystic ovary disease Polyhydramnios Large baby, confirmed by scan i.e. fetal abdominal circumference above the 90 th centile Women of Afro-Caribbean, African, Asian, Middle Eastern origins Previous gestational diabetes: NB refer to the Diabetic Specialist Nurse and either perform a GTT at booking and repeat the GTT at 28 weeks gestation if the result is normal or commence blood glucose monitoring at the diagnosis of pregnancy Please see Appendix A for Glucose Tolerance Testing Procedure. All women selected for a GTT should be booked to attend the Antenatal Clinic at 9am following an overnight fast of 10-16 hours during which only water is allowed. Give a patient information leaflet obtained via SharePoint/intranet (Pathology link ward Protocols and Patient Information). A diagnosis of Gestational Diabetes is made if:- o Preload blood glucose is above 5.6 mmol/l o The 2 hour blood glucose is above 7.8mmol/l. If a GTT shows Gestational Diabetes Mellitus the woman must be contacted by the Antenatal Clinic to inform her of her results. The midwife / obstetrician must contact the Diabetes Specialist Nurse on ext 3201/6333 at RGH or the Diabetes Centre at PCH (8490 / 8575 / 8511) with any diagnosis of Gestational Diabetes. They aim to see women within 24 hours of referral. A referral to the Diabetes Clinic must be completed by the midwife / Obstetrician and sent to the Consultant Endocrinologist; Dr Lane (RGH) or Dr Okosieme / Dr Baglioni (PCH) 2

Antenatal Care ALL women with diabetes will be managed in the joint diabetes clinic. RGH: Mr Pembridge (Obstetrician) Dr Lane (endocrinologist) PCH: Mrs Marx/ Mrs Bayliss (Obstetrician), Dr Okosieme and Dr Baglioni. Women with diabetes at booking should be offered 75mg aspirin from 12 weeks gestation until the birth of the baby to reduce the risk of hypertension in pregnancy. Women with diabetes are at increased risk of a variety of antenatal problems, therefore their management is more intensive than women without diabetes. The aim is careful management of their diabetes with an emphasis on very close control of their blood glucose levels. Advise all pregnant women with any form of diabetes to maintain their capillary plasma glucose below the following target levels, if these are achievable without causing problematic hypoglycaemia: Pre meal < 5.3 mmol/l 1 hour Post meal < 7.8 mmol/l Test urgently for ketonaemia if pregnant women with any form of diabetes presents with hyperglycaemia or is unwell, to exclude diabetic ketoacidosis. Obstetric supervision is also significantly increased. The aim of this dual approach is to reduce the risk associated with diabetes in pregnancy as far as is achievable. Women are also offered full access to midwifery care, dietician and the diabetes specialist nurse. This should maximise co-ordination between professionals and prevent women having to make multiple visits to see numerous professionals involved in their care. All women who choose to breastfeed their babies must be referred to the Infant Feeding Advisor during the antenatal period. Please also see Cwm Taf University Health Board Antenatal Care Guideline. 3

Pre- Existing Insulin Dependent Diabetes Guidance Preconception Planning All these women should have the opportunity for prenatal counselling in the Diabetes ANC. This is dependent upon them presenting to clinic or being referred by their General Practitioner (GP). It is desirable that diabetes control should be as good as possible prior to conception. This will be overseen by the diabetes team. All women will be offered the opportunity to discuss the effects of diabetes on pregnancy and their likely pattern of care with the obstetric team. Advise women with diabetes who are planning to become pregnant to aim for the same capillary plasma glucose target ranges as recommended for all people with type 1 diabetes [NICE 2015] Women with pre-existing diabetes should be informed to take folic acid at a dose of 5mg daily preconceptually up until 12 weeks gestation. Antenatal Care Following conception women will be seen early in pregnancy. Their diabetic control will be closely monitored by Dr Lane/ Dr Baglioni / Dr Okosieme. Appointments will be given as necessary. These women will be seen at least every 2-3 weeks even if their control seems to be satisfactory. These women should be considered high risk and be booked under consultant led care. They will not need to be seen by an obstetrician at each visit unless there are obstetric problems. All women who attend the clinic will normally be seen by the clinic midwife. Women will have a dating scan before 11 completed weeks of gestation. They will then see the obstetric consultant to discuss management of the pregnancy. All women will have the following ultrasound scans as a minimum; The first trimester Fetal anomaly survey at 20 weeks. [NICE 2015] Serial scan at 4 weekly intervals from 28 weeks. Scans 2 weekly from 36 weeks. If there are any reasons for concern scans for growth/liquor volume/doppler studies will be carried out more frequently. After each scan there will be a review by the consultant obstetrician or senior registrar. 4

If a woman with insulin dependent diabetes needs to be admitted for sliding scale insulin in the first trimester of pregnancy please use the Variable Rate Intravenous Insulin Infusion (VRIII) sliding scale. For IV fluids, use prescription advice on the chart to guide administration. NB. This is different to treatment later in pregnancy If antenatal corticosteroids are required, the woman should be admitted to the antenatal ward for VRIII and managed as per Appendix D if no specific plan is in place. At around 35 weeks gestation, a VRIII and birth plan to cover diabetic concerns will be formulated. It will be placed in both the patient notes and the hospital held notes. Birth plans and mode of birth will be decided individually for each woman. Advise pregnant women with pre-existing diabetes and no other complications to have an elective birth by induction of labour, or by elective caesarean section if indicated, between 37+0 weeks and 38+6 weeks of pregnancy [NICE 2015]. Regular tests for fetal wellbeing including doppler studies and CTG should be commenced for those awaiting spontaneous labour after this time (NICE 2008). NB. Diabetes is not in itself a contraindication for VBAC. If fetal macrosomia is diagnosed by scan the risk and benefits of various modes of vaginal birth, IOL and CS should be discussed. Labour and Birth Consult the notes for details of any antenatal problems, fetal macrosomia etc and also for any plan of management for the labour. Site Intravenous cannula Commence Cardiotocograph (CTG) monitoring. If the woman has attended the Diabetes Antenatal Clinic, a specific diabetes delivery management plan may have been completed around 35 weeks by Dr Lane / Dr Okosieme / Dr Baglioni, and should be in the Obstetric notes. If there are no specific instructions, use the generic birth plan Appendix B and C. The preferred fluid is usually 500ml of 10% Dextrose with 10 mmols KCl infused over 8 hours. If the BM is >10 then Dextrose should be substituted with Normal Saline. 5

If there is no birth plan in the notes, contact the diabetes team (or if unavailable, the on-call medical registrar) to review. In the absence of any medical input, the VRIII on the Adult Insulin Prescription chart should be used until a review can be arranged. The VRIII should be started immediately if the woman is in established labour. The capillary blood glucose should be maintained between 4 7 mmol/ l during labour and birth. If on VRIII and BM s > 10 on 2 consecutive readings despite giving appropriate insulin doses, the insulin dose scale will need to be adjusted SEEK GUIDANCE FROM DIABETES TEAM Contact the diabetic team or medical team if there is any sign of persistent hypoglycaemia. Do not start an oxytocin infusion without a senior obstetric review. In case of problems during labour, there should be early discussions with a senior obstetrician. At birth it is important to remember the greatly increased risk of shoulder dystocia and to act early if any problems are suspected (see also Shoulder Dystocia guideline). Elective Caesarean Section Pre Clerking Arrangements should be made to attend for Pre Clerking in the Day Assessment Unit. This appointment should include; Admission and clerking Bloods for Full Blood Count and Group + Save; Routine anaesthetic review Antacid prophylaxis arranged There should be a specific plan in the notes detailing the diabetes management and the insulin required for the woman. This plan will cover any changes to the usual dosage of insulin to be given the night before the operation (normally the same as their usual dose). If there is no such plan found in the notes, use the generic plan this is the variable rate IV insulin Infusion (VRIII) on the Adult Insulin Prescription chart. 6

The Day of the Operation Insulin Dependant Diabetic women should be prioritised for caesarean section and be first into theatre wherever possible. Omit the morning dose of insulin. 0700: Check blood glucose and site IV cannula; then commence VRIII as detailed in the notes. If there is no sliding scale specific to the woman use the VRIII sliding scale on the Adult Insulin Prescription chart (generic plan Appendix C) until review by the diabetes team. 0730: Routine antacid prophylaxis. 0800: Blood glucose check; prepare woman for theatre. 0900: Blood glucose check. Transfer to theatre as soon as theatre ready and staff available Postnatal Management for All Modes of Birth Following delivery of the placenta, insulin requirements will fall rapidly. Consult the patient specific VRIII for any post-delivery instructions. If there are none, initially, halve the rate of infusion. When the woman is ready to eat, start a normal diet and give the prepregnancy insulin dose. Perform 4 hourly capillary glucose monitoring. Aim for BMs of 5-9mmol/L. If a woman is breastfeeding, insulin requirements may be reduced by around 10-25%. The pre-pregnancy dose of insulin should therefore be reduced by 10% in the first instance. Tight control may be difficult to achieve and is not absolutely vital in the immediate postnatal period. Capillary glucose should be measured 4 hourly and levels should be 5-9 mmol/l. Most patients will be able to adjust their own dosage. Post Surgery The usual post-operative care should be given including thromboprophylaxis. From the next morning (Day 1 post caesarean section), if the woman can eat normally, subcutaneous insulin should be recommenced at the pre-pregnancy level (not pre-birth levels). All women should be referred to and reviewed by the Diabetes Nursing Team (3201 or 6333) or Diabetes Centre (8490/8575/8511). 7

Pre Existing Non Insulin Dependent Diabetes Antenatal Care Women with pre existing non-insulin dependent diabetes will be offered prenatal counselling. It is expected that most of these women will need insulin control of their diabetes at some time during the pregnancy. It is intended that their control should be as careful as that of women with insulin dependant diabetes and for this reason insulin may be required. The decision will be made by the consultant in charge Dr Lane/Dr Okosieme/Dr Baglioni or his deputy. Antenatal visits and ultrasound scans will normally follow the same pattern as those for women with insulin dependent diabetes (see above). Labour and Birth Women with non-insulin dependent diabetes will have their timing and mode of birth planned when they reach approximately 36 weeks of gestation. The plan for labour and birth will depend upon individual circumstances and the woman s preferences. Offer IOL or C/S if indicated at 37+0 38+6 weeks gestation [NICE 2015] Consult the maternal notes for details of any antenatal problems, such as fetal macrosomia and also for any plan of management for labour. Site IV cannula Continuous CTG monitoring should be performed throughout labour Monitor the capillary BM hourly. The capillary blood glucose should remain between 4 7 mmol/l. If the BM level >8 then commence VRIII (Adult scale). If the woman has required insulin injections during pregnancy, a sliding scale of insulin may be needed during labour. In case of problems in labour, there should be early discussions with a consultant. Caesarean Section Keep nil by mouth from midnight Hourly BM monitoring from 0700 hours. Commence dextrose infusion If BM > 8 then consider an VRIII and ask for a diabetic team review. The usual post-operative care should be given including thromboprophylaxis. 8

Gestational Diabetes Diagnosis and Antenatal care Gestational diabetes will be diagnosed according to the screening criteria. Diagnosis is made if the woman has either: - A fasting plasma glucose level of 5.6 mmol/litre or above or - A 2-hour plasma glucose level of 7.8mmol/litre or above. Women with suspected or confirmed gestational diabetes should be referred to the joint clinic. Some women may prefer to remain under the care of their current obstetric consultant and they must be allowed to do so. However they will need to attend to see Dr Lane/Dr Okosieme/Dr Baglioni with regard to their diabetes care on a Monday / Tuesday at the joint clinic. The diabetic control of women with gestational diabetes needs to be very tight. The methods used to achieve diabetes control will be decided by Dr Lane/Dr Okosieme/Dr Baglioni in consultation with the individual. Women with gestational diabetes will need to have ultra sound scans at a minimum of 4 weekly intervals from 28 weeks of gestation or the point at which gestational diabetes is confirmed. Timing and mode of birth will be decided based on individual factors and the woman s preferences. Advise women to give birth no later than 40+6 weeks and offer induction of labour or caesarean section if indicated [NICE 2015] Labour Consult the maternal notes for details of any antenatal problems, such as fetal macrosomia and also for any plan of management for labour. Site IV cannula Continuous CTG monitoring should be performed throughout labour Monitor the capillary BM hourly. The capillary blood glucose should remain between 4 7 mmol/l. If the BM level >8 then commence VRIII (Adult scale). If the woman has required insulin injections during pregnancy, a VRIII may be needed during labour. In case of problems in labour, there should be early discussions with a consultant. 9

Caesarean Section If the woman is on insulin, this should be stopped after the evening meal/dose Keep nil by mouth from midnight Hourly Capillary glucose from 0700 Site a dextrose infusion If blood glucose is > 8, consider a VRIII and ask for diabetic team review The usual post-operative care should be given including thromboprophylaxis. Postnatal Management Women with GDM will not require insulin after birth. Following delivery of the placenta, the insulin infusion should be stopped. Perform one random blood sugar prior to discharge from hospital to exclude persisting hyperglycaemia. Follow up in the diabetes clinic is always required. For women who were diagnosed with Gestational Diabetes and whose blood glucose levels return to normal after the birth: Offer lifestyle advice (including weight control, diet and exercise). Perform glucose tolerance test at the 6 week post natal check Annual review with G.P to include HbA1c test 10

References British Diabetic Association (2000) WHO care recommendations for the management of pregnant women with diabetes (including gestational diabetes). CEMACH (2007) Diabetes in Pregnancy. CEMACH Definition, Diagnosis and Classification of Diabetes Mellitus and its Complications, WHO, 2015 fact sheet no 32 Kaushal et al. Diabetic Medicine 2003. 20; 73-75 National Service Framework (2006) Diabetes and Pregnancy NICE Guidelines [NG3] Feb 2015 Diabetes in Pregnancy 11

Appendix A - Oral Glucose Tolerance Test for the Diagnosis of Gestational Diabetes Mellitus The carbohydrate source used for this test is POLYCAL which contains the equivalent of 67g glucose/100 ml as glucose and glucose polymers. A dose of 113 ml is used which gives a glucose load of 75g. Start the test between 08:00h and 10:00h after a minimum of three days on an unrestricted diet and usual physical activity. The woman must fast overnight (10-16 hours) before the test. Water may be drunk during the fast. Collect a fasting venous blood sample into a fluoride-oxalate containing (grey-top) vacutainer. Label bottle clearly as 0 minute sample. Give the patient 113 ml POLYCAL made up to 250-300 ml with water. This should be drunk within a five minute period. Do not allow the patient to smoke or eat during the test. Water may be drunk if desired but only 15 minutes after the POLYCAL has been given. During the test the patient should be inactive. Collect venous blood into fluoride-oxalate at two hours following administration of the glucose load. Label specimen bottle as 120 minutes. Send both samples to the laboratory with one request form only. The investigation requested should be GTT. Women with glucoses results in either the diabetic or impaired categories should be regarded as having gestational diabetes mellitus. Glucose Concentration (mmol/l) Fasting 120 minutes Normal < 5.6 <7.8 Gestational Diabetes >5.6 > 7.8 NB. These criteria are based on Definition, Diagnosis and Classification of Diabetes Mellitus and its Complications, NICE 2015 12

Appendix B Dextrose and Insulin Infusion Regime Generic guideline, to be used in the absence of a personalised delivery plan This guideline gives background information on the use of Dextrose/Insulin infusions during labour and birth. Some patients will have individualised plans in their maternal notes. In the absence of such a plan this guideline gives advice on how to set up a Dextrose/Insulin infusion. Why use Dextrose and Insulin Infusions? Labour and birth can last for over 24 hours. Diabetic patients may not be able to eat and/or manage their insulin treatment during this time. Failure to provide substrate (calories) and to match this with insulin can lead to serious metabolic disturbances. Combined infusion of insulin and dextrose through the same cannula is a simple and safe way of maintaining stable glucose levels for several days if necessary. Why use 10% Dextrose? 10% Dextrose provides 400 calories per litre and is an effective buffer to the insulin infusion, reducing the risk of a patient becoming hypoglycaemic. 10% Dextrose is therefore preferred over 5% Dextrose. Fluid replacement during labour and after birth should be kept to a minimum to reduce the risk of overload especially in hypertensive women and those undergoing a Caesarean Section. A standard regime would call for 1 litre of 10% Dextrose given by infusion pump over 16 hours. For this purpose 500ml 10% dextrose with 10mmol Potassium Chloride (KCL) should be infused over 8 hours ie 62.5ml/hour. Why add Potassium? Patients may not eat during labour and may often vomit, which can lower potassium concentrations. Hypokalaemia is dangerous and can cause cardiac rhythm problems. The infusion of both Dextrose and Insulin moves potassium from the extracellular fluid into cells, further reducing potassium concentrations. Any excess potassium is simply and safely excreted in the urine. 13

What insulin scale will be needed? The amount of insulin needed varies from person to person. Those on higher 24-hour doses need higher hourly rates. Type One Diabetics are totally insulin deficient. They always need some insulin otherwise they become keto-acidotic. Never stop insulin in this type of patient. Type 2 and Gestational Diabetics will produce some of their own insulin. They may have their insulin discontinued if necessary. Most scales will call for variable doses of insulin depending on measured capillary glucose results, which should be performed hourly. In the absence of an individualised delivery plan use the scale suggested below Can a diabetic woman eat during labour? Yes, as long as this is acceptable from an obstetric perspective. What happens at birth? At birth (actually with separation of the placenta) insulin resistance falls. Insulin requirements go back to pre-pregnancy levels within a very short period of time. Insulin infusion rates are therefore halved following birth for Type 1 and insulin treated Type 2 Diabetes. In the absence of an individualised plan, continue the insulin and dextrose infusion but halve the insulin rate. Gestational Diabetes and Type 2 patients who were previously treated with diet and/or tablets can have their insulin stopped. What happens when the woman is eating normally? They are recommenced on their pre-pregnancy insulin regime. This will be specified in their delivery plan. 14

Appendix C - Generic VRIII Plan for Labour and Birth To be used when there is no other specific patient information. If present, individual patient plans will override this generic plan. Dextrose 10%. 500ml 10% dextrose with 10mmol KCL should be commenced to infuse over 8 hours, repeated until VRIII is no longer required. NB. If BM s > 10, replace 10% dextrose with Normal Saline. Intravenous insulin Infused through the same IV cannula. Please use the Variable Rate IV Insulin Infusion (VRIII) on the Adult Insulin Prescription Chart. Note if long acting insulin is continued no insulin should be infused if the BM < 4. Measure capillary glucose hourly. Aim for BM s 4-7 mmol/l. Be prepared to increase/decrease the insulin rate if the patient runs high/or low respectively after discussion with medical team. If BM s > 10 on two consecutive readings, despite giving appropriate insulin doses, the insulin dose scale will need to be adjusted: SEEK ADVICE FROM DIABETES TEAM Halve insulin rate at delivery. In the absence of an individual birth plan ask the Diabetes Team to see the patient. 15

Appendix D - Dexamethasone Administration - DEXAMETHASONE ADMINISTRATION IN WOMEN REQUIRING INSULIN If present, individual patient plans will override this generic plan If delivery is expected before 36 weeks, or elective CS before 39 weeks, then dexamethasone should be given Patients to be admitted to the Antenatal ward Continue standard dietary measures Patient remains active as usual At time of first steroid dose commence VRIII and stop s/c rapid acting insulin. Continue the long acting (background) insulin. Please use the Variable Rate IV Insulin Infusion (VRIII) on the Adult Insulin Prescription chart. Note if long acting insulin is continued no IV insulin should be administered if the BM < 4. Supplementary fluids can be administered 500ml 5% dextrose plus 10 mmol KCl, infused at 40 ml/hour. If the BM is > 10, the dextrose should be stopped. Hourly capillary glucose measurements Continue insulin regime until 24 hrs post second steroid injection. DEXAMETHASONE ADMINISTRATION IN TABLET CONTROLLED DIABETES AND GESTATIONAL DIABETES NOT REQUIRING INSULIN If delivery is expected before 36 weeks, or elective CS before 39 weeks, then dexamethasone should be given Patients to be admitted to the Antenatal Ward The blood glucose should be kept <8mmol/l Blood sugars should be monitored hourly If sugars >8mmol/l: Please use the Variable rate IV Insulin Infusion (VRIII) on the Adult Insulin Prescription chart as above. 16

Appendix E TRUST GUIDELINE FOR THE TREATMENT OF HYPOGLYCAEMIA 17

Appendix F Flow Chart for the Use of Variable Rate Intravenous Insulin Infusion (VRIII) in Pregnancy First Trimester Second and Third Trimester During Use of Corticosteroids During Delivery/ Labour/ CS On Insulin Not on Insulin Refer to Delivery Plan Delivery plan unavailable Refer to guidance for VRIII with fluids suggested on chart. Fluids may need to be revised based on clinical assessment Start VRIII and stop regular short acting insulin. Refer to guidance for VRIII but with 500ml 5% dextrose plus 10mmol potassium chloride infused at 40ml/hr. Continue for 24 hours after last corticosteroid injection. Continue background (longacting) insulin Monitor blood glucose hourly. If > 8mmol/l refer to guidance for VRIII but with 500ml 5% dextrose plus 10 mmol potassium chloride infused at 40ml/hr. Continue for 24 hours after last corticosteroid injection. On Insulin Start VRII and stop short acting insulin. Refer to guidance for VRIII but with 500 ml 10% dextrose plus 10 mmol potassium chloride infused at 62.5 ml/hr. Continue background (long acting) insulin Not on Insulin Monitor blood glucose hourly. If > 8mmol/l refer to guidance for VRIII but with 10% dextrose plus 10mmol potassium chloride infused at 62.5 ml/hr. Aim for blood glucose 4-7mmol/l If on VRIII and blood glucose persistently > 10 mmol/l discuss with diabetes team Fluids may need to be revised based on clinical assessment 1