Guidelines for the Management of Patients with Hyperglycaemia Or Diabetes and Suspected

GUIDELINES FOR THE MANAGEMENT OF PATIENTS WITH HYPERGLYCAEMIA OR DIABETES AND SUSPECTED ACUTE CORONARY SYNDROMES

ELIGIBLE PATIENTS

All patients with capillary blood glucose greater than 11 mmol/L and all patients with diabetes (regardless of blood glucose) with acute coronary syndromes including ST elevation and non-ST elevation MI and unstable angina.

For patients not known to have diabetes with capillary blood glucose between 7 and 11 mmol/L on admission, wait for laboratory plasma glucose. If it is greater than 11 mmol/L commence infusions, if not monitor capillary blood glucose 4 hourly for 24 hours and treat as per protocol if plasma glucose exceeds 11 mmol/L.

AIMS OF TREATMENT

To achieve and maintain plasma glucose between 4 and 9 mmol/L within 4 hours of admission.

1.  ON ADMISSION

Check capillary blood glucose and check urine for ketones. If initial capillary blood glucose is greater than 15 mmol/L give iv bolus of 8 units soluble insulin and sign and date the prescription.

Draw up blood for the following laboratory investigations:

FBC Plasma glucose

U&E, LFT CK and troponin

Cholesterol HbA1c

2.  WITHIN THE FIRST HOUR

As soon as possible (and through the same venflon) commence two separate but concurrent infusions A and B. All oral hypoglycaemic agents must be stopped when the insulin regimen is started.

A: Human soluble insulin 50 units diluted in 50 ml sodium chloride 0.9% (1 unit per ml) infused as per sliding scale

B: 10% Dextrose with potassium 20 mmol per 500ml infused at a rate of 40ml per hour (reduced to 20ml per hour in severe heart failure). Use ready mixed bags. Omit KCl while K+ is over 5.3

SLIDING SCALE REGIMEN

Capillary blood glucose
(mmol/L) / Standard insulin regime
(units per hour) / Modification 1
(units per hour) / Modification 2
(units per hour)
0 – 3.9 / 0 / 0
4 – 6.9 / 1 / 2
7 – 8.9 / 2 / 4
9 – 10.9 / 3 / 6
11 – 16.9 / 4 / 8
17 + / 6 / 12

  Check capillary blood glucose hourly until within target range (4 – 9 mmol/L), then hourly for a further 4 hours and then 2 hourly.

  If capillary blood glucose is greater than 9 mmol/L at 2 hours, double the rate of insulin infusion (modification 1).

  If capillary blood glucose is greater than 15 mmol/L at 4 hours, call doctor and give a repeat bolus of 8 units soluble insulin.

  If capillary blood glucose is less than 3 mmol/L for 2 consecutive readings, call doctor.

  Refer to diabetes nurse on fax extension 2191 on the first working day and sign and date the prescription.

  If modification 1 is ineffective seek senior advice for customised rates.

Continue iv Dextrose infusion and sliding scale for at least 24 hours. If the patient is changed onto double rate (modification 1), they should stay on this regimen until converted to subcutaneous insulin or until the regimen is stopped. If the patient becomes clinically or biochemically hypoglycaemic the insulin rate should be reduced to the previous regimen.

MEALS

When patients are eating properly, if the iv regime is still running, increase the infusion rate to double rate for one hour only, starting with the meal.

3.  AFTER 24 TO 48 HOURS

CHANGING TO SUBCUTANEOUS INSULIN

1.  Four times daily subcutaneous insulin is to be used in all patients.

2.  Divide the total intravenous insulin dose over preceding 24 hours into four equal doses and round down by 10 – 20% to an even number of units. For example, with an average infusion rate of 4 ml per hour, total daily dose would be 96 units, which would be four lots of 24 units, minus 10 – 20 % would equal 20 units at each injection.

3.  Give three injections per day of soluble insulin (Novorapid) immediately before meals and one injection of isophane (Humulin I) at bedtime.

4.  Discontinue IV insulin and dextrose infusions immediately after the first dose of subcutaneous insulin has been administered.

5.  Adjust doses daily to achieve pre-meal and bedtime blood glucose between 4 and 9 mmol/L.

4.  DISCHARGE

Liaise with diabetes team whether insulin is to be continued post discharge. If control has been good on previous regimen this may well be continued. Pen injectors (other than preloaded disposables) are only appropriate if the patient is being discharged on insulin.

PLEASE NOTE THAT ALL INFORMATION SHOULD BE RECORDED ON THE ASSIGNED PRESCRIPTION, ADMINISTRATION AND MONITORING CHART AND THAT THE DOCUMENTS MUST BE FILED IN THE PATIENTS NOTES ON COMPLETION / DISCHARGE. A SPECIFIC PATHWAY WILL FOLLOW WHEN AVAILABLE.

Diabetes/ACS Guidelines 2009