/ CHHS17/242

Canberra Hospital and Health Services

Clinical Procedure

Hyperglycaemia in Infants (inc. Neonates)

Contents

Contents 1

Purpose 2

Scope 2

Section 1 – Management of Hyperglycaemia 2

Section 2 – Preparation of Insulin Solution 3

Section 3 – Administration of Insulin Solution 4

Related Policies, Procedures, Guidelines and Legislation 5

References 5

Definition of Terms 6

Search Terms 6

Purpose

This guideline provides a framework for the management of hyperglycaemia in infants including initiating and maintenance of insulin infusion and monitoring of blood glucose levels.

Background

·  There is continued uncertainty as to what constitutes a level of hyperglycaemia that is likely to result in an adverse outcome and thus justifies specific intervention.

·  Treatment is suggested when True Blood Glucose (TBG) > 10-12mmol/L, and there is significant spilling of glucose in the urine.

·  Normal Blood Glucose: 2.6-4.4mmol/L

·  Hyperglycaemia: BGL>8.3mmol/L

·  Significant hyperglycaemia: BGL>10-12mmol/L

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Scope

This document pertains to infants nursed in the Department of Neonatology at the Centenary Hospital for Women & Children.

This document applies to the following Canberra Hospital Health Services (CHHS) staff working within their scope of practice:

·  Medical Officers

·  Registered Nurses and Midwives

·  Student Nurses and Midwives working under supervision

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Section 1 – Management of Hyperglycaemia

·  Measure glucose levels on:

  1. premature infants
  2. other at risk infants including

i.  severely growth restricted infants

ii.  asphyxiated infants

iii.  septic infants

iv.  infants on corticosteroids

v.  infants infused with high dextrose infusions

·  Perform urine analysis on infants with persistently high BGL > 10mmol 6 hourly to assess ketonuria and glycosuria

·  Commence Total Parenteral Nutrition (TPN) as soon as possible as amino acids promote insulin secretion

·  Commence gastric feeds if condition allows as feeding promotes the secretion of hormones that promote insulin secretion

·  Measure glucose delivery rate (GDR) in mg/kg/min in all infants with hyperglycaemia

o  GDR (mg/kg/min) = TFI (ml/kg/day) x % dextrose in infusion / 144

·  Assess the infant for possible underlying cause as listed above

·  Consider reducing GDR to 9 mg/kg/min especially if receiving large volume of fluids or underlying cause for hyperglycaemia e.g. post-surgery/sepsis

·  If hyperglycaemia persists for > 6 hours despite reduction in GDR and is associated with significant glycosuria >=2+, commence treatment with insulin infusion

·  Insulin improves blood glucose levels , caloric intake and weight gain

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Section 2 – Preparation of Insulin Solution

Equipment

·  Alcohol based hand rub (ABHR)

·  The Neonatal Intensive Care Unit (NICU) Drug Manual 2014 (p82)

·  Written insulin infusion prescription on fluid order sheet (use actrapid as per NICU drug manual)

·  Prepared Insulin Infusion from Pharmacy (in working hours)

·  Out of hours preparation of infusion by nursing staff

o  Dressing tray

o  Actrapid – Soluble Insulin (found in Unit refrigerator)

o  Drawing up needles x 4 (do not use filter needle)

o  1 mL syringe

o  50 mL syringe

o  10 mL syringe

o  Normal saline 20mLs

o  0.9% Saline

o  Medication additive label

o  Extension set

o  Alcohol swab

o  1 syringe driver with drug library

Procedure

1.  The infusion is prepared as per the NICU Drug Manual 2014 and checked by 2 nurses

2.  Prime the extension line with prepared insulin solution and leave for one hour to precondition the tubing

3.  The line is flushed with 2ml of the prepared insulin solution

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Section 3 – Administration of Insulin Solution

1.  Attend moments of Hand hygiene

2.  Identify the correct infant as per patient identification and procedure matching procedure

3.  Syringe driver with drug library must be used.

4.  No filter is to be used in the extension line.

5.  Use sterile procedure to connect infusion.

6.  Connect the insulin infusion into the maintenance line at port closest to the infant.

7.  Do not use this line for administration of medications or flush line.

8.  Infusion and lines are changed daily.

Insulin Sliding Scale (maybe adjusted according to patient’s needs)

Starting dose usually 0.05units/kg/hr, then adjusted according to requirement

·  Blood glucose > 15mmol/L INCREASE infusion by 0.02 U/kg/hr

·  Blood glucose > 10mmol/L INCREASE infusion by 0.01 U/kg/hr

·  Blood glucose 6 -10mmol/L KEEP infusion THE SAME then wean at least once daily by 0.01U/kg/hr if stable in this range

·  Blood glucose < 6mmol/L STOP INFUSION

If there is a SHARP fall in the blood glucose level, the insulin rate MUST be reduced by 0.02-0.04 U/kg/hr or stopped if the drop is significant and inform medical officer.

Management

1.  The infusion rate is not to be included in the daily fluid balance chart unless the volume of the insulin infusion becomes > 1ml/hour (as generally the volumes infused are very small)

2.  Check and document BGL

  1. one hour following commencement of insulin infusion
  2. then 2 hourly until reading < 10mmol
  3. then 4-6 hourly for the duration of the infusion if stable unless directed by consultant
  4. if BGL <8mmol/L it may be necessary to do more frequent BGL measurements in order to avoid hypoglycaemia

3.  Check the urine for glycosuria 6 hourly

4.  Notify consultant/registrar of any BGL > 10mmol or < 6mmol

5.  Wean according to insulin sliding scale protocol as above

6.  Document in clinical record.

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Related Policies, Procedures, Guidelines and Legislation

Policies

·  ACT Health Nursing and Midwifery Continuing Competence Policy

·  CHHS Consent and Treatment Policy

·  CHHS Patient Identification and Procedure Matching Policy

·  Medication Handling Policy

Procedures

·  CHHS Healthcare Associated Infections Clinical Procedure

·  CHHS Patient Identification and Procedure Matching Procedure

Guidelines

Neonatal Intensive Care Unit Drug Manual 2014

Legislation

·  Health Records (Privacy and Access) Act 1997

·  Human Rights Act 2004

·  Work Health and Safety Act 2011

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References

1.  Hume, R., Burchell, A., Williams, F., & Koh, D. Glucose Homeostasis in the Newborn. Early Human Development 2005. p.81, 95-101.

2.  Hall, S., Smith, E. & Pierro, A. Hyperglycaemia is associated with increased morbidity and mortality rates in neonates with necrotizing enterocolitis Journal of Pediatric Surgery 2004. 39, p.898-901

3.  Alsweler, J., Kuschel, C. & Bloomfield, F. Survey of the management of neonatal hyperglycaemia in Australia Journal of Paediatrics and Child Health 2007. 43, p. 632-635

4.  Ogilvy-Stuart, A. & Midgley, P. Practical Neonatal Endocrinology. Cambridge University Press. 2006.

5.  Thureen P. & Hay, W. Nutritional requirements of the very low birth weight infant In Neu, J. Gastroenterology and Nutrition: Neonatalogy questions and controversies. Philadelphia Elservier 2008.

6.  Wilker R. Hypoglycaemia and hyperglycaemia In Cloherty, J., Echenwald, E. & Stark, A. Manual of Neonatal Care. Philadelphia, Wolters Kluwer 2008.

7.  Ditzenberger G, Collins, S. & Binder N. Continuous Insulin Intravenous Infusion Therapy for VLBW Infants. Journal of Perinatal and Neonatal Nursing 1999. 13(3) p. 70-82.

8.  Raney M., Donze A., & Renaud Smith J. Insulin Infusion for the Treatment of Hyperglycaemia in Low Birth Weight Infants: examining the evidence. Neonatal Network 2008. 27(2) p. 127-140.

9.  RPA Newborn Care Drug Database Insulin-Hyperglycaemia Http://www.cs.nww.gov.au/rpa/nenatal/html/listview.asp?DrugID=27 accessed 25/06/2008

10.  Simeon P. The premature infant with hyperglycaemia: use of continuous insulin infusion. Journal of Perinatal and Neonatal Nursing 1992. 6(1), p.52-60

The Canberra Hospital Centre for Newborn care Neonatal Intensive Care Drug Manual p81-82

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Definition of Terms

Normal Blood Glucose: 2.6-4.4mmol/L

Hyperglycaemia: True blood glucose (TBG)>10-12mmol/L

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Search Terms

Hyperglycaemia, Neonate, Neonatal, Insulin, Infant

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Disclaimer: This document has been developed by ACT Health, Canberra Hospital and Health Service specifically for its own use. Use of this document and any reliance on the information contained therein by any third party is at his or her own risk and Health Directorate assumes no responsibility whatsoever.

Date Amended / Section Amended / Approved By
Eg: 17 August 2014 / Section 1 / ED/CHHSPC Chair
Doc Number / Version / Issued / Review Date / Area Responsible / Page
CHHS17/242 / 1 / 25/10/2017 / 01/10/2022 / WY&C - Neonatology / 1 of 6
Do not refer to a paper based copy of this policy document. The most current version can be found on the ACT Health Policy Register