diabetes management including hypoglycaemia, iv insulin ... · web viewthis section refers to the...

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Canberra Hospital and Health ServicesClinical Guideline Diabetes Management: Including Hypoglycaemia, IV Insulin Infusions and Insulin Pumps (Adults only)Contents

Contents....................................................................................................................................1

Guideline Statement.................................................................................................................3

Scope........................................................................................................................................ 3

Section 1 – Collecting capillary blood glucose levels (cBGL)......................................................4

Section 2 – Hypoglycaemia.......................................................................................................4

Symptomatic.........................................................................................................................4

Asymptomatic.......................................................................................................................4

Key points in managing hypoglycaemia.................................................................................5

Section 3 – Adult patients requiring intravenous insulin infusion therapy...............................5

Insulin infusion commencement and management..............................................................5

Serum potassium and sodium levels.....................................................................................8

Ceasing an insulin infusion....................................................................................................9

Section 4 – Use of patient controlled subcutaneous insulin pumps in hospital.......................10

In an emergency..................................................................................................................11

Preadmission.......................................................................................................................11

On admission...................................................................................................................... 11

Assessment of continued competency to operate the Insulin Pump during hospitalisation............................................................................................................................................ 11

Contraindications to continued use....................................................................................12

Patient Agreement Form.....................................................................................................12

Ongoing management.........................................................................................................13

Accu-chek Insulin Pump Systems........................................................................................14

Animas................................................................................................................................ 14

Temporary disconnection from the insulin pump...............................................................14

Implementation...................................................................................................................... 14

Related Policies, Procedures, Guidelines and Legislation.......................................................15

References.............................................................................................................................. 15

Definition of Terms................................................................................................................. 16

Doc Number Version Issued Review Date Area Responsible PageCHHS17/155 1 20/07/2017 01/07/2020 Medicine 1 of 18

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

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Search Terms.......................................................................................................................... 17

Attachments............................................................................................................................17

Attachment 1 - Flowchart for management of Hypoglycaemia.........................................18



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Guideline Statement

BackgroundThe purpose of this guideline is to provide clinicians with best practice information to effectively manage adult patients with diabetes mellitus also referred to as type 1 diabetes, in hospital. The guideline covers three important aspects of diabetes management in the acute care setting: Hypoglycaemia Intravenous insulin infusions Continuous subcutaneous insulin pumps

Key objectiveTo ensure safe and appropriate management of adult inpatients with diabetes mellitus.

Alerts Consider asking for endocrine unit consultations for all type 1 diabetes patients admitted

to hospital. All inpatients on continuous subcutaneous insulin pumps require review by an

Endocrinologist. If the patient’s blood glucose level is not below 4mmol/L, but is exhibiting signs and

symptoms of hypoglycaemia, treatment must be given. If a patient is demonstrating impaired consciousness (uncooperative or aggressive) or is

unconscious, and hypoglycaemia is suspected, the Medical Emergency Team (MET) should be called.

Contact the Endocrinologist on call if the patient is in diabetic ketoacidosis (DKA) or a diabetic hyperosmolar hyperglycaemic state (DHHS).

Back to Table of Contents

Scope

This document refers to adult patients with diabetes mellitus that are treated with insulin and/or oral hypoglycaemic agents at Canberra Hospital and Health Services (CHHS).

This document applies to CHHS staff working within their scope of practice: Medical Officers Nurses and Midwives Students under direct supervision.

Exclusions: For insulin management of Women during labour and post delivery please refer to the

Insulin Infusion for Labour and Birth Clinical Procedure. For management of the paediatric and adolescent patient with diabetes please refer to

the Paediatric and Adolescent Diabetes Guideline.



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For management of diabetic patients in the Exercise Physiology Department please refer to Exercise Physiology Department Management of hypoglycaemia and hyperglycaemia in DMT1 and DMT2patients.


Section 1 – Collecting capillary blood glucose levels (cBGL)

Ensure the lancing site is cleaned with water or alcohol swab prior to the cBGL being attended.

Calibrate and control test the blood glucose meter prior to commencement of monitoring.


Section 2 – Hypoglycaemia

Hypoglycaemia is a condition in which blood glucose levels drop below 4 mmol/L. Delays in recognising or treating hypoglycaemia have the potential to cause serious adverse advents such as injury, unconsciousness or convulsions. When blood glucose levels become low the patient may present with the following signs and symptoms. It should be noted however that a patient with low blood glucose levels may be asymptomatic (e.g. Hypoglycaemia unawareness).

SymptomaticSymptoms and signs of hypoglycaemia include: tremors palpitations sweating hunger nausea vomiting irritability disorientation diminished mental efficiency convulsions and or coma.

Asymptomatic When a capillary blood glucose level (cBGL) of < 4 mmol/L is measured on routine blood glucose monitoring and no signs or symptoms are evident in the patient.For further information regarding the treatment pathway see Attachment 1 - Flowchart for management of Hypoglycaemia

Equipment Blood glucose monitoring kit



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Personal protective equipment e.g. gloves Hypoglycaemia treatment items held in the medication room. (E.g. of supplies to treat

hypos; glucose gel, high glucose snacks such as jelly beans, juice and biscuits, glucagon and IV glucose solutions)Food and hypo kits can be sourced from Food Services. Food Services deliver ward pantry food supplies daily on imprest.

Confirm hypoglycaemia with a capillary blood glucose test. Maintain patient safety at all times

Key points in managing hypoglycaemia Identify and treat the cause of hypoglycaemia. If the patient is hypoglycaemic when the next dose of insulin is due, delay administration

until after correction of the hypoglycaemia. Do not omit next insulin dose, consider dose adjustment. If the hypoglycaemia is severe/recurrent, or the patient has type 1 diabetes, seek expert

advice from the endocrine unit.

Important general information in managing hypoglycaemia If unsure, always seek advice. With-holding insulin in type 1 diabetes patients places them at risk of diabetic

ketoacidosis (DKA).


Section 3 – Adult patients requiring intravenous insulin infusion therapy

This section refers to the management of adult patients requiring intravenous insulin infusion therapy for glycaemic control. This includes adult patients with diabetic ketoacidosis (DKA) or a hyperosmolar hyperglycaemic state, unstable diabetes control related to intercurrent illness, or patients fasting for procedures or operations.

Insulin infusion commencement and management

Preparation of the insulin infusion Insulin infusions should be prepared immediately prior to administration.

Afterhours, insulin infusions are prepared in the ward/unit (short acting insulin (e.g. Actrapid), a 100 mL 0.9% sodium chloride bag and an additive label). If insulin is required and not available on the ward, please contact 6A or ED or contact afterhours CNC.

Standard Insulin Preparation 100 units short acting insulin in 100 mL 0.9% sodium chloride: 1 unit = 1 mL

Soluble short acting insulin e.g. Actrapid is to be used.



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Two lines are to be maintained for the duration of the infusion: a MAINLINE (insulin) and a SIDELINE (e.g. normal saline or glucose).

An intravenous insulin infusion must be prescribed (mainline). Prime tubing to saturate line with insulin. If BGL is >15 a normal saline (sideline) needs to be prescribed. If BGL <15 a glucose

intravenous infusion, including a constant glucose infusion rate (usual 125 mL per hour of 5% glucose or 4% dextrose in 1/5 normal saline), must be prescribed (sideline).

Insulin and glucose infusions are given via the same cannula. Intravenous insulin infusions and accompanying normal saline/glucose sideline infusions

must be administered through pumps using the built in dose error reduction software. The rate of the insulin infusion depends on the capillary blood glucose level (cBGL). Insulin infusions must commence at least 2 hours prior to an invasive procedure if the

patient is to be fasted. Additional maintenance intravenous fluid (in addition to the glucose infusion) may be

prescribed depending on the patient’s volume status, renal and cardiac function. Electrolytes should also be carefully monitored and corrected (particularly potassium) as

per recommendations in the following section. A fluid balance chart must be maintained.

Insulin dosage adjustment The insulin is adjusted according the cBGL as below:

Capillary BGL(mmol/L)

mL per hour unit per hour Alerts

<4 0 0 Alert 1 (see below)4- 5 0.5 0.5

5.1 - 7 1 17.1 – 9 2 2

9.1 – 11 3 311.1 – 13 4 4 Alert 2 (see below)13.1 – 15 5 515.1 – 20 5.5 5.5

>20 6 6 Alert 3 (see below)

Alert 1If cBGL less than 4 mmol/L Stop the insulin infusion, continue the glucose infusion. Check cBGL every 15 minutes until cBGL is greater than 5mmol/L. Once cBGL is greater than 5 mmol/L restart the insulin infusion. Standard insulin rate (as per the table above). If cBGL less than 3.5 mmol/L and/or the patient has symptoms of hypoglycaemia Stop the insulin infusion. Administer a bolus of glucose by increasing the glucose infusion rate to 300 mL/hour

until cBGL is greater than 5 mmol/L. Seek urgent medical review.



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If the patient has a sudden fall in level of consciousness or seizures, Dial 8 and activate the Medical Emergency Team (MET).

If recurrent or severe hypoglycaemia, the insulin infusion orders may need downward adjustment by the medical officer.

Alert 2If cBGL remains greater than 11mmol/L for more than 2 hours and there is no downward trend from previous higher readings, the insulin orders may need upward adjustment, seek medical review.

Alert 3If cBGL is greater than 20mmol/L and there is no downward trend from previous higher readings, the insulin infusion orders may need upward adjustment, seek medical review. Please check blood ketones.

Capillary Blood Glucose Levels (cBGL)

The cBGL is checked hourly for the first 24 hours then 2nd hourly if stable after 24 hours. A “stable cBGL” is within the range of 5.1-11 mmol/L for 3 consecutive hours without

need for a change in the insulin infusion rate. For cBGLs that may be dramatically different from the previous level (e.g. a difference of

greater than 4 mmol/L up or down), recheck by: o repeating the test at a different siteo ensuring the IV cannula site is patento that the specimen has not been taken from the limb receiving the insulino that the insulin infusion bag is not more than 24 hours old.

Glucose sideline infusion Patients with DKA will require rehydration with 0.9% sodium chloride prior to commencing the glucose infusion. Once cBGL has fallen to less than 15 mmol/L the glucose infusion should be commenced.

Standard Glucose Prescription5% Glucose (or 4% Glucose 0.18% sodium chloride) with appropriate potassium

infused at 125 mL/hCan only be altered following expert medical advice (consider endocrine consult).

The glucose infusion must be prescribed as a pre-ordered constant infusion. It is important that the glucose infusion remains stable to achieve constant rate of

glucose delivery. The glucose infusion prescription may need to be altered (e.g. use of 10% glucose infused

more slowly) for patients with renal or cardiac disease according to expert medical advice.



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Serum potassium and sodium levels Electrolytes (potassium and sodium) should be measured at least daily in patients. (More often in patients with DKA; 2nd Daily if long term infusion).

Serum potassium levels Refer to Potassium Replacement Prescribing Monitoring and Administration-Adult

Procedure. Serum potassium should be maintained between 4-5 mmol/L when treating DKA. Potassium should be supplemented as required. In patients with DKA intravenous potassium supplement will be required and should be

given as soon as insulin and fluids are commenced AND the potassium level is known to be below the upper limit of the reference range (i.e. less than 5 mmol/L).

Note: If potassium is less than 3.5 conduct an ECG and seek urgent advice from endocrinologist on call regarding timing of initiation of insulin infusion.

If serum potassium concentration is not being maintained with intravenous potassium replacement as outlined above, review the delivery rate and seek advice from the medical registrar.

Serum sodium levels Hyponatraemia may necessitate a change in the glucose infusion prescription to 5%

dextrose with 0.45% sodium chloride. Expert medical advice should be obtained.

Blood ketones To be measured 2 hourly for patients in DKA and for patients with a cBGL greater than 15

mmol/L. In DKA, blood ketone levels greater than or equal to 2 mmol/L that are not decreasing

with successive measurements – seek medical review and endocrine unit involvement. In other patients, any blood ketone level greater than or equal to 2 mmol/L should be

reported to the medical treating team.

General observations Observe patient closely for signs and symptoms of hypoglycaemia i.e. cBGL less than 4

mmol/L, shakiness, pallor, confusion, drowsiness, sweating and manage as per hypoglycaemia alert (see Alert 1).

Document any changes to infusion rates and the action taken. Insulin infusion and intravenous cannula Insulin and glucose infusions including delivery sets must be changed every 24 hours. Replace a tissued cannula as a matter of urgency (within 20 min) as intravenous insulin

has a half-life of approximately 5 minutes(– if it can’t be replaced within 20 minutes, then this needs to be escalated, as there is a risk of adverse patient outcomes if it is a prolonged period without insulin).

The cannula should be replaced every 48 hours. A second cannula should be inserted if additional intravenous medications are required

or additional IV hydration is required. Doc Number Version Issued Review Date Area Responsible PageCHHS17/155 1 20/07/2017 01/07/2020 Medicine 8 of 18


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Ceasing an insulin infusion Cessation is to be determined and documented by the treating team once the patient is

able to tolerate an oral diet and fluids. Oral hypoglycaemic agents or subcutaneous insulin must be ordered by the treating

medical officer and administered prior to ceasing the infusion (see table below). Stopping an insulin infusion should be planned for early in the day whenever possible. In most circumstances the glucose sideline infusion will be stopped at the same time as

the insulin infusion.

For resolving DKA patients Patients with resolving DKA, ceasing the intravenous insulin infusion and commencing

subcutaneous insulin may be considered when two successive measurements of blood ketones are less than 1mmol/L (as measured on ward meter and appropriate strips).

Patients treated with oral hypoglycaemic medications Aim to stop insulin infusion early morning (e.g. breakfast). Give the prescribed oral hypoglycaemic medications just prior to the meal. Stop the insulin infusion once the oral hypoglycaemic medications have been given.

Patients treated with subcutaneous insulin Give prescribed subcutaneous insulin (should usually be a combination of short or rapid

acting and long acting insulin) before the meal. The insulin infusion is to continue until the peak action of the rapid or short acting

subcutaneous insulin is reached as per the table below. If the patient is on a basal insulin only consider starting this 4 or more hours prior to ceasing the insulin infusion.

Insulin Peak action after subcutaneous injection

When to cease an insulin infusion

Rapid acting insulin analogues (e.g. NovoRapid, Humalog, Apidra)

Pre-mixes with rapid acting component (e.g. Novomix 30, Humalog Mix 25)

Less than 1 hour 1 hour after the subcutaneous injection

Short acting insulin (e.g. Actrapid, HumilinR) Pre-mixes with short acting component (e.g. Mixtard 30/70 and Humulin 30/70)

2 – 4 hours 2 hours after the subcutaneous injection

Basal insulin e.g. Lantus, Levemir, Protaphane or Humulin NPH

6 – 8 hours If on basal insulin only - cease insulin infusion after 4 or more hours after the subcutaneous injection

Post infusion care



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Continue hourly cBGLs for 2 hours after removing the insulin infusion then at standard ward times as ordered by the Medical Officer.

Continue to document cBGLs.


Section 4 – Use of patient controlled subcutaneous insulin pumps in hospital

An insulin pump is a medical device used for the administration of insulin by subcutaneous infusion in the day to day care of diabetes (mostly type 1 diabetes). This approach to insulin delivery is also termed Continuous Subcutaneous Insulin Infusion (CSII) therapy. The continued use of insulin pumps during a period of hospitalisation is dependent upon the patient being assessed as being competent and available to successfully operate their own device.

Insulin pumps use only rapid acting analog insulin (e.g. Novorapid or Humalog). Rapid acting insulin starts working within 10 to 15 minutes of delivery, peaks within one to three hours and ceases working after three to five hours. Insulin pump users do not use long acting insulin.

Due to the use of rapid acting insulin only in pumps, insulin pump users are at increased risk of developing diabetic ketoacidosis (DKA) if the pump is stopped, disconnected or malfunctions. For this reason, it is important that the insulin pump is not disconnected for more than two hours without giving insulin by subcutaneous injection or intravenous (IV) infusion.

Orders for an alternative method of insulin delivery must be charted by a Medical Officer (MO) prior to disconnection of an insulin pump.

In an emergencyUse of the insulin pump must be ceased and the patient commenced on an intravenous insulin infusion (see Section 2). Refer to the information below on contraindications to continued use, for further information.

PreadmissionConsideration of competency for self-management of CSII insulin pump therapy should commence in the preadmission clinic, where possible.

On admission (including admission via Emergency Department)1. The admitting medical officer (MO) must document the following information in the

patient’s clinical record: The brand of insulin pump device. The brand name of insulin used in pump. The location of the pump infusion site and skin condition at the site (eg.

Lipohypertrophy).



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The date and time of the most recent pump infusion site change, and the patient’s home insulin regime regarding current pump settings:o basal rates of insulino insulin to carbohydrate ratioo correction/insulin sensitivity factoro target blood glucose levelo insulin action time, ando any recent changes to basal rates and most recent bolus dose.

Prior to an endocrinology assessment, medication chart orders for the insulin pump should correspond to the patient’s home insulin regime.

2. The admitting MO must arrange referral for consultation by: Adult endocrinologist ACT Diabetes Service registered diabetes nurse educator (and dietitian depending on

reason for admission).

Assessment of continued competency to operate the Insulin Pump during hospitalisation1. The endocrinologist will:

Assess the patient’s ability to continue to self-manage the insulin pump during hospital admission.

Document the result of the assessment in the clinical record. Confirm agreed range of basal insulin rates and pump settings. Document insulin orders on the patient’s medication chart, and Document ongoing management of capillary blood glucose levels (cBGLs) and insulin

requirements.

2. If the patient is assessed as competent to manage the insulin pump, it will be necessary for the patient to sign a Use of Insulin Pumps in Hospital - Patient Agreement form. Refer to the Clinical Forms Register to access this form.

3. Should use of the insulin pump be discontinued due to the outcome of the assessment, insulin must be administered via an alternative route prior to the removal of the insulin pump.

Contraindications to continued useContraindications to continued use of insulin pump therapy may include, but are not limited to: Fasting (Pump delivers insulin only/ no dextrose or glucose). When a patient is unable to manage own pump (e.g. under general anaesthetic). Patients unable to participate in care of the pump (e.g. too unwell). Patient has altered state of consciousness. The critically ill patient requiring intensive care. Any patient at risk of self harm/suicide.



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Other circumstances where medical staff do not feel ongoing use of the insulin pump is in the patient’s best interest.

Lack of infusion sets, spare batteries and other equipment required to maintain patient on insulin pump therapy.

Patient does not wish to continue to use the pump and requests an alternative method of insulin delivery.

Insulin pump failure.

Alert: Insulin pumps must not be directly exposed to x-ray beams or strong magnetic fields such as MRI, direct x-ray and ultrasound. The pump must be temporarily disconnected and kept outside the room for all radiological procedures.

Patient Agreement Form (Refer to the Clinical Forms Register: http://inhealth/acthmr/default.aspx, to access this form)

Patients are asked to agree to certain responsibilities by signing a Patient Agreement – Use of Insulin Pump in Hospital form to ensure: informed consent patient safety best outcomes, and collaboration and communication between the patient and their treating team of

medical and nursing staff.

The form requires the patient to agree to: Keep staff informed about basal rates and bolus doses of insulin to ensure that these are

documented on their medication chart. Show and report the daily dose of insulin to staff. Show staff blood glucose level meter readings, or written record of blood glucose level

readings, as well as basal rates and bolus doses for documenting in the clinical record. Consultation with an endocrinologist before making changes to pump settings outside of

the agreed range. Notify staff of rising/falling cBGLs and trends. Notify staff of any concerns about pump function or pump supplies. Notify staff of any skin problems at infusion site. Responsibility for changing infusion site, with assistance from nursing staff if necessary. Provide their own supply of pump supplies e.g. infusion sets, reservoirs.

The conditions under which the agreement to use the insulin pump is ended are also included on the form. These are: Changes in the patient’s judgement or ability to participate in care. Changes in level of awareness or consciousness e.g. sedation. A procedure that requires permanent pump disconnection and/or removal. Medical staff orders.



http://inhealth/acthmr/default.aspx

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Ongoing management1. cBGL can fall at any time and without warning. Staff must ensure that patients always

have immediate access to supplementary glucose and are provided with a supply for use during hospital admission.

2. Patients must be reviewed daily by an endocrinologist to collaborate on, and confirm ongoing management. Patients may require more frequent review as dictated by: A change in their medical condition. A change in blood glucose levels. The presence of blood ketones. Tests, procedures or surgery. Other concerns raised by patient or nursing/medical staff.

3. Insulin requirements and minimum frequency of capillary blood glucose level (cBGL) monitoring is determined by an endocrinologist and reviewed daily and as necessary.

4. Intraoperative management of cBGLs and insulin requirements is the responsibility of the anaesthetist. The continued use of insulin pump therapy may be considered in reference to the endocrinologist’s recommendations and the consumer’s wishes.

5. An insulin pump delivery problem should be suspected for any unexplained cBGL greater than 15mmol/L. Blood ketone levels should be checked along with the insulin pump, the infusion set and the site. Notify the endocrinology consultant if blood ketones are greater than 0.6mmol/L. A subcutaneous injection of insulin and a change of infusion set may be required in this instance.

6. There are several insulin pumps currently available for use in Australia. Customer service contact numbers for trouble-shooting pump problems are:Accu-chek Insulin Pump Systemswww.accu-chek.com.auCustomer Service Hotline: 1800 633 457 (24 hrs/7 days a week)Animaswww.amsl.com.auCustomer Service: 02 9882 3666 (office hours)24 hour Hotline: 1300 851 056Medtronicwww.medtronic-diabetes.comCustomer Service: 1800 668 670 (0800 – 1800 Monday to Friday)Customer Service After hours and pump emergencies: 1800 777 808 (24 hrs/7 days a week)



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Temporary disconnection from the insulin pump1. Insulin pumps may be temporarily disconnected safely without the removal of the

insulin pump infusion set or the cannula under the patient’s skin.

2. Blood glucose levels (cBGL) must be monitored hourly (as a minimum requirement) during temporary disconnection from the pump. Prompt treatment of rising cBGL is essential in order to prevent hyperglycaemia, ketonuria or diabetic ketoacidosis.


Implementation

This document will be implemented through nursing staff ward in-service education sessions, education sessions from the Diabetes Ward Resource Nurses and through the existing training programs such as the Diabetes Modules.

Information from this document will also be incorporated into existing training programs, orientation plans, staff meetings, and Safety and Quality meetings.


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 Potassium Replacement Prescribing Monitoring and Administration – Adult Procedure Insulin Infusion for Labour and Birth Clinical Procedure Exercise Physiology Department Management of hypoglycaemia and hyperglycaemia in

DMT1 and DMT2 patients

Guidelines CHHS Fasting Guidelines – Elective and Emergency Surgery Patients Paediatric and Adolescent Diabetes Guideline

Legislation Health Records (Privacy and Access) Act 1997



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Human Rights Act 2004 Work Health and Safety Act 2011


References

1. Anthony, M (2007). Treatment of Hypoglycaemia in Hospitalised Patients: A Descriptive Study. The Diabetes Educator, 33: 709-717.

2. Harderm, R.D. and Quinn, N.D. (2003) Emergency management of diabetic ketoacidosis in adults. Emergency Medicine Journal. 20:210-213.

3. Moghissi, E.S., Korytkowski, M.T., Dinardo, M, Einhorn, D. et al. (2009) American Association Consensus Statement on Inpatient Glycemic Control. Diabetes Care, 32(6), 1119-1131

4. 4. Diabetes Complications [revised Nov 2013]. In: eTG complete [Internet]. Melbourne: Therapeutic Guidelines Limited; 2017.


Definition of Terms

Active insulin time – An adjustable setting that the pump uses to define the amount of insulin remaining active. The pump uses this setting when recommending the amount of additional insulin required to correct hyperglycaemia. Adjustments to this setting, outside of the scope agreed by the endocrinologist, should only be made with the advice of an endocrinologist.

Continuous Subcutaneous Insulin Infusion (CSII) ‘insulin pump’ – An insulin pump is a small battery-operated electronic device about the size of a pager or small mobile phone which is controlled by a microprocessor and delivers insulin by subcutaneous infusion. The device delivers rapid acting insulin in two ways:1) The basal rate (background insulin) – continuous delivery of small amounts of rapid

acting analog insulin (replacing the need for long acting basal insulin injections), and2) Bolus doses – delivery of a dose of rapid acting analog insulin at the time of carbohydrate

consumption, or to correct blood glucose levels above target.

An insulin pump is operated by the patient, or carer, and worn 24 hours a day but may be disconnected for short periods of less than 1 – 2 hours (providing blood glucose levels are stable between 4 – 8mmol/L) e.g. showering, exercise or short clinical procedures.

Insulin pumps must not be directly exposed to x-ray beams or strong magnetic fields such as MRI and direct x-ray. The pump must be temporarily disconnected and kept outside the room for all radiological procedures. Ultrasound transducers should not be pointed directly



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at the insulin pump or site. If pump or site is directly in range of transducer the pump should be temporarily disconnected.

Correction or insulin sensitivity factor – The fall in blood glucose levels expected (expressed in mmol/L /unit of insulin) per unit of insulin. This is an adjustable setting and more than one setting can be programmed each day.

Diabetic ketoacidosis (DKA) – Diabetic Ketoacidosis is a potentially life threatening condition that arises as a result of insulin deficiency. This causes imbalances in body fluid and electrolyte levels, leading to dehydration and build up of acids in the blood. In addition to blood ketones > 2mmol/L, biochemical criteria for diagnosis includes BGL > 11mmol/L, Venous pH < 7.3 and Bicarbonate < 15mmol/L.

Hypoglycaemia – low blood glucose levels less than 4 mmol/L, or at a level close to this with symptoms of hypoglycaemia.

Insulin to carbohydrate ratio – The number of grams of carbohydrate that one unit of insulin will cover. More than one setting can be programmed throughout each day.

Infusion Set – flexible tubing and cannula.

Ketones – arise from the breakdown of fats and signify insulin deficiency. They are a normal finding in fasting patients, but in patients with diabetes rising ketone levels in the presence of hyperglycaemia may signify evolving diabetic ketoacidosis (DKA). DKA requires urgent medical review.

Pump reservoir/cartridge – a small syringe for storage of insulin inside the pump.

Stable BGL – no change in insulin infusion rate for 3 hours with normal glucose concentration


Search Terms

Diabetes, Diabetes Management, Insulin, Insulin infusion, Hypoglycaemia, Hyperglycaemia, Insulin pump


Attachments

Attachment 1 - Flowchart for management of Hypoglycaemia

Disclaimer: This document has been developed by Health Directorate, Canberra Hospital and Health Services 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.



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(to be completed by the HCID Policy Team)Date Amended Section Amended Approved ByEg: 17 August 2014 Section 1 ED/CHHSPC Chair



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Attachment 1 - Flowchart for management of Hypoglycaemia

Key Points in Managing Hypoglycaemia* Identify and treat the cause of hypoglycaemia.* If the patient is hypoglycaemic when the next dose of insulin is due, delay administration until after correction of the hypoglycaemia.* Do not omit next insulin dose, consider dose review.* If the hypoglycaemia is severe/recurrent, or the patient has type 1 diabetes, seek expert advice from endocrine unit (or ward medical registrar if endocrinology unavailable).

General Information* If unsure, always seek advice.* With-holding insulin in type 1 diabetes places them at risk of diabetic ketoacidosis (DKA).* Consider asking endocrine unit for consultations for all type 1 diabetes patients admitted to hospital.



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