Work package Treatment Pathway and care guidelines for Diabetic

Treatment Pathway and care guidelines for Diabetic Ketoacidosis and Hyperglycaemic Hyperosmolar State Diagnostic Tool / Criteria For diagnostic criteria see Management of Diabetic Ketoacidosis and Hyperglycaemic Hyperosmolar State (DKA and HHS) guidelines (already submitted). Community treatment and referral pathway First aid guidelines for GP, patient will need admission if: Blood sugar greater than 14, despite treatment adjustments Ketones equal to or greater than 2 Any signs and symptoms of DKA / HHS Refer to medical team on call and admit to acute medical admission ward for assessment. First aid guidelines for ambulance crew / paramedics Follow medical emergencies guideline Ensure airway maintained Ensure high flow O2 therapy Obtain IV access, and commence rehydration using sodium chloride intravenous 0.9%, 250mls rapidly (up to 20ml/kg in children) and then reassess vital signs, preferably on route to hospital If vital signs and perfusion improve, slow down infusion “to keep vein open” rate If no improvement, give a further 250mls and reassess, repeating process to maximum 2 litres of fluid (40ml/kg in children). Provide hospital alert message / information call and transport to nearest receiving hospital for urgent hospital treatment. Acute DKA and HHS pathway Follow Management of Diabetic Ketoacidosis and Hyperglycaemic Hyperosmolar State (DKA and HHS) guidelines (already submitted). For prescription and treatment in ward areas see Guideline for the management of blood sugars in Hyperglycaemic emergencies in adults with Diabetes (Diabetic ketoacidosis (DKA) and Hyperglycaemic Hyperosmolar State (HHS) (already submitted). In practice this form is colour coded to yellow, ICP should follow this. Discharge procedure Before discharge patient should be seen by Diabetes Specialist Nurse for education regarding sick day rules. Follow up appointment with Diabetologist Referral to community DSN for ongoing support and contact advice. Prevention and self management with first aid guidance Ten key points: 1. Be prepared, any illness can affect Diabetes and usually increase blood glucose levels, so even if you are not eating or drinking very much, your blood glucose can rise. Illnesses such as common cold, flu, abscesses, urinary infections, stomach upsets, sore throats or bronchitis, can affect your Diabetes. Always have a supply of monitoring equipment and sugary fluids / sweets at home. 2. Blood glucose often rises, at times of illness, your body is under stress and this usually raises your blood glucose levels. Do test your blood glucose more regularly, every 2 - 4 hours depending on how poorly you are feeling. If you are unable to check ask a friend or relative for help. If your blood sugars are above 14 mmol/l, and you take Insulin injections, also check your blood or urine for Ketones. (See point 6.) 3. Never Stop Taking Your Diabetes Medication / Insulin, even if you are not eating or drinking very much. 4. Consider alternative drinks / foods, try to drink plenty of liquids such as water or sugar free squash, especially if your blood glucose is high (hyperglycaemia) sip 3 - 4 litres a day. If your blood glucose is low (hypoglycaemia under 4 mmol/l) drink sugary soft drinks, milk or fruit juices. Aim for one small glass of sugary drink an hour (if your blood glucose is low) as well as lots of water or sugar free drinks. You maybe unable to eat your usual meals, and will need to have alternative foods that have starch or carbohydrate at regular intervals (every 2 - 3 hours) if your blood glucose is lower you may need to have it more often. The foods / drinks below all contain 10 grams of Carbohydrate. 200ml thickened/ broth based soup 1 plain yoghurt 1 dried fruit yoghurt 1 scoop of ice cream 3 Glucose tablets 1 sachet of Complan 50mls of Lucozade 100mls natural fruit juice 100mls of Cola, Lemonade or other full sugared fizzy drink (defizzed is easier to sip) 200ml of milk 5. Tell a friend or relative, if you are on your own, that you are ill, and ask them to check on you every 4 - 6 hours. 6. Test for ketones, if you have insulin injections, and your blood sugars rise above 14 mmol/l or you are feeling nauseous, have been sick or have abdominal discomfort test your urine or blood for ketones. Ketones are a sign that your body is lacking insulin, and requires larger insulin doses. If ketones persist or increase in quantity, you can become unwell due to your diabetes. Do not exercise if ketones are present. Ketone level Actions required Ketone levels of 1 or under in blood or urine An acceptable reading, and a sign that your body is breaking down fat to provide your fuel. Ketone level of 1-2 in your blood or urine An elevated reading and a sign that extra insulin is required Test blood glucose and ketone (urine or blood) every 2 hours Contact your GP or Diabetes centre for ongoing advice Ketone level of 2 -3 in your urine or Blood This is a sign of serious diabetes illness (Diabetic Ketoacidosis) You should contact your GP or attend A&E for immediate help and medical treatment. 7. Consider Having More Insulin. When your blood glucose is above 14 mmol/l for more than 2 readings and urine or blood ketones are present. Increase all future insulin doses by 1/5 Continue to test blood glucose 1-2 hourly and urine or blood ketones every 2 hours. Blood glucose above 20 mmol/l or higher / and / or urine or blood ketones present This requires immediate treatment If you use a clear quick acting, analogue insulin (Novorapid, Humalog Lispro, Actrapid, Humulin S) take 8 units as an extra dose. If you have a twice a day insulin regime (Novomix 30, Humalog Mix 25 , Humalog Mix 50 or Human Mixtard 10, 20, 30, 40, 50 or Humulin M3 , M5) take 1/5 of usual insulin (or 10 units if usual dose above 50 units) now as extra dose. Continue to test your blood glucose every 1-2 hours and urine or blood ketones every 2 hours and discuss making further increases with your GP or Diabetes Specialist Nurse. 8. Contact your GP or Diabetes Specialist Nurse for support when: Vomiting or diarrhoea for more than 6 hours Unable to eat or drink for 4 hours Your illness has not improved after 2 days You have had high blood glucose levels (above 14 mmol/l) for 2