2021+JBDS-IP指南：成人糖尿病患者低血糖的住院管理（修订版）

JBD

DiabetesSoc

frinpatientcre

PJ"Brh

TheHospitalManagementofHypoglycaemiainAdultswithDiabetesMellitus

RevisedApril2021

ThisdocumentiscodedJBDS01intheseriesofJBDSdocuments:

OtherJBDSdocuments:

Thehospitalmanagementofhypoglycaemiainadultswithdiabetesmellitus

JBDS01

Themanagementofdiabeticketoacidosisinadults

JBDS02

Managementofadultswithdiabetesundergoingsurgeryandelectiveprocedures:

improvingstandards

JBDS03

Self-managementofdiabetesinhospital

JBDS04

Glycaemicmanagementduringtheinpatiententeralfeedingofstrokepatients

withdiabetes

JBDS05

Themanagementofthehyperosmolarhyperglycaemicstate(HHS)inadultswith

diabetes

JBDS06

Admissionsavoidanceanddiabetes:guidanceforclinicalcommissioninggroupsand

clinicalteams

JBDS07

Managementofhyperglycaemiaandsteroid(glucocorticoid)therapy

JBDS08

Theuseofvariablerateintravenousinsulininfusion(VRIII)inmedicalinpatients

JBDS09

Dischargeplanningforadultinpatientswithdiabetes

JBDS10

Managementofadultswithdiabetesonthehaemodialysisunit

JBDS11

Managementofglycaemiccontrolinpregnantwomenwithdiabetesonobstetric

wardsanddeliveryunits

JBDS12

Themanagementofdiabetesinadultsandchildrenwithpsychiatricdisordersin

inpatientsettings

JBDS13

Agoodinpatientdiabetesservice

JBDS14

Inpatientcareofthefrailolderadultwithdiabetes

JBDS15

Diabetesatthefrontdoor

JBDS16

ThesedocumentsareavailabletodownloadfromtheABCDwebsiteat

https://abcd.care/joint-british-diabetes-societies-jbds-inpatient-care-groupandthe

DiabetesUKwebsiteat

.uk/joint-british-diabetes-society

TheseguidelinescanalsobeaccessedviatheDiabetologists(ABCD)app(needABCDmembershiptoaccesstheapp)

@JBDSIP

/JBDSIP/

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3

Copyrightstatement

Theseguidelinesarefreeforanyonetodistribute,amendanduse.However,wewould

encouragethosewhousethemtoacknowledgethesourceofthedocumentandcitetheJointBritishDiabetesSocietiesforInpatientCare

TheGuidelinesproduced

bytheJointBritishDiabetesSocietiesforInpatientCarearelicensedunder

CCBY-NC4.0

Disclaimer

Theinformationcontainedinthisguidanceisaconsensusofthedevelopmentandconsultationgroups’viewsoncurrenttreatment.Itshouldbeusedinconjunctionwithanylocalpolicies/

procedures/guidelinesandshouldbeapprovedforuseaccordingtothetrustclinicalgovernanceprocess.Carehasbeentakeninthepreparationoftheinformationcontainedintheguidance.Nevertheless,anypersonseekingtoconsulttheguidance,applyitsrecommendationsoruse

itscontentisexpectedtouseindependent,personalmedicaland/orclinicaljudgementinthecontextoftheindividualclinicalcircumstances,ortoseekoutthesupervisionofaqualifiedclinician.Thegroupmakesnorepresentationorguaranteeofanykindwhatsoeverregardingtheguidancecontentoritsuseorapplicationanddisclaimanyresponsibilityforitsuseor

applicationinanyway.

Toenabletheguidelinetostayrelevant,itisenvisagedthatalloftheJBDSguidelineswillbe

updatedorreviewedeachyear.Assuchtheseare‘living’documents–designedtobeupdatedbasedonrecentlypublishedevidenceorexperience.Thus,feedbackonanyoftheguidelinesiswelcomed.Pleaseemail

christine.jones@nnuh.nhs.uk

withanycomments,suggestionsor

queries.

Conflictofintereststatement

Theauthorsdeclarenoconflictsofinterest

Contents

Foreword 6

Leadauthorship 7

Previousauthors 7

Supportingorganisationsandfunders 7

Currentwritinggroup 7

Distributedandincorporatedcommentsfrom: 7

Whathaschangedsincethepreviousguideline? 8

“Trafficlight”hypoglycaemiaalgorithm9

Treatmentofhypoglycaemiaalgorithms10

A.Adultswhoareconscious,orientatedandabletoswallow 11

B.Adultswhoareconsciousbutconfused,disorientated,unabletocooperateor

aggressivebutareabletoswallow 13

C.Adultswhoareunconsciousand/orhavingseizuresand/orareveryaggressive 15

D.Adultswhoare‘nilbymouth’ 17

E.Adultsrequiringenteral/parenteralfeeding 18

Whenhypoglycaemiahasbeensuccessfullytreated(afterfollowingtheinitialsteps

outlinedinalgorithmsA-E) 20

SupportingEvidence21

Hypoglycaemiainadultswithdiabetes 21

Definition 22

Frequency 22

Hypoglycaemiafrequencyduringhospitaladmissions 22

Glycaemictargetsforpeoplewithdiabetesinhospital(PWDiH) 24

“Looming”hypoglycaemia 24

ClinicalFeatures 25

Impairedawarenessofhypoglycaemia 26

Riskfactorsforhypoglycaemia 26

PotentialofhypoglycaemiaforPWDiH(Table3)27

causes

MorbidityandmortalityofhypoglycaemiaaffectingPWDiH27

4

5

Managementofhypoglycaemia28

Introduction 28

Preventinghypoglycaemiainpeoplewithdiabetesinhospital(PWDiH) 28

HumanapproachestoreducinghypoglycaemiainPWDiH 28

ComputerisedapproachestoreducinghypoglycaemiainPWDiH 29

Continuoussubcutaneousinsulininfusions(CSII) 29

Evidencefororaltreatmentoptions29

Quantityofrapid-actingcarbohydrate 29

Typeofrapid-actingcarbohydrate 30

Timetoresolutionandretestinginterval 30

Hypoglycaemiarequiringthirdpartyassistanceanddriving 31

“Sugartax” 31

Evidenceforparenteraltreatmentoptions32

Glucagon 32

Intravenousglucose 33

“Hypo”boxes 33

Conclusion34

References35

Appendix1:Examplecontentsofahypobox 39

Appendix2:Auditstandards 40

Appendix3:HypoglycaemiaAuditForm 41

HypoglycaemiaAuditForm(Cont’d) 42

Appendix4:ExampleofaHypoglycaemicEpisodeLabel 43

Appendix5:Dextrose10%and20%infusions 44

Appendix6:MembershipofJBDSIPGroup 46

Foreword

Hypoglycaemiacontinuestobeoneofthemostfearedshort-termcomplicationsofdiabetes

mellitusamongstpeoplewithdiabetes,healthcareprofessionalsandlaycarersalike.Despite

advancesintherapeuticsandtechnology,forpeoplereceivinginsulinorsulfonylureatherapy

astreatmentfortheirdiabetes,evidencewouldsuggestthatachievinggoodglycaemiccontrolwhileavoidinghypoglycaemiaremainsverydifficult.Intercurrentillnessandthehospital

settingcompoundsthissituation,withoftendisruptedaccesstomedications,mealsandsnackscomparedwiththehomeenvironment.

Oftenpeoplewithdiabetesareadmittedtohospitalwithanissueunrelatedtotheirdiabetes.Theycanbeunderthecareofmanydifferentmedicalorsurgicalspecialties;thiscanresultinthembeingtreatedbystaffwithoutspecialistdiabetesknowledge.

InresponsetotheseissuesthisguidelinewasproducedbytheJointBritishDiabetesSocieties

(JBDS)forInpatientCaretoofferclearguidancefortheeffectivemanagementofhypoglycaemiainhospital.ItappearsclearthatTrustsinEnglandhavewelcomedthiswithover90%reportingthattheyuseittoguidehypoglycaemiamanagementwithintheirhospital(s).

Theguidelineisreviewedregularlyandupdatedinresponsetonewevidence,nationalchangesandcommentsreceived.Theauthorswouldliketothankallinvolvedfortheircommentsandwouldencouragepeopletocontactuswithanyfurthersuggestions.

Thisisthefifthiterationofthisguideline(originalMarch2010withrevisionsSeptember2013,April2018andJanuary2020).

Wehopethatallhealthcareprofessionalsinvolvedinthecareofpeoplewithdiabetesinhospitalwillfindthisausefuldocument.Byadoptingtheprinciplesandadaptingwherenecessary,

theseguidelinesshouldhelpensuregoodquality,timelyandeffectivetreatmentforpeoplewithdiabetesinhospital.

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Leadauthorship

DrAlexGraveling,AberdeenRoyalInfirmary,NHSGrampian

EstherWalden(RGN),NorfolkandNorwichUniversityHospitalsNHSFoundationTrustDrDanielFlanagan,PlymouthHospitalsNHSTrust

Previousauthors

DebbieStanisstreet:thecurrentauthorshipisgratefultoDebbieforallherhardworkwithearlierversionsofthisguidance

Supportingorganisationsandfunders

AssociationofBritishClinicalDiabetologists(ABCD),Chair:DrDipeshPatel(RoyalFree,London)DiabetesInpatientSpecialistNurse(DISN)UKGroup,Chair:EstherWalden(Norwich)

DiabetesUK:DavidJones,AssistantDirectorPolicy,CampaignsandImprovement

JointBritishDiabetesSocieties(JBDS)forInpatientCare,Chair:ProfessorKetanDhatariya(Norwich)

Endorsedby

RoyalCollegeofNursing

Currentwritinggroup

ProfessorKetanDhatariya,NorfolkandNorwichUniversityHospitalsNHSFoundationTrustDrClareCrowley,OxfordUniversityHospitalsNHSFoundationTrust

ProfessorBrianFrier,TheQueen’sMedicalResearchInstitute,UniversityofEdinburghDrNicholasLevy,WestSuffolkHospitalNHSFoundationTrust

Previousmembersofthewritinggroup

ProfessorStephanieAmiel,King’sCollegeHospitalNHSFoundationTrustDrRifatMalik,King’sCollegeHospitalNHSFoundationTrust

Distributedandincorporatedcommentsfrom:

DiabetesInpatientSpecialistNurse(DISN)UKGroupmembership

JointBritishDiabetesSocieties(JBDS)InpatientCareWorkingGroupmembersDiabetesUK

AssociationBritishClinicalDiabetologists(ABCD)

TheDiabetesManagementandEducationGroup(DMEG)oftheBritishDieteticAssociation

UnitedKingdomClinicalPharmacyAssociation(UKCPA)Diabetes&EndocrinologyCommitteeGuildofHealthcarePharmacists(GHP)

RoyalCollegeofPhysicians(RCP)

Training,ResearchandEducationforNursesinDiabetes(TRENDDiabetes)AmbulanceServiceNetwork

DiabetesNurseConsultantsGroup

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Whathaschangedsincethepreviousguideline?

●Themajorchangehasbeentomovethemanagementsectionandmanagement

algorithmtothefrontofthedocument.Thisistomakeiteasierforpeopletoaccessthemostfrequentlyusedsectionsoftheguideline.

●Thepotentialof“looming”hypoglycaemiainpeoplewithdiabetesinhospitalis

discussedwhenbloodglucoselevelsareintherange4.0-6.0mmol/L.Theimportanceofproactiveadjustmentofdiabetestreatmentandindividualisedtargetsforglycaemiccontrolhasbeenemphasisedforpeoplewithdiabetesinhospital.

●Theintroductionclarifiesthetreatmentof16-18yearoldpeoplewithdiabetes.

●Thetermglucosehasbeenconsistentlyappliedtoglucosecontainingpreparationssuitableforintravenousadministration.

●Theamountofintravenousglucoseadministeredhasbeenspecifiedratherthanasuggestedrange,thisistosimplifytreatmentinanemergencysituation.

●Wehaveusedtheterm“people/personwithdiabetesinhospital(PWDiH)”ratherthan“patients”or“inpatients”wherepossible.

AlgorithmfortheManagementofHypoglycaemiainAdultswithDiabetesinHospital

Hypoglycaemiaisaseriousconditionandshouldbetreatedasanemergencyregardlessoflevelofconciousness.Hypoglycaemiaisdefinedasbloodsugarglucoseof<4.0mmol/L(ifnot<4.0mmol/Lbutsymptomaticgiveasmallcarbohydratesnackforsymptomrelief)Seefullguideline“The

HospitalManagementofHypoglycaemiainAdultswithDiabetesMellitus”

at.uk/joint-british-diabetes-society

9

Treatmentofhypoglycaemiaalgorithms

Allnon-pregnant,adultswithdiabetesinhospitalwithabloodglucoselevellessthan4.0mmol/L(withorwithoutsymptomsofhypoglycaemia)shouldbetreatedasoutlinedinthisguideline;

remember“4.0isthefloor”.

Promotetheprescriptionofhypoglycaemia“rescue”treatmentforallpeoplewithdiabetesinhospital(PWDiH)oninsulinorsulfonylureatherapy.Thiscouldinvolvea“PRN(prorenata)”or“asneeded”prescriptionofintravenous(IV)glucoseand/orintramuscular(IM)glucagon.Theadventofelectronicprescribingallowingtheuseofan“orderset”shouldmakethisprocess

easier.

InPWDiHwhoareconsciousandabletoswallow,15-20gofrapid-actingcarbohydrateisthe

treatmentofchoice(seealgorithmA).Ifthepersonisfastingforaprocedureoroperation,thenconsiderusingintravenousglucosetoavoidtheoperationorprocedurebeingpostponedduetooralcarbohydrateconsumption.Subsequenttreatmentalgorithmsdiscusstreatmentoptionsforthoseunabletoconsumeoralcarbohydrateforavarietyofreasons(seealgorithmsB,C,D&E).Thesefivealgorithmsaresummarisedinthe“trafficlight”algorithmontheprecedingpage.

Adultswhohavepoorerglycaemiccontrolmaystarttoexperiencesymptomsofhypoglycaemiaabove4.0mmol/L.Thereisnoevidencethethresholdsforcognitivedysfunctionarereset

upwards.Adultswhoareexperiencinghypoglycaemiasymptomsbuthaveabloodglucoselevelgreaterthan4.0mmol/Lshouldbegivenacarbohydratecontainingsnack(e.g.banana,asliceofbreadornormalmealifdue).

TheriskofloominghypoglycaemiashouldbeconsideredinPWDiHwhohaveabloodglucoselevelof4.0-6.0mmol/Lwhileinhospital.ForthemajorityofPWDiHonanyinsulinpreparationand/oranyinsulinsecretagogues,considerinterveningatacapillarybloodglucose(CBG)of

<6.0mmol/Ltopreventhypoglycaemia.Thismayrequireoralorintravenouscarbohydratedependingontheclinicalsituation.Anindividualisedapproachisalwaysneededandadviceshouldbesoughtfromtheinpatientdiabetesteamifunsure.

ForsomePWDiH,especiallythoseusinginsulinpumpsand/orwearableglucosesensors,arangeof4-6mmol/Lmaybetheirnormalwhentheyarenoteating.ForthesePWDiHitisimportanttohaveadiscussionwiththemabouttheneedtoavoidseverehypoglycaemia,theymayneedtoaimforhigherglucoselevelsthantheyareusedto.Thedecisionastowhethertointerveneatabloodglucoseof<6.0or<5.0mmol/LshouldideallybeajointdecisionbetweenthePWDiHandinpatientdiabetesteam.

weretemporaryandrequiredreview(e.g.withholdingasulfonylureaandmetforminafterhypoglycaemiaduringaperiodofacutekidneyinjury).

Pleaseconsiderhowbesttocommunicatewithcolleaguesinprimarycareiftherehavebeensignificanttreatmentchanges.Thiswouldbeparticularlyimportantiftreatmentchanges

WeareawarethatdifferentNHStrustsusedifferenceintravenousglucosepreparations.Apowerpointversionofthealgorithmwillbeavailablethatcanbemodifiedtosuitlocal

circumstancesandtreatmentavailability.

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A.Adultswhoareconscious,orientatedandabletoswallow

1.Quicklycheckthefollowing.Don’tspendtoomuchtimeonthis,particularlyifthepersonisotherwisewell,beforemovingontostep2:

a.Airway

b.Breathing

c.Circulation

d.Disability(includingGlasgowComaScale(GCS)andbloodglucose)

e.Exposure(includingtemperature)

2.Ifthepersonwithdiabetesinhospital(PWDiH)hasaninsulininfusioninsitu,stopimmediately

3.Give15-20grapid-actingcarbohydrateofthepersonwithdiabetesinhospital’sPWDiH’schoicewherepossible.Someexamplesare:

a.5-7Dextrosol®tablets(or4-5LiftGlucoTabs™)

b.1bottle(60ml)Liftjuiceshots

c.150-200mlpurefruitjuice(e.g.orangejuice),donotuseiffollowingalowpotassiumdiet(e.g.totreatchronickidneydisease)inviewofitspotassiumcontent

d.3-4heapedteaspoonsofsugardissolvedinwater(sugardissolvedinwaterisnotaneffectivetreatmentforPWDiHtakingacarboseasitpreventsthebreakdownofsucrosetoglucose)

4.Repeatcapillarybloodglucosemeasurement10-15minuteslater.Ifitisstilllessthan

4.0mmol/L,repeatstep1(nomorethan3treatmentsintotal).Ifitisabove4.0mmol/Lthengotostep5.

5.Ifbloodglucoseremainslessthan4.0mmol/Lafter30-45minutesor3treatmentcycles,callformedicalassistance.Ifagreedlocally,glucagon(andIVglucose)maybegivenwithoutprescriptioninanemergencyforthepurposeofsavingalifeorviaaPatient

GroupDirective.Consider:

a.1mgofglucagonIM(onlylicensedforinsulininducedhypoglycaemia,maybelesseffectivewhenadministeredrepeatedly,inPWDiHprescribedsulfonylureatherapyorPWDiHwithahistoryofalcoholabuseorchronicliverdisease)

b.100mlof20%glucose(at400ml/hourover15minutes)or200mlof10%

glucose(at800ml/hourover15minutes).Careshouldbetakenwithinfusionpumpsettingsiflargervolumebagsareusedtoensurethewholebagisnotinadvertentlyadministered.Considersmallestpossiblevolumeinrenaland/orcardiacfailure

6.Repeatcapillarybloodglucosemeasurement10minuteslater.Ifitisstilllessthan

4.0mmol/L,repeatstep3.

7.Oncebloodglucoseisabove4.0mmol/LandthePWDiHhasrecovered,givealong-

any.PWDiHa

portionoflong-actingcarbohydrate(40g)toreplenishglycogenstores(doublethe

suggestedamountsbelow)althoughnauseaassociatedwithglucagoninjectionsmaybeanissue.Examplesinclude:

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actingcarbohydratesnack(20g)ofthePWDiH’schoicewherepossible,takinginto

considerationspecificdietaryrequirementsgivenglucagonrequirelarger

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a.Twobiscuits

b.Onesliceofbread/toast

c.200-300mlglassofmilk(notsoyaorotherformsof‘alternativemilk,e.g.almondorcoconut)

d.Normalmealifdue(mustcontaincarbohydrate)

8.PWDiHwhoself-managetheirinsulinpumps(CSII)maynotneedalong-acting

carbohydrate,butshouldtakeinitialtreatmentasoutlinedandadjusttheirpump

settingsappropriately.ManyPWDiHwillhavealocallydevisedhypoglycaemiaprotocolthatshouldbecheckedtoensureitremainsappropriateforuseintheinpatientsetting.

9.DONOTomitinsulininjectionifdue.Theinsulininjectionabouttobegivenis

unlikelytobetheinsulindosethatwasactiveatthetimeofthehypoglycaemiaepisodeandsoshouldnotbeomitted.However,considerationwillhavetobegivenastowhichinsulindosewasactiveatthetimeofthehypoglycaemicepisodeandsoareviewoftheirinsulinregimenislikelytoberequired.

10.Ifthehypoglycaemiawascausedbysulfonylureaorlong-actinginsulintherapythenbeawaretheriskofhypoglycaemiamaypersistforupto24-36hoursfollowingthelastdose,especiallyifthereisconcurrentrenalimpairment.

11.DocumenteventinPWDiH’sclinicalrecord.Ensureregularcapillarybloodglucose

monitoringiscontinuedforatleast24to48hours.AskthePWDiHtocontinuethisathomeiftheyaretobedischarged.GivehypoglycaemiaeducationorrefertolocalDiabetesInpatientTeam.AneducationleafletisavailablefromtheTrendDiabetes

website(

https://trenddiabetes.online/

)(loginrequired).

B.Adultswhoareconsciousbutconfused,disorientated,unabletocooperateoraggressivebutareabletoswallow

1.Quicklycheckthefollowing.Don’tspendtoomuchtimeonthisbeforemovingontostep2:

a.Airway

b.Breathing

c.Circulation

d.Disability(includingGlasgowComaScale(GCS)andbloodglucose)

e.Exposure(includingtemperature)

2.Ifthepersonwithdiabetesinhospital(PWDiH)hasaninsulininfusioninsitu,stopimmediately

3.IfthePWDiHiscapableandcooperative,followsectionAinitsentirety.

4.IfthePWDiHisnotcapableand/oruncooperative,butisabletoswallow,give2tubes

40%glucosegel(e.g.Glucogel®)squeezedintothemouthbetweentheteethand

gumsor(ifthisisineffective)giveglucagon1mgIM(onlylicensedforinsulininduced

hypoglycaemia,glucagonmaybelesseffectiveinPWDiHprescribedsulfonylureatherapyorPWDiHwithahistoryofalcoholabuseorchronicliverdisease).

5.Repeatcapillarybloodglucoselevelsafter10-15minutes.Ifitisstilllessthan4.0mmol/Lrepeatsteps1and3(nomorethan3treatmentsintotalandonlygiveIMglucagon

once).

6.Ifbloodglucoseremainslessthan4.0mmol/Lafter30-45minutesor3treatment

cycles,callformedicalassistance.Ifagreedlocally,IVglucosemaybegivenwithoutprescriptioninanemergencyforthepurposeofsavingalifeorviaaPatientGroup

Directive.Give100mlof20%glucoseat400ml/houror200mlof10%glucoseat

800ml/hourover15minutes.Careshouldbetakenwithinfusionpumpsettingsif

largervolumebagsareusedtoensurethewholebagisnotinadvertentlyadministered.Considersmallestpossiblevolumeinrenalimpairmentand/orcardiacfailure.

7.Repeatcapillarybloodglucosemeasurement10minuteslater.Ifitisstilllessthan

4.0mmol/L,repeatsteps3and4ifrequired.

8.Oncebloodglucoseisabove4.0mmol/LandthePWDiHhasrecovered,givealong-

actingcarbohydratesnack(20g)ofthePWDiH’schoicewherepossible,takinginto

considerationanyspecificdietaryrequirements.PWDiHgivenglucagonrequirealargerportionoflong-actingcarbohydrate(40g)toreplenishglycogenstores(doublethe

suggestedamountsbelow)althoughnauseaassociatedwithglucagoninjectionsmaybeanissue.Examplesinclude:

a.Twobiscuits

b.Onesliceofbread/toast

c.200-300mlglassofmilk(notsoyaorotherformsof‘alternative’milk,e.g.almondorcoconut)

9.PWDiHwhoself-managetheirinsulinpumps(CSII)maynotneedalong-acting

carbohydrate,butshouldtakeinitialtreatmentasoutlinedandadjusttheirpump

settingsappropriately.ManyPWDiHwillhavealocallydevisedhypoglycaemiaprotocolthatshouldbecheckedtoensureitremainsappropriateforuseintheinpatientsetting.

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d.Normalmealifdue(mustcontaincarbohydrate)

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10.DONOTomitinsulininjectionifdue.Theinsulininjectionabouttobegivenis

unlikelytobetheinsulindosethatwasactiveatthetimeofthehypoglycaemiaepisodeandsoshouldnotbeomitted.However,considerationwillhavetobegivenastowhichinsulindosewasactiveatthetimeofthehypoglycaemicepisodeandsoareviewoftheirinsulinregimenislikelytoberequired.

11.Ifthehypoglycaemiawascausedbysulfonylureaorlong-actinginsulintherapythenbeawaretheriskofhypoglycaemiamaypersistforupto24-36hoursfollowingthelastdose,especiallyifthereisconcurrentrenalimpairment.

12.DocumenteventinPWDiH’sclinicalrecord.Ensureregularcapillarybloodglucose

monitoringiscontinuedforatleast24to48hours.AskthePWDiHtocontinuethisathomeiftheyaretobedischarged.GivehypoglycaemiaeducationorrefertolocalDiabetesInpatientTeam.AneducationleafletisavailablefromtheTrendDiabetes

website(

https://trenddiabetes.online/

)(loginrequired).

C.Adultswhoareunconsciousand/orhavingseizuresand/orareveryaggressive

1.Check:

a.Airway(andgiveoxygen)

b.Breathing

c.Circulation

d.Disability(includingGlasgowComaScale(GCS)andbloodglucose)

e.Exposure(includingtemperature)

2.Ifthepersonwithdiabetesinhospital(PWDiH)hasaninsulininfusioninsitu,stopimmediately

3.Requestimmediateassistancefrommedicalstaff

4.Ifagreedlocally,IVglucoseorIMglucagonmaybegivenwithoutprescriptioninanemergencyforthepurposeofsavingalifeorviaaPatientGroupDirective.

5.IfIVaccessisavailablegive100mlof20%glucoseat400ml/houror200mlof10%glucoseat800ml/hourover15minutes.Ifaninfusionpumpisavailablethenusethis,butifnotavailabletheinfusionshouldnotbedelayed.Careshouldbetakenwith

infusionpumpsettingsiflargervolumebagsareusedtoensurethewholebagisnotinadvertentlyadministered.Thesmallestpossiblevolumeshouldbeadministeredinrenaland/orcardiacfailure.

6.IfnoIVaccessisavailablethengive1mgGlucagonIM.Glucagonisonlylicensed

forinsulininducedhypoglycaemiaandmaybelesseffectiveinPWDiHprescribed

sulfonylureatherapy(maytakeupto15minutestotakeeffect).Glucagonmobilises

glycogenfromtheliverandwillbelesseffectiveinthosewhoarechronically

malnourished(includingthosewhohavehadaprolongedperiodofstarvation),abusealcoholorhavechronicliverdisease.InthissituationIVglucoseisthepreferredoption.IfnoIVaccessisavailableinitially,continuetryingtoachieveIVaccessasIMglucagonislesslikelytobesuccessfulifrequiredforasecondtime.

7.Repeatcapillarybloodglucosemeasurement10minuteslater.Ifitisstilllessthan

4.0mmol/L,repeatstep5(or6ifIVaccessremainsunavailable).

8.Oncebloodglucoseisabove4.0mmol/LandthePWDiHhasrecovered,givealong-

actingcarbohydratesnack(20g)ofthePWDiH’schoicewherepossible,takinginto

considerationanyspecificdietaryrequirements.PWDiHgivenglucagonrequirealargerportionoflong-actingcarbohydrate(40g)toreplenishglycogenstores(doublethe

suggestedamountsbelow)althoughnauseaassociatedwithglucagoninjectionsmaybeanissue.Examplesinclude:

a.Twobiscuits

b.Onesliceofbread/toast

c.200-300mlglassofmilk(notsoyaorotherformsof‘alternative’milk,e.g.almondorcoconut)

9.IfPWDiHremainsnilbymouthseealgorithmD.

15

d.Normalmealifdue(mustcontaincarbohydrate)

16

10.PWDiHwhoself-managetheirinsulinpumps(CSII)maynotneedalong-acting

carbohydrate,butshouldtakeinitialtreatmentasoutlinedandadjusttheirpump

settingsappropriately.ManyPWDiHwillhavealocallydevisedhypoglycaemiaprotocolthatshouldbecheckedtoensureitremainsappropriateforuseintheinpatientsetting.

11.DONOTomitinsulininjectionifdue.Theinsulininjectionabouttobegivenis

unlikelytobetheinsulindosethatwasactiveatthetimeofthehypoglycaemiaepisodeandsoshouldnotbeomitt