Summary:  Jared Ellsmore

Editor:  Glynis Ross

 

With Associate Professor Glynis Ross, Endocrinologist at Royal Prince Alfred Hospital, Sydney, Australia

This week’s podcast is the second part of the discussion around managing deranged blood glucose levels on the wards, with a focus on hypoglycaemia.

 

Associate Professor Glynis Ross is a Visiting Endocrinologist at Royal Prince Alfred Hospital and part-time Senior Staff Specialist at Bankstown-Lidcombe Hospital, Sydney. She has been in charge of the Diabetes in Pregnancy Service at Royal Prince Alfred Women’s and Babies’ Hospital for over 25 years.

Glynis was a member of the Australasian Diabetes in Pregnancy Society (ADIPS) Council from 1991-1998 and 2002-2012, and President from 2008-2010. She has been on the Australian Diabetes Society Council since 2012 and is currently Vice-President and President-Elect. Her major clinical and research interests are Diabetes in Pregnancy, Type 1 Diabetes, Insulin Pump Therapy and In-patient Diabetes Management. Dr Ross serves on State and National Working Parties in these areas. She is involved in the teaching programs of trainees of the Australasian Colleges of Anaesthetics, Obstetrics & Gynaecology, and Physicians, as well as education programmes for Midwives, General Practitioners and Medical Undergraduates.

Introduction

Part 2 continues the discussion of blood glucose management on the wards. Hypoglycaemia remains a commonly encountered situation requiring management and review, and requires junior doctors to have a thorough understanding of more general diabetes management and control.

 

Case 1 – You are a junior doctor on the wards. Nursing staff contact you to report a patient with a blood glucose level (BGL) of 3.0 mmol.

 

1. Immediate management if patient capable of oral intake

  • Patient requires rapid acting glucose, approx. 15 gm initial dose
    • E.g. Half cup of juice/soft drink, 3 teaspoons of honey, 6 jelly beans, oral glucose
  • Note: do not mix these with longer acting forms of carbohydrate, e.g. the patient’s meal, as this will decrease absorption of rapid acting glucose
    • As such, the patient should cease any meal until BGL>4.0 mmol
  • Monitor BGL every 10-15 minutes until BGL>4.0 mmol
  • If BGL levels remain low, give further 15 gm rapid acting carbs
  • If BGL>4.0 mmol, proceed to meal/more substantial food
  • Once hypoglycaemia has been adequately treated, check BGL hourly for the next 4-6 hours
    • Note: active longer acting insulin or sulfonylureas may still place the patient at risk of hypoglycaemia recurring for up to 12-24 hours

2. Immediate management if patient incapable of oral intake

  • Due to decreased mental state or physical limitations, patient may not be able to take glucose orally
  • Administer 150 mL 10% dextrose IV (=15 g glucose)
  • Option of 50% dextrose IV push, however this may irritate vein
  • If unconscious, consider additional glucagon injection
    • Although this should be avoided unless absolutely necessary

3. Investigating Causes of Hypoglycaemia

  • Once the patient is stabilised, it is important to assess why the hypoglycaemic event occurred in order to prevent future recurrence
  • Causes of hypoglycaemia may include:
    • Medications given when patient fasting
    • Patient not eating (full) meals
    • Changes to steroid doses
    • Enteral/NGT feeding where an occlusion has occurred in the lumen but not been recognised

4. Fasting

  • Planned fasting
    • Withhold all oral medications, especially SGLT2 inhibitors (generally cease these during inpatient stays)
    • Withhold meal-time insulin (correction insulin still permissible)
  • Unplanned fasting
    • Rapid review of all medications with individualised plan, ensuring IV cannula in and dextrose commenced and increased frequency of monitoring

5. Does the patient need an Endocrine Review?

  • Simply having diabetes is not an indication for referral of a patient to the Endocrinology team
  • Patients with diabetes should be referred for formal consultation if they meet any of the following criteria:
    • Type 1 diabetes
    • Insulin pump therapy
    • Diabetes managed with complex regimens
    • Diabetes with eating disorders
    • Insulin treated patients requiring enteral feeds
    • Patients on concentrated insulin, e.g. 300 Units/mL or 500 Units/mL
    • Pregnancy
    • Diabetes emergencies
  • Patients with diabetes should be considered for referral (formal or informal advice) if they have:
    • Poor glycaemic control (HbA1c over 9%)
    • Unstable diabetes
    • Perioperative preparation advice
    • Recurrent hypoglycaemia
    • Persistently elevated glucose levels despite medication adjustment
    • Steroid therapy
  • Any patient newly commenced on insulin as in inpatient and who is likely to require ongoing insulin post discharge needs timely referral to diabetes services

Take home messages

  • All episodes of hypoglycaemia require a plan for rapid acting carbohydrate, increased BGL monitoring and a thorough review of potential causes
  • Endocrine review is not compulsory for all inpatients with diabetes, but should be requested for all patients with type 1 diabetes and all patients type 2 diabetes who have complex insulin regimens or more complex medical status

 

If you enjoyed listening to this week’s podcast feel free to let us know what you think by posting your comments or suggestions in the comments box below.

 

 

Podcast

Part 2: Blood glucose monitoring – Hypoglycaemia