Guidelines for the management of hypoglycaemia in adults

rcht.nhs.uk

Guidelines for the management of hypoglycaemia in adults

CLINICAL GUIDELINE FOR THE CARE OF PEOPLE WITH

DIABETES THE MANAGEMENT OF HYPOGLYCAEMIA IN

ADULTS

1. Aim/Purpose of this Guideline

This guideline is for the management of Hypoglycaemia in Adults with Diabetes.

It has been benchmarked against national guidance, to provide detailed guidance

on the clinical management of hypoglycaemia in line with best practice

guidelines. This guideline applies to all healthcare professionals involved in the

treatment of hypoglycaemia

2. The Guidance

Hypoglycaemia

Hypoglycaemia (which literally means low sugar in the blood) occurs when the blood

glucose falls below 4 mmol/l

Symptoms of Hypoglycaemia

may include one or more of the following

Sweating

Hunger

Pallor

Headache

Odd behaviour, confusion, aggression

Weakness

Drowsiness

All episodes of hypoglycaemia i.e. glucose < 4mmol/l should be treated even if symptoms

are not present

References






G. Williams, J Pickup 2009 :The Handbook of Diabetes 3 rd Edition.

The Oxford Centre for Diabetes, 2002 Endocrinology and Metabolism.

Diabetes UK 2010 (Online)

Resuscitation Council(UK) 2010 (Online)

NHS Diabetes 2010 : The Hospital Management of Hypoglycaemia in Adults with Diabetes Mellitis

Clinical Guideline For The Care Of People With Diabetes The Management Of Hypoglycaemia In Adults

Page 1 of 8


Initial Management of Hypoglycaemia

(For patients who are enterally fed whilst nil by mouth see page 3)

Is the peripheral blood glucose < 4 mmol/l

Yes

If the peripheral blood glucose < 2.8 mmol/l a

venous sample must be obtained as per policy

Clinical guideline for use of Nova Stat Strip blood

glucose meter

(Do not wait for the result before treating the hypo)

No

Hypoglycaemia management is not

appropriate.

BUT consider other reasons for

symptoms and review soon as blood

glucose may be dropping rapidly

Is the patient conscious and able to swallow?

Yes No

1. Inform medical staff

2. Give 15 - 20 grams of fast acting carbohydrate

15-20 grams is

150-200 mls of pure fruit juice

90-120 mls of Lucozade original

150-200 mls of Coca Cola original

30-40 mls (to be diluted) of Ribena original

4 - 5 Glucotabs

3 - 4 heaped teaspoons of sugar dissolved in

a non milky drink

Or

3. If the patient is Nil By Mouth

1½ - 2 tubes of Glucose oral gel squeezed into the

side of the mouth. (not swallowed).Rubbing the cheek

can aid absorption.

4. Repeat peripheral blood glucose in 10 minutes.

N.B. follow this process twice only then seek medical

review for Intravenous glucose / IM Glucagon

1. Inform medical staff

2. Intravenous injection of 50 mls of 10% glucose

(must be prescribed)

3. Further intravenous injection 50mls of 10%

glucose every minute until the glucose is > 4 mmol/l

(must be prescribed) (give up to 150 mls in total)

Or

4. 1 mg of glucagon s.c, or i.m. (must be prescribed)

*

Then

5. Repeat peripheral blood glucose in 10 minutes.



Glucagon may be ineffective in episodes of

hypo precipitated by the ingestion of alcohol

N.B. follow this process twice only then seek

medical review

Is the peripheral blood glucose< 4mmol/l

Yes

If the patient is conscious and not nil by mouth

1. Follow up with long acting carbohydrate i.e. 2 plain biscuits or 1 slice of toast or 200-300 mls of milk (Double

the amount if Glucagon used)

Or

2. A meal with carbohydrate if the next meal is due.

If the patient remains unconscious or is nil by mouth obtain medical review

Guidance Notes

Do not withhold insulin / medication. Once the hypoglycaemia has been treated as per the above

guidelines, administer usual insulin / medication to prevent rebound hyperglycaemia.

Intravenous Insulin Infusion is not a treatment for hypoglycaemia

Note that hypo due to overdose of oral hypoglycaemics/insulin/ may be prolonged and may require

prolonged dextrose infusion

Continue regular blood glucose monitoring for at least 24 -48 hours. Long term management - medical

review of insulin / medication / cause of repeated episodes of hypoglycaemia.

For further advice refer to Diabetes In-Patient Specialist Nurse bleep 2205 / #3104 or the Endocrine team

No

Clinical Guideline For The Care Of People With Diabetes The Management Of Hypoglycaemia In Adults

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Initial Management of Hypoglycaemia

Adult inpatients with Diabetes who are being ENTERALLY fed whilst nil by mouth

Is the peripheral blood glucose < 4 mmol/l

Yes

No

If the peripheral blood glucose < 2.8 mmol/l a

venous sample must be obtained as per policy

Clinical guideline for use of Nova Stat Strip

blood glucose meter

(Do not wait for the result before treating the

hypo)

Hypoglycaemia management is not

appropriate.

BUT consider other reasons for symptoms

and review soon as blood glucose may be

dropping rapidly

1. Inform medical staff

2. Give 15 - 20 grams of fast acting carbohydrate via the enteral feeding tube (by gravity– use a

purple syringe as per NPSA).




15-20 grams is

45-60 mls Juice style Supplement Drink (ProvidExtra Juice Drink, Ensure Plus Juice or

Fortijuice)

30-40 mls of Ribena original (do not dilute)

3-4 heaped teaspoons of sugar dissolved in sterile water


flush with 50mls of sterile water

Then

N.B. follow this process twice only then seek medical review for Intravenous glucose / IM Glucagon

Repeat peripheral blood glucose in 10 mins

Is the peripheral blood glucose< 4mmol/l

Yes No



1. Follow up with long acting carbohydrate via enteral feeding tube:

Restart Enteral feed

or

give 100 mls of Milky Supplement drink

(Fresubin Energy Drink, Ensure Plus Milk Shake Style, Fortisip)

CC/BH

Guidance Notes

Do not use Oral Glucose Gel due to risk of aspiration

Avoid using fizzy drinks or fruit juice as these can damage the tube

Do not withhold insulin / medication. Once the hypoglycaemia has been treated as per the above guidelines,

administer usual insulin / medication to prevent rebound hyperglycaemia.

Continue regular blood glucose monitoring for at least 24 -48 hours. Long term management - medical review

of insulin / medication / cause of repeated episodes of hypoglycaemia.

Intravenous Insulin Infusion is not a treatment for hypoglycaemia

Note that prolonged hypo may require prolonged dextrose infusion

For further advice refer to Diabetes Dietitian bleep 2955 / #4569 / #2409

Clinical Guideline For The Care Of People With Diabetes The Management Of Hypoglycaemia In Adults

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3. Monitoring compliance and effectiveness

Element to be

monitored

Lead

Tool

Frequency

Reporting

arrangements

Acting on

recommendations

and Lead(s)

Compliance

Specialist Adult In-Patient Diabetes Team

Patient Documentation

Adult diabetes In-patients who are reviewed by the specialist

diabetes team who have required management of Hypoglycaemia

Non compliance will be reported to the ward /area manager.

Repeated non compliance will be reported via Datix

Ward / Area managers will undertake subsequent

recommendations and action planning for any or all deficiencies

and recommendations within reasonable timeframes for their areas

The Specialist Adult In-Patient Diabetes Team will undertake any

trust wide recommendations and action planning for any or all

deficiencies and recommendations within reasonable timeframes

Change in

practice and

lessons to be

shared

Lesson learned or changes to practice will be shared with all the

relevant stakeholders

4. Equality and Diversity

4.1. This document complies with the Royal Cornwall Hospitals NHS Trust service

Equality and Diversity statement.

4.2. Equality Impact Assessment

The Initial Equality Impact Assessment Screening Form is at Appendix 2.

Clinical Guideline For The Care Of People With Diabetes The Management Of Hypoglycaemia In Adults

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Appendix 1. Governance Information

Document Title

Date Issued/Approved: 19 Jul 12

Clinical Guideline For The Care Of People

With Diabetes The Management Of

Hypoglycaemia In Adults

Date Valid From: 19 Jul 12

Date for Review: 1 July 2015

Directorate / Department responsible

(author/owner):

Amanda Veall Clinical Nurse Specialist

Diabetes

Contact details: 01872 253104

Brief summary of contents

Treatment for hypoglycaemia in adults with

diabetes

Suggested Keywords:

Target Audience

Executive Director responsible for

Policy:

Diabetes

RCHT PCT CFT


Medical Director

Date revised: April 2012

This document replaces (exact title of

previous version):

Approval route (names of

committees)/consultation:

Divisional Manager confirming

approval processes

Guidelines For The Management Of

Hypoglycaemia In Adults

Diabetes In-Patient Specialist Nurses,

Specialist Diabetes Dietitian, Consultant

Endocrinologists

Rowena Green

Name and Post Title of additional

signatories

Signature of Executive Director giving

approval

Publication Location (refer to Policy

on Policies – Approvals and

Ratification):

Document Library Folder/Sub Folder

Not Required

{Original Copy Signed}

Internet & Intranet Intranet Only

Clinical/ Endocrine And Diabetes

Links to key external standards NSF Diabetes Standards 7 and 8

Related Documents:

NHS Diabetes: The Hospital Management

Clinical Guideline For The Care Of People With Diabetes The Management Of Hypoglycaemia In Adults

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Training Need Identified?

of Hypoglycaemia in Adults with Diabetes

Mellitus March 2010

Yes / Learning and Development have been

informed via email 15/05/2012

Version Control Table

Date

March

2010

30 April

2012

Version

No

V1.0 Initial Issue

V2.0

Summary of Changes

Amendment to quantities of CHO and

enterally fed patients in accordance with

national guideline

Changes Made by

(Name and Job Title)

Amanda Veall

Clinical Nurse

Specialist Diabetes

Amanda Veall

Clinical Nurse

Specialist Diabetes

All or part of this document can be released under the Freedom of Information

Act 2000

This document is to be retained for 10 years from the date of expiry.

This document is only valid on the day of printing

Controlled Document

This document has been created following the Royal Cornwall Hospitals NHS Trust

Policy on Document Production. It should not be altered in any way without the

express permission of the author or their Line Manager.

Clinical Guideline For The Care Of People With Diabetes The Management Of Hypoglycaemia In Adults

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Appendix 2.Initial Equality Impact Assessment Screening Form

Name of service, strategy, policy or project (hereafter referred to as policy) to be

assessed: Clinical Guideline For The Care Of People With Diabetes The Management

Of Hypoglycaemia In Adults

Directorate and service area: Diabetes

Is this a new or existing Procedure?

Existing

Telephone: 01872 253104

Name of individual completing

assessment: Amanda Veall

1. Policy Aim* To provide detailed guidance on the clinical management of

hypoglycaemia in line with best practice guidelines.

2. Policy Objectives* To provide a consistent approach to the management

of hypoglycaemia at RCHT sites.

3. Policy – intended

Outcomes*

4. How will you measure

the outcome?

5. Who is intended to

benefit from the Policy?




To maintain patient safety and improve outcomes for

patients experiencing hypoglycaemia whilst inpatients

at RCHT sites

Consistent management of hypoglycaemia at RCHT

sites.

Prompt and safe management of hypoglycaemic

episodes and follow up care.

Audit

Datix Reporting

Review of nursing/ medical documentation as required

All patients with diabetes who experience hypoglycaemia in

hospital at RCHT sites.

6a. Is consultation

required with the

workforce, equality

groups, local interest

groups etc. around this

policy?

b. If yes, have these

groups been consulted?

c. Please list any groups

who have been consulted

about this procedure.

Yes

Yes

Diabetes Inpatient Specialist Nurses

Consultant Endocrinologists

Diabetes Dietician

*Please see Glossary

7. The Impact

Please complete the following table using ticks. You should refer to the EA guidance notes

for areas of possible impact and also the Glossary if needed.

Where you think that the policy could have a positive impact on any of the equality

group(s) like promoting equality and equal opportunities or improving relations

within equality groups, tick the ‘Positive impact’ box.

Where you think that the policy could have a negative impact on any of the equality

group(s) i.e. it could disadvantage them, tick the ‘Negative impact’ box.

Clinical Guideline For The Care Of People With Diabetes The Management Of Hypoglycaemia In Adults

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Where you think that the policy has no impact on any of the equality group(s) listed

below i.e. it has no effect currently on equality groups, tick the ‘No impact’ box.

Equality

Group

Age

Positive

Impact

Negative

Impact

No

Impact

x

Reasons for decision

Disability

x

Religion or

belief

Gender

x

x

Transgender

x

Pregnancy/

Maternity

Race

x

x

Sexual

Orientation

Marriage / Civil

Partnership

x

x

You will need to continue to a full Equality Impact Assessment if the following have

been highlighted:

A negative impact and

No consultation (this excludes any policies which have been identified as not

requiring consultation).

8. If there is no evidence that the policy

promotes equality, equal opportunities

or improved relations - could it be

adapted so that it does? How?

Full statement of commitment to policy of

equal opportunities is included in the policy

Please sign and date this form.

Keep one copy and send a copy to Matron, Equality, Diversity and Human Rights,

c/o Royal Cornwall Hospitals NHS Trust, Human Resources Department, Chyvean

House, Penventinnie Lane, Truro, Cornwall, TR1 3LJ

A summary of the results will be published on the Trust’s web site.

Signed ________Amanda Veall________________________________

Date _____10-07-2012____________________________________

Clinical Guideline For The Care Of People With Diabetes The Management Of Hypoglycaemia In Adults

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