1. 1 Diabetes In Hospital Prepared by [Lynne Gilks] [CNC Diabetes Education] [Tamworth Diabetes Centre] [Nov 2010]

2. Diabetes & hospitalisation Issues to consider: Type of Diabetes Glycaemic control during hospitalisation Managing fasting in the diabetic patient Use of sliding scale insulin Lack of basal insulin Discharge planning Follow up

3. Diabetes & hospitalisation Important to determine and document whether: Type 1 diabetes Type 2 diabetes Type 2 insulin requiring

4. Diabetes & hospitalisation Admission necessary the day before surgery for thorough assessment if : Type 1 DM Type 2 DM insulin requiring DM that is poorly controlled Major surgical procedures Patient is likely to be NBM for a prolonged period pre or post operatively

5. Diabetes & hospitalisation Optimal BGL prior to, during and after surgery will assist with wound healing, reduce the risk of post-operative complications (including infection) and shorten hospital time Stress of anaesthetic and surgery tends to cause BGL to rise An increase in diabetes treatment may be required for an extended period Patient should be informed that medication/insulin doses should return to pre-operative doses as they recover and become more active Monitor BLG 4 times per day or more frequently if appropriate

6. Diabetes & hospitalisation Blood glucose levels as close to normal as possible improves in-hospital morbidity & mortality rates. Demonstrated strong association between hospital hyperglycaemia and adverse clinical outcomes. Aim for blood glucose levels 5 to 10 mmol/l Never stop insulin in a Type 1 diabetic Avoid routine use of sliding scale insulin as this destabilises diabetes in most patients. Sliding scale insulin should only be used in limited circumstances

7. Diabetes & hospitalisation Insulin regimes should target prospective (anticipated BGL) rather than reactive retrospectively to previous BGL It is better to adjust overall regime to prevent further rises in BGL If at any stage diabetes management targets are not being met, contact medical team for review of patient

8. Diabetes & hospitalisation Oral Hypoglycaemic agents (OHA) which are started or increased during hospitalisation generally do not work quickly enough to control hyperglycaemia Inpatients who have adequate diabetes control and have no contraindications (patient being acutely ill or renal impairment) OHAs can be continued An insulin/glucose infusion would be used if the patient requires insulin and is fasted for a prolonged period of time (more than 6 hrs) or patient is very unstable

9. Diabetes & hospitalisation The frequency of BG monitoring needs to be assessed regularly Notify Medical Officer if BGL is > 15 mmol/l on 2 consecutive readings or any BGL > 20 mmol/l Check urine ketones in Type 1 patients if BGL is > 15 mmol/l or if the patient is very ill. If ketones are present especially if large urinary ketones or blood ketones are >1.6 or ketoacidosis is suspected contact Medical Officer

10. Diabetes & hospitalisation Surgery: Anaesthetic consult. Advice regarding insulin regimes can be obtained by contacting Endocrinologist or Physician if necessary Metformin should be ceased 48 hrs prior to surgery Sulphonylureas need to be withheld on the day of surgery Daonil, because of it’s long action, may need to be withheld the night before surgery Management determined by BGL and whether the person is eating or not

11. Diabetes & hospitalisation All people with DM should have their BGL checked within 1 hr prior to going to theatre Notify Anaesthetist if: BGL is < 5 mmol/l BGL is > 10 mmol/l BGL should be done during surgery and immediately post-operatively People with Type 1 DM are particularly at risk from ketosis. Notify Anaesthetist or Medical Officer if ketones are present in urine or blood

12. Diabetes & hospitalisation Before giving insulin to a person who is fasting ensure there is an IV glucose infusion in place, that is running Ensure optimal hydration & electrolyte balance (dehydration increases BGL) Operate early in the day (in Type 1 DM prolonged fasting predisposes to DKA) In patients with gastro paresis allow longer period of fasting before surgery All patients with Type 1 DM should be receiving some insulin at all times even when NBM Most people with Type 2 DM will usually need insulin for major surgical procedures

13. Diabetes & hospitalisation Type of IV fluid given will depend on whether the person is receiving insulin, fasting or not and their BGL Glucose infusion must be used if the patient has received insulin prior to or during surgery Monitor BGL at least every 2 hrs- hrly if IV glucose/insulin infusion in situ

14. Diabetes & hospitalisation Check BGL on arrival at recovery Then every 4 to 6 hrs If on IV insulin/glucose infusion then hrly Once stable and eating -before meals All people with Type 1 DM require checks for ketones: At least 8 hrly If BGL > 15 mmol/l If vomiting or generally unwell

15. Diabetes & hospitalisation Discharge planning should start at admission Recommence anticipated discharge regime for at least 24 hrs prior to discharge Patient should be advised of regime on discharge

16. Radiological Procedures Book earliest possible appointment time to minimise problems for people with DM Radiology Dept should be notified the patient has DM and their current treatment regime Medication/ Insulin orders may be modified according the patient’s type of DM, medication/ insulin and time of procedure Any dose reduction needs to be discussed with MO and the person with DM

17. Radiological procedures Well controlled Type 2 DM on diet only or OHA Omit morning dose of OHA if fasting is necessary Metformin should be stopped 48 hrs prior to a procedure Assess serum creatinine levels before restarting Metformin Type 1 & 2 receiving insulin: Individual advice based on insulin regime

18. Radiological procedures BG monitoring equipment should be available BG should be check before, during and after the procedure especially in patient feels unwell or hypoglycaemic All patients with diabetes should bring with them: some quick acting CHO in case of hypoglycaemic episode Radiology Dept should have available: Hypoglycaemia guideline, BG meter and hypo kit

19. Radiological procedures Special precautions may be necessary for people having any radio contrast study which includes angiography, CT scan with enhancement, intravenous pyelography. Those most at risk: Impaired renal function-GFR< 30ml per min Dehydration or effective reduction in blood volume-eg CCF, Hypotension, septic shock or intensive diuretic therapy Other nephrotoxic drugs or medications that may contribute to decreasing GFR-eg gentamicin, diuretics, ACE inhibitors, Angiotensin II receptor antagonists, NSAID, cyclo-oxygenase 2 inhibitors, cyclosporin, vancomycin, tacrolimus, amphotericin.

20. Radiological procedures The following precautions may need to be considered by MO: Stopping certain medications several days before the procedure-eg diuretics, NSAID Hydration before, during and after the procedure

21. Radiological procedures After the procedure: Once eating and drinking recommence medication except for Metformin-check serum creatinine/GFR prior to restarting this It may be necessary to reduce insulin dose if food intake is reduced. Discuss medication adjustment with MO or Diabetes Educator

22. Type 1 diabetes & insulin need Type 1 Diabetics: At diagnosis 80 to 90% of their beta cells have been destroyed by an autoimmune process They become insulin deficient Insulin deficiency results in: -hyperglycaemic -Osmotic diuresis leading to dehydration -ketosis -metabolic acidosis -electrolyte loss

23. Insulin deficiency

24.  Rapid acting –Immediate onset, very short duration –Novorapid, Humalog & Apidra

25.  Short acting  -rapid onset and short duration  -Actrapid & Humulin R

26. Basal/bolus insulin

27. References Guideline for the management of Diabetes during surgery, Diabetes Centre POW hospital Hospitalisation, section 4 Diabetes Manual 7 th edition A guide to Diabetes Management 2009 National Associations of Diabetes Centre Course for Nurses & Allied Health Professional Significance of Hyperglycaemia for Hospitalised patients, N.Wah Cheung. Westmead Hospital