Authors: Carly Smith, Charlotte Davies, Ify Chika / Editors: Joseph Nunan, Liz Herrieven / Codes: C3AP4, EnP3, SLO1, SLO3 / Published: 26/11/19
“This patient has attended with a blood sugar of 23. They’re a known diabetic – could you just prescribe them some insulin whilst they’re waiting?”
If that seems like a common clinical presentation, this blog post is for you. We’re talking about hyperglycaemia in the ED. There aren’t any official guidelines on management, but our experience has shown that there’s a huge variation in practice, and many cases are mismanaged.
Diabetes is a problem with sugar control. There are two types:
- Type 1
- Type 2 (may or may not be on insulin)
- NIDDM and IDDM are old descriptors, and should not be used as they just lead to confusion.
Presentation One – hyperglycaemia in the well patient, with no history of diabetes
This is a common presentation to the ED. You need to first confirm they are well – check finger prick ketones (not urine ketones), a venous blood gas, and calculate the osmolality.
The temptation is to assume they are all type 2 if they’re adults, but this is wrong. We’re seeing increasing numbers of Northern Europeans presenting with new onset type 1 diabetes. It’s all about the symptoms. Diabetologists will do blood tests (GAD/Islet cell antibodies, C-peptide and a plasma glucose) to confirm whether it is type 1 or 2, but you won’t get those results back in time for ED review.
If the patient is likely type 1, and definitely well, they’ll need an urgent diabetes review. Starting these patients on a sliding scale will not be in their best interests – commencing subcutaneous long acting insulin is safest. Your trust will have a guideline – ours advises starting with a low dose of a long-acting insulin such as Lantus (0.2units/kg), which can be titrated up by the diabetes team once home blood glucose monitoring meters and education have been provided.
If the patient likely has type 1 diabetes but has biochemical derangement (like an acidosis) or ketonaemia, even if they don’t have symptoms, admit them under the care of the medical team.
If the patient likely has type 2 diabetes, but again is well, confirm there is no biochemical derangement or ketonaemia. Your management will depend on the absolute blood glucose level and the patient’s symptoms.
Blood sugars <11.1mmol should be followed up by the GP, with no further actions. Patients with a blood sugar >11.1mmol and <20 should be given dietary advice. General practice is not to start any drug therapy until 6 months after dietary modifications have been made – the GP can follow this up and will probably refer to a diabetes dietary education programme. Blood sugars >20mmol start to enter the grey area of management. The first thing is to check for any osmotic symptoms (thirst, polyuria, polydipsia, blurred vision, thrush). If there are osmotic symptoms, encourage good oral hydration and consider IV fluids.
Osmotic symptoms are really likely >25mmol, and blood sugars >25mmol are more likely to progress onto complications. There is a high risk of complications at this level, even if patients don’t have HHS (hyperosmolar hyperglycaemic state) yet, so we suggest admitting these patients for monitoring and hyperglycaemic control. Subcutaneous insulin is often not recommended as it causes significant blood sugar swings, but in this case some short acting insulin such as Actrapid can be useful.
Presentation Two – known type 1 DM with hyperglycaemia
The first step is to look for any red flags and make sure the patient isn’t in DKA. If they are, treat according to DKA guidelines.
If the patient is not in DKA, look for a reason why they might be hyperglycaemic.
– Confirm compliance – living with a chronic disease like diabetes, some patients don’t use their insulin as they know they should
– Check injection sites for lipatodermatosclerosis
– Check insulin storage
– Rule out intercurrent illness
– Ask if they’ve just eaten a meal (re-check CBG after two hours)
If the patient is well, correct any modifiable risk factors. If there is no obvious cause, we’d first suggest that the patient contacts their diabetes specialist team. If no team is available (e.g. if it’s a weekend), it is usually safer to titrate their short acting insulin first.
Presentation Three – known type 2 DM with hyperglycaemia
These are really tricky to manage, as there are so many different agents!
This may help pic.twitter.com/jbF4dOJ5v3
— Rowan Gossedge (@RowanLGossedge) November 26, 2019
The first step is always to make sure the patient is well with no red flags (blood ketones <1.5, pH normal, normal sodium and osmolality). If they’re not well, treat them as HHS (previously called HONK).
Blood sugars <20 can be managed with dietary advice and GP review to alter medications. Blood sugars 20 – 25 need dietary advice and adjustments to medications. Our local guidelines are here.
Blood sugars >25 should be treated with IV fluids. Short-acting subcutaneous insulin such as Actrapid (6 – 10 units) should be considered. The patient shouldn’t be discharged until their sugar is <25 due to the risk of progressing to HHS. Some trusts will want to admit BMs >20 – check with your local diabetes team.
Your hospital is very likely to have a friendly diabetes team. The management of diabetes is ever evolving and ever exciting – so do get in touch with them.
- An increasing number of people with diabetes are presenting to hospital acutely unwell.
- It is highly likely that the first healthcare professional who assesses and initially manages the patient will not be a specialist in diabetes.
- Opportunities to ensure safe, effective diabetes care from early in the hospital admission process are not fully appreciated or utilised.
- Uncontrolled diabetes can delay clinical recovery of other illnesses.
- Raising awareness of diabetes at the hospital front door is an important issue to help improve efficiency and reduce risk in diabetes care.
If this has inspired you why not read or complete a module about treating hypoglycaemia. If high sugars are what you want to learn about, we also have a module, SAQ and induction blog on DKA. If you think DKA and HHS are easy… see if these two tweets change your mind!
Rare but happens side effect of Gliflozins. DKA but sugars normal. Must check but likely to see more of these as very effective and seem to reduce heart and renal failure in diabetics pic.twitter.com/4t9WlzRyVy
— Katherine Henderson (@KatherineRCEM) October 5, 2019
Thread/— Jamie Willows (@jamiekwillows) September 21, 2020
Do you look after patients with HHS?
UK guidelines use calculated osmolality = 2Na + Glucose + Urea
“What’s the problem?”
Including urea lowers the diagnostic threshold in patients with CKD
– a group at ⬆️risk of treatment harm
But it gets much worse 👇#medtwitter