HYWEL DDA LOCAL HEALTH BOARD
Guidance for the management of glycaemic
control in Adult Critical
Care patients
(including the management of insulin infusions, and
frequency of blood glucose measurements)
1
Policy Number:
Version
No:
Date Of
Review:
Supercedes:
Reviewer
Name:
Completed
Action:
NA
Standards For
Healthcare
Services No/s
Approved by:
Date
Approved:
New
Review
Date:
1
Brief Summary
of Document:
This guideline describes the glycaemic control of patients in Adult Critical
Care. It includes instruction on how to manage insulin infusions, and how
often to measure blood glucose levels.
To be read in
conjunction with:
Surviving Sepsis Campaign: International guidelines for management of
severe sepsis and septic shock.
NICE-SUGAR Study: Intensive versus conventional glucose control in
critically ill patients
Classification:
Category:
Freedom Of
Information
Status
Authorised by:
Job Title
Signature:
HYWEL DDA LOCAL HEALTH BOARD
Responsible
Officer/Author:
Liz Collins
Dept
Critical Care
Job
Title:
Senior Nurse for Critical Care
Base
Carmarthenshire
Contact Details:
Tel No
2072
ORGANISATION
WIDE
Scope
E-mail:
[email protected]
DEPARTMENT
ONLY
DIRECTORATE

Critical Care
Staff Group
Administrative/
Estates
Medical & Dental

Allied Health
Professionals

Ancillary
Nursing

Scientific &
Professional
COUNTY ONLY

Carmarthenshire

Maintenance
Other
Please indicate the name of the individual(s)/group(s) or committee(s) involved in the
consultation process and state date agreement obtained.
CONSULTATION
Individual(s)
Group(s)
Dr Rice, Chris Hayes
Date(s)
Critical care Service
Improvement Group
Date(s)
Committee(s)
Date(s)
RATIFYING AUTHORITY
KEY
(in accordance with the
Schedule of Delegation)
NAME OF COMMITTEE
A = Approval
Required
FR = Final
Ratification
Date Equality Impact
Assessment
Undertaken
Pre audit Dec
2012/Jan 2013
Post audit:???
Please enter any keywords to be
used in the policy search system
to enable staff to locate this policy
Database No:
Group
completing
Equality impact
assessment
Date Approval
Obtained
COMMENTS/
POINTS TO NOTE
Glycaemic Management Task and Finish group
Glycaemic control; Insulin infusions; Blood glucose
measurement; Adult critical care
Page 2 of 13
Insert name of policy
Version
HYWEL DDA LOCAL HEALTH BOARD
Document Implementation Plan
How Will This Policy Be
Implemented?
Nursing staff: Education presentation.
Anaesthetic Staff: Presentation clinical audit meeting.
Who Should Use The
Document?
Nursing, Medical and allied heath care staff working in adult critical care
areas within Glangwili General and Prince Philip Hospital.
What (if any)
Training/Financial
Implications are
Associated with this
document?
Training will take place during working time hours
Action
By Whom
What are the Action
Plan/Timescales for
implementing this policy?
Database No:
Page 3 of 13
Insert name of policy
Version
By When
HYWEL DDA LOCAL HEALTH BOARD
CONTENTS
1. INTRODUCTION –
5
2. POLICY STATEMENT –
5
3. SCOPE –
5
4. AIMS –
5
5. OBJECTIVES –
5
6. BODY OF GUIDELINE

Method of blood glucose sampling
6

On admission to critical care
6

Glucose sampling frequency
6

Treatment of high blood glucose levels
7

Stopping Feeding
8

Hypoglycaemia
8

Management of Severe hypoglycaemia
8

“Normal” diabetic treatment in patients previously
known to be diabetic
9

Discharge from adult critical care
9

Glucose control for the Non Insulin Diabetic and
Hyperglycaemic patient within critical care .
10

Glucose control for the Insulin Controlled Diabetic
patient within critical care.
11

Blood sampling flow chart
12
Database No:
Page 4 of 13
Insert name of policy
Version
HYWEL DDA LOCAL HEALTH BOARD
1. INTRODUCTION –
In critically ill patients, stress induced hyperglycaemia is a common problem, with severe
hyperglycaemia being associated with an increased morbidity and mortality. In critically ill
insulin-controlled diabetic patients, the stress response together with altered nutritional intake
further exacerbates hyperglycaemia resulting in an increase insulin requirement.
Recommendations from National guidelines on the management of severe sepsis and septic
shock support the use of conventional glucose control with an upper blood glucose limit of
10mmol/l (Dellinger et al 2012). Consequently in addition to the insulin controlled diabetic
patient, there may also be a need to administer insulin to the non-diabetic patient who is
critically ill to maintain glucose levels within recommended limits. It is also essential to avoid
hypoglycaemia in all Adult Critical Care patients and therefore blood glucose levels should be
measured regularly.
2. POLICY STATEMENT –
The purpose of this guideline is to set out the management of blood glucose in non-diabetic
and diabetic critically ill patients managed within a critical care area.
It states the strict processes that must be followed which are necessary for the effective
risk management and care of the patient requiring variable rate insulin infusion for
hyperglycaemia, and/or who develops hypoglycaemia and makes clear the responsibilities of,
and gives clear guidance to, the staff who are making decisions with regard management
requirements.
3. SCOPE –
The guideline outline is the responsibility of medical, nursing, and allied health care
professionals who have responsibility for managing critically ill patients within the following
areas:
 Adult Critical Care Glangwili General Hospital
 Intensive Care Unit, Prince Philip Hospital.
It does not apply to paediatric cases, patients with diabetic ketoacidosis DKA (refer to Hywel
Dda Health Board DKA guidelines), patients managed outside Critical Care and adults within
Critical Care for whom it has been decided that it has been deemed inappropriate to continue
active treatment.
4. AIMS –
The aim of this policy is to clarify the clinical accountability of the nursing, medical and allied
health care professionals’ who are responsible for patient’s care within critical care areas in
Carmarthenshire.
5. OBJECTIVES –
To ensure that there is:
 Consistent management of glycaemic control in critically ill patients.
 Prompt and appropriate management of hyperglycaemia and hypoglycaemia.
 Processes in place to limit the risk of hypoglycaemia.
Database No:
Page 5 of 13
Insert name of policy
Version
HYWEL DDA LOCAL HEALTH BOARD
6. BODY OF POLICY
In critically ill patients, stress induced hyperglycaemia is a common problem, with severe
hyperglycaemia and hypoglycaemia being associated with an increased morbidity and
mortality. It is therefore essential that all patients admitted to critically care have their blood
glucose managed appropriately so as to reduce the risk of patients developing hyper and
hypoglycaemia as far as possible.
Method of blood glucose sampling
Blood glucose levels may be measured using a nova glucometer, a blood gas analyser or a
venous sample sent to the laboratory. Staff should ensure that they have been properly
trained with the relevant equipment beforehand.
Both glucose meters and blood gas machines may be needed for the measurement of patients
managed on adult Critical Care. Blood gas analysis machines are recognised as being more
accurate, and when indicated should be used in preference to blood glucose meters.
Samples taken using a finger-prick technique may be less accurate in hypotensive patients or
those on large doses of vasopressors, or in Hyperosmolar Hyperglycaemic State. Repeated
finger-prick for samples will result in increase trauma and discomfort for the patient, therefore
the use of blood aspirated from a arterial line, or a central venous catheter provided it is not
being used to deliver a glucose-containing infusion, will be more reliable for measuring glucose
levels and where possible should be used in preference to samples obtained from a finger
prick.
On admission to an Adult Critical Care area:



All patients must have a blood glucose measured.
Blood glucose levels MUST be checked in the event of sudden LOSS OF
CONSCIOUSNESS, SWEATING, TACHYCARDIA, HYPOTENSION
Any abnormal blood glucose level (>18mmol/L or <4mmol/L) MUST be confirmed by
taking a second sample (after confirming that there are NO GLUCOSE CONTAINING
FLUIDS contaminating the sample).
 A VENOUS BLOOD SAMPLE MUST BE SENT TO THE LABORATORY
FOR either BLOOD GLUCOSE MEASUREMENT from a BLOOD GAS OR
GLUCOSE METER MEASUREMENT OF <2.2MMOL/L (or where results
are unexpected), but this MUST NOT DELAY TREATMENT.
Glucose sampling frequency
The absolute minimum frequency of blood glucose measurement for patients with glucose
level between 4 – 10mmol/L’s should be:



On admission
At the Fourth hour after admission
Every 8 hours thereafter
NB Refer to page 10 for detail guidance on frequency of blood glucose measurement.
Database No:
Page 6 of 13
Insert name of policy
Version
HYWEL DDA LOCAL HEALTH BOARD
BUT: If Variable Rate Intravenous Insulin Infusion is started, blood glucose levels should be
measured every hour for the first 2 hours, only if the blood glucose remains stable can
frequency of measurements be decreased to 2 hourly. If feeding started or stopped, or 50%
glucose given for hypoglycaemia, then blood glucose levels should be measured at least
hourly until the patient is stable.
Treatment of high blood glucose levels
Any blood glucose greater than 10mmol/L should be checked again 1 hour later. If a blood
glucose level is high on two consecutive readings an hour apart then an insulin infusion may
be prescribed by the medical staff.
Before commencing an insulin infusion ALWAYS:


If a finger prick sample has been used, recheck blood glucose using a arterial or venous
sample.
If arterial or venous sample has been used, recheck blood glucose using either arterial
or venous sample.
The prescription used should be the variable rate insulin infusion pre-printed on the front of the
Adult Critical Care Intravenous Infusions Chart. ONLY this chart may be used for a variable
rate insulin infusion whilst patients are in Adult Critical Care areas (ACC in GGH and ITU in
PPH)
The target blood glucose is 4-10mmol/L. Insulin infusions should be made up using Human
Actrapid Insulin. 50 units of insulin (0.5ml) should be added to 49.5mls of Sodium Chloride
0.9% to make a total volume of 50mls.
The infusion should be set according to the insulin prescription.
Insulin infusions MUST be accompanied by either:



A 5% glucose infusion, or a 4% glucose/0.18% sodium chloride (dextrose/saline)
infusion
Parenteral nutrition (TPN)
Eating and drinking, or feeding via a nasogastric (NG), nasojejunal (NJ),
jejunostomy (jej) or percutaneous gastrostomy (PEG) tube
There may be some rare occasions where starved hyperglycaemic patients are not
commenced on glucose-containing infusions (or on infusions at a very low rate) – THIS
IS A CONSULTANT-ONLY DESICION and must be documented in the medical records
and Blood Glucose levels MUST be CHECKED EVERY HOUR if a patient is receiving an
insulin infusion.
Medical staff MUST be informed if a blood glucose level is:



Ever <4mmol/L
Ever >20mmol/L
>10mmol/L after 6 hours of insulin
The insulin infusion scale should be modified accordingly if there are repeated hypoglycaemic
episodes (BM < 4mmol/L) or if glycaemic control is not adequately gained (blood glucose
repeatedly >10mmol/L). Modifications should be written in the blank sections and the standard
variable rate infusion crossed out.
Database No:
Page 7 of 13
Insert name of policy
Version
HYWEL DDA LOCAL HEALTH BOARD
Factors which may increase insulin requirements include:




Rises in TEMPERATURE will increase insulin requirements
DIABETIC patients, or patients with a high Body Mass Index (BMI)
STEROID therapy is likely to increase requirements usually by 20%
FITTING is likely to lead to raised requirements post-seizure
Stopping feed
Insulin infusions MUST be accompanied by a glucose-containing infusion, or parenteral
nutrition (TPN), or enteral feed (NG, NJ or Jejunostomy feeding)
If feeding is stopped the insulin MUST also be stopped, or a glucose containing infusion
commenced (any decision not to start a glucose containing infusion must be made by a
Consultant). If feeding started or stopped, or 50% glucose given for hypoglycaemia, then
recommence hourly blood glucose measurements.
Hypoglycaemia
Hypoglycaemia occurs when the blood glucose level is low. This can become dangerous when
the levels are very low for prolonged periods of time, starving the vital organs, including the
brain, of glucose. Hypoglycaemia typically occurs when:




Too much insulin is inadvertently given
Insulin is given in the absence of feeding or glucose
Occasionally in severely septic patients
Occasionally in patients with severe liver failure or adrenal failure
Symptoms of hypoglycaemia may be difficult to spot in sedated patients, but they include:




Loss of consciousness, include seizure activity
Sudden sweating
Sudden tachycardia
Sudden hypotension or resistance to inotropes
If these symptoms are present then a blood glucose level MUST be checked. If at any time a
blood glucose is low (<4mmol/L) medical staff should be informed as it may become
necessary to treat for hypoglycaemia
Management of severe hypoglycaemia (<2.2mmol/L)
Severe hypoglycaemia with a blood glucose level of <2.2mmol/L will always need treatment
and the following should be done:





Recheck blood glucose confirm severe hypoglycaemia (< 2.2mmol/L)
Stop infusion of insulin
Send a laboratory blood glucose sample if possible (do not delay treatment)
Give 20mls of 50% glucose IV,(or 80ml of 20% glucose IV) recheck blood glucose
within 15 minutes and commence hourly blood glucose measurements thereafter as
appropriate.
Consider cause of hypoglycaemic episode (e.g. failure to absorb feed, liver failure, etc)
Database No:
Page 8 of 13
Insert name of policy
Version
HYWEL DDA LOCAL HEALTH BOARD
“Normal” diabetic treatment in patients previously known to be diabetic
All patients admitted to Adult Critical Care will have their blood glucose assessed according to
the above guidelines
All unstable patients will be managed according to the above guidelines, regardless of whether
or not they were known to have diabetes prior to admission to Adult Critical Care.
Where patients are stable and are known to have diabetes prior to admission to Adult Critical
Care it may become appropriate to restart their normal anti-diabetic medications, which may
include oral anti-diabetic tablets or subcutaneous insulin preparations. It is rarely appropriate
for this to be required in patients who are not fully conscious, or who are level 3 patients.
(Re: section below. Awaiting feedback from diabetic team)
If oral anti-diabetic medications are restarted whilst on critical care then the insulin MUST have
already been discontinued, the patient MUST be being fed, and blood glucose levels must be
checked 2 hourly for a minimum of 6 hours after the first tablet
If subcutaneous insulin preparations are restarted whilst on critical care then stop the insulin
infusion 1 hour after the first subcutaneous injection of insulin. The patient MUST be being fed.
The subcutaneous insulin MUST be prescribed on the Hywel Dda Health Board diabetes
prescription chart, and blood glucose levels must be checked as per individual management
plan.
Discharge from Adult Critical Care wards
In a ward environment, the dangers of hypoglycaemia left unmonitored outweigh the benefits
of tight glycaemic control. A previously non-insulin requiring patient on < 2 units/hour can be
discharged without insulin, with a request that the blood glucose be checked within 4 hours.
If insulin of > 2units/hour is required to maintain blood glucose then a variable rate infusion
should be prescribed on the Ward Hospital insulin prescription sheet and the receiving team
informed and asked to refer the patient, as a new or undiagnosed diabetic, to an appropriate
physician or endocrinologist.
Database No:
Page 9 of 13
Insert name of policy
Version
HYWEL DDA LOCAL HEALTH BOARD
Glycaemic Control in Non Insulin Dependent Diabetic and Hyperglycaemic
Adult Critical Care Patients
On admission to Adult Critical Care
Blood glucose level
< 4mmol/L
4-10mmol/L
10.1 – 15mmol/L
> 15.1mmol/L
Actions
Inform medical staff, who should identify the cause
and consider treating for hypoglycaemia
No Action
If blood glucose > 10mmol/L on two consecutive
samples, ensure the patient is fed (oral, enteral or
parenteral), or receiving a glucose-containing infusion
and commence insulin infusion: see standard variable
rate infusion regime
Inform medical staff – commence insulin infusion see
standard variable rate infusion regime
Next Blood Glucose
within 15 minutes
4hrs then 8hrly thereafter
1 hour
1hour
Blood glucose levels whilst on Critical Care
Standard variable rate insulin infusion regime
Glucose level
<4mmol/L
Insulin Infusion Rate
Next Blood Glucose
Stop inform medical staff
Within 15 minutes
0 unit
1Hour
6.1 – 10
0 unit/hour
1 Hour
10.1-12mmol/L
1 units/hour
1 Hour
12.1-15mmol/L
2 units/hour
1Hour
15.1- 18mmol/L
3 units/hour
1Hour
4.0- 6mmol/L
>18mmol/L
4 units/hour and inform medical staff
Where patients are persistently >18mmol/L a more aggressive sliding scale regimen may be used.
Blood glucose monitoring for patients receiving variable rate insulin infusion.
Blood glucose must be checked hourly until stable then 2 hourly thereafter.
Blood glucose levels must be undertaken hourly until stable following any adjustments to insulin
infusion rate.
Other actions
Actions
Next Blood Glucose
If feeding is started
1 hour
If feeding is stopped
Stop insulin OR commence
1 hour
glucose containing infusion
If treatment for
hypoglycaemia is administered
15 minutes
If high concentration
glucose infusions are used (e.g. for
the treatment of hyperkalaemia)
1 hour, if not sooner
If there is new Sweating, Loss of consciousness, Tachycardia, or Hypotension
Check blood glucose level immediately
Database No:
Page 10 of 13
Insert name of policy
Version
HYWEL DDA LOCAL HEALTH BOARD
Glycaemic Control in INSULIN DEPENDENT Adult Critical Care Patients
Blood glucose level
< 4mmol/L
4-6mmol/L
6.1-10mmol/L
10.1 – 15mmol/L
> 15.1mmol/L
Glucose level
<4mmol/L
On admission to Adult Critical Care
Actions
Inform medical staff, who should identify the cause
and consider treating for hypoglycaemia
No action
Inform medical staff, ensure the patient is fed (oral,
enteral or parenteral), or receiving a glucosecontaining infusion and commence insulin infusion:
see Insulin dependant diabetic variable rate infusion
regime.
Inform medical staff, commence Insulin dependant
diabetic variable rate infusion regime.
Inform medical staff, commence insulin Dependant
diabetic variable rate infusion regime.
Next Blood Glucose
within 15 minutes
1 hour
1 hour until stable.
2 hourly thereafter.
1 hour.
1 hour.
Blood glucose levels whilst on Critical Care
Insulin Dependant variable rate insulin infusion regime
Insulin Infusion Rate
Next Blood Glucose
Stop inform medical staff
Within 15 minutes
4.0- 6mmol/L
6.1 – 10
10.1-12mmol/L
12.1-15mmol/L
15.1- 18mmol/L
0 unit
1Hour
1 unit/hour
2 units/hour
3 units/hour
4 units/hour
1 Hour
1 Hour
1Hour
1Hour
5 units/hour and inform medical staff
>18mmol/L
Where patients are persistently >18mmol/L and normally managed using high doses of insulin when well, a
more aggressive sliding scale regimen may be used.
Blood glucose monitoring for patients receiving variable rate insulin infusion.
Blood glucose must be checked hourly until stable then 2 hourly thereafter.
Blood glucose levels must be undertaken hourly until stable following any adjustments to insulin
infusion rate.
Other actions
Actions
If feeding is started
If feeding is stopped
If treatment for
hypoglycaemia is administered
If high concentration
glucose infusions are used
(e.g. for the treatment of
hyperkalaemia)
Continue insulin and
commence glucose containing
infusion
Stop insulin variable rate
insulin regime
Refer to insulin dependant
variable rate insulin regime
Next Blood Glucose
1 hour
1 hour
15 minutes
1 hour, if not sooner
If there is new Sweating, Loss of consciousness, Tachycardia, or Hypotension
Check blood glucose level immediately
Database No:
Page 11 of 13
Insert name of policy
Version
HYWEL DDA LOCAL HEALTH BOARD
Glucose Blood Sampling
Finger Prick for capillary blood should only be undertaken in patients with no central
venues or arterial access.
Blood glucose levels should be checked via:
Arterial access
No
Yes
Arterial line blood sample
measured on a Nova
Glucometer or Blood Gas
analyser as appropriate.
Central Venous Access
No
Capillary Sample
Yes
Central Venous blood sample
measured on a Nova
Glucometer, blood gas
analyzed or laboratory sample
as appropriate.
Finger prick technique measured
on a Nova Glucometer.
Please be aware that the results may be
erroneously low in severe dehydration,
hypotension, shock and hyperosmolar sates.
Before commencing insulin infusion ALWAYS re-check blood glucose using a different
technique (e.g. arterial line, venous laboratory sample or finger-prick)
RESPONSIBILITIES –
All nursing, medical and relevant allied health care professionals must ensure that the
principles outlined within this document are applied within the sphere of their responsibility and
scope of professional practice.
Critical care Service Improvement Group
Development of guideline by sub group of the critical care service improvement group. This
sub group will be established when necessary to examine and address specific issues relating
to glycaemic control within critical care. Reporting on compliance against this guideline is via
the Critical care Service Improvement Group
Doctors
Recognise and managing the blood glucose of non –diabetic and diabetic patients within
critical care including prescription of variable rate insulin infusion, treatment for hypoglycaemia,
“normal” therapy for diabetic patients and nutrition. Referral to the dietician for support with
ongoing nutritional care.
.
Nurses
Through following the guidance on method of sampling, frequency of monitoring and
administration of prescribed management to include variable rate insulin infusion, patients’
normal therapy for diabetes control, nutrition, and highlighting any problems related to
glycaemic control to medical staff.
Dietician:
To support consulting team and nursing staff through provision of expert advice, feeding
regimes and monitoring nutritional status.
Database No:
Page 12 of 13
Insert name of policy
Version
HYWEL DDA LOCAL HEALTH BOARD
Pharmacist
Provision and advice on drug therapy for glycaemic control.
TRAINING
Education package to be developed and undertaken by all nursing staff. Glycaemic control up-date
session included on yearly mandatory programme for nursing staff.
Training / awareness sessions for medical staff delivered during to be discussed.
IMPLEMENTATION AND MONITORING
Monitoring of this guideline will be through Critical Care Service Improvement Group.
7. CLINICAL POLICIES
Clinical policies should also include a review of the evidence used and a reference list of that
evidence.
To be discussed
8. REVIEW
This Policy will be reviewed after 2 years April 2015.
References
Dellinger RP, Levy MM, Rhodes A, et al (2013): Surviving Sepsis Campaign: International
guidelines for management of severe sepsis and septic shock:. Crit Care Med. 41: 580-637.
Finfer S, Chittock DR, Su SY, et al. (2009) Intensive versus conventional glucose control in
critically ill patients. (NICE-SUGAR Study) New England Journal Medicine. Mar
26;360(13):1283-1297.
Database No:
Page 13 of 13
Insert name of policy
Version