Admissions

Admission blood glucose & HbA1c

Note

The following guidance is for all patients admitted to critical care.

All patients should have their HBA1c checked on admission to Critical Care. Those with elevated HbA1c (> 48 mmol/mol) will require subsequent referral to the Diabetes Specialist Team for ongoing input on step-down.

HBA1c in the diagnosis of diabetes

HbA1c of 48 mmol/mol is considered the cut-off point for the diagnosis of diabetes. However a HbA1c of < 48 mmol/mol does not exclude a diagnosis of diabetes.

All patients should have an admission blood glucose checked either via an ABG / VBG sample or a laboratory glucose.

Monitoring blood glucose

Patients commencing enteral or parenteral feed need their blood glucose monitoring every 4-6 hours.

Patients on an insulin infusion need their blood glucose monitoring as per the hyperglycaemia section of this guideline.

Documentation of diagnoses

Any relevant diagnosis should be documented in the patient’s electronic patient record including:

• Type 1 diabetes
• Type 2 diabetes
• Gestational diabetes
• Critical illness induced hyperglycaemia
• Steroid induced hyperglycaemia

Existing diabetes

It is important to note that the most patients with diabetes will be admitted to critical care for reasons other than their diabetes.

Medication

WARNING

Critical care patients have unpredictable absorption of subcutaneous insulin and this may pose a risk of both under and overdosing of insulin.

A management plan for basal/long acting insulin and other existing diabetes medications should be made on admission to critical care.

INFO

There is an increasing prevalence of type 2 diabetes in the population and with it recent advances in novel antidiabetic agents that may have specific risks and benefits for the critically ill patient. For instance, the use of sodium – glucoseco - transporter 2(SGLT-2) has an associated risk of euglycaemic ketoacidosis. Consult the section of this document for specific risks and guidance on the use of oral and subcutaneous hypoglycaemic agents in the critical care unit.

Feet

Always assess and exclude acute foot infection (may be the source of sepsis) or critical limb ischaemia.

Always ensure the foot is intact and protected.

Insulin pumps

Refer to insulin pump protocol. In DKA or critical illness the absorption of insulin can vary: insulin pumps should be removed and replaced with a variable rate insulin infusion. Consultation with the Diabetes Specialist Team is advised.

Newer Technology

Continuous glucose monitors (CGM) and Freestyle Libre (FSL) devices can usually be left on the patient but conventional capillary glucose monitoring will still be necessary.

WARNING

For imaging, insulin pumps, Continuous Glucose Monitors (CGM) and FreeStyle Libre (FSL) devices need to be removed for magnetic scans such as MRI.

Protocol