Beware of hypoglycaemia as cause of drowsiness in people with stroke. Feed stopped for physiotherapy/ procedure, Misplacement or removal of nasogastric tube, Insulin and oral medication not given at appropriate time for feed, Reduced carbohydrate intake as feed volume reduced, Alteration of type of feed, or timing of feed, Change in time or duration of rest period, Increased physical activity (e.g. capillary blood glucose up to 12 mmol/l), however, then metformin liquid may be considered in people with well controlled Type 2 diabetes, or as an adjunct in uncontrolled Type 2 diabetes. Minimize the use of intravenous insulin infusions/VRIII. When blood glucose level >4 mmol/l and the patient has recovered, give a long‐acting carbohydrate. The nursing care will vary for each, depending on the If capillary blood glucose level <4 mmol/l, inform doctor, give another dose of treatment (see options above) then re‐check blood glucose 10 min later. 0000022723 00000 n People with diabetes admitted to hospital on a basal‐bolus insulin regimen should be reviewed by the diabetes inpatient specialist nurse or diabetes inpatient team at the earliest opportunity. ���"�o 0000055835 00000 n In the absence of ketonaemia, subcutaneous insulin doses can usually be increased safely by 2–4 units (or 10–20%) incrementally, and increased daily if necessary, until the target capillary glucose control is achieved. The person should thus be monitored for signs of hypoglycaemia and the capillary blood glucose level checked hourly, and more frequently (up to every 15 min) if symptoms or signs of hypoglycaemia are present. If blood glucose level still <4 mmol/l, bleep a doctor, and if not done already, ensure intravenous access and start intravenous 10% dextrose at 100 ml/h, increasing intravenous volume given if necessary, according to response. A multidisciplinary approach to managing a person requiring enteral feeding is advocated. In hospital, patients with AP are typically nil by mouth. We would love to hear about the hospital food you have been served recently. Treat if capillary blood glucose persistently >12 mmol/l. Continue subcutaneous basal analogue insulin (glargine or detemir) if treated with basal analogue insulin on admission. A diagnosis of diabetes at least doubles the risk of stroke 1; thus, a considerable proportion of those presenting to hospital with acute stroke will have Type 2 diabetes and, less commonly, Type 1 diabetes. Since then, traffic congestion has grown ever worse and long delays have become a feature of daily life for those who live and work there. This article looks at car… A pre‐mixed (30/70) human insulin at the time of feed commencement, with the second dose at the midpoint of the feed; 50% of the required insulin can be administered with each dose. When the feed is stopped unexpectedly, and insulin has been or is being administered, healthcare practitioners should be acutely aware of the risk of hypoglycaemia. In the event of hypoglycaemia, rapid action is indicated to correct the capillary blood glucose to >4 mmol/l, and to maintain blood glucose above this level. Poor quality hospital food has been highlighted by patient advocates as an issue for decades but Covid-19 isolation measures and a lack of visitors have made this problem even more stark. There is much debate about the target blood glucose for people with diabetes in the acute stages after a stroke 18, 19, with little evidence on how best to achieve this control 20; however, infection rates and other morbidity outcomes from inpatient hospital stay increase with deteriorating glucose control 21.
Others are fed during the day, and in these circumstances, the risk of nocturnal hypoglycaemia is high, particularly if medium‐ or long‐acting insulin products are administered. Involve the diabetes inpatient specialist nurse/diabetes inpatient team immediately in event of hypoglycaemia or recurrent hyperglycaemia. It is advantageous to include the diabetes inpatient specialist nurse or diabetes inpatient team, to plan the diabetes treatment once the enteral feed protocol has been recommended by the dietitian or the multidisciplinary feeding/nutrition team. There are currently no data to support the use of glucagon like peptide‐1 mimetics or gliptins in the management of hyperglycaemia during enteral feeding; however, because these agents work in a glucose‐dependent manner, they may be useful. g���Y�l�>A1� �s~�kJ6��vYf���sGM��-���` $��| endstream endobj 26 0 obj <> endobj 27 0 obj <> endobj 28 0 obj <>stream
There are many options available when choosing an insulin regimen. A fasting period before surgery ensures that if vomiting occurs during surgery, no stomach contents will aspirate into the lungs. In the event of hypoglycaemia or recurrent hyperglycaemia, capillary blood glucose may need to be recorded on a more frequent basis (e.g. 10% dextrose if feed off/not prescribed and nil by mouth. 0000014832 00000 n Insulin dose adjustment according to carbohydrate content of feed. Evidence to support target ranges of blood glucose for inpatients with diabetes is weak 15, 16 and data to support target glucose ranges for people with diabetes receiving enteral feed are weaker still 17. With special thanks to Christine Jones for her administrative work and help with these guidelines and with the JBDS Inpatient Care Group.
Learn more. Someone admitted to a hospital with alcohol poisoning may be placed on a Nil By Mouth (NBM) order. JBDS Inpatient Care Group: B. Allan, Hull and East Yorks Hospital NHS Trust; K. Dhatariya, Norfolk and Norwich University Hospitals NHS Foundation Trust; D. Flanagan, Plymouth Hospitals NHS Trust; M. Hammersley, Oxford University Hospitals NHS Trust; R. Hillson, MBE, National Clinical Director for Diabetes; J. James, University Hospitals of Leicester NHS Trust; J. McKnight, NHS Lothian; R. Malik, King's College Hospital NHS Foundation Trust; G. Rayman, Ipswich Hospitals NHS Trust; K. Richie, Southern Health and Social Care Trust, Northern Ireland; M. Sampson (Norwich) Joint British Diabetes Societies (JBDS) Inpatient Care Group Chair; M. Savage, Pennine Acute Hospitals NHS Trust; A. Scott, Sheffield Teaching Hospitals NHS Foundation Trust; D. Stanisstreet, East and North Hertfordshire NHS Trust; L. Stuart, Pennine Acute Hospitals NHS Trust; J. Thow, York Teaching Hospital NHS Foundation Trust; E. Walden, Norfolk and Norwich University Hospitals NHS Foundation Trust; C. Walton, Hull and East Yorks Hospital NHS Trust; P. Winocour, East and North Hertfordshire NHS Trust. Early involvement of a dietitian to determine an appropriate feed regimen.
The HSE are aware of the problem, as ‘hospital food’ received one of the lowest scores on the National Inpatient Experience Survey over the past three years. For people with diabetes prescribed glargine or detemir on admission to hospital and receiving continuous feeding with capillary blood glucose >12 mmol/l, soluble human insulin may be administered at the start and midpoint of the feed. Send us your photos and experience to [email protected]. This guideline concentrates solely on control of blood glucose during enteral feeding in people with stroke. Lowering blood glucose in people with diabetes during acute stroke has not been shown to significantly improve outcomes 5-7, although glucose‐lowering with insulin has been shown to limit cerebral infarct size in animal studies 8.
We will also look at the difference a nutritionally-sound hospital diet complements treatment by looking at latest research and comparing practices in other countries. 0000020585 00000 n 0000060859 00000 n In response, it has produced a new nutrition policy. Oral care might reduce oral bacteria count, which is associated with pneumonia onset, and may prevent recurrence of pneumonia. Some people may require far larger dose titrations to achieve adequate glucose control; involve the diabetes inpatient specialist nurse or diabetes inpatient team as early as possible in the care of these people. 0000004189 00000 n The consensus of the present writing group is that tolerating a range as low as 4 mmol/l is unsafe in a patient group with a recent cerebrovascular event, who may be susceptible and perhaps highly sensitive to hypoglycaemia. trailer <]/Prev 114909>> startxref 0 %%EOF 93 0 obj <>stream Metformin powder for re‐suspension is not currently widely available in the UK. 0000001736 00000 n If the person with Type 1 diabetes is not being administered basal insulin or premixed insulin, VRIII combined with intravenous 10% dextrose is advised should the feed be stopped for a prolonged period (e.g. As the feed rate and volume increases, the subcutaneous insulin dose will need to be titrated appropriately by 10–20% per titration. Recommencing VRIII should be avoided if possible, unless the person is clinically unwell and the measured capillary blood glucose is rising uncontrollably.
Any capillary blood glucose <4.0 mmol/l should be treated and all prescribed treatment reviewed.
Crushing oral hypoglycaemic medications, such as sulfonylureas, to manage hyperglycaemia during enteral feeding is not advised given the unpredictable absorption and difficulties in administration associated with this action, as well as the risk of tube blockage with crushed debris; however, once the enteral feed is stopped and the person is able to swallow safely, the person with Type 2 diabetes may be able to return to oral pharmacotherapy to control hyperglycaemia. VRIII is reactive management to an elevated capillary glucose level, and much discussion in the literature is devoted to the effectiveness of VRIII 26. Access to public transport has been highlighted as a problem in Ireland for many years with notice needed for commuter trains, numerous bus stops inaccessible, some areas not covered by any service and accessible taxis in short supply. 0000056109 00000 n It is important to recognize that most people requiring enteral feeding will be cared for on a general medical or stroke ward. Nursing staff need to have a good understanding of the following: Nursing staff should also be aware that immobility and impaired movement and sensory disturbances increase the risk of foot/heel ulceration. 0000006391 00000 n The HSE has said that “an implementation plan supported by a training programme will be developed in 2020” to support its Food, Nutrition and Hydration Policy. %PDF-1.5 %���� It should be stressed that people receiving enteral feed should not have their blood glucose checked only at the ward meal times. advising the stroke or medical team to prescribe the type and dose of insulin according to capillary blood glucose levels, and the type and duration of the feed; consultation in the event of hypoglycaemia and persistent hyperglycaemia; education of staff in clinical areas involved in the management of people with stroke who have diabetes. 10% intravenous dextrose at 100 ml/h.
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