Introduction

This chapter covers several special inpatient groups. For each of these groups a summary of the current guidance is given. Early involvement of the specialist diabetes team is recommended for patient groups covered in this chapter:

• Patients on continuous subcutaneous insulin infusion (CSII)

• Patients who are pregnant including patients in labour

• Patients undergoing enteral feeding following a stroke

• Patients on steroids

Continuous subcutaneous insulin infusion (CSII or insulin pump therapy)

Continuous subcutaneous insulin infusion (CSII or insulin pump therapy) is a method of delivering intensive insulin therapy used by 10-15% of people with type 1 diabetes. CSII involves a continuous basal (or background) infusion of short acting insulin (the hourly rate typically varies over a 24 hour period), in combination with meal-time boluses of the same insulin. This insulin is delivered through a small subcutaneous cannula usually sited on the abdomen. Only 7% of the in-patient diabetic population has type 1 diabetes thus, at most only 1% of inpatients with diabetes will be treated with CSII. However the majority of these patients are admitted for a variety of non-diabetes related reasons and as such they will be primarily under the care of non-diabetes specialist teams with little or no experience of insulin pump therapy.

It is usually best for the patient to continue to self-manage their diabetes with CSII when admitted to hospital, except:

• If unconscious, confused or incapacitated e.g. if illness/pain prevents self-management

• If undergoing major procedures under general anaesthetic and lasting >2 hours

• If admitted with diabetic ketoacidosis (DKA)

Points to remember when you manage people on CSII:

• People on CSII do NOT take any long acting insulin so if there is any interruption to insulin delivery (e.g. if the cannula is blocked/dislodged/removed) hyperglycaemia and then diabetic ketoacidosis can develop very quickly. In these situations, the problem has to be identified and rectified, e.g. by re-siting the cannula, changing the tubing, or starting alternative insulin such as an intravenous infusion.

• If alternative insulin therapy (intravenous insulin infusion or subcutaneous insulin) is required during the hospital stay, caution should be exercised both when stopping and restarting pump. The insulin in a CSII is very short acting therefore alternative insulin must be started immediately to avoid risk of diabetic ketoacidosis.

• The pump together with its tubing may be unclipped/removed leaving only the SC cannula in place, unless cannula site is infected or in surgical field.

• It is important not to cut tubing or disconnect the pump from the tubing as the remaining insulin in the tube may infuse quickly risking hypoglycaemia. Place the CSII into a suitable container and do not attempt to turn off; the amount of insulin “lost” into the container will be minimal.

• Pumps are expensive. When removed, document where the pump is stored, or to whom it has been given.

• Restarting CSII : if transferring from IV insulin infusion to CSII : ask patient to insert new cannula and re-start CSII after performing a fixed prime (there is no need to wait until a meal); wait 60 minutes before discontinuing IV insulin. If transferring from subcutaneous insulin to CSII : patient inserts new cannula, performs a fixed prime and re-starts CSII. CSII settings may need to be reprogrammed. Patient may need to temporarily reduce background insulin infusion rate (e.g. drop to a 70% temporary basal rate for 24hrs) while previously administered long acting subcutaneous insulin is still active - increased glucose monitoring may be required. Re-check blood glucose 1-2 hours after CSII re-start. Please discuss all CSII patients with a member of the diabetes team.

IDEA Pump School 

• Guidelines for managing continuous subcutaneous insulin infusion (CSII)/ pump therapy in hospitalised patients

Glycaemic management during the inpatient enteral feeding of stroke patients with diabetes 

A diagnosis of diabetes at least doubles the risk of stroke. Thus a considerable proportion of patients presenting to hospital with acute stroke will have type 2 diabetes, and less commonly type 1 diabetes. Patients with evolving cerebral damage may be particularly vulnerable to the neuroglycopaenic effects of hypoglycaemia. Thus avoidance of excessive hyperglycaemia and hypoglycaemia should be aspirational in the management of all people with diabetes in hospital.

NOTE: some trusts do not stock Metformin powder, an alternative would be Metformin solution 500mg/5ml

Pregnancy and Labour

Approximately 5% of women who give birth in England and Wales have either pre-existing diabetes or gestational diabetes. Of the women who have diabetes during pregnancy, it is estimated that approximately 87.5% have gestational diabetes (which may or may not resolve after pregnancy), 7.5% have type 1 diabetes and the remaining 5% have type 2 diabetes.

Diabetes in pregnancy is associated with risks to the woman and to the developing fetus. Miscarriage, pre-eclampsia and preterm labour are more common in women with pre-existing diabetes.The CEMACH (Confidential Enquiry in to Maternal and Child Health) of women with type 1 and type 2 diabetes showed that the prevalence of delivery before 37 weeks was 36%.In addition, diabetic retinopathy can worsen rapidly during pregnancy. Stillbirth, congenital malformations, macrosomia, birth injury, perinatal mortality and neotnatal adaptation problems (such as hypoglycaemia) are more common in babies born to women with pre-existing diabetes.

The level of risk for the pregnancy for women with pre‑existing diabetes increases with an HbA1c level above 48 mmol/mol (6.5%). There is international consensus over the importance of tight glucose control before conception and throughout pregnancy to optimise pregnancy outcomes. NICE advice on the target blood glucose range 4.0 -7.8 mmol/L during pregnancy and 4.0-7.0 mmol/L during labour and delivery.

The scope of this chapter however is to support management of glycaemic control when pregnant women with diabetes are admitted to obstetric wards in the following situations:

• Steroid administration for lung maturation if risk of premature labour

• Induction of labour and delivery

• Specific issues in relation to diabetic ketoacidosis in pregnancy

NOTE: If a pregnant lady with diabetes is admitted to hospital then their care should be discussed with the relevant specialist teams, e.g., obstetrics and diabetes teams. Always follow local guidance and contact local specialist team.

ITS ANIMATION: PREGNANCY AND TYPE 1 DIABETES

• Diabetes in Pregnancy UHL guideline

Patients on steroids

Synthetic glucocorticoids mimic the effect of the endogenous steroids. It is often used for its anti-inflammatory effects (see chapter on pregnancy and labour for obstetric indications). Steroid administration also modulates carbohydrate metabolism via complex mechanisms, including effects on beta cell function as well as inducing insulin resistance by effects on insulin receptors in liver, muscle and adipose tissue. These effects promote hyperglycaemia in "at risk individuals". Predisposing factors leading to increased risk of hyperglycaemia with steroid therapy-

• Pre-existing type 1 or type 2 diabetes 

• People at increased risk of diabetes (e.g. obesity, family history of diabetes, previous gestational diabetes, ethnic minorities, polycystic ovarian syndrome) 

• Impaired fasting glucose or impaired glucose tolerance, HbA1c 42-47mmol/mol 

• People previously hyperglycaemic with steroid therapy 

• Those identified to be at risk utilising the University of Leicester/Diabetes UK diabetes risk calculator (riskscore.diabetes.org.uk) 

A single or short course of steroid (e.g. prednisolone) in the morning may be the commonest mode of administration. In susceptible patients, this will often result in a rise in blood glucose by late morning that continues into the evening. Overnight the blood glucose generally falls back, often to baseline levels the next morning. Thus treatment should be tailored to treating the hyperglycaemia, whilst avoiding nocturnal and early morning hypoglycaemia. 

Many hospital inpatients will receive multiple daily doses of steroids. Glucose levels in most individuals can be predicted to rise approximately 4 to 8 hours following the administration of oral steroids and sooner following the administration of intravenous steroids. 

The recommended CBG target level for glucose in hospital inpatients is 6-10mmol/L, accepting a range of 4- 12mmol/L. However, certain patient groups (e.g. frail, elderly, those with dementia) do not require such tight control. 

An HbA1c prior to the commencement of steroids in patients perceived to be at high risk of steroid induced diabetes and in those with known diabetes may be informative. 

In people without a pre-existing diagnosis of diabetes  

Monitoring should occur at least once daily – preferably prior to lunch or evening meal, or alternatively 1-2 hours post lunch or evening meal. 

If the initial blood glucose is less than 12mmol/L continue to test once prior to or following lunch or evening meal 

If a subsequent capillary blood glucose is found to be greater than 12mmol/L, then the frequency of testing should be increased to four times daily (before meals and before bed) • If the capillary glucose is found to be consistently greater than 12mmol/L i.e. on two occasions during 24 hours, then the patient should enter the treatment algorithm . See JBDS Management of Hyperglycaemia and Steroid (Glucocorticoid) Therapy Guidelines page 23.

In people with a pre-existing diagnosis of diabetes 

• Test four times a day, before or after meals, and before bed, irrespective of background diabetes control 

• If the capillary glucose is found to be consistently greater than 12mmol/L i.e. on two occasions during 24 hours, then the patient should enter the treatment algorithm 

See JBDS Management of Hyperglycaemia and Steroid (Glucocorticoid) Therapy Guidelines page 24.

Hospital Discharge in patients without a previous diagnosis of diabetes

When a patient is discharged from hospital on steroid therapy a clear strategy for the management of hyperglycaemia or potential hypoglycaemia should be in place. The titration of therapy to address the hyperglycaemia should be communicated to the community diabetes team, GP or community DSNs.