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GUIDELINES FOR THE MANAGEMENT OF PATIENTS

WITH HYPERGLYCAEMIA OR DIABETES AND


SUSPECTED ACUTE CORONARY SYNDROMES

ELIGIBLE PATIENTS
All patients with capillary blood glucose greater than 11 mmol/L and all
patients with diabetes (regardless of blood glucose) with acute coronary
syndromes including ST elevation and non-ST elevation MI and unstable
angina.

For patients not known to have diabetes with capillary blood glucose between 7
and 11 mmol/L on admission, wait for laboratory plasma glucose. If it is
greater than 11 mmol/L commence infusions, if not monitor capillary blood
glucose 4 hourly for 24 hours and treat as per protocol if plasma glucose
exceeds 11 mmol/L.

AIMS OF TREATMENT
To achieve and maintain plasma glucose between 4 and 9 mmol/L within 4
hours of admission.

1. ON ADMISSION
Check capillary blood glucose and check urine for ketones. If initial
capillary blood glucose is greater than 15 mmol/L give iv bolus of 8
units soluble insulin and sign and date the prescription.

Draw up blood for the following laboratory investigations:

FBC Plasma glucose


U&E, LFT CK and troponin
Cholesterol HbA1c

2. WITHIN THE FIRST HOUR


As soon as possible (and through the same venflon) commence two separate but
concurrent infusions A and B. All oral hypoglycaemic agents must be stopped
when the insulin regimen is started.

A: Human soluble insulin 50 units diluted in 50 ml sodium chloride 0.9%


(1 unit per ml) infused as per sliding scale

Diabetes/ACS Guidelines 2009


B: 10% Dextrose with potassium 20 mmol per 500ml infused at a rate of
40ml per hour (reduced to 20ml per hour in severe heart failure). Use
ready mixed bags. Omit KCl while K+ is over 5.3

SLIDING SCALE REGIMEN

Capillary blood Standard insulin Modification 1 Modification 2


glucose regime (units per hour) (units per hour)
(mmol/L) (units per hour)
0 – 3.9 0 0
4 – 6.9 1 2
7 – 8.9 2 4
9 – 10.9 3 6
11 – 16.9 4 8
17 + 6 12

 Check capillary blood glucose hourly until within target range (4 – 9


mmol/L), then hourly for a further 4 hours and then 2 hourly.
 If capillary blood glucose is greater than 9 mmol/L at 2 hours, double the
rate of insulin infusion (modification 1).
 If capillary blood glucose is greater than 15 mmol/L at 4 hours, call doctor
and give a repeat bolus of 8 units soluble insulin.
 If capillary blood glucose is less than 3 mmol/L for 2 consecutive
readings, call doctor.
 Refer to diabetes nurse on fax extension 2191 on the first working day and
sign and date the prescription.
 If modification 1 is ineffective seek senior advice for customised rates.

Continue iv Dextrose infusion and sliding scale for at least 24 hours. If the
patient is changed onto double rate (modification 1), they should stay
on this regimen until converted to subcutaneous insulin or until the
regimen is stopped. If the patient becomes clinically or biochemically
hypoglycaemic the insulin rate should be reduced to the previous
regimen.

MEALS
When patients are eating properly, if the iv regime is still running, increase the
infusion rate to double rate for one hour only, starting with the meal.

Diabetes/ACS Guidelines 2009


3. AFTER 24 TO 48 HOURS

CHANGING TO SUBCUTANEOUS INSULIN


1. Four times daily subcutaneous insulin is to be used in all patients.
2. Divide the total intravenous insulin dose over preceding 24 hours into four
equal doses and round down by 10 – 20% to an even number of units. For
example, with an average infusion rate of 4 ml per hour, total daily dose
would be 96 units, which would be four lots of 24 units, minus 10 – 20 %
would equal 20 units at each injection.
3. Give three injections per day of soluble insulin (Novorapid) immediately
before meals and one injection of isophane (Humulin I) at bedtime.
4. Discontinue IV insulin and dextrose infusions immediately after the first
dose of subcutaneous insulin has been administered.
5. Adjust doses daily to achieve pre-meal and bedtime blood glucose between 4
and 9 mmol/L.

4. DISCHARGE

Liaise with diabetes team whether insulin is to be continued post discharge. If


control has been good on previous regimen this may well be continued. Pen
injectors (other than preloaded disposables) are only appropriate if the patient is
being discharged on insulin.

PLEASE NOTE THAT ALL INFORMATION SHOULD BE RECORDED


ON THE ASSIGNED PRESCRIPTION, ADMINISTRATION AND
MONITORING CHART AND THAT THE DOCUMENTS MUST BE
FILED IN THE PATIENTS NOTES ON COMPLETION / DISCHARGE.
A SPECIFIC PATHWAY WILL FOLLOW WHEN AVAILABLE.

Diabetes/ACS Guidelines 2009


Diabetes/ACS Guidelines 2009