EP.FRI.98 Perioperative blood glucose monitoring and handover in Post-Laparotomy Diabetic patients admitted to Intensive Care

Aim To identify the percentage of diabetic laparotomy patients admitted to ITU who had a pre-operative blood glucose check, and the frequency of post-operative blood glucose checks in the immediate 24 hours post-operatively, with any association with 30 day mortality Method We identified diabetic post-laparotomy patients admitted to a large tertiary hospital ICU, identifying handover between medical and critical care teams and perioperative blood glucose monitoring up to the first 24 hours of ICU admission post-operatively using both physical and electronic notes. Results We identified 79 diabetic laparotomy patients admitted to ICU of which 49.3% (39/79) did not have diabetes recorded as a comorbidity in nursing handover charts. We found that 27.8% of these patients did not have an intra-day pre-operative blood glucose recorded and that frequency of post-operative glucose monitoring in the first 24 hours ranged from 0.5 to 10 hourly. ITU monitoring charts could only be found for 69 of the 79 patients, out of which 40.7% of patients had at least one hyperglycaemic episode while 11.6% of patients had a hypoglycaemic episode. We found no correlation between incidences of hyperglycaemia and hypoglycemia or handover with 30 day mortality (13.9%). Conclusion 72.2 percent of post laparotomy diabetic patients admitted to ICU have a preoperative blood glucose recorded, with considerable variance in blood glucose monitoring frequency 24 hours post-laparotomy from half hourly to 10 hours between blood glucose monitoring but we found no association between hyperglycaemic and hypoglycaemic events in the first 24 hours post-laparotomy with 30 day mortality.

A retrospective cross-sectional analysis of re-contact rates and clinical characteristics in diabetic patients referred by paramedics to a community diabetes service following a hypoglycaemic episode

Aims: To report the re-contact rates and clinical characteristics of individuals referred to community diabetic teams following non-conveyance by HCPC paramedics.Methods: A retrospective cross-sectional study of routinely collected data by the Northern Ireland Ambulance Service HSC Trust of individuals referred to a community diabetic service following ambulance attendance and non-conveyance. Data were collected over a 3-month period with ambulance service re-contact and clinical data analysed.Results: 418 emergency calls were identified as relating to hypoglycaemia with 169 referrals being made, a referral rate of 40.4%. Patients treated with insulin represented the majority of calls and tended to have a lower Glasgow Coma Scale score, but demonstrated many successful referrals. Increased age and multimorbidity were associated with repeat hypoglycaemic episodes and EMS attendance while other subgroups traditionally considered higher risk, such as patients with infections or under the influence of alcohol, showed potential for safe community management.Conclusion: The majority of paramedic referrals to community diabetic teams were successful, with less than 5% re-contacting the ambulance service within 3 days. This study, although demonstrating a lower referral rate than previous research, reinforces the safety of paramedic management and community referral for hypoglycaemia.

Comparative study of physiological changes of nil per oral vs glucose water vs free water in patients undergoing laparoscopic cholecystectomy: A randomized prospective study

The aim of this study was to compare the effect of ingestion of clear water and glucose water over 10 hours NPO in elective laparoscopic cholecystetctomy surgery.An observational study was conducted in Sir Sunderlal hospital, Banaras Hindu University. The study included ASA I-II patients undergoing laparoscopic cholecystectomy surgery. Patients undergoing general anaesthesia were included in the study. Among three groups, the control fasted in accordance to nil per os for 10 hours, second and third group received 200 mL of clear water and 200 ml of glucose water, respectively 2 hours before the surgery. Arterial Blood Gas analysis and blood glucose level was done in the immediate post-operative period. Arterial pH, serum electrolytes, serum lactate and blood glucose levels were compared for the above 3 groups. Results were given as mean ± SD. Data collected were analysed using Student’s t-test. Differences were considered statistically significant if P values were <0.05. A total of 45 patients were included and 15 patients each were randomly assigned to one of the 3 groups. Patients who had 200 ml of clear water before surgery had lesser variation in serum K+ [p=0.045] and serum lactate level [p=0.001] than NPO. Patients fed with 200 ml of glucose water before surgery had lesser variation in serum K+ level [p=0.02], serum lactate level [p<0.001], in Random Blood Sugar level [p<0.001] and no episode of hypoglycaemia observed as compared to NPO. Patients given 200 ml of glucose water exhibited lesser variation in serum lactate level [p=0.004], in RBS level [p<0.001] and no hypoglycaemic episode recorded contrary to those supplied with 200 mL of clear water. More fluctuations in extreme values of pH and serum electrolytes values observed in group A. Episodes of hypoglycaemia found more frequent in NPO and patients that received only clear water. No significant side-effects were observed in any group.We conclude that it is safe to give clear drinks 2 hours prior to surgery. Prolonged withholding of oral fluid may cause imbalance in pH, serum electrolytes and hypoglycaemia. The finding confirms the recent ASA guidelines which no longer recommends an indiscriminate ‘NPO after midnight’ policy.

A Rare Cause of Severe Hypoglycaemia

A 67-year old woman presented with an unwitnessed fall and decreased oral intake. She had a learning disability, hypertension, epilepsy, asthma, chronic iron deficiency anaemia, mild lymphopenia, osteoporosis and treated uterine cancer. After clinical review, she was treated for Hospital-acquired pneumonia (following a recent hospital admission) with possible aspiration. She was noted to have hyponatraemia secondary to dehydration. She was commenced on intravenous Levofloxacin and Metronidazole along with supportive care, based on antibiotic guidance due to her known allergy to penicillin.On day 3 of admission, she was found unresponsive with a capillary blood glucose of 0.6 mmol/L, which improved with 10% glucose infusion. The low blood glucose was attributed to poor oral intake. However, her serial blood sugar results demonstrated persistent hypoglycaemia for 72h needing further intravenous glucose infusions. A medication review was undertaken and Levofloxacin was discontinued. After 24hrs of discontinuation, the hypoglycaemic episode resolved. A short synacthen test showed a normal cortisol response. There were no further episodes of hypoglycaemia. Conclusion As her persistent hypoglycaemia resolved on discontinuation of Levofloxacin, a diagnosis of fluoroquinolone induced hypoglycaemia was reported to MHRA. Fluoroquinolones are thought to induce hypoglycaemia by increasing the insulin release via blockade of adenosine triphosphate-sensitive K+channels in the β cells of the pancreas. This effect may not be clinically evident in all patients because of physiologic mechanisms that regulate blood glucose levels. Health professionals should be aware of the potential risk of severe hypoglycaemia with the use of Fluoroquinolones which are a first or second-line treatment for common infective processes. Fluoroquinolones should be stopped immediately and switch to a non-Fluoroquinolones antibiotic if possible. In elderly patients with compromised oral intake or in those with other comorbidities, regular blood glucose monitoring should be carried out to avoid life-threatening hypoglycaemic episodes.

Fear of hypoglycaemia among patients with type 2 diabetes mellitus: a cross-sectional study

To investigate the fear of hypoglycaemia in patients with type 2 diabetes mellitus (T2DM), to identify factors related to this fear, and thus to provide evidence for clinical assessment. A total of 385 patients with T2DM who were admitted to the departments of endocrinology in five tertiary grade-A hospitals in Chongqing, China were included in this study. A questionnaire for general information and a Chinese version of Hypoglycemia Fear Survey (HFS) were used to collect the data. The average total score on the HFS was 71.67 ± 17.06 (HFS-W was 38.15 ± 10.57; HFS-B was 33.52 ± 9.54).The three items with the highest average score for HFS-W were not recognising low blood glucose (BG), not having food available, experiencing a hypoglycaemic episode alone, and for HFS-B were eating large amount of snacks, measuring BG six or more times per day, and keeping BG > 150 mmol/L. Regressions showed that number of hospitalisations for T2DM, receiving health education on diabetes, age and hypoglycaemia history because of T2DM were associated with fear of hypoglycaemia (all p < 0.05). Fear of hypoglycaemia in hospitalised patients with T2DM was strongly associated with diabetes health education, hospitalisation for diabetes, age, and hypoglycaemia history. Medical professionals should attach importance to the specific psychological interventions, health education on diabetes and the early prevention of hypoglycaemia or diabetic complications for patients with T2DM to reduce the fear of hypoglycaemia and improve their health status.

Severe hypoglycaemia and absolute risk of cause-specific mortality in individuals with type 2 diabetes: a UK primary care observational study

Aims/hypothesis Several pathophysiological mechanisms would suggest a causal link between hypoglycaemia and cardiovascular death; conversely, current knowledge would not support a causal relationship with other causes of death. To clarify the nature and the magnitude of the association between hypoglycaemia and death, we investigated the 5 year mortality risks for cardiovascular disease, cancer and other causes in individuals with type 2 diabetes admitted to hospital for a severe hypoglycaemic episode. Methods We defined in the UK Clinical Practice Research Datalink database a prevalent cohort of adults with type 2 diabetes diagnosed between 1 January 1998 and 1 January 2011 (index date), with available linkage to the Office for National Statistics (ONS) and the Hospital Episode Statistics (HES). A hospital admission reporting hypoglycaemia as the underlying cause was identified before the index date in the HES; date and underlying cause of death were obtained from the ONS. We quantified the 5 year risk of cause-specific death in people with and without admission to hospital for severe hypoglycaemia, adjusting for potential confounders and accounting for competing risk. Results Of the 74,610 subjects included in the cohort, 388 (0.5%) were admitted at least once for a severe hypoglycaemic episode; subjects admitted were older, with higher HbA1c and a greater prevalence of multimorbidity. During a median follow-up of 7.1 years, 236 (60.8%) and 18,539 (25.0%) deaths occurred in subjects with and without a previous severe hypoglycaemia, respectively. Non-cardiovascular causes accounted for 71% of all deaths in both subjects with and without hypoglycaemia. In a 60-year-old person with severe hypoglycaemia, the 5 year absolute risk of death, adjusted for age, sex, ethnicity, systolic blood pressure, total cholesterol, HbA1c, BMI, eGFR, smoking status, alcohol consumption and deprivation (Townsend score), was 6.6%, 1.1% and 13.1% for cardiovascular, cancer and other causes, respectively, while the 5 year absolute risk difference compared with a subject without severe hypoglycaemia was 4.7% (95% CI 1.0, 8.3) for cardiovascular, −1.4% (−4.1, 1.4) for cancer and 11.1% (6.1, 16.1) for other causes of death. Results were consistent in models further adjusted for medications and comorbidities (myocardial infarction, stroke, peripheral artery disease, heart failure, atrial fibrillation, cancer), with sulfonylurea and insulin associated with increased mortality rates (from cause-specific hazard ratio of 1.06 [95% CI 0.99, 1.14] for cancer death with use of sulfonylurea to 1.42 [1.29, 1.56] for cardiovascular death with use of insulin). Results were robust to missing data. Conclusions/interpretation The results of this study indicate severe hypoglycaemia as a marker of, rather than causally linked to, an increased risk of long-term mortality. Regardless of the nature of the association, a severe hypoglycaemic episode represents a strong negative prognostic factor in patients with type 2 diabetes.

Persistent bradycardia after hypoglycaemia: a case report and a brief literature review

Hypoglycaemia can cause cardiac arrhythmias such as QT interval prolongation and ventricular arrhythmias. Supraventricular arrhythmias and sinus bradycardia were rarely reported. We present the clinical case of an 84- year-old man who developed a persistent bradycardia after a hypoglycaemic episode. After restoration of normoglycaemia, bradycardia persisted for almost eighteen hours, without QT prolongation or any symptoms. Hypoglycaemia is an unusual cause of bradyarrhytmias mainly mediated by neurologic and endocrine systems. Our clinical case supports recent recommendations for more relaxed inpatient glycaemic targets in frail older adults who may be particularly vulnerable to hypoglycaemia and its consequences.

Spontaneously remitting insulin autoimmune syndrome in a patient taking alpha-lipoic acid

Summary Insulin autoimmune syndrome (IAS), or Hirata disease, is a rare hypoglycaemic disorder caused by the presence of high titer of insulin autoantibodies (IAA) in patients without previous exposure to exogenous insulin. Even though its pathogenesis is not fully understood, striking evidences link IAS to previous exposure to sulphydryl-containing medications, like alpha-lipoic acid, a widely used nutritional supplement. Although challenging, a careful differential diagnosis from other causes of hyperinsulinaemic hypoglycaemia (such as insulinoma) is mandatory, since these conditions require different therapeutic approaches. In the present study, we report a 35-year-old woman originally from Sri Lanka who was referred to our University Hospital on suspicion of occult insulinoma. Her medical history was positive for endometriosis, treated with estroprogestins and alpha-lipoic acid. The latter supplement was begun 2 weeks before the first hypoglycaemic episode. Our tests confirmed the presence of hypoglycaemia associated with high insulin and C-peptide concentrations. When insulin concentrations were compared using different assays, the results were significantly different. Moreover, insulin values significantly decreased after precipitation with polyethylene glycol. An assay for IAA proved positive (530 U/mL). A genetic analysis revealed the presence of HLA-DRB1*04,15, an immunogenetic determinant associated with IAS. On the basis of clinical data we avoided a first-line approach with immunosuppressive treatments, and the patient was advised to modify her diet, with the introduction of frequent low-caloric meals. During follow-up evaluations, glucose levels (registered trough a flash glucose monitoring system) resulted progressively more stable. IAA titer progressively decreased, being undetectable by the fifteenth month, thus indicating the remission of the IAS. Learning points: Insulin autoimmune syndrome (IAS) is a rare cause of hyperinsulinaemic hypoglycaemia, whose prevalence is higher in East Asian populations due to the higher prevalence of specific immunogenetic determinants. Nevertheless, an increasing number of IAS cases is being reported worldwide, due to the wide diffusion of medications such as alpha-lipoic acid. Differential diagnosis of IAS from other causes of hyperinsulinemic hypoglycaemia is challenging. Even though many tests can be suggestive of IAS, the gold standard remains the detection of IAAs, despite that dedicated commercial kits are not widely available. The therapeutic approach to IAS is problematic. As a matter of fact IAS is often a self-remitting disease, but sometimes needs aggressive immunosuppression. The benefits and risks of any therapeutic choice should be carefully weighted and tailored on the single patient.

Suggested Insulin Regimen for Pregnant Women with Diabetes Who Wish To Fast in Ramadan

Introduction: Pregnant women are among those who are exempted from Ramadan fasting. Despite that, many pregnant women had chosen to fast despite understanding the risk of complications especially hypoglycaemia. In Hospital USM (HUSM), an insulin regime for pregnant women who wish to fast was designed based on expert opinion of obstetricians, but its safety and efficacy are yet to be determined. Objective: To determine the safety and efficacy of the formulated insulin regime using subcutaneous Actrapid® and Insulatard® amongst pregnant women with diabetes who fast in Ramadan. Methodology: Pregnant patients with diabetes on insulin who wish to fast during Ramadan were invited to participate in the study. The total daily dose of insulin requirement prior to Ramadan was divided 3 parts; 2/3 for iftar (sunset meal) and 1/3 for sahur (pre-dawn meal). For each timing, 2/3 of the calculated dose was given as short-acting insulin Actrapid® and remaining 1/3 as intermediate-acting insulin Insulatard®. Three patients were monitored in the ward while fasting for two days. Blood glucose checked eight times a day. Following that, eight patients were followed up during Ramadan fasting with this regime. Weekly blood sugar profile (BSP) was taken and glycaemic control evaluated. Results: All patients were able to fast without any hypoglycaemic episode, both during in-patient study and during out-patient Ramadan fasting. Mean daily blood glucose per day for in-patient monitoring was 7.3 mmol/l with the lowest being 4.56 mmol/l in the afternoon. During Ramadan fasting, average glucose level was higher (6.79 mmol/l) compared to prior to Ramadan value (5.67 mmol/l) (p> 0.05). However, improvement of glycaemic control was observed towards end of Ramadan. Conclusion: Pregnant women with diabetes treated with insulin can fast safely during Ramadan using the suggested insulin regime with improvement of glycaemic control observed at the end of Ramadan.