When is admission into hospital recommended

Admission to hospital is recommended in the following cases:

1. when poor glycaemic control is accompanied by an alteration in the level of conscience;

2. ketonuria or ketonaemia are present and persist for more than six hours, despite the administration of insulin, carbohydrates and fluids;

3. blood glucose levels are > 400 mg/dl (22.2 mmol/L) in more than two repeated measurements, despite the administration of rapid-acting insulin.

4. inability to get hydration by mouth. CASE STUDY 1

A 30 year old man with Type 1 DM is under treatment with isophane insulin (NPH), 10 units in the morning and 14 units in the evening, as well as insulin Aspart before each meal (at a dose determined based on the carbohydrate content of the meal and the pre-prandial blood glucose level). The usual daily dose of insulin Aspart is 20-24 units). His glycaemic control is very good (recent HbA1c: 6.9 percent). The patient called his primary physician in the morning because during the previous night he had four episodes of vomiting, abdominal pains and three episodes of diarrhoea. His blood glucose level in the morning was 320 mg/dl (17.8 mmol/L). He continued to feel intense nausea and when attempting to drink water, he vomited again.

The doctor initially asked the patient to check his urine for ketones with a special urine stripe (which the patient had been instructed in the past to have at home) and call him back.

A few minutes later the patient informed the doctor that the urine test was positive for ketones (semi-quantitative determination: ++). Based on the guidelines analysed above, the doctor recommended the injection of eight units of insulin Aspart subcutaneously (20 percent of the total daily dose - see previous paragraphs) and repeat blood glucose measurement and ketones in 2-3 hours. At the same time, the doctor asked the patient to drink tea with some sugar (one teaspoon - 30 g per glass) slowly (at least one glass every 30-45 minutes). Furthermore, he gave additional instructions to the patient (see relevant questions of the present chapter) and asked him to call again if urine ketones still persisted in six hours (or earlier if they increased) or if blood glucose level was persistently higher than 300 mg/dl (16.7 mmol/L), despite the administration of insulin.

Two and a half hours later the patient had a blood glucose level of 237 mg/dl (13.2 mmol/L) and urine ketones had decreased to (1+). The sugar beverage had been well tolerated. Nausea had subsided but there had been two additional diarrhoeal bowel movements. Eight units of insulin Aspart subcutaneously were administered and the tea beverage continued. Three hours later the patient felt much better, despite again having diarrhoea; his blood glucose level was 173 mg/dl (9.6 mmol/L) and ketones were no longer detected in the urine. He had a light meal (soup with chicken broth and some rice with a piece of toast) and calculated the pre-prandial Aspart dose as usual with an addition of five units (10 percent of total daily dose - see relevant questions of the present chapter). In the afternoon he felt weak, but diarrhoeas had significantly decreased. Blood glucose level was 135 mg/dl (7.5 mmol/L) and no more insulin was administered. After his (light) dinner he returned to his regular schedule.

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