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hepatic glucose production and may directly inhibit insulin release (Delaunay et al. 1997, Ogawa et al. 1992, Wallymahmed 2007). For this reason these patients will need blood glucose monitoring and potential changes to their insulin needs or to temporarily commence insulin.

Hypoglycaemia

Hypoglycaemia is described as a blood glucose level that is unable to meet the metabolic needs of the body (Marini and Wheeler 2010), normally lower than 4 mmol/L (Wallymahmed 2007). Often young, healthy individuals can be asymptomatic during this inadequate level of glucose in the blood but early symptoms can be sweating, tremor, weakness, nervousness, tachycardia and hypertension (Wallymahmed 2007), although these depend on not only the absolute blood glucose but also its rate of decline (Tortora and Derrickson 2009). Severe hypoglycaemia can lead to mental disorientation, convulsions, unconsciousness and death but a blood glucose less than 3 mmol can start to affect the brain.

The most common causes of hypoglycaemia are missed or delayed meals, not eating enough, exercise without carbohydrate compensation, too much glucoselowering medication (e.g. insulin) and excessive alcohol (Wallymahmed 2007). Other causes could be infection, muscle and fat depletion (e.g. anorexia), diarrhoea and vomiting, hepatic failure due to tumour or cirrhosis, salicylate poisoning, insulinsecreting tumours, ventilation, congestive heart failure, cerebral vascular accident, concurrent medications (betablockers, adrenaline) and surgery (D’Hondt 2008, Marini and Wheeler 2010).

Treatment should ideally be the administration of glucose. The route will depend on the consciousness level of the patient, their treatment and their ability to take oral substances (Marini and Wheeler 2010). If they can tolerate an oral or enteral intake they should be given a fastacting carbohydrate such as 3–6 glucose tablets, 150 mL sugary fizzy drink or 50–100 mL Lucozade followed by a longer acting carbohydrate such as a sandwich or biscuits. If unconscious or unable to take food and drink then they can receive intramuscular glucagon or intravenous dextrose (Wallymahmed 2007). Blood glucose needs to be checked 5–10 minutes after treatment and then as necessary. Diabetic treatment should not be omitted because of a single episode of hypoglycaemia, but if it remains a consistent problem treatment should be reviewed (Wallymahmed 2007).

Evidencebased approaches

Rationale

Blood glucose monitoring provides an accurate indication of how the body is controlling glucose metabolism and provides feedback to guide clinicians and patients about their treatment adjustments in order to achieve optimal glucose control. In the short term it can prevent hypo and hyperglycaemia and in the long term it can significantly reduce the risk of prolonged, lifethreatening microvascular complications (Rizvi and Saunders 2006).

Capillary blood glucose monitoring is preferred due to immediacy of results and its ability to inform us whether blood sugar is high or low, whereas urine testing only indicates instances of high blood sugar (Wallymahmed 2007). Capillary blood glucose monitoring is also referred to as pointofcare testing (POCT).

Indications

Conditions in which blood glucose monitoring will need to take place include the following.

To make a diagnosis of diabetes indicated by signs and symptoms of polyuria, polydipsia, weightloss for type 1 or weight gain, family history for type 2 (WHO 2006).

To monitor and manage the daytoday treatment of known type 1 and type 2 diabetes (Wallymahmed 2007).

In acute management of unstable diabetes, that is, evidence of hyperglycaemia, hypoglycaemia, diabetic ketoacidosis, hyperosmolar nonketonic coma (once severe dehydration is corrected) (Wallymahmed 2007).

Hospitalized patients with diabetes according to morbidity and treatment, that is, sliding scales, nutritional intake/support (McNight and Carter 2008, Wallymahmed 2007).

Initial parenteral and enteral nutritional support of all patients (McNight and Carter 2008).

Patients taking steroids