Box 2.

Scenario 2

A 45-year-old man with type 1 diabetes (T1D) managed with Levemir twice daily and NovoRapid with meals (dose adjusted to carbohydrate portion) is admitted with an infected diabetic foot ulcer. Although febrile, he feels well in himself and is maintaining oral intake. You are alerted as his pre-meal capillary blood glucose (CBG) is elevated at 24 mmol/L. His capillary ketones are 1.4 mmol/L and he is not acidotic on a venous blood gas. He is a DAFNE graduate, is familiar with sick day rules and is happy to self-manage his diabetes, though in hospital the nursing staff have been administering fixed doses of NovoRapid with his meals. He has been receiving Levemir at his usual times. How should his hyperglycaemia be managed? This patient is hyperglycaemic and ketotic though not in diabetic ketoacidosis. As he has T1D his Levemir must not be omitted. Given he is clinically well, attempts should be made to manage his hyperglycaemia and ketonaemia with a stat correction dose of NovoRapid (as per DAFNE principles or 4–6 units) rather than a variable rate insulin infusion (VRII). He is trained in diabetes self-management and should be allowed to continue to self-administer insulin in hospital while it is safe for him to do so. His CBGs and ketones should be repeated 2 hourly and a further correction dose of NovoRapid be considered after 4 hours if he remains ketotic and/or hyperglycaemic. In the event of a deterioration or persistent ketonaemia a VRII should be commenced (with continuation of Levemir alongside this).