How to get an accurate glucose reading for diabetic patients
Updated October 31, 2016
Diabetes is a significant health care problem in the United States and is the seventh leading cause of death . EMS personnel frequently encounter patients experiencing some type of diabetic event. Familiarity with the pathophysiology, signs, and symptoms can help responders differentiate diabetic patients from other patients with similar symptoms.
Reasons for inaccurate glucose readings
Over-the counter monitors are designed for single patient use. These monitors allow a patient suffering from diabetes to monitor their own glucose state and adjust their self-administered medication based on those results. Point-of-care monitors are used in a professional setting such as an emergency department or EMS agency. POC monitors are designed for use on many patients.
Although a number of studies demonstrate acceptable accuracy for handheld blood glucose monitors under controlled conditions, accuracy is often suboptimal during actual clinical situations, which could have a significant impact on therapy [3, 4, 5, 6,7,8,9,10, 11, 12, 13, 14].
An Australian study demonstrates that meters tend to overestimate glucose levels when compared to reference values, with one common meter averaging about 25 mg/dl higher than the reference device.In an investigation involving more than 18,000 patients, Canadian researchers found glucose measurement differences greater than 90 mg/dl in one in 200 meters designed for home use .
This degree of measurement error could result in patient self-administration of higher than necessary insulin doses, which could lead to hypoglycemic episodes. In fact, older meters may result in over administration of insulin by about 40 percent of patients using them . If all patients suffering from Type 1 diabetes used the least accurate meter, the error would result in about 300,000 episodes of hypoglycemia per year .
For critically ill patients, POC glucose testing may overestimate glucose levels, especially in patients receiving blood pressure support through the use of vasopressors, in patients with diabetic ketoacidosis or hyperglycemic hyperosmolar syndrome [16, 17]
Capillary samples taken from patients with severe edema may underestimate by as much as 46 percent of reference value . In these cases, the sample may be more representative of tissue glucose levels rather than capillary levels.
A number of factors may contribute to the measurement error associated with these devices. Poor or missing calibration, temperatures outside the intended range, outdated strips, improper technique, poor timing, insufficient sample size, and contamination can all provide misleading results. Repeated opening of the container used to store the test strips allows various contaminants a pathway of entry into the container. In addition, touching more than one test strip to the inside of the container can also be the source of contamination. Contamination is especially serious, since it can happen so easily and is likely to result in episodes of hypoglycemia going unrecognized and untreated. Even a very tiny amount of glucose contamination can seriously alter a reading.
Next, glucometers and test strips may be calibrated for either capillary or venous samples. Using venous blood to determine point-of-care glucose levels from tests strips calibrated for capillary blood can affect the accuracy of the reading. For the most accurate reading possible, obtain the blood sample from the source recommended by the glucometer and test strip manufacturer.
After swabbing the sample finger with alcohol, you must wipe the area dry with a sterile gauze pad. This allows any residual alcohol to be removed and avoids contamination of the sample blood.
For added accuracy, the first drop of blood available from the finger-stick should also be wiped with the gauze pad. This ensures that the second blood drop is the most accurate and least contaminated sample that can be taken.
If the patient is still conscious and can provide airway self-protection, start with oral glucose. Place the gel under the tongue or in the pouch of the cheek. Encourage the patient to hold the gel in the mouth for as long as possible in order to maximize absorption. Take care to prevent the patient from aspirating the glucose and always have suction available.
If the patient is unconscious, treat the hypoglycemia with intravenous dextrose. Fifty-percent dextrose (D50) is virtually free of adverse effects but it is not without its hazards. D50 is a very concentrated form of sugar and if it infiltrates into the tissues from the IV site, extensive tissue necrosis is possible with widespread damage. The IV line must be patent in a large, stable vein before administration of dextrose in any concentration.
Effects of glucagon administration
Glucagon administration will temporarily raise the blood glucose levels of the body; however, the drug takes 10 to 20 minutes to take effect. A two milligram intranasal dose is as effective within the first thirty minutes as a one milligram intramuscular dose .
Glucagon is only effective in patients with a sufficient reserve of glycogen in the liver. If the glycogen reserves have been depleted, such as might be the case in chronic alcoholics or patients with liver disease, the effectiveness of glucagon will be compromised.
The United States Food and Drug Administration has recently recommended implementation of two separate sets of standards for glucose meters, one for over-the-counter meters and one form POC meters. These new standards will likely have a greater impact on the POC meters and improve the accuracy of glucose measurement in the prehospital environment.
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17. Corl, D. E., Yin, T. S., Mills, M. E., Spencer, T. L., Greenfield, L., Beauchemin, E., Cochran, J., Suhr, L. D., Thompson, R. E., & Wisse, B. E. (2013). Evaluation of point-of-care blood glucose measurements in patients with diabetic ketoacidosis or hyperglycemic hyperosmolar syndrome admitted to a critical care unit. Journal of Diabetes, Science, and Technology, 7(5), 1265-1274.
18. Lenhard, M. J., DeCherney, G. S., Maser, R. E., Patten, B. C., & Kubik, J. (1995). A comparison between alternative and trade name glucose test strips. Diabetes Care, 18(5), 686-689. doi:10.2337/diacare.18.5.686
19. Pontiroli, A., Calerara, A., Pajetta, E., Albertetto, M., & Pozza, G. (1989). Intranasal glucagon as a remedy for hypoglycemia. Studies in healthy subjects and type 1 diabetic patients. Diabetes Care. 12(9), 604–608. doi:10.2337/diacare.12.9.604
20. American Association for Clinical Chemistry. (2014). FDA proposes two sets of standards for glucose meters. Retrieved from http://labtestsonline.org/news/140313glucose-meters/Kenny Navarro is an Assistant Professor in the Department of Emergency Medicine at the University of Texas Southwestern Medical School at Dallas. He also serves as the AHA Training Center Coordinator for Tarrant County College. Mr. Navarro serves as an Emergency Cardiovascular Care Content Consultant for the American Heart Association, served on two education subcommittees for NIH-funded research projects, as the Coordinator for the National EMS Education Standards Project, and as an expert writer for the National EMS Education Standards Implementation Team. Send correspondence concerning any articles in this section to Kenneth W. Navarro, The University of Texas Southwestern Medical School at Dallas, 5323 Harry Hines Blvd MC 8890, Dallas, Texas 75390-8890, or e-mail email@example.com.
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