E 9 Glucometer

This equipment is important for Hypoglycaemia and Hyperglycaemia as decribed in How to Manage Hypoglycaemia or Hyperglycaemia in NYI.

Subsection of this chapter:

  1. Clinical Problem
  2. Assessment
  3. Management
  4. Infection Prevention
  5. Complications
  6. Care & Maintenance
  7. Troubleshooting & Repair

NEST360°. Newborn Essential Solutions and Technologies-Education – Clinical Modules: Glucometer. (June 2020). License: CC BY-NC-SA 4.0.

Clinical Problem

Assessment of blood glucose with a glucometer should be conducted as part of routine assessment for all infants on admission.

Glucometers should also be used during continuing management for all sick or at-risk patients. Hypoglycaemia may present as:1

Hypoglycaemia may also be asymptomatic or the signs may be very non-specific and identified incidentally as part of routine blood glucose testing.1 It is important to identify
hypoglycaemia as it may lead to permanent brain damage. Prematurity, intrauterine growth retardation, birth asphyxia, babies born to diabetic mothers, and sick babies are all especially prone to develop hypoglycaemia.

Assessment

Hypoglycaemia occurs in 10% of healthy neonates but can also directly contribute to both morbidity and mortality.2,3 It is the most common medical emergency to occur in neonatal patients.

Glucometers (2.1) provide a rapid measurement of approximate whole blood glucose level1 to direct treatment for patients with mild to severe hypoglycaemia. Where available, point of care tests should be confirmed by laboratory analysis when hypoglycaemia is persistent, recurrent, or there is concern about accuracy of the point of care device.

Glucometers use test strips (2.2) with a glucose oxidase electrode. These strips generate a current proportional to the glucose in the blood that reacts with the glucose oxidase, which is then measured and analysed to determine an estimated blood glucose level.



There are multiple types of glucometers, including portable and benchtop. Glucose strips that change colour according to a visual scale are also available for measuring glucose levels. These are not recommended due to their higher inaccuracy and subjective nature of measurement. Not all glucometers are accurately able to measure hypoglycaemia in neonatal patients;4,5 all devices in use should be thoroughly validated for use both in neonatal patients and as an assessment of hypoglycaemia.

Glucose levels in all neonatal patients should not fall below 2.5 mmol/L (45 mg/dL).

Management

Management of a glucometer covers how to use the device in a variety of settings, including set up for a patient, patient preparation & conducting & concluding the assessment.

SETTING UP FOR A PATIENT

  1. Collect: (3.1)
  2. Turn on the glucometer. This may be completed by pressing the power button of the glucometer or inserting a glucometer strip into the glucometer strip port.


  3. Fully insert a test strip into the meter. (3.2) The strip should click into place.
  4. A Quality Control test should be conducted daily. If this has not been completed, perform a test using the control solutions provided with the glucometer (3.3), or a solution of known glucose content. The solution should be placed on the strip as with a normal sample. (3.4) The results should appear within seconds as a Pass. (3.5)

PREPARING A PATIENT

  1. Assess patient for clinical conditions associated with hypoglycaemia.
  2. Always explain the purpose, risks and benefits of a procedure to guardians BEFORE performing the procedure.
  3. Follow handwashing protocol and put on gloves.
  4. Collect:
  5. Clean the skin on the outer edge of the patient’s heel using cotton wool soaked in alcohol. (3.6) Allow the alcohol to dry before testing. Blood glucose samples should never be taken from the finger of a neonate. Avoid areas of skin which are poorly perfused, oedematous, inflamed or infected.

ASSESSING A PATIENT

  1. Collect: (3.7)
  2. Follow handwashing procedures & put on gloves.
  3. Insert glucometer strip into glucometer and ensure it is turned on.
  4. Using the lancet, prick the disinfected outer edge of the heel. (3.8) A blood drop should form. If this does not occur, massage the heel to generate the blood drop. The patient may cry during blood collection as use of the lancet can be painful.
  5. Wipe the first drop from the patient’s skin and generate an additional blood drop. Collect the second blood drop on the tip of the glucometer strip. (3.9) The glucometer should automatically absorb the blood drop.


  6. Using a dry cotton swab, apply pressure to the heel to stop the bleeding. (3.10)
  7. Blood glucose level will be displayed as a number on the glucometer screen. (3.11) Read and record the glucose levels. If the measurement is not in accord with the clinical condition of the patient, repeat the test.


  8. Compare glucose levels to normal standards.6
    9. CAVE - this is the NEST recommendation. Find the COIN recommendation: here

Whenever hypoglycaemia is found and treated, the blood glucose should be rechecked 30 minutes after intervening.


? ALERT 3.1: Variance in international standards for hypoglycaemia management
American Academy of Pediatrics, Pediatric Endocrine Society and WHO are all in agreement that glucose levels below 2.5mmol/L (45mg/dL) signify hypoglycaemia in newborns. However, they differ on the specific actions that should be taken and how aggressively to manage glucose levels below 45mg/dL, (2.5 mmol/L). For a full discussion of management of hypoglycaemia in newborns, these documents should be referenced and local practices put into place.7–9

CONCLUDING ASSESSMENT

Remove the glucose strip from the glucometer and dispose of strip in hazardous waste container. Dispose of the used lancet in sharps container. Remove gloves, dispose in hazardous waste container, and wash hands.

Infection Prevention

Routine and adequate cleaning of medical devices is critical to prevent hospital-acquired infections in newborn care units. If devices and equipment are not disinfected or reprocessed promptly or adequately between patients, they may pose a significant infection risk.

GENERAL INFECTION PREVENTION

  1. Clean hands with soap and water or alcohol before and after assessing a patient using a glucometer or handling any materials that will be used on a patient (e.g., a lancet). Gloves should be worn throughout the process of taking a blood glucose measurement and disposed of immediately after concluding the measurement.
  2. Always thoroughly clean the patient’s skin before taking a measurement using a glucometer. Inadequate cleaning of the skin may result in an infection. Taking a sample from a site with a skin infection also poses the risk of infection dissemination.
  3. Ensure that all patient-related consumables are new before use. Materials used in blood glucose measurements should never be reused.
  4. All patient-related consumables should be stored in a clean, dry location. Glucometer measurement strips should be stored in an airtight container and according to hospital policy.
  5. Follow universal precautions of handling sharps.

? ALERT 4.1 Equipment Disinfection
Disinfection of equipment should always comply with manufacturer guidelines. General guidance on environmental cleaning and disinfection of equipment was taken from the Infection Prevention and Control: Reference Manual for Health Care Facilities with Limited Resources, Jhpiego, Module 68 which lists isopropyl alcohol (70-90%), sodium hypochlorite (0.05% or >100ppm available chlorine) quaternary ammonium, and Iodophor germicidal detergent as appropriate for low level disinfection. Phenolic germicidal detergent is also listed in this category but should not be used in neonatal wards since affordable, effective alternatives are available; and, there are concerns it may cause hyperbilirubinemia and/or neurotoxicity in neonates.9

When utilizing re-processed devices meant for single-use (like temperature probes), careful attention must always be paid to assure that devices are continuing to function properly.

DISINFECTION AFTER USE

  1. Remove the glucose strip from the glucometer and dispose of strip in hazardous waste container. Dispose of used lancet in sharps container. Remove gloves, dispose in hazardous waste container, and wash hands.
  2. Wipe down the glucometer with 70% alcohol. (4.1) Be careful not to submerge or drip alcohol onto the glucometer, particularly in its glucometer strip reading slot.


Complications

Introduction of equipment in newborn care units poses clinical and device complications for patients. Awareness of potential complications is critical to maximise patient safety.

CLINICAL COMPLICATIONS

DEVICE COMPLICATIONS

Care & Maintenance

Users are responsible for basic first-line care and maintenance to ensure equipment lasts to their potential lifetime.

POWER SOURCE

A glucometer is powered by replaceable or rechargeable (6.1) batteries. If using a rechargeable device, the users should regularly charge the pulse oximeter when not in use to ensure power in the event of a power outage.

WARD LOCATION

The glucometer and associated glucometer testing strips should be stored in a clean, dry and secure area. As glucometers are fairly small, care should be taken to ensure that they remain on the ward and accessible for use when required. If the glucometer has a docking or charging station, it should be kept on the dock or charging station when not in use. (6.2)

USER PREVENTIVE MAINTENANCE

Glucometers require little preventive maintenance beyond recharging or replacing batteries. A Quality Control test using the control solutions provided with the glucometer (6.3), or a solution of known glucose content should be conducted monthly or when changing glucometer strip containers to ensure consistent results. The solution should be placed on the strip as with a normal sample. (6.4) The results should appear within seconds as a Pass. (6.5)

Troubleshooting & Repair

Although users are not responsible for repairing their devices, there are steps that may be taken to troubleshoot first-line errors that may occur before contacting maintenance or engineering support.

1 The glucometer is not turning on
  • Some models of glucometer require a strip to be inserted and will automatically turn on once this is completed. Try inserting a glucometer strip.
  • If the glucometer still does not turn on, try charging or replacing the batteries. If the glucometer still does not turn on, contact your maintenance department.

2 The glucometer is providing results consistently incompatible with patient conditions:
  • Check the expiration date of the glucometer strips. If the strips are expired, try using non-expired strips.
  • If the results are still inconsistent, complete a quality control test as described in Glucometer: Care & Maintenance | Preventive Maintenance If the results are still inconsistent, contact your maintenance department.

References


  1. Thompson-Branch, A. & Havranek, T. Neonatal Hypoglycemia. Pediatr Rev 38, 147–157 (2017).
  2. Samayam, P. Study of Asymptomatic Hypoglycemia in Full Term Exclusively Breastfed Neonates in First 48 Hours of Life. Journal of Clinical and Diagnostic Research. 9, 4 (2015).
  3. Heck, L. J. & Erenberg, A. Serum glucose levels in term neonates during the first 48 hours of life. The Journal of Pediatrics 110, 119–122 (1987).
  4. Ho, H. T. Evaluation of ‘point of care’ devices in the measurement of low blood glucose in neonatal practice.Archives of Disease in Childhood - Fetal and Neonatal Edition 89, F356–F359 (2004).
  5. Beardsall, K. Measurement of glucose levels in the newborn. Early Human Development 86, 263– 267 (2010).
  6. Committee on Fetus and Newborn. Postnatal Glucose Homeostasis in Late-Preterm and Term Infants. PEDIATRICS 127, 575–579 (2011).
  7. Committee on Fetus and Newborn. Postnatal Glucose Homeostasis in Late-Preterm and Term Infants. PEDIATRICS 127, 575–579 (2011).
  8. Thornton, P. S. et al. Recommendations from the Pediatric Endocrine Society for Evaluation and Management of Persistent Hypoglycemia in Neonates, Infants, and Children. The Journal of Pediatrics 167, 238–245 (2015).
  9. Williams, A. F. Hypoglycaemia of the newborn: Review of the literature. World Health Organization (1997).