Diabetes care in hospital Flashcards
(22 cards)
What is diabetes
Its a metabolic condition characterised by a state of persistant hyperglycaemia. as a result of inulin deficiency, insulin resistance or some combination of both
Why do we all need insulin in our bodies?
- insulin the key to permitting cellular glucose uptake and reducing hepatic glucose output - LIVER
- insulin also promotes the cellular uptake of potassium
- also has an anabolic role
History taking: Key factors include?
Diabetes type (1,2 or 3) & duration
Are you known to have any damage to the body due to diabetes?
Diabetes treatments: tablets? insulin? both? times, doses, insulin pump? Who administers medications?
Does the patient check glucose levels at home? especially at home
Smoking, Alcohol intake, Fluid intake, Bowel habit
Visual problems?
Foot problems: changes in colour, shape, swelling, pain, discharge?
Are they aware of having any low sugar episodes (hypoglycaemic episodes), awareness + frequency?
Do you drive? always check sugar levels before you drive - UK legal requirement.
Physical examination: Clinical findings of note
- Blind patient
- A stroke patient
- Ketones on breath (sweet breath from ketoacidosis, unwell)
- Body surface areas - abscess, acanthosis nigricans
- A patient with renal disease: Fistula/dialysis
- An amputee or bandaged lower limbs (must check under bandages)
- Leg swelling (heart failure, immobile, dependent oedema due to gravity, kidney problems or liver disease)
- Lipohypertrophy (repeated insulin jabs in the same place cause lumps)
- Wearable diabetes tech (eg a ‘flash’ glucose meter measures skin fluid glucose but blood), (an insulin pump in type 1 diabetes patients , or a continuous glucose monitoring device)
Useful investigations
Ensure bedside blood glucose monitoring is in place
- Hba1c (from within last 6 months ideally) - broadly aiming for 48-58 mmol/mol where possible (nb frail and elderly)
- eGFR
- BP
- weight (often recorded on admission)
treatment plan - always consider diabetes related factors and start discharge planning early
Types of diabetes:
Type 1 (have particular vigilance, this patient makes absolutely no insulin at all)
Type 2
Type 3 (pancreatic diabetes types)
A plea for type 1 D
- People with Type 1 diabetes need insulin in bodies at ALL times
- Will hopefully be carbohydrate counting - so they can adjust their insulin to what they’re eating (menu carbohydrate available on ward?)
- S/C injections: usually 2 times daily ‘Fixed Mix’ or ‘Basal Bolus’ regimens
- CSII (personal pump) - disconnect and use IV insulin if patient cannot self manage
- Respect the patient voice (concerns, anxieties etc)
- vomiting!!! = DKA until proved otherwise
Vomiting is the first sign of?
impending Diabetic Keto Acidosis - until proven otherwise
In the UK, risk of keto acidosis is?
1 in 25
Acute illness + diabetes points:
Stress of acute operations or health problems (eg sepsis) can destabilise diabetes
Interventions can upset diabetes control:
- eg steroids, feeds, fasting, reduced mobility, incorrect prescribing, delayed diabetes medicines administration
Need to communicate effects of interventions on diabetes to the patient where relevant
Diabetes problems can cause non-specific symptoms:
- vomiting or short of breath = DKA?
- confusion/drowsiness = hypoglycaemia, HHS, foot sepsis?
- see R.E.D
Remember Emergencies in Diabetes: R.E.D
- Diabetic KetoAcidosis (DKA)
- Hyperosmolar Hyperglycaemic State (HHS)
- Hypogylcaemia
- Uncontrolled hyperglycaemia
- Active Diabetic Foot disease
For any unwell patient (with or without diabetes) what score do we use?
ABCDE (NEWS2)
don’t ever forget glucose
- ABCDEFG
if levels are too high or low, appropriate action should be taken promptly
Hyperglycaemia can increase length of stay and delay clinical recovery by:
hyperglycaemia can suppress the immune system by 90% and delay clinical recovery from acute illness and sepsis
Can also delay wound healing after surgery - risky state to ignore
Aim for blood glucose?
Level 5-12mmol/L in hospital
BGM issues: ‘obs stable’ is WRONG
When would you suspect a ward patient has hyperglycaemia?
Sustained BGL > 15 more than 3-4 hrs
context? new problem? usual diabetes control
Type 1 diabetes? check ketones +/- VBG to exclude DKA
Glucose High = Why & Dry
CauseS include:
- Suboptimal prescribing or medication dose adjustment
- States of diabetes emergency (eg DKA, HHS)
- Sepsis (foot disease?)
- Sedentary
- Suspected new diabetes diagnosis
- Steroids
- Supplements (feeds)
- State of mind… (eating wrong footd, not taking medication etc)
Not just a ‘stat’ dose of rapid acting insulin please!
Its great to hydrate
What about hypoglycaemia?
BGL < 4 mmol/L
Medical emergency
9 Rs of hypoglyaemia?
- Recognise
- Respond (ward hypo kit)
- Reflect (cause?)
- Record & handover
- Reassess, but don’t omit post hypo insulin if due
- Renal (if insulin clearance is reduced it could cause hypoglycaemia?)
- Reduce risk (therapies/doses ok? Leaflets, driving)
- Refer?
- Responsibility?
Not eating & drinking?
NMB (for surgery), vomiting etc
might need to use IV insulin infusion, if they’re not having food or drink they MUST be given some glucose based fluids to act as a substrate for the insulin
- should be monitored every hour or 2
Stop the DAMN druGS : drugs that should be questioned:
Diuretics
Antihypertensives
Metformin
NSAIDs
GLP-1s
SGLT-2 inhibitors
Review diabetes meds - suspend/reduce? usually being taken?
When someone is unwell, dehydration with evidence of poor tissue perfusion: which drugs are considered risky if continued?
Metformin (suspended if unwell, due to risk of causing lactic acidosis)
Sulphonylurea (eg Gliclazide): if patient can’t eat properly suspend otherwise hypoglycaemia
SGLT2 inhibitors (‘flozins’: DNA signal (suspend if unwell))
GLP-1 injectables (‘atides’) - work by causing reduced GI transit so should be suspended if unwell to reduce risk of vomiting for example
Don’t forget Insulin - Dose may need reviewing to increase/decrease however is always continued
Key safety points:
Safe prescribing ESPECIALLY insulin
- Safe use of IV insulin (with BGM)
- Type 1 diabetes care - Never stop insulin
- SGLT2 inhibitors (DKA risk)
- Suspend other meds if indicated
- Focussed foot exam (to exclude active diabetic food disease)
- Frailty
- Discharge planning
Never cannulate a patient’s foot who’s diabetic!! if infected can lead to need of amputation
Symptoms & signs - eg SOB, drowsy?
Remember Emergencies in Diabetes (R.E.D)
