Diabetes e-learning Flashcards
Diabetic Ketoacidosis signs
Tachycardia
Rapid resp rate
Low BP
Diagnosing DKA
Urine ketones >++
Blood glucose > 11mmol
Venous pH <7.3
Serum Bicarbonate < 16mmol
Causes of hypoglycaemia in hospital patients
- Too much insulin/ sulphonylureas
- Not enough food
- Delayed/ missed meals or snacks
- Other illnesses esp. renal impairment
- Exercise (e.g. physio)
Examples of sulphonylueas
glicazide or tolbutamide
Why do sulphonylureas cause hypoglycaemia?
Trigger the pancreas to release insulin
Why does renal impairment lead to hypoglycaemia?
Most diabetic medications are renally excreted so stay in the system for longer when renal function is impaired, leading to hypoglycaemia.
Adrenergic Hypoglycaemia
- Noradrenaline, adrenaline and hypoglycaemia
- work with glucagon to oppose insulin
- raise blood glucose
Neuroglycopenic Hypoglycaemia
- consequence of low blood glucose on the brain
- brain function is impaired below blood glucose of 3.5 mmol
Signs of Adrenergic Hypoglycaemia
Pallor, Perspiration, Bradycardia, Tremor, Tachycardia
Symptoms of Adrenergic Hypoglycaemia
Sweating, Shaking, Anxiety, Palpitations, Tingling Lips
Signs of Neuroglycopenic Hypoglycaemia
Confusion, Irritability, Lethargy, Fitting, Odd Behaviour, Slurred Speech, Coma, Hemi-paresis
Symptoms of Neuroglycopenic Hypoglycaemia
Difficulty speaking/concentrating, visual disturbances, Drowsiness, Hunger, Dizziness
Treating Hypos- conscious pt, able to swallow
glucojuice/ glucotabs
Treating Hypos- conscious pt, able to swallow not able to cooperate
Glucogel
Treating Hypos- pt unconscious, maybe fitting, has IV access
10% glucose with giving set
3 way tap, 50ml syringe for 50ml boluses
Treating Hypos- pt unconscious, no IV access
Glucagen
Dose Reduction after Hypoglycaemia
Sulphonylureas
- BG may be low for 24-48 hours
- continue 100mls/hr 10% glucose after hypoglycaemia coma
- omit further doses until Diabetes review if BG <3mmol
- Reduce dose by 50% if BG between 3-3.9 mmol without cause (e.g. missed meal)
Dose Reduction after Hypoglycaemia
Insulin
- do not omit next dose if Type 1 DM –> May reduce
- next dose may be omitted if T2DM with review from DM team.
Quick Acting Insulin
- usually given with meals (3x daily)
- not given at bedtime
- Short acting insulin - Actrapid and Humulin S. Peak at 2 hours
- rapid acting insulin analogues (genetically engineered, usually quicker than short acting insulin) Humalog and Novarapid. Peak at 15 mins
Medium or Long Acting Insulin
- usually given twice a day (morning and bed time)
- medium acting insulins - Humulin I and Insulatard
- long acting insulin analogues - Lantus and Levemir
Insulin Mixtures
Normally BD. Provide basal and meal time coverage. Never given before bed. Sometimes OD in the elderly.
- Premixed Insulins e.g. Humulin M3 - give 15-20 mins before a meal
- Biphasic Analogue Mixtures e.g Novomix30 or Humalog Mix25 - with or 15mins after carbs
Multiple Injection Insulin Regime
quick acting insulin with each meal
1-2 background long acting insulin
T1DM, some T2DM
Twice Daily Insulin Regime
Insulin mixtures. T2DM
Once Daily Insulin Regime
Medium/long acting insulin at bedtime, plus oral hypoglycaemics in T2DM.
Occasionally elderly pts long acting/mixture in the morning
Insulin pumps
- if Hypoglycaemic treat with IV insulin- pump may be broken
- if pump is disconnected at risk of DKA very quickly- give SC insulin
DAFNE
Dose Adjustment For Normal Eating
- pre-meal/snack short acting, BD medium acting
- estimate carb content of food
- calculate insulin requirements of food
- should be able to self manage
- should still record doses and monitoring of self managing pts.
Metformin
Doesn’t make patients gain weight
Biguanide
Favourable action on lipids, anti-cancer and cardio-protective
Impaired renal function - lactic acidosis in eGFR < 30, diarrhoea and abdominal discomfort
Sulphonylureas
gliclazide
- stimulate insulin release by binding to B-cell receptors
improves glycaemic control at the significant weight gain
doesnt prevent gradula failure of insulin secretion
can cause hypoglycaemia- occasionally prolonged and fatal- especially in elderly and renally impaired.
Thiazolidinediones
pioglitazone - activates genes that promote gluocse uptake and utilisation and lipid metabolism improve insulin sensitivity need insulin fro a therapeutic effect relatively rare
Thiazolidinediones
Side Effects
Weight gain macular oedema Oedema Heart Failure Increased fracture risk
Incretin concept
Enteral glucose
Effects of GLP-1
stimulates insulin secretion suppresses glucagon secretion slows gastric emptying reduces food intake rapidly degraded
Therapeutic effect of GLP-1 in T@DM
reduces energy intake, blood glucose
SGLT2 inhibitors
Block reabsorption of glucose in the kidney, increase glucose excretion and lower blood glucose levels
e.g. empagliflozin, canaglioflozin, dapagliflozin
may benefit CV mortality
SGLT2 inhibitor
Side Effects
genital thrush
increased risk of euglycaemic ketoacidosis
Bed time insulin
Long acting- maintains liver secretion over night
Combination of bedtime background insulin (NPH) and oral agents
weight gain in insulin therapy
- decrease in energy loss as glucosuria ceases and is not compensated for by comparable reduction in energy intake
- ? increase in appetite with an anabolic hormone
bariatric surgery
can produce profound weight loss and may also alter secretion of incretin hormones
- gastric anding/ gastric bypass
can cure T2DM in up to 70% even in those treated with insulin
DKA
raised BG metabolic acidosis (Bicarb <16, pH<7.3) Blood ketones>3mmol / ketonuria >++/4mmol/40mg/l
Causes of DKA
older age groups- infection
<30 omission of insulin
Mortality of DKA
5-10% lower in specialist centres
causes
- elderly- comorbidities and late presentation
-vomiting - 12-24 hours to live without treatment
DKA treatment
- restore circulating blood volume
- Replace lost electrolytes
- Return blood glucose towards normal while giving sufficient insulin to inhibit hepatic gluconeogeneis
DKA teatment
1l saline in first hour 1 l in next 2 1l in next 4 1l in next 6 - reduce in elderly or in cardiac disease
DKA potassium
normal or high serum potassium but low total potassium
add potassium to the IV when plasma potassium is known
>5.5
DKA insulin
0.1 unit/kg/hr
double concentration if insulin resistant
monitor glucose hourly
keep high- when BG <14 add glucose to NaCl
Target blood glucose is between 8-14 mmol
Other measures of DKA
- SpR DM
-Urinary catheter
-EWS
-NG–> HDU
commence prophylactic anticoagulation
Dont give bicarb
Hyperosmolar Hyperglycaemic State
hypovolaemia
hyperglycaemia >30mmol
HHS
T2DM High mortality Sodium increases normal saline, anticoagulants manage with sulphylureas Don't use insulin routinely slow and steady- prevent rapid fluid shifts treat underlying cause if infection
