Diabetes Mellitus Flashcards
Definition of Hypoglycaemia
- ANY EPISODE OF LOW BG (< 4 mmol/L) WITH/WITHOUT SYMPTOMS
- MAY OCCUR IN PT. TAKING INSULIN/SULPHONYLUREAS
- IF SEVERE = MAY REQ. 3RD PARTY INTERVENTION
T1DM = EVEN IF UNTREATED, MOST ISOLATED HYPO EPISODES RECOVER SPONTANEOUSLY + NOT ASS. W/ PERMANENT DAMAGE
Hypoglycaemia Symptoms
AUTONOMIC:
SWEATING, PALPITAITONS, SHAKING, HUNGER
NEUROGLYCOPENIC:
CONFUSION, DROWSINESS, ODD BEHAVIOUR, SPEECH DIFFICULTY, INCO-ORDINATION
GENERAL MALAISE:
HEADACHE, NAUSEA
Treatment of Hypoglycaemia
IF ABLE:
• 15-20g SIMPLE CHO
• 5-7 DEXTROSOL/4-5 GLUCOTABS or • 200mL FRUIT JUICE
OUT OF HOSPITAL/MODERATE HYPOGLYCAEMIA:
• Pt. may be able to swallow but confused/disorientated/aggressive
IF CAPABLE + ORIENTATED = TREAT AS W/ MILD HYPOGLYCAEMIA
IF NOT CAPABLE & ORIENTATED:
• 1mg I/M GLUCAGON or • GLUCOGEL/DEXTROGEL
IN HOSPITAL/SEVERE HYPOGLYCAEMIA:
• Pt. unconscious/fitting, v. aggressive/nil by mouth GIVE IV GLUCOSE OVER 10-15mins as:
• 75-80mL 20% GLUCOSE or • 150mL 10% GLUCOSE or • 1mg GLUCAGON I/M ONCE ONLY or • 25-50mL 50% IV DEXTROSE
CHECK AFTER 10-15mins:
* IF NOT HYPOGLYCAEMIC = GIVE LONG-ACTING CHO * IF STILL HYPOGLYCAEMIC = REPEAT CURRENT TREATMENT UP TO 3 MORE TIMES * IF PT. LOOKS LIKE THEY'RE DETERIORATING = CALL DOCTOR & CONSIDER IV GLUCOSE/1mg GLUCAGON IM (once only)
What to do after a patient has recovered from hypoglycaemia?
DETERMINE CAUSE OF HYPOGLYCAEMIA AFTER PT. RECOVERED:
* WRONG REGIMEN; DOSE/INSULIN * CONTROL & MONITORING * HYPOGLYCAEMIA UNAWARENESS * DISCUSS DRIVING/WORK etc. * FOOD/ACTIVITY/INSULIN * INJECTION SITES
AVOIDANCE OF HYPOGLYCAEMIA IN INSULIN-TREATED DIABETES:
* BLOOD GLUCOSE MONITORING * ROTATE & CHECK INJECTION SITES * REVIEW SNACKS & DIET - CHO COUNTING * CONSIDER CHANGE OF INSULIN REGIMEN * AVOID LOW GLUCOSE - 4 is the floor (7 at bedtime & 5 to drive) * ALTER INSULIN BEFORE & AFTER EXERCISE
Aetiology + At-Risk Groups of Hypoglycaemia
• IMBALANCE BWTN: FOOD, ACTIVITY, INSULIN/SOME ORAL HYPOGLYCAEMICA
○ Food = too little/wrong type ○ Activity - during/after ○ Insulin/some oral hypoglycaemics = dose, injection techniques
e.g. too much insulin, inappropriate timing of insulin, injection site problems, inadequate food intake/fasting, exercise, alcohol
At Risk Groups:
Tight glycaemic control Impaired awareness Cognitive impairment Extremes of age Malabsorption/gastroparesis Hypoadrenalism/abrupt steroid withdrawal Coeliac disease Renal/hepatic impairment Pancreatectomy Pregnancy
Loss of Warnings of Hypoglycaemia
INABILITY TO PERCEIVE NORMAL WARNING SYMPTOMS OF HYPOGLYCAEMIA ass. w/
* RECURRENT SEVERE HYPOGLYCAEMIA * LONG DURATION OF DISEASE * OVER TIGHT CONTROL * LOSS OF SWEATING/TREMOR
DKA Presentation (symptoms & signs)
Symptoms:
* NAUSEA & VOMITING * SOB, WEAKNESS * ABDOMINAL PAIN * SWEET, SMELLING, KETOTIC BREATH * DROWSINESS * RAPID DEEP SIGHING RESPIRATIONS (but chest sounds clear when auscultating, called Kussmaul respiration) • COMA
O/E:
* DRY MUCUS MEMBRANES, DEHYDRATION * SUNKEN EYES * TACHYCARDIA, HYPOTENSION * ALTERED MENTAL STATE * HYPOTHERMIA * KUSSMAUL RESPIRATION, KETOTIC BREATH
Investigations in Hospital for DKA
1st:
RAPID ABC
IV ACCESS
VITAL SIGNS
CLINICAL ASSESSMENT + FULL CLINICAL EXAMINATION
Investigations:
GLUCOSE
VENOUS BLOOD GAS
URINALYSIS/BLOOD KETONES
FBC, U&E
CULTURE BLOOD/URINE
ECG & CARDIAC MONITOR
CONSIDER CXR
Management of DKA by patient
ACUTE INSULIN TREATED PATIENTS:
* NEVER STOP INSULIN * INCREASE/ADJUST INSULIN DOSE ACCORDING TO BG * PERFORM MORE FREQ. BG CHECKS & CHECK URINE/BLOOD FOR KETONES * CHO INTAKE MUST BE MAINTAINED BY FLUIDS IN UNABLE TO TOLERATE FOOD
• IF FEELING UNWELL/HIGH BG LVL = CHECK FOR KETONES
○ HOWEVER, IF DISPLAYING DANGER SIGNS (persistent vomiting for 2-4hrs, abdo pain, dehydration, heavy/rapid breathing) = URGENT HOSPITAL ASSESSMENT
- IF NO KETONES = check BG 4x daily & ketones 2x daily until symptoms pass/ketones present in which case retest w/I 2hrs
- IF KETONES = CONSIDER BG LVLS○ <12 mmol/L = starvation ketosis, I feeling queasy have sips of sugary drink + aim to have surgary drink every 1-2hrs + follow steps for if no ketones were found○ >12 mmol/L = extra dose of insulin - recheck BG lvls 4hrs later if still high = another extra insulin dose (repeat until still elevated 12hrs later - contact diabetic team)
Management of DKA by HDU in Hospital
MEASURE GLUCOSE, U&E, KETONES, BICARBONATE, ABG
IV SALINE (5L in 24hrs)
IV INSULIN
IV K+ IN SALINE
MAY NEED ANTIBIOTICS
CONSIDER HEPARIN, NGT
Complications of DKA
- HYPER & HYPOKALAEMIA
- HYPOGLYCAEMIA○ REBOUND KETOSIS
○ ARRTHYMIAS
○ ACUTE BRAIN INJURY○ CEREBRAL OEDEMA (children more susceptible)○ ASPIRATION PNEUMONIA
○ ARTERIAL & VENOUS THROMBOEMBOLISM
○ ARDS
- HYPOGLYCAEMIA○ REBOUND KETOSIS
Risk Factors of DKA
- KNOWN T1DM
- INADEQUATE INSULIN
- INFECTION
- SEVERE STRESS
- OTHER PRECIPITANT
Preventing Further DKA
EDUCATION PACKAGE + INVOLVEMENT OF DIABETES TEAM:
* IN-PATIENT SERVICES * COMMUNITY/PRIMARY CARE TEAM * REDUCE HOSPITAL STAY * EMPOWER PT. * PREVENT COMPLICATIONS * PSYCHOLOGY TEAM
What is a Healthy Lifestyle?
- EAT BALANCED DIET, DON’T SMOKE, REGULAR PHYSICAL ACTIVITY
- MODERATE ALCHOL USE, NO RECREATIONAL DRUGS
- GOOD WORK/LIFE BALANCE, LEARN TO DEAL w/ STRESS APPROPRIATELY
Changes that occur in diabetes to lifestyle
MEDICATION/INJECTIONS BLOOD TESTING DIET, WGT. LOSS, PHYSICAL ACTIVITY DEALING w/ HYPOS & ILLNESS TRAVEL HOBBIES WORK FAMILY/FRIENDS
However, DON’T NEED TO SWITCH TO “DIABETIC DIET” - just need to eat balanced diet in moderation
Why can diabetes be so hard?
LONG TERM CONDITION w/ COMPLEX MANAGEMENT
LIFESTYLE MANAGEMENT
DELAYED & PROBABLISTIC REWARD
MAY NOT FIT IN w/ LIFE
Why can diabetes be especially hard on young people?
DESIRE TO BE SAME AS PEERS
SPORT
NIGHTS OUT, ALCOHOL/DRUGS
FESTIVALS, SEX/CONTRACEPTION
TATOOS, PIERCINGS
TRAVEL
LEARNING TO DRIVE
LEAVING HOME
Dietary Changes in Diabetes (both types)
NEED FOR WGT. LOSS
CHO = MAIN CONSIDERATION IN MANAGING GLYCAEMIC CONTROL
HIGH GI = SHORT SHARP BURST IN BG LVLS LOW GI = LONG SLOW RELEASE IN BG
CHO COMPOSITION ALTERS HOW QUICKLY CHO ABSORBED FROM GUT (fat lsows down CHO absorption) - MAY NEED TO ADJUST INSULIN TIMING FOR HIGHER GI FOODS
CONSIDER EFFECTS OF DIET ON LIPIDS/BP
Alcohol & diabetes
ALCOHOL REDUCES GLYCOGENOLYSIS (which is exacerbated by insulin also inhibiting glycogenolysis)
ALCOHOL CONTAINS CALORIES - results in rise & then fall in glucose
SAME LIMIT AS GENERAL POPULATION + > 2-3 UNITS AT ONE TIME INCREASES HYPO RISK
EAT BEFORE & SNACK AT BEDTIME WHEN DRINKING + NOTE OTHER ACTIVITY AT TIME OF ALCOHOL
MAKE SURE SOMEONE CHECKS ON THEM
Smoking & diabetes
SMOKER DIE 10 YRS BEFORE NON-SMOKERS
INCREASE RISK OF DIABETES 1.5x & >2x MACROVASCULAR DISEASE
DIABETIC SMOKER AT RISK OF IHD
Basically increases risk of all complications - stopping smoking more beneficial than gaining a few kgs
NICTOINE REPLACMENT & OTHER DRUGS CAN BE USED IN DIABETES
Burden of Physical Inactivity
CORONARY HEART DISEASE COLON CANCER BREAST CANCER T2DM PREMATURE ALL-CAUSE MORTALITY
Benefits of Exercise
CV BENEFIT REDUCES CANCER RISK CONSIMES ENERGY BUILDS LEAN TISSUE & CONSUMES FAT IMROVES STRENGTH, ENDURANE, BALANCE, FLEXIBILITY IMPROVES MOOD & SELF-ESTEEMS SOCIABLE
How can we help to increase physical activity lvls?
TALK TO THEM ABOUT = what do they do, why do they enjoy it, opportunities
ADDRESS DIABETES SPECIFIC BARRIER = fear of hypos, insulin adjustment - before & after, lack of knowledge, nutrition
PROVIDE FACILITIES/SOCIAL/WORK PLACE STRUCTURES
COMMUNITY INVOLVEMENT/SCHOOLS
COUNCILS/GOVERNMENT STRATEGIES
Some hobbies/work to consider carefully in diabetes
SCUBA DRIVING
SCAFFOLDER/WINDOW CLEANER
SOLO YACHTSPERSON
ENDURANCE SPORTS
TAXI DRIVER
EMERGENCY VEHICLE DRIVER
BUS/LORRY DRIVER
Holidays & Diabetes
NO RESTRICTIONS - USE COMMON SENSE, consider insurance
MONITOR GLUCOSE + DRINK PLENTY OF FLUIDS
AVOID RISKS OF GASTROENTERITIS
ALWAYS CARRY INSULIN W/ YOU + may adjust insulin when crossing time zones
