Management of Diabetes (type 1) Flashcards
What are the aims (areas) of type 1 diabetes management
Prompt diagnosis
Encouragement of appropriate self-management skillset
Correction of current and future metabolic upsets
Facilitate long term health and well being
What are the key symptoms of type 1 diabetes?
Thirsty
Thinner
Tired
Toilet
In children under 5, what other symptoms/signs of diabetes may present?
Aside from Thirst, tired, thin, toilet
Blurred vision
Candidiasis (oral, vulval)
Constipation
Recurring skin infections
Irritability/mood changes
What are the symptoms and signs of DKA?
Nausea & vomiting
Abdominal pain
Sweet-smelling breath (ketotic)
Drowsiness
Rapid, deep ‘sighing’ respiration
Coma
How do you investigate suspected DKA?
Finger prick capillary blood glucose test
> 11 mmol/L = diabetic
Do not bother with other blood/urine tests
Then refer to paeds diabetic team for same-day referal
What educational services are used for type 1 diabetes?
Team-based:
- Diabetic specialist nurse (DSN), practice nurse, dietitians, podiatrists, doctors
Structured education:
- DIANE, education for dose adjustment for normal eating
However - diabetes management is pretty much all down to self management (very little health professional contact)
What nutrional and lifestyle advice is used in the management of type 1 diabetes?
CHO counting
Physical exercise
What skills are type 1 diabetic patients taught?
Includes:
Home blood glucose monitoring
Injection technique
Hypo situation training
Sick day rules
Why cant insulin be taken orally?
inactivated by the gastrointestinal tract
When insulin is injected into subcutaneous fat - what happens?
In the subcutaneous fat the Insulin molecule in solution has a tendency to self-associate into hexamers
Hexamers need to dissociate into monomers before absorption through the capillary bed. Thus soluble insulin is given 30 mins before eating
Rapid acting analogues do not form hexamers - thus dissociate much faster and can be taken just before eating
What are the different types of non-mixture insulin medications (by duration of action)
Rapid-acting analogue:
- Humalog, Novorapid, Apidra
Short-acting soluble:
- Humalin S, Actrapid
Intermediate-acting soluble:
- Humalin I, Insulatard
Long-acting analogue:
- Lantus, Levemir
What are the types of mixture insulin medications?
Rapid-acting soluble intermediate mixture:
- Humalog mix 25/50, Novomix 30
Short-acting intermediate mixture:
- Humulin M3, Insuman Comb 15/25/50
What is Basal bolus therapy?
Insulin treatment regime - involving a combination of Rapid (short) acting insulin for meals & basal long-acting insulin for background
Describe the insulin regime for if the patient takes insulin:
a) Twice daily
b) Three times daily
c) Four times daily
a) Twice daily:
* Rapid-acting & intermediate-acting mixture (eg Humalog mix) BB, BT
b) Three times daily:
- Rapid-acting & intermediate-acting BB
- Rapid-acting BT
- Intermediate-acting BBed
c) Four times daily:
- Short-acting BB, BL, BT
- Intermediate BBded or Long-acting at fixed point each day
What is CSII?
Continuous Subcutaneous Insulin infusion (CSII)
Another option for insulin administration
Describe hypoglycaemia as a complication of diabetes
Hypoglycaemia refers to any episode of low blood glucose ( < 4 mmol/L )
In diabetic patients - often due to problems taking Insulin or Sulphonylureas
What are the reasons that hypoglycaemia may occur?
Medication:
- Too much insulin/SU
- Inappropriate timing
- Injection site problems
Inadequate food intake/fasting
Exercise
Alcohol
What groups (of diabetics) are at risk of being hypoglycaemic?
- Tight glycaemic control
- Ie people with really bad diabetes
- Impaired awareness
- Cognitive impairment
- Hypoadrenalism/steroid withdrawal
- Coeliac disease
- Renal/hepatic impairment
- Pregnancy
- pancreatectomy
What happens if hypoglycaemia is left untreated?
Most isolated hypoglycaemia episodes recover spontaneously
important to reassure patients of this
What are the symptoms of hypoglycaemia?
Autonomic symptoms:
- Sweating
- Palpitations
- Shaking
- Hunger
Neuroglycopenic symptoms:
- Confusion
- Drowsiness
- Mood change/odd behaviour
- Incoordination
General malaise symptoms:
- Headache
- Nausea
An inability to perceive normal warning signs of hypoglycaemia is associated with?
Recurrent severe hypoglycaemia
Long duration of disease
Overly tight control
Loss of sweating/tremor (autonomic response decrease)
What medications can interact with hypoglycaemic agents and precipitate hypoglycaemia?
Warfarin
Somatostatin analogues
Quinine
Sulphonamides
NSAIDS
What would be classed as mild hypoglycaemia?
How is this managed?
Patient - conscious, orientated, able to swallow, not fasting
Management:
- 15-20g simple CHO
- 5-7 dextrosol/4-5 glucotabs
- 200 ml fruit juice
- Check Blood glucose after 15 mins and repeat i.n
What would be classed as moderate hypoglycaemia?
How would it be managed?
Patient - conscious, orientated and able to swallow - but aggressive or confused
Management:
- 1.5-2.0 tubes Glucose gel (glucogel)
- Check bloods and repeat i.n
WHat would be classed as severe hypoglycaemia?
How is severe hypoglycaemia treated?
Patient - unconscious/flitting or very confused
Management - Out of hospital:
- 1 mg IM glucagon
Management - in hospital:
- IV glucose
- 75-80ml 20% glucose or
- 150-160ml 10% glucose or
- 25-50ml 50% dextrose IV
Follow up with long acting CHO (in any episode of hypo)
What is contained in a ‘hypo box’
box containing supplies for management of hypo episodes:
Fruit juice
Dextro energy
Glucogel
20% or 50% dextrose
Hypo management protocol
What should be discussed with a patient following a hypo episode?
Wrong regimen; dose/insulin
Control and monitoring
Hypoglycaemia unawareness
Discuss driving / work etc
Food/activity/insulin
Injection sites
What advice should be given to diabetic patients about driving and hypoglycaemia?
Patients should be advised to:
- check their blood glucose before/within 2 hours of driving and during long car journeys
- always carry carbohydrate in the car.
No awareness then no driving
No more than one episode of severe hypo (Group 1) in a year to be allowed to drive
What are the symptoms of diabetic ketoacidosis (DKA)?
Polyuria
Polydipsia
Weight loss
Weakness
Nausea/vomiting
Abdo pain
Breathlessness
What are the risk factors for DKA
Known T1DM
inadequate insulin
infection
other precipitant
What are the signs of diabetic ketoacidosis DKA?
(signs much more of a giveaway for diagnosis of DKA)
Dry mucus membranes
Sunken eyes
Tachycardia
Hypotension
Ketotic breath
Kussmaul respiration - fast, deep, sighing
Altered mental state
Hypothermia
What are the overall rules for when treating acute illness in patients who are diabetic?
Never stop insulin
- Increase/adjust insulin dose according to blood glucose
Perform more frequent blood glucose checks
Check urine or blood for ketones
Carbohydrate intake must be maintained by fluids (eg fruit juice) if unable to tolerate food
What causes DKA to happen?
Results from too little insulin - leading to breakdown of fat(producing tons of ketones) with fluid depletion
Usually associated with high glucose
May be caused by infection / severe stress/insulin omission
What ketone level risks DKA
> 1.5 mmol/L
Describe the initial investigations for DKA
Initial response:
- Rapid A,B,C
- IV access
- Vital signs
- Clinical assessment
- Full clinical examination
Investigations:
- Glucose
- Venous blood gas - shows pH of blood (acidosis)
- Urinalysis/blood ketones
- U&Es, FBC
- Culture blood/urine to check for infection as cause
- ECG & cardiac monitor
- Possible CXR
What are the possible complications of DKA
Hyper/Hypokalaemia
Hypoglycaemia:
- Rebound ketosis
- Arrhythmias
- Acute brain injury
Cerebral oedema (especially in kids)
Aspiration pneumonia
Arterial and venous thromboembolism
ARDS
Give a summary of the management of DKA
Main investigations:
- glucose
- U&E’s
- Ketones
- Bicarbonate
- Arterial blood gas
IV saline - to rehydrate
IV insulin - drive glucose and potassium into cells
IV potassium in saline
IV antibiotics - if infection
Heparin if needed
NG tube if needed
