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Endocrying > Management of Diabetes (type 1) > Flashcards

Management of Diabetes (type 1) Flashcards

1
Q

What are the aims (areas) of type 1 diabetes management

A

Prompt diagnosis

Encouragement of appropriate self-management skillset

Correction of current and future metabolic upsets

Facilitate long term health and well being

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2
Q

What are the key symptoms of type 1 diabetes?

A

Thirsty

Thinner

Tired

Toilet

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3
Q

In children under 5, what other symptoms/signs of diabetes may present?

A

Aside from Thirst, tired, thin, toilet

Blurred vision

Candidiasis (oral, vulval)

Constipation

Recurring skin infections

Irritability/mood changes

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4
Q

What are the symptoms and signs of DKA?

A

Nausea & vomiting

Abdominal pain

Sweet-smelling breath (ketotic)

Drowsiness

Rapid, deep ‘sighing’ respiration

Coma

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5
Q

How do you investigate suspected DKA?

A

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

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6
Q

What educational services are used for type 1 diabetes?

A

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)

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7
Q

What nutrional and lifestyle advice is used in the management of type 1 diabetes?

A

CHO counting

Physical exercise

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8
Q

What skills are type 1 diabetic patients taught?

A

Includes:

Home blood glucose monitoring

Injection technique

Hypo situation training

Sick day rules

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9
Q

Why cant insulin be taken orally?

A

inactivated by the gastrointestinal tract

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10
Q

When insulin is injected into subcutaneous fat - what happens?

A

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

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11
Q

What are the different types of non-mixture insulin medications (by duration of action)

A

Rapid-acting analogue:

  • Humalog, Novorapid, Apidra

Short-acting soluble:

  • Humalin S, Actrapid

Intermediate-acting soluble:

  • Humalin I, Insulatard

Long-acting analogue:

  • Lantus, Levemir
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12
Q

What are the types of mixture insulin medications?

A

Rapid-acting soluble intermediate mixture:

  • Humalog mix 25/50, Novomix 30

Short-acting intermediate mixture:

  • Humulin M3, Insuman Comb 15/25/50
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13
Q

What is Basal bolus therapy?

A

Insulin treatment regime - involving a combination of Rapid (short) acting insulin for meals & basal long-acting insulin for background

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14
Q

Describe the insulin regime for if the patient takes insulin:

a) Twice daily
b) Three times daily
c) Four times daily

A

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
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15
Q

What is CSII?

A

Continuous Subcutaneous Insulin infusion (CSII)

Another option for insulin administration

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16
Q

Describe hypoglycaemia as a complication of diabetes

A

Hypoglycaemia refers to any episode of low blood glucose ( < 4 mmol/L )

In diabetic patients - often due to problems taking Insulin or Sulphonylureas

17
Q

What are the reasons that hypoglycaemia may occur?

A

Medication:

  • Too much insulin/SU
  • Inappropriate timing
  • Injection site problems

Inadequate food intake/fasting

Exercise

Alcohol

18
Q

What groups (of diabetics) are at risk of being hypoglycaemic?

A
  • Tight glycaemic control
    • Ie people with really bad diabetes
  • Impaired awareness
  • Cognitive impairment
  • Hypoadrenalism/steroid withdrawal
  • Coeliac disease
  • Renal/hepatic impairment
  • Pregnancy
  • pancreatectomy
19
Q

What happens if hypoglycaemia is left untreated?

A

Most isolated hypoglycaemia episodes recover spontaneously

important to reassure patients of this

20
Q

What are the symptoms of hypoglycaemia?

A

Autonomic symptoms:

  • Sweating
  • Palpitations
  • Shaking
  • Hunger

Neuroglycopenic symptoms:

  • Confusion
  • Drowsiness
  • Mood change/odd behaviour
  • Incoordination

General malaise symptoms:

  • Headache
  • Nausea
21
Q

An inability to perceive normal warning signs of hypoglycaemia is associated with?

A

Recurrent severe hypoglycaemia

Long duration of disease

Overly tight control

Loss of sweating/tremor (autonomic response decrease)

22
Q

What medications can interact with hypoglycaemic agents and precipitate hypoglycaemia?

A

Warfarin

Somatostatin analogues

Quinine

Sulphonamides

NSAIDS

23
Q

What would be classed as mild hypoglycaemia?

How is this managed?

A

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
24
Q

What would be classed as moderate hypoglycaemia?

How would it be managed?

A

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
25
Q

WHat would be classed as severe hypoglycaemia?

How is severe hypoglycaemia treated?

A

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)

26
Q

What is contained in a ‘hypo box’

A

box containing supplies for management of hypo episodes:

Fruit juice

Dextro energy

Glucogel

20% or 50% dextrose

Hypo management protocol

27
Q

What should be discussed with a patient following a hypo episode?

A

Wrong regimen; dose/insulin

Control and monitoring

Hypoglycaemia unawareness

Discuss driving / work etc

Food/activity/insulin

Injection sites

28
Q

What advice should be given to diabetic patients about driving and hypoglycaemia?

A

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

29
Q

What are the symptoms of diabetic ketoacidosis (DKA)?

A

Polyuria

Polydipsia

Weight loss

Weakness

Nausea/vomiting

Abdo pain

Breathlessness

30
Q

What are the risk factors for DKA

A

Known T1DM

inadequate insulin

infection

other precipitant

31
Q

What are the signs of diabetic ketoacidosis DKA?

(signs much more of a giveaway for diagnosis of DKA)

A

Dry mucus membranes

Sunken eyes

Tachycardia

Hypotension

Ketotic breath

Kussmaul respiration - fast, deep, sighing

Altered mental state

Hypothermia

32
Q

What are the overall rules for when treating acute illness in patients who are diabetic?

A

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

33
Q

What causes DKA to happen?

A

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

34
Q

What ketone level risks DKA

A

> 1.5 mmol/L

35
Q

Describe the initial investigations for DKA

A

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
36
Q

What are the possible complications of DKA

A

Hyper/Hypokalaemia

Hypoglycaemia:

  • Rebound ketosis
  • Arrhythmias
  • Acute brain injury

Cerebral oedema (especially in kids)

Aspiration pneumonia

Arterial and venous thromboembolism

ARDS

37
Q

Give a summary of the management of DKA

A

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

38
Q
A

Endocrying (21 decks)

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