Management of Type 1 Diabetes Flashcards
Why is delayed diagnosis a problem?
DK is preventable and early diagnosis improves quality of life and reduces risk of developing complications
What is the 3 Ts of early diagnosis?
THINK - keep symptoms in mind
TEST
TELEPHONE - local specialist team for a a same say review
4 Ts of symptoms of type 1?
Thirsty
Thinner
Tired
Toilet
What is a red flag symptom of type 1?
Return to bed wetting or day wetting in a previously dry child
Early symptoms for children under 5?
- Heavier than usual nappies
- Blurred vision
- Candidiasis - oral/vulval
- Constipation
- Recurring skin infections
- Irritibility and behaviour changes
Symptoms of DKA?
- Nausea and vomiting
- Abdo pain
- Dehydration
- Sweet smelling ketotic breath
- Drowsiness
- Rapid, deep sighing respiration
What is normal blood pH?
7.35-7.45
How do we TEST immediately is type 1 is suspected? What should we not do?
Finger prick capillary blood glucose test
- >11mmol/l = diabetes
- <11mmol/l = other cause
Do NOT do a returned urine specimen, a fasting blood glucose test, an oral glucose tolerance test as these take TIME - something the patient may not have
Why do we arrange (telephone) a same day review with a specialist team?
Children can get DKA very quickly so important not to delay
Current strategies to support people with type 1?
- Education
- Nutrition and lifestyle management - exercise, calorie counting and CHOs
- Skills training - home BG testing and injection technique
- Insulin - analogues, pens, pumps
What to do before you inject insulin?
Check its the right insulin, right dose, right time and right way
Why is insulin injected?
It is a polypeptide hormone which is inactivated by the GI tract so can’t be consumed orally
Why is insulin given 30 mins before eating and not right before?
In the subcutaneous fat the Insulin molecule in solution can self-associate into hexamers Hexamers need to dissociate into monomers before absorption through the capillary bed - takes time
What types of insulin can be taken right before eating and why?
Fast acting analogues because they do not associate with hexamers
What can change the rate of insulin absorption?
Changing the structure of insulin or binding it to other molecules
How much insulin should be injected for a meal?
The amount of insulin injected for meals should balance the carbohydrate intake consumed
Name the current insulin regimes?
Twice daily
- Rapid + intermediate (mixed) before breakfast
- Rapid + intermediate before tea
Three times daily
- Rapid + intermediate before breakfast
- Rapid + intermediate before tea
- Intermediate before bed
Four times daily
- Short acting before, breakfast
- Short acting before lunch
- Short acting before dinner
- Intermediate before breakfast OR long acting at a fixed time
Why is a multiple injection regime that combines short and long acting insulin useful? What type of patients will use it?
Insulin and food go together so meal times and sizes can vary without affecting metabolic control - so more flexible Younger patients use it
What is the honeymoon period for type 1s?`
Some recovery of endogenous insulin secretion may occur over the 1st few months of treatment in type 1s where the insulin dose may need to be reduced But after insulin requirements do rise after this period
Target BG values before and after meals for type 1s?
4-7 mmoles/L before meals and 4-10 after a meal
Why is strict glucose control helpful from the onset in type 1s?
Prolongs b-cell function = better glucose levels and less hypos
What is a CSII?
Continuous s/c insulin infusion
Explain how a CSII works.
A small pump strapped around the waist that infuses a constant trickle of insulin via a needle in the s/c tissue
Mealtime doses delivered when user instructs pump to deliver a bolus of insulin at start of meal
Positives of the CSII device
Useful in overnight period as the rate can be programmed to fit each patients need
Negatives of the CSII device
Nuisance of being attatched to the gadget
Skin infections
Risk of ketoacidosis if flow breaks
Cost
What constitutes a hypo
less than 4 mmol/l BG with or without symptoms
Reasons for hypos?
- Too little food
- Too much activity
- Insulin/sulphonylureas (oral hypoglyceamis)
How dangerous is a hypo in a type 1 ?
Most isolated hypo’s resolve themselves without treatment in type 1s
Symptoms of a hypo?
- Headache
- Nausea
- Sweating
- Palpitations
- Shaking
- Hunger
- Confusion
- Drowsiness and odd behaviour
When does loss of warning signs for hypos occur?
- Recurrent severe hypoglycemia
- Long duration of disease
- Too tight a control
- Loss of sweating/tremor
Treatment for a hypo?
- 15 - 20gs CHOs
- 5-7 dextrosol tablets
- 4-5 glucotabs
- 200 ml fruit juice
Treatment for a hypo in a patient unable to take oral CHOs?
- Out of hospital - 1 mg glucagon injection
- In hospital - IV glucose or dextrose
What must be done in regards to hypo’s and driving?
- Check blood glucose before 2 hours of driving and during long car journeys
- Carbs should be in the car
- Not allowed more than one episode of severe hypo in a year
In what situations does DKA arise?
- Previously undiagnosed type 1
- Interruption of insulin therapy
- Stress of incurrent illness
What is the most common error in management that causes patients to get DKA?
Reduce or omit insulin because they feel unable to eat - either due to sickness or vomiting
Explain the pathological mechanism behind DKA.
- No insulin and high glucagon = high levels of glucose in blood via glycogenolysis and gluconeogenesis
- Lipolysis due to glucagon = FFAs —> ketones
- No insulin means ketones can’t be took into cells so –> acidosis
- High glucose levels = dehydration and loss of electrolytes
What is acidotic breathing and why is it a response to DKA?
Hyperventilation to reduce CO2 levels in blood to make it less acidotic
Investigations for DKA?
- Glucose levels
- ABGs - pH less than 7.1 is bad
- Blood ketones - Over 6 mmol/l
- Bicarbonate - Less than 12 mmol/l
Initial managemnt of DKA?
- Replace fluid and electrolyte loss (potassium as soon as insulin is given as it helps K+ uptake)
- Replace insulin
- Restore acid-base balance via bicarbonate - patient with healthy kidneys will do this itself when circulation is restored so bicarbonate is actually rarely needed
Once DKA is controlled what shoud we think about?
- Underlying cause
- Monitoring glucose levels regularly
Problems of DKA managment?
- Hypotension - may cause renal shutdown, treat with NaCl 0.9% Hypokalaemia due to osmotic diuresis
- Hypoglycaemia
- Cerebral oedema due to excessive re-hydration - rare but children more susceptible
- Arterial and venous thromboembolism
- ARDS
- Aspiration pneumonia
