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ZA - Endocrine System > Management of Type 1 Diabetes > Flashcards

Management of Type 1 Diabetes Flashcards

1
Q

Why is delayed diagnosis a problem?

A

DK is preventable and early diagnosis improves quality of life and reduces risk of developing complications

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2
Q

What is the 3 Ts of early diagnosis?

A

THINK - keep symptoms in mind

TEST

TELEPHONE - local specialist team for a a same say review

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3
Q

4 Ts of symptoms of type 1?

A

Thirsty

Thinner

Tired

Toilet

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4
Q

What is a red flag symptom of type 1?

A

Return to bed wetting or day wetting in a previously dry child

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5
Q

Early symptoms for children under 5?

A
  1. Heavier than usual nappies
  2. Blurred vision
  3. Candidiasis - oral/vulval
  4. Constipation
  5. Recurring skin infections
  6. Irritibility and behaviour changes
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6
Q

Symptoms of DKA?

A
  • Nausea and vomiting
  • Abdo pain
  • Dehydration
  • Sweet smelling ketotic breath
  • Drowsiness
  • Rapid, deep sighing respiration
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7
Q

What is normal blood pH?

A

7.35-7.45

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8
Q

How do we TEST immediately is type 1 is suspected? What should we not do?

A

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

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9
Q

Why do we arrange (telephone) a same day review with a specialist team?

A

Children can get DKA very quickly so important not to delay

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10
Q

Current strategies to support people with type 1?

A
  1. Education
  2. Nutrition and lifestyle management - exercise, calorie counting and CHOs
  3. Skills training - home BG testing and injection technique
  4. Insulin - analogues, pens, pumps
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11
Q

What to do before you inject insulin?

A

Check its the right insulin, right dose, right time and right way

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12
Q

Why is insulin injected?

A

It is a polypeptide hormone which is inactivated by the GI tract so can’t be consumed orally

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13
Q

Why is insulin given 30 mins before eating and not right before?

A

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

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14
Q

What types of insulin can be taken right before eating and why?

A

Fast acting analogues because they do not associate with hexamers

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15
Q

What can change the rate of insulin absorption?

A

Changing the structure of insulin or binding it to other molecules

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16
Q

How much insulin should be injected for a meal?

A

The amount of insulin injected for meals should balance the carbohydrate intake consumed

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17
Q

Name the current insulin regimes?

A

Twice daily

  1. Rapid + intermediate (mixed) before breakfast
  2. Rapid + intermediate before tea

Three times daily

  1. Rapid + intermediate before breakfast
  2. Rapid + intermediate before tea
  3. Intermediate before bed

Four times daily

  1. Short acting before, breakfast
  2. Short acting before lunch
  3. Short acting before dinner
  4. Intermediate before breakfast OR long acting at a fixed time
18
Q

Why is a multiple injection regime that combines short and long acting insulin useful? What type of patients will use it?

A

Insulin and food go together so meal times and sizes can vary without affecting metabolic control - so more flexible Younger patients use it

19
Q

What is the honeymoon period for type 1s?`

A

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

20
Q

Target BG values before and after meals for type 1s?

A

4-7 mmoles/L before meals and 4-10 after a meal

21
Q

Why is strict glucose control helpful from the onset in type 1s?

A

Prolongs b-cell function = better glucose levels and less hypos

22
Q

What is a CSII?

A

Continuous s/c insulin infusion

23
Q

Explain how a CSII works.

A

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

24
Q

Positives of the CSII device

A

Useful in overnight period as the rate can be programmed to fit each patients need

25
Q

Negatives of the CSII device

A

Nuisance of being attatched to the gadget

Skin infections

Risk of ketoacidosis if flow breaks

Cost

26
Q

What constitutes a hypo

A

less than 4 mmol/l BG with or without symptoms

27
Q

Reasons for hypos?

A
  • Too little food
  • Too much activity
  • Insulin/sulphonylureas (oral hypoglyceamis)
28
Q

How dangerous is a hypo in a type 1 ?

A

Most isolated hypo’s resolve themselves without treatment in type 1s

29
Q

Symptoms of a hypo?

A
  1. Headache
  2. Nausea
  3. Sweating
  4. Palpitations
  5. Shaking
  6. Hunger
  7. Confusion
  8. Drowsiness and odd behaviour
30
Q

When does loss of warning signs for hypos occur?

A
  • Recurrent severe hypoglycemia
  • Long duration of disease
  • Too tight a control
  • Loss of sweating/tremor
31
Q

Treatment for a hypo?

A
  • 15 - 20gs CHOs
  • 5-7 dextrosol tablets
  • 4-5 glucotabs
  • 200 ml fruit juice
32
Q

Treatment for a hypo in a patient unable to take oral CHOs?

A
  • Out of hospital - 1 mg glucagon injection
  • In hospital - IV glucose or dextrose
33
Q

What must be done in regards to hypo’s and driving?

A
  1. Check blood glucose before 2 hours of driving and during long car journeys
  2. Carbs should be in the car
  3. Not allowed more than one episode of severe hypo in a year
34
Q

In what situations does DKA arise?

A
  1. Previously undiagnosed type 1
  2. Interruption of insulin therapy
  3. Stress of incurrent illness
35
Q

What is the most common error in management that causes patients to get DKA?

A

Reduce or omit insulin because they feel unable to eat - either due to sickness or vomiting

36
Q

Explain the pathological mechanism behind DKA.

A
  1. No insulin and high glucagon = high levels of glucose in blood via glycogenolysis and gluconeogenesis
  2. Lipolysis due to glucagon = FFAs —> ketones
  3. No insulin means ketones can’t be took into cells so –> acidosis
  4. High glucose levels = dehydration and loss of electrolytes
37
Q

What is acidotic breathing and why is it a response to DKA?

A

Hyperventilation to reduce CO2 levels in blood to make it less acidotic

38
Q

Investigations for DKA?

A
  1. Glucose levels
  2. ABGs - pH less than 7.1 is bad
  3. Blood ketones - Over 6 mmol/l
  4. Bicarbonate - Less than 12 mmol/l
39
Q

Initial managemnt of DKA?

A
  1. Replace fluid and electrolyte loss (potassium as soon as insulin is given as it helps K+ uptake)
  2. Replace insulin
  3. Restore acid-base balance via bicarbonate - patient with healthy kidneys will do this itself when circulation is restored so bicarbonate is actually rarely needed
40
Q

Once DKA is controlled what shoud we think about?

A
  1. Underlying cause
  2. Monitoring glucose levels regularly
41
Q

Problems of DKA managment?

A
  1. Hypotension - may cause renal shutdown, treat with NaCl 0.9% Hypokalaemia due to osmotic diuresis
  2. Hypoglycaemia
  3. Cerebral oedema due to excessive re-hydration - rare but children more susceptible
  4. Arterial and venous thromboembolism
  5. ARDS
  6. Aspiration pneumonia

ZA - Endocrine System (21 decks)

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