Management of Type 1 Diabetes Flashcards
What are the aims of managment?
- Prompt diagnosis
- Encouragement of self management skill set
- Correction of acute metabolic upsets at diagnosis and thereafter
- Facilitate long term health and well being
What is the acronym for symptoms of diabetes?
THINK
What are the the three actions needed to make an early diagnosis of diabetes?
- THINK symptoms
- TEST immediately - finger prick capillary Glc test > 11mmol/l
- TELEPHONE urgently
What are the different THINK symptoms?
- Thirsty
- Thinner
- Tired
- Using the Toilet more
Other than the THINK symptoms, what else should you look for in under 5s?
- Heavier than usual nappies
- Blurred vision
- Candidiasis (oral, vulval)
- Constipation
- Recurring skin infections
- Irritability, behaviour change
What is a red flag symptoms of diabetes?
A return to bedwetting or day-wetting in a previously dry child
What are the six symptoms of diabetic ketoacidosis (DKA)?
- Nausea&vomiting
- Abdominalpain
- Sweetsmelling,”ketotic”
- Breath
- Drowsiness
- Rapid, deep “sighing” respiration
- Coma
What is the TEST used to carry out early diagnosis?
Finger prick capillary blood glucose test
Result > 11mmol/l - Diabetes
Result < 11mmol/l - Other cause
What tests shoud NOT be carried out of early diagnosis in acute situation?
- Request a returned urine specimen.
- Aarrange a fasting blood glucose test.
- Arrange an Oral Glucose Tolerance Test.
- Wait for lab results (urine or blood).
Who should you TELEPHONE for an early diagnosis?
Call local specialist paediatric diabetes team for a same day review
Name four current strategies used to support those with IDDM?
- Education
- Nutrition and lifestyle management
- Skills management - home BG monitoring, injection technique, hypos, sick day rules
- Insulin - analogues, pens, pumps
What four factors should be checked before a person injects insulin?
- Right insulin
- Right dose– check strength and how much insulin to give.
- Check the numbers very carefully.
- Right time – with food? At bedtime?
- Right way– via syringe, pen or pump?
What does insulin need to be injected subcutaneously or intravenously?
As insulin is a polypeptide which is inactivated by the gastrointestinal tract
Why is soluble insulin given 30mins before eating?
In the subcutaneous fat Insulin molecule in solution has a tendency to self-associate into hexamers
Hexamers need to dissociate into monomers before absorption through the capillary bed.
How far in advance before a meal do rapid acting analogues of insulin need to be injected?
They do not associate and can be injected just before eating
How much insulin is injected prior to a meal?
The amount of insulin injected for meals should balance the carbohydrate intake consumed
What are different forms in which education is provided?
- Patient handbooks
- Leaflets
- Set curriculum (DIANE)
- Insulin pump starts
- Education days
- My Diabetes My Way (NHS online)
What is DIANE education?
Diabetes Insulin Adjustment for Normal Eating course • Deal life life issues • Food, exercise, travel etc • Insulin, blood testing • Sick day rules
What are the different types of insulin?
- Rapid acting
- Short acting
- Intermediate acting
- Long acting
- Continuous subcutaneous insulin infusion (CSII)
What are the four factors of insulin injection technique?
- Needle size
- Location
- Rotation
- Technique
Name the different injection sites
• Thighs
• Buttocks
• Belly
(• Arms but not commonly used as easy to inject into muscle)
What are the components on insulin therapy regimens?
- Suitable for a flexible lifestyle
- Better for shift workers
- Rapid acting insulin to cover CHO at meals 1 units per 10g CHO
- Basal long acting insulin as backgroup
What is the current insulin regimen with twice daily administration?
- Rapid acting mixed with intermediate acting
* Before breakfast (BB) and evening meal (BT)
What is the current insulin regimen with three times daily administration?
- Rapid acting mixed with intermediate acting BB
- Rapid acting BTea
- Intermediate acting at bedtime BBed
What is the current insulin regimen with four times daily administration?
- Short acting BBreakfast BLunch BTea
* Intermediate BBed or long acting insulin at a fixed time once daily
What adjustments have to be made with a diagnosis of diabetes?
- Lifestyle
- Exercise
- Driving
- Alcohol
- Conception
- Drugs
- Holidays
- Employment
What are two acute metabolic upsets?
- Hypoglycaemia
* Hyperglycaemia - diabetic ketoacidosis
Define hypoglycaemia
Refers to any episode of low blood glucose (<4mmol/l) with or without symptoms and may occur in patients taking insulin or sulphonylureas.
Name different causes of hypoglycaemia
- Too much insulin/SU
- Inappropriate timing of insulin/SU
- Injection site problems
- Inadequate food intake/fasting
- Exercise
- Alcohol
Name five at risk of hypoglycaemia groups
- Cognitive impairments
- Extremes of age
- Malabsorption
- Coeliac disease
- Pregnancy
What are the symptoms of hypoglycaemia?
Autonomic:
• Sweating
• Palpitations
Neuro: • Confusion • Drowsiness • Speech difficulty • Incoordination
General malaise:
• Headache
• Nausea
Why does a loss of warnings of hypoglycaemia occur?
- Recurrent severe hypoglycaemia
- Long duration of disease
- Over tight control
- Loss of sweating / tremor
What is the treatment of hypoglycaemia?
If able: 15-20g simple CHO
• Dextrosol/Glucotabs
• 200ml fruit juice
If unable to take oral CHO
Out of hospital:
• 1mg IM glucagon
• GlucoGel®/ Dextrogel®
In hospital:
• Glucose or dextrose IV
Follow-up with long-acting CHO
What is usually found inside a hypobox?
- Fruit juice
- Dextro energy
- Glucogel
- Dextrose
- Hypo management protocol
How does hypoglycaemia affect the ability to drive?
- Patients should check their blood glucose before 2 hours of driving and during long car journeys and should always carry carbohydrate in the car.
- No awareness then no driving
- No more than one episode of severe hypo (Group 1) in a year
What are the sick day rules?
- Never stop insulin
- Perform more frequent BG checks
- Check urine or blood for ketones
- CHO intake to be maintained by fluid (fruit juice) if unable to tolerate food
How does diabetic ketoacidosis occur?
- Results from too little insulin leading to fat breakdown and by-product of this are ketones
- Usually associated with high glucose
- Fluid deplete
What is the clinical presentation of diabetic ketoacidosis?
- Dehydrated
- Thirsty
- Abdominal pain
- Acidotic breathing (Kussmauls)
- Acetone on breath
- Tachycardic and low BP
What are the initial investigations used for DKA?
Rapid ABC:
• IV access
• Vital signs
- Glucose
- Venous blood gas
- Urinalysis/Blood ketones / bicarbonate
- U+E, FBC
- Culture blood/urine
- ECG + cardiac monitor
- Consider CXR
What are the possible complications of DKA?
• Hyper and hypokalaemia
• Hypoglycaemia
- Rebound ketosis
- Arrhythmias
- Acute brain injury
• Cerebral oedema
• Aspiration pneumonia
• Arterial and venous thromboembolism
• ARDSHow is DKA treated?
- Give IV saline (5L in 24hrs)
- Give IV insulin (drives glucose and potassium into cells)
- Give IV potassium in saline
- May need antibiotics
- Consider heparin, NG tube
How can a person faciliatate long term health and well being?
- Optimal BG control (HbA1c)
- Optimal BP control
- Mange CVS risk factors - smoking, cholesterol
- Screen for early detection of complications - feet, eyes + kidneys
