Management of Type 1 DM Flashcards
What are the aims of T1DM management?
- Prompt diagnosis
- Encourage appropriate self-management
- Correction of acute metabolic upsets
- Facilitate long-term health
What immune factors take place in T1D?
Islet autoantibodies HLA class 2 association Beta-cell T cells found in human islets Immune modulation delays progress
How many children are diagnosed with diabetes every year?
300
How are a large portion of children diagnosed with diabetes?
1 in 4 present with DKA
Symptoms of childhood T1D?
Thirsty
Thinner
Tired
Toileting more
What must be done for suspected diabetes?
THINK - symptoms
TEST - capillary glucose
TELEPHONE - specialist for same day review
What capillary glucose is suggestive of T1D?
> 11mmol/L
What is the red flag symptom of childhood diabetes?
Return to bedwetting
What key symptoms are more common in children under 5?
Heavier nappies Blurred vision Candidiasis Constipation Recurring skin infections Irritability, behaviour changes
Symptoms of DKA?
Nausea and Vomiting Abdominal Pain Polyuria Polydipsia Ketotic breath Drowsiness/Confusion Rapid "sighing" breath - Kussmaul Coma
What should you do for a patient suspected to be in DKA?
Finger prick test
Who should you call in a DKA positive child?
Paediatric diabetes team same day
What blood tests should be performed in a suspected DKA patient after prick test?
Blood Glucose
Blood ketones
What strategies are in place to support T1D patients?
Education
Nutrition and lifestyle management
Skills training
Insulin
What should be checked before giving insulin?
Right insulin
Right dose
Right time
Right way - medium
Why must insulin be injected?
Its inactivated by the GIT
Why is insulin injected before eating?
Insulin in fat forms hexamers which take approximately 30 mins before breaking up
What are rapid acting analogues?
This Insulin does not associate and can be injected right before eating
What are the fast acting analogues?
Insulin lispro
Insulin aspart
What are the slow acting analogues?
Insulin glargine
Detemir insulin
What is the rough ratio of units of fast acting insulin to grams of sugar?
1 unit of insulin for 10g of carbs
What factors can be considered part of educating diabetic patients?
Handbooks, leaflets, Insulin pump starts, pregnancy, education days, help groups
Mydiabetes myway
What things need to be in a structured education of a T1D patient?
Dealing with real life issues Food Exercise Travel Insulin Blood testing/hypo Sick days
When is a patient in DKA?
Blood ketones >3mmol/L
At what blood ketone level should a diabetes team be contacted?
> 1.5mmol/L
What is a normal ketone level?
<0.6mmol/L
What do you do if you have a ketone level between 0.6-1.4 and blood sugar >14?
Drink sugar fluids
Correction dose insulin
Retest in 1-2hrs
What do you do if you have a ketone level below 0.6 and blood sugar >14?
Retest in 1-2hrs
What do you do if you have a ketone level between 1.5-2.9 and blood sugar >14?
Drink sugar fluids
Correction dose of insulin
Retest hourly
CONTACT DIABETES TEAM
What do you do if you have a ketone level over 3 and blood sugar >14?
Sugar fluids
Correction dose insulin
Retest hourly
Attend hospital probs lol
What types of insulin action are there?
Rapid acting Short acting Intermediate acting Long acting Continuous subcutaneous infusion
What are the current insulin regimens?
Twice daily
Three daily
Four times daily
What is the regimen for twice daily insulin?
Rapid mixed with intermediate acting
Before breakfast and evening meal
What is the regimen for three times daily insulin?
Rapid mixed with intermediate before bed
Rapid acting before evening meal
Intermediate at bedtime
What is the regimen for four times daily insulin?
Short acting before breakfast, lunch and dinner
Intermediate before bed
OR
Long acting at fixed time once each day
What factors can be adjusted to help with care of a T1D patient?
Lifestyle Exercise Driving Alcohol Contraception Drugs Holidays Employment
What is hypoglycaemia?
ANY episode of low blood sugar <4mmol/L with or without symptoms
What factors cause hypoglycaemia in a T1D patient?
Activity Food Insulin - timing, volume, injecton site Alcohol Oral hypoglycaemics
Which groups are at high risk of hypoglycaemia?
Tight glycaemic control Lowered awareness/cognitive function Extremities of age Malabsorption Hypoadrenalism Renal impairment Pancreatectomy Pregnancy Coeliacs
What should patients be taught about hypoglycaemia?
How to avoid, recognise and treat it
What are the symptoms of hypoglycaemia?
Vary between individuals
Autonomic
Neuroglycopenic
Malaise
What are the autonomic symptoms of hypoglycaemia?
Sweating
Palpitations
Shaking
Hunger
What are the neuroglycopenic symptoms of hypoglycaemia?
Confusion Drowsiness Odd behaviour Speech difficulty Incoordination
INABILITY TO PERCIEVE NORMAL WARNING SYMPTOMS OF HYPOGLYCAEMIA is associated with what?
Recurrent severe hypo
Long duration of disease
Loss of sweating/tremor
Over tight control
Which patients should be told to carry CHO with them?
Patients on insulin or sulphonylureas
How should hypoglycaemia be treated in a patient able to take oral CHO?
If able to take oral CHO: 15-20g simple CHO 5-7 dextrosol/4-5 glucotabs 200ml fruit juice Follow up with long acting CHO
How should hypoglycaemia be treated in a patient unable to take oral CHO?
Out of hospital: - 1mg IM glucagon - Glucogel/dextrogel Hospital: - 75-80ml 20% glucose IV - 25mls 50% dextrose IV Follow up with long acting CHO
All patients in hypo should have their treatment followed up with what?
Long acting CHO
Whats in the Hypobox?
Fruit juice Dextro energy Glucogel 20% or 50% dextrose Hypo management protocol
What should you do with the patient after recovery?
Establish cause of hypo Control/monitoring? Hypoglycaemia awareness Repeated injection site? Driving/work
How can hypos be avoided in insulin-treated diabetes?
Blood glucose monitoring Rotate injection sites Review snacks and diet Consider changing regimen Avoid low glucose Insulin before + after exercise
How should diabetic patients approach driving?
Always carry carbohydrates
No driving if not aware
Measure glucose before
No more than 1 hypo in a year
What are the symptoms of DKA?
Polyuria Polydipsia Weight loss Weakness N+V Abdo pain Breathlessness
What are the signs of DKA?
Ketone breath Coma Hypotension Tachycardia Altered mental state Sunken eyes Dry mucus membranes Kussmaul breathing
What patients are at risk of DKA?
T1DM
Inadequate insulin
Infection
What are the rules of managing diabetes with acute illness?
Never stop insulin Increase/adjust insulin More frequent checks Check urine/blood for ketones Carbohydrate intake must be maintained
How does increased glucagon aid to trigger DKA?
Increased lipolysis
How does increased cortisol aid to trigger DKA?
Decreased glucose utilisation
How does increased GH aid to trigger DKA?/??\/????
Increased proteolysis
Decreased protein
How does increased catecholamines aid to trigger DKA?
Increased Glycogenolysis leading to increased gluconeogenesis
What investigations should be done on a suspected DKA?
Rapid ABC Iv access Vitals Glucose ABG U+E, FBC Blood culture ECG Consider CXR
Complications of DKA
Hyper/hypokalaemia Hypoglycaemia Cerebral oedema Aspiration pneumonia Thromboembolism ARDS
Cerebral oedema is more common in who? How does it present?
Children
Hyperosmolar hyperglycaemic state
How is DKA treated in the HDU?
IV saline Iv insulin Iv Potassium ?heparin, NG tube FIND OUT WHY IT HAPPENED
