Modules

Question 1

who should be referred to the specialist diabetes team on admission to hospital (8)?

Answer 1

DKA
diabetes and pregnancy
new type 1 diagnosis
HHS
recurrent or severe hypoglycaemia
Poor glycaemic control
Require insulin initiation
complications such as autonomic neuropathy and/or foot ulcers

Question 2

what unrelated illnesses/treatments may cause a required alteration to diabetes treatment?

Answer 2

acute coronary syndrome
parenteral feeding
vomiting
sepsis
treatment with corticosteroid
IV insulin for >48 hrs
Continuous subcutaneous insulin infusion pumps

Question 3

who is at increased risk of foot problems while in hospital?

Answer 3

patients with neuropathy
previous ulcer or amputation
bed bound or fragile skin

Question 4

a what points should blood glucose be measured in a diabetic patient during a hospital stay?

Answer 4

1. on admission

2. before every SC insulin injection, or hourly while on IV insulin

Question 5

how often is blood glucose measured if unwell patient?

Answer 5

4 times per day

Question 6

when is blood glucose checked if hypoglycaemic?

Answer 6

15 mins after administering treatment (to check if its working)

Question 7

how often do you check blood glucose if on SURs vs metformin?

Answer 7

SURs = twice daily
metformin = once daily (before meals)

Question 8

how often do you check blood glucose in diet controlled diabetic?

Answer 8

once daily (before meals)

Question 9

definition of hypoglycaemia in people on treatment for diabetes?

Answer 9

<4mmol/L

Question 10

which hormones are involved in the autonomic nervous system response to blood glucose?

Answer 10

cortisol
glucagon
adrenaline
growth hormone

Question 11

how does the liver respond to hypoglycaemia and how can this be impaired>

Answer 11

releases glucose from glycogen stores
can be impaired in people with
- malnourished
- extensive liver disease
- recurrent hypoglycaemia
- consumed alcohol to excess

Question 12

what are the autonomic symptoms of hypoglycaemia?

Answer 12

trembling
anxiety
numbness/tingling
palpitations
irritability
hunger
pale and sweaty
vulnerable and afraid

Question 13

what causes neuroglycopaenic symptoms in a hypoglycaemic episode?

Answer 13

when blood glucose falls <2mmol/L, impaired supply to the brain

Question 14

what neuroglycopaenic symptoms can occur with hypoglycaemia?

Answer 14

problems with weakness, coordination and concentration
slurred speech
problems with vision
loss of consciousness
seizures

Question 15

how can hypoglycaemia be quickly managed in patients who can swallow?

Answer 15

give quick acting carbohydrates

• 150-200ml fruit juice (avoid in renal failure)
• 60ml glucojuice
• 4-5 glucotabs

Question 16

how can hypoglycaemia be quickly managed in patients who are drowsy/confused but can swallow?

Answer 16

glucose gel

1.5-2 tubes squeezed between teeth and gums

Question 17

how can hypoglycaemia be managed in an unconscious patient?

Answer 17

ABCDE
call a doctor
stop any IV insulin
IV glucose or IV/intra-muscular glucagon

Question 18

how is IV glucose administered?

Answer 18

150ml 10% glucose over 10-15 mins

75ml 20% glucose over 10-15 mins

Question 19

what may reduce the effectiveness of glucagon injection?

Answer 19

liver disease
malnourishment
repeated hypoglycaemia
OHA induced hypoglycaemia

Question 20

how is glucagon administered?

Answer 20

don’t use in OHA induced hypo
1mg in adults (>25kg)500 micrograms in kids <8 (<25kg)
store in the fridge
given via subcutaneous, intramuscular or IV injection

Question 21

how do you know if further glucose treatment is needed in hypoglycaemia?

Answer 21

if blood glucose is still >4 after 15 mins

Question 22

where are the common sites for subcutaneous insulin injection?

Answer 22

abdomen
upper outer thigh
upper outer leg
buttocks

Question 23

what are the 4 key principles of insulin injection?

Answer 23

rotate site for each injection (i.e if injecting 4 times a day - inject at different site each time)
use the same general location for injection at the same time of day
change the pen needle or syringe each time
inject the same insulin in the same area every day (e.g long acting always in the abdomen) while ensuring that you rotate the specific site of injection within the area each time

Question 24

what is the most common complication that can occur at insulin injection sites and what are the implications of this?

Answer 24

lipohypertrophy at site of repeated injection

causes reduced absorption of insulin at that site so should be avoided for insulin injection

Question 25

at what concentration is insulin usually given in hospitals in the UK?

Answer 25

100 units per ml

Question 26

name 2 therapies which can cause hyperglycaemia?

Answer 26

corticosteroids

parenteral nutrition

Question 27

give 2 common errors which result in the incorrect delivery of insulin

Answer 27

use of wrong syringes which are marked in ml rather than insulin units
abbreviation of “units” to “U” which could be misread as a 0 - i.e “10 U” could be misread as “100”

Question 28

rapid acting analogue vs short acting?

Answer 28

rapid = immediate effect, peaks at 2 hrs
short = takes 30 mins to take effect, peaks at 4 hrs

Question 29

give 3 examples of rapid acting insulin analogues

Answer 29

Humalog
novorapid
aprida

Question 30

give 3 examples of short acting insulin?

Answer 30

actrapid
humalin S
insuman rapid

Question 31

intermediate vs long acting insulin?

Answer 31

intermediate = lasts 16 hrs but higher peak basal insulin level than long acting
long acting = lasts 24 hrs but lower peak basal insulin level

Question 32

what are the two types of fixed insulin mixtures available?

Answer 32

rapid acting-intermediate mixture (humulog mix/novorapid mix)
short acting-intermediate mixture (humalin M3

Question 33

what problems could arise if Humalog is given instead of Humalog mix?

Answer 33

high risk of hypoglycaemia as Humalog os 100% rapid acting insulin

Question 34

kidney failure can lead to hypo or hyperglycaemia?

Answer 34

hypoglycaemia

impaired kidney function = impaired excretion of insulin so its effects last longer

Question 35

how do you review blood glucose patterns in patients on twice daily insulin regimens?

Answer 35

measure blood glucose pattern over past 48 hrs

Question 36

what advice would you give if 48hr blood glucose pattern is over target in someone on twice daily insulin regimen?

Answer 36

increase insulin dose by 10% either before breakfast or dinner

Question 37

what advice would you give if 48hr blood glucose pattern is under 6 in someone on twice daily insulin regimen?

Answer 37

reduce insulin dose by 10% either before breakfast or before dinner

Question 38

does insulin have a long or a short half life, what are the implications of this>

Answer 38

short (5 mins)
means risk of insulin omission if IV line is disconnected
- can lead to DKA

Question 39

rule for patients on multiple daily injections if on IV insulin?

Answer 39

continue long acting basal insulin

prevents DKA by aiding transfer from IV to SC

Question 40

how are insulin and fluids prescribed together?

Answer 40

through the same cannula

Question 41

is IV insulin always prescribed with fluids?

Answer 41

yes

apart from in critical setting and advised by senior

Question 42

what measures insure insulin and fluid remain infusing safely?

Answer 42

anti-syphon valve - prevents free flow in insulin from the syringe driver
anti-reflux valve - prevents backflow of insulin

Question 43

is mealtime insulin needed during IV insulin treatment?

Answer 43

usually not - if fasting

can be used alongside if post DKA or antenatal

Question 44

how often should you check capillary glucose after stopping IV insulin?

Answer 44

4 times in 24 hrs following end of IV treatment

Question 45

when do you transfer back to oral medication after IV insulin?

Answer 45

when patient is clinically stable and tolerating food and fluids
start medications at a meal time and then stop IV after 1 hr
check for contraindications (renal function) and check blood glucose regularly

Question 46

how often do you check blood glucose while on IV insulin?

what else do you check?

Answer 46

hourly

also check Us&Es daily