SESSION 4

Question 1

What is the definition of hypoglycemia?

Answer 1

Blood glucose <4.0mmol/L

Question 2

What are the three severity levels of hypoglycemia?

Answer 2

• Mild: Conscious, oriented, able to swallow
• Moderate: Conscious but confused/aggressive
• Severe: Unconscious/fitting/very aggressive/nil by mouth

Question 3

What is the initial treatment for mild hypoglycemia?

Answer 3

15-20g quick-acting carbohydrates

Options include 5-7 Dextrosol tablets or 150-200ml fruit juice.

Question 4

What should be done after administering treatment for mild hypoglycemia?

Answer 4

Recheck blood glucose after 10-15 minutes

Question 5

What is the treatment for moderate hypoglycemia if the patient is uncooperative?

Answer 5

Give 2 tubes of 40% glucose gel if they can swallow
If they cannot swallow then consider IV dextrose or IM glucagon as per severe pathway

Test BG after 10-15 mins

Question 6

What is the treatment for severe hypoglycemia?

Answer 6

100ml 20% dextrose or 200ml 10% dextrose over 15 minutes
1mg Glucagon IM if no IV access

Rechecking glucose after 10 minutes is important. If still <4 then repeat

Question 7

What should be done once glucose levels rise above 4.0mmol/L after hypoglycemia treatment?

Answer 7

• Provide 20g long-acting carbohydrate e.g. 2 biscuits, slice of brain, 200mls of milk, next meal etc
• Continue regular BG monitoring for 24-48 hours
• Review insulin doses - do not omit subsequent insulin doses!
• Provide education on hypoglycaemia
  Follow-up care is crucial to prevent recurrence.

Question 8

What are the diagnostic criteria for Diabetic Ketoacidosis (DKA)?

Answer 8

• Blood glucose >11 mmol/L
• Ketones >3 mmol/L
• Venous pH <7.3 or bicarbonate <15 mmol/L

All three criteria must be met for diagnosis.

Question 9

What is the initial management protocol for DKA?

Answer 9

• Start 0.9% sodium chloride - 1L over 1 hour, then 1L over 2 hours, repeate, then 1L over 4 hours, repeat, then 1L over 8 hours
  Begin fixed rate insulin infusion (0.1 unit/kg/hr)
• Regular monitoring of vital signs

Question 10

What should be done if blood pressure is less than 90mmHg during DKA management?

Answer 10

Administer 500ml sodium chloride over 10-15 minutes
Re-assess. Repeat if needed
Once stabilised then start aggressive fluid resuscitation with 1L of 0.9% sodium chloride as part of DKA management

Question 11

What are the types of insulin?

Answer 11

• Fast-acting: Regular soluble (Actrapid, Humulin S), Analogues (Novorapid, Humalog)
• Intermediate-acting: Isophane (Humulin I, Insulatard), Biphasic mixtures (NovoMix 30)
• Long-acting: Glargine (Lantus), Detemir (Levemir)

Question 12

What is the starting dose for Multiple Daily Injections (MDI) regimen?

Answer 12

0.5-0.75 units/kg/day
50% is given as short acting insulin and 50% as long acting insulin. The short acting is split into 3 and will be given just before each meal

Question 13

What is a common dosing strategy for Twice Daily Biphasic insulin?

Answer 13

0.5-0.75 units/kg of body weight split into 1/3rds… give 2/3 before breakfast and 1/3 before the eveming meal

Question 14

Management of hyperglycaemia if pt is clinically well and does not have raised ketones?

Answer 14

If BG >25 then consider giving 6-10 units of actrapid insulin 1 off dose. Check BG after 2-4 hours. They may need a variable rate insulin infusion
If BG >18 for 24 hours or >11 for 48 hours then increase doses of oral agents or insulin doses

Question 15

Types of fast-acting insulin?

Answer 15

Regular soluble human insulin e.. actrapid or humulin S
Short acting insulin analogues e.g. novorapid or humalog lispro

Question 16

Pharmacokinetics of soluble human insulin?

Answer 16

Onset 30-60 mins
Peak effect 2-4 hours
Duration 6-8 hours

Question 17

Pharmacokinetics of short-acting insulin analogues?

Answer 17

Onset 5-15 mins
Peak effect 1-2 hours
Duration 4-6 hours

Question 18

Pharmacokinetics of intermediate-acting insulin ?

Answer 18

Onset 12 hours
Peak effect 6-10 hours
Duration 12+ hours

Question 19

Examples of intermediate acting insulins (NPH insulin (isophane)?

Answer 19

Insulatard
Humulin I

Question 20

What are examples of biphasic insulins?

Answer 20

Humulin M3
Novomix 30

Question 21

What does the 30 of NovoMix30 mean?

Answer 21

30% short acting insulin
The rest is 70% NPH human insulin

Question 22

Examples of long acting insulins?

Answer 22

Lantus - insulin glargine
Levemir - insulin detemir

Question 23

Pharmacokinetics of long-acting insulins?

Answer 23

Onset about 1 hour
Peak effect 5 hours
Duration up to 24 hours

Question 24

What are the 4 regimens for insulin?

Answer 24

Type 1 diabetes:
MDI - multiple daily injection regimen (basal-bolus)
Continuous subcutaneous insulin infusion (insulin pump therapy)

Type 2 diabetes:
Twice daily biphasic regimen (pre-mixed) - note some older T1DM pts may use this
Once daily long acting analogue

Question 25

How does the once daily long acting analogue work?

Answer 25

This is a bedtime dose of insulin which is used in combination with oral hypoglycaemic agents
A long-acting insulin is used and is titrated against fasting BG - aiming for 6mmol/L

Question 26

Who gets a continous subcutaneous insulin infusion pump?

Answer 26

T1 diabetics over 12 years old with poor glycaemic control refractory to alternative ways of
Quite rare! 6% of adults with T1Dm have it and 19% of chidlren

Question 27

Aims of treatment in DKA/

Answer 27

Ketones should fall at 0.5mmol/L/hour
Bicarbonate should rise 3mmol/L/hour
Blood glucose should fall 3mmol/L/hour (no more than 5 due to risk of cerebral oedema)

Question 28

Monitoring during DKA management?

Answer 28

Hourly BG
Hourly blood ketones
VBG at 1 hour, 2 hour & then 2 hourly - this will check pH, HCO3- and K+

Question 29

What happens in management of DKA when BG falls to 14?

Answer 29

You stop fixed rate insulin and start a variable rate insulin infusion with GKI (dextrose, potassium and insulin)

Question 30

What should you do when a pt has normal ketones, pH over 7.3 and is eating?

Answer 30

Start them on a multiple daily dosing regimen or restart their pre-admission insulin regimen - when restarting the short-acting insulin remember to keep the GKI going until 30 mins after the dose is given after a meal

Question 31

How should you manage a T1 diabetic on a multiple daily dosing regimens insulin when they come in with DKA?

Answer 31

Stop their short acting insulins but continue their long acting insulin

Question 32

Pt information when prescribing metformin?

Answer 32

inform pt of signs and Sx of lactic acidosis and advise them to seek medical attention: dyspnoea, muscle cramps, abdominal pain, hypothermia or asthenia

Question 33

What is the most appropriate monitoring option to assess beneficial effect of insulin therapy during treatment of DKA?

Answer 33

Capillary blood ketones

Question 34

Outline the missed pill rules for the POP?

Answer 34

• If vomiting occurs within 2 hours of taking oral POC another pill should be taken ASAP, if replacement pill not taken within 3 hours of normal time or if persistent d/v then take the missed pill asap and continue with the rest of pack but condoms should be used until pill taking has been re-established for 48 hours (note if cerazette then no action is required provided pill is less than 12 hours late)

Question 35

Which insulin appears cloudy?

Question 36

When treating severe hypoglycaemia and an unconscious patient what is the recommended initial IV dextrose concentration and volume??

Answer 36

100ml of 20% dextrose OR 200ml of 10% dextrose

Question 37

What is the recommended dose of glucagon for severe hypoglycaemia when IV access is not possible?

Answer 37

1mg IM

Question 38

How much longer acting carbohydrate should be given when hypoglycaemia has to be treated with glucagon?

Answer 38

40g rather than the usual 20g