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S3 Case 4 - Endocrine > T1DM Acute Care > Flashcards

T1DM Acute Care Flashcards

1
Q

What is T1DM?

A

Cell-mediated autoimmune destruction of pancreatic beta cells causing absolute deficiency of endogenous insulin

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2
Q

What are the 4 Ts?

A

Thirst
Tired
Toilet
Thinner

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3
Q

What are other symptoms that may be noticed before diagnosis?

A

Thrush
Cuts/wounds taking longer to heal
Blurred vision

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4
Q

What other autoimmune disorders may lend in the diagnosis?

A

Grave’s disease
Hashimoto’s thyroiditis
Addison’s disease
Celiac

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5
Q

What are the main diagnostic factors?

A

Glucose in urine (6-14 mmol/L)
Nocturia
Increase from habitual levels
Weight loss
Blurred vision

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6
Q

What are the diagnostic tests for auto-antibodies?

A

GAD65
IAA
IA-2A
ZnT8

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7
Q

What is DKA?

A

Diabetic ketoacidosis

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8
Q

What are the 3 things in DKA?

A

Hyperglycaemia
Acidosis = bicarbonate <15mmol/L + pH <7.3
Ketonemia = >3mmol/L
Ketonuria = >++ on urine ketone stick

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9
Q

How does acidosis occur in DKA?

A

Beta-oxidation of free FAs = ketone bodies
= deplete acid buffers
= acidosis

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10
Q

How does hyperglycaemia occur in DKA?

A

Insulin deficient = insulin-mediated uptake of glucose into tissues does NOT happen =hepatic glucose output unchecked
Dysregulation of counter-regulatory hormones = enhances breakdown of triglycerides into FAs = increases rate of gluconeogenesis = hyperglycaemia

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11
Q

What are the symptoms of DKA?

A

Symptoms of hyperglycaemia
Abdominal pain + vomiting
Deep sighing respirations
Sweet smelling
Reduce consciousness

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12
Q

What is the overall goal in management of DKA?

A

Controlled gradual correction of metabolic abnormalities, fluid + electrolyte deficiencies - usually in 24hrs

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13
Q

What is the management of DKA?

A
  1. Confirm diagnosis
  2. Commence 1L NaCl 0.9% over 1hr within 30mins of admission = record time treatment started
  3. Glucose >13mmol/L commence actrapid insulin IV infusion 6 units/hr
    Prescribe 50 units Actrapid insulin in 50ml 0.9% saline to be infused IV 6 units/hr (6mls/hr)
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14
Q

What is the fluid + electrolyte therapy for DKA?

A

0.9% NaCl 15-20ml/kg/hr or 1L/hr
Followed by 250ml/hr after 2-3hrs
IF low in Na must be carefully not to give it back too quickly

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15
Q

What is the IV insulin therapy for DKA?

A

0.1unit/kg/hr as continuous IV infusion
Actrapid insulin + Humulin S

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16
Q

What treatment of other comorbidities of DKA may be present?

A

Infection can precipitate
MI
Stroke
PE
Thrombophlebitis
Acute GI disorder

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17
Q

What monitoring must be down hourly in DKA?

A

Blood glucose
Ketones
Na
K
Renal function
Cardiovascular function
Mental performance

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18
Q

What are the aims of insulin therapy?

A

Match physiological insulin requirements
Optimise any anticipated rise in blood glucose - post-prandial
Should be initiated within 6hrs if in DKA

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19
Q

What are the different types of insulin?

A

Ultra rapid acting
Rapid acting
Short acting
Intermediate acting
Long acting
Ultra long acting
Human mixed insulins
Analogue mixed insulins

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20
Q

What is an example of ultra rapid acting insulin?

A

Fiasp

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21
Q

When do you take ultra rapid acting insulin?

A

Just before, with or up to 20mins after food

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22
Q

What is the onset of ultra rapid acting insulin?

A

2-3mins

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23
Q

What is the peak of ultra rapid acting insulin?

A

30-90mins

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24
Q

What is the duration of ultra rapid acting insulin?

A

Up to 5hrs

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25
Q

What are examples of rapid acting insulin?

A

NovoRapid
Insulin Lispro

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26
Q

When do you take rapid acting insulin?

A

Just before, with or just after food

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27
Q

What is the onset of rapid acting insulin?

A

10-20mins

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28
Q

What is the peak of rapid acting insulin?

A

1-3hrs

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29
Q

What is the duration of rapid acting insulin?

A

2-5hrs

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30
Q

What is an example of short-acting insulin?

A

Actrapid

31
Q

When is short-acting insulin taken?

A

30 mins before food

32
Q

What is the onset of short-acting insulin?

A

30-60mins

33
Q

What is the peak of short-acting insulin?

A

1-5hrs

34
Q

What is the duration of short acting insulin?

A

5-9hrs

35
Q

What is an example of intermediate acting insulin?

A

Insuman basal

36
Q

When is intermediate acting insulin taken?

A

30mins before food or bedtime

37
Q

What is the onset of intermediate acting insulin?

A

60-90mins

38
Q

What is the peak of intermediate acting insulin?

A

2-12hrs

39
Q

What is the duration of intermediate acting insulin?

A

12-24hrs

40
Q

What is an example of long-acting analogue insulin?

A

Levemir
Lantus

41
Q

When do you take long-acting insulin?

A

Once or twice/day

42
Q

What is the onset of long-acting insulin?

A

2-4hrs

43
Q

What is the duration of long-acting insulin?

A

16-20hrs = Levemir
Lantus = 20-24hrs

44
Q

What is the risk of Lantus insulin?

A

Hypo later in the day

45
Q

What are examples of ultra long-acting insulin?

A

Tresiba
Toujeo

46
Q

When is ultra long-acting insulin taken?

A

OD

47
Q

What is the onset of ultra long-acting insulin?

A

Toujeo = 6hrs
Tresiba = 30-90mins

48
Q

What is the duration of ultra long-acting insulin?

A

Toujeo = up to 36hrs
Tresiba = over 42hrs

49
Q

What is good about Tresiba?

A

Missed dose = still covered

50
Q

What are examples of analogue mixed insulin?

A

Novomix
Humalog Mix

51
Q

When are analogue mixed insulin taken?

A

Just before, with or just after food

52
Q

When is the onset of analogue mixed insulin?

A

10-20mins

53
Q

What is the peak of analogue mixed insulin?

A

1-4hrs

54
Q

What is the duration of analogue mixed insulin?

A

Up to 24hrs

55
Q

What is an example of human mixed insulin?

A

Insuman Comb

56
Q

When is human mixed insulin taken?

A

30mins before meal

57
Q

What is the onset of human mixed insulin?

A

30mins

58
Q

What is the peak of human mixed insulin?

A

1-4hrs

59
Q

What is the duration of human mixed insulin?

A

12-24hrs

60
Q

What is Humulin R?

A

500 unit/ml
Hospital supply only

61
Q

What does the dose of insulin depend on?

A

Age
Exercise
Physical activity
Stress
Hormonal changes

62
Q

How does multiple daily injections work?

A

Basal or bolus
Basal administered once/twice a day
Bolus administered at each main meal

63
Q

How do you initiate + self-manage multiple daily injections?

A

Insulin 0.3-0.5units/kg = total daily dose
= 50% given basal
= 50% prandial divided across 3 meals

64
Q

What are the advantages of multiple daily injections regime?

A

Flexibility
Greater dietary freedom
Flexibility with dose adjustments

65
Q

What are the disadvantages of multiple daily injections regime?

A

Greater frequency of injections
Regular self monitoring blood glucose

66
Q

What is the “honeymoon” period?

A

When no insulin or much insulin is required when first starting treatment
= can last up till a year

67
Q

What needle length is suitable?

A

4,5,6mm regardless of BMI

68
Q

At what angle do you inject?

A

90 degrees

69
Q

What may be needed for slim people?

A

Need a lifted skin fold

70
Q

What happens if you are using an 8mm needle?

A

Use lifted skin fold
Or give into buttocks

71
Q

What is the fastest sites of absorption when injecting?

A

Abdomen
Back of arm

72
Q

What is the slowest sites of absorption when injecting?

A

Thighs
Arse

73
Q

What must you never do?

A

Do NOT inject through clothing

74
Q

What is the injection technique?

A

Clean skin
Insert needle
Push button
Leave in place for 10mins
Remove needle

S3 Case 4 - Endocrine (17 decks)

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