Type 1 Diabetes Flashcards
What is Type 1 Diabetes
Diabetes is caused by a deficiency in or resistance to insulin. There are 4 main types of diabetes: Type 1, Type 2, Secondary or gestational diabetes. Insulin is normally released by the body after eating, and increased the metabolism of the liver, fat and skeletal tissue. It increases glucose uptake into cells, increases synthesis of glycogen, and increases the storage of fats in adipose tissue.
Type 1 diabetes is caused by an absolute deficiency in insulin. Resulting from an autoimmune defect in beta cells in the pancreas. This means that type 1 diabetics are required to inject insulin daily to maintain the normal basal levels of insulin that the body would normally produce.
Type 1 diabetics are at risk of diabetic ketoacidosis. In the DKA the bod effetely enters a state of starvations, with no insulin available for the body to access glucose. This causes ketone levels to rise. These ketones are acidotic and cause many problems
What are the causes of Type 1 Diabetes
Autoimmune process that is triggered by viral infection, stress, toxins or diet
What will you find on a history of Type 1 Diabetes
Symptoms:
Polyuria
Polydipsia
Lethargy
Recurrent infections
Weight Loss – The body cannot access glucose so uses fat stores
Blurred Vision - Due to varying blood sugars
Any symptoms of DKA - Nausea and Vomiting, Abdominal Pain, Tachypnoea, Lethargy, Coma, Dehydration, Acidosis
Risk Factors:
Generally affects young People
Associated with personal or family history of other autoimmune condition’s – Thyroid disease, Addison’s, Coeliac, pernicious anaemia
Family history
Specific Questions to ask:
Recent Viral infection - Commonly activates the Type 1 diabetes
Job - Do they drive? This may have an impact
Current infection can be what pushes a patient into DKA bringing them in, so go infection hunting
Differentials:
Type 2 diabetes - Older patients, obesity, family history likely to be present. No weight loss. No DKA
Secondary Diabetes – Ask about history of steroid use, pancreatitis or symptoms of pancreatic carcinoma (weight loss, steatorrhea), Look for stigmata of endocrinopathy e.g. Cushingoid features
Other causes of metabolic acidosis – Methanol poisoning, starvation, Lactate acidosis (sepsis), Ethanol Poisoning (Alcoholism). Hyperosmolar non ketoic syndrome can present in a similar way to DKA but is associated with type 2 diabetes
What will you find on examination of a patient with Type 1 Diabetes
Examination findings: Look for signs of dehydration or DKA End of the bed: Weight loss/ Muscle Wasting Confusion – If DKA Hands: Tachycardia - Dehydration Hypotension - Dehydration Face: Dry mucous membranes - Dehydration Sweet breath - Ketones Kussmaul’s breathing – If in DKA Chest: Raised Resp Rate in DKA due to Metabolic Acidosis Abdomen: Abdominal Pain in DKA Look around the groin for signs of thrush
What investigations will you order in suspected type 1 diabetes?
Bedside:
Urinalysis – Looking for Glucose and Ketones, also leukocytes could be raised if a UTI was the infection pushing them into DKA. Urinary K+ may be paradoxically raised even though very low serum levels
ECG - If presenting in DKA as acidosis can cause hyperkalaemia, also DKA can be precipitated by MI
Glucose and Ketone levels – Looking for raised levels or DKA. IF raised do a proper blood test for both
Full set of observations
Bloods:
HBa1c - Reflection of last 3 months of glucose levels, results of >6.5% are diagnostic
Serum Glucose – 2 different results of >11.1 (random) or >7 (fasting) is diagnostic. Only 1 result is required in presence of symptoms
Autoimmune screen - To look for other autoimmune diabetes
ABG - Looking for DKA (Metabolic acidosis with an increased anion gap), DKA can also cause a lactic acidosis so look for a raised lactate
U&E - Looking for dehydration (Raised Urea and creatinine, low NA+) and commonly hyperkaliaemic (H+ for K+ exchange in acidosis)
Amylase and Lipase - Assess Pancreatic function to look for possible secondary cause
Creatinine Kinase - DKA associated with rhabdomyolysis (Fluid moves into muscles and damages them)
Troponin - DKA can be precipitated by MI
FBC - Looking for infection that may have precipitated the DKA
Imaging:
CXR - DKA precipitated by infection commonly pneumonia
What is the management of type 1 diabetes?
Lifestyle:
Optimise BMI - Patients may have lost a lot of weight
Reduce other cardiovascular risk factors
Dietitian referral and Diabetic Carb counting education (DAFNE Programme)
Wear medical emergency bracelet
Talk to DVLA about driving
4 times daily measuring of blood glucose – Before each meal and before bed
Annual Review, and annual optician review (see below)
Educate on symptoms of DKA and when to come in
Educate them to rotate injection sites
Medical:
Insulin is required, patient’s decision along with doctor on regimen, do they prioritise better control or less injections
Aim for 5-7 glucose mmol/l before meals
Example regimens - Twice daily mixed insulin or basal bolus (long acting through the day, short acting at each meal)
There is a subcutaneous pump available that can adjust insulin doses as needed, but this is not normally offered straight away
Type 1 diabetes yearly review
Check Glycaemic Control - HbA1c and set aims for the next year e.g. Changes in medication
Assessing for any complications:
Cardiovascular Assessment - BMI, Lipid Profile, Blood pressure, Diabetics have upper limit of 135/85 before treatment
Renal - Urinary Albumin excretion, eGFR
Eyes - Examine for retinopathy/cataracts
Feet - Check for ulcers, sensation and feel pulses
Examine injection sites
Ask about impotence in men, and give conception advice in women, ask about depression
Autoimmune screen in children
What is the management of DKA?
Resuscitation:
A-E approach
Get IV Access (2 large bore cannulas)/Give O2 to maintain sats of 94+ /Attach 12 lead ECG
Insert a catheter to monitor fluid output
Assessment with AMPLE history and brief examination - If known type 1 diabetic coming in with DKA ask about precipitants (Missing dose of insulin, Infection, MI, Surgery)
Get help - Medical reg on call/Warn ITU as likely to end up there
Frequent Observations - Constant or 15 minutely
Give fluid challenge if BP low, otherwise just start a 1L bag of saline over 1 hour
Patient will require lots of IV saline, they are very dehydrated - typically 100ml needed per Kg, so 70kg man needs 7l
Consider NG tube if patient vomiting or in coma
Medical:
Add 50 units of insulin to 50ml saline, infuse at 0.1 units/kg/hour to achieve a drop in glucose levels by 3mmol/l/hr or reduction in blood ketones by 0.5mmol/l/hr
If these targets not achieved increase dose by 1 unit/hour. Stop insulin if K+ <3.3 (Insulin causes hypokalaemia) and add K+ whenever needed after first bag of fluid (Not given in firs bag as K+ can’t be given very fast)
At the same time give patient normal long acting insulin
If glucose < 14 start 10% dextrose at 125ml/hour alongside the saline
Start all patients on LMWH
Hourly blood glucose and ketones
Stop the insulin when blood ketones <0.6, pH >7.3 and bicarb >15, Do not use urinary ketones as they stay raised for longer
