Type 1 Diabetes

Question 1

Pathophysiology

Answer 1

Autoimmune destruction of pancreatic beta Islet cells of Langerhan therefore absolute deficiency of insulin

Question 2

Presentation

Answer 2

More common in younger population

Loss of weight despite eating
Polydipsia
Polyuria

Fatigue 
Dehydration
Abdo pain 
Visual disturbances 
Sweating 
Dizziness and LOC 
Drowsy 
Sunken eyes 
Reduced skin turgor

Question 3

Signs

Answer 3

Fruity acetone smell on breath
Kussmaul breathing - if acidosis
Prolonged capillary refill time - severe

Question 4

Ketones in blood and urine

Answer 4

High if:
2+ - urine
3 mmol - blood

Question 5

Investigations

Answer 5

Random plasma glucose < 11
Fasting ≥7mM
Blood and urine ketones
VBG - acidosis

Question 6

When to suspect T2DM in child

Answer 6

Strong FHx
Obesity
Afro - Caribbean

Question 7

Management

Answer 7

Insulin therapy
Provide home blood glucose testing
Education - care plan

Question 8

HbA1c target

Answer 8

48mmol or less

Question 9

DKA

Answer 9

Blood glucose level > 11mmol

Symptomatic:

• weight loss
• abdominal pain and vomiting
• visual disturbances
• lethargy and confusion
• acetone smell on breath
• Kussmaul breathing
• dehydration
• shock - tachycardia, hypotension, cap refill > 2 seconds, reduced urine output

Question 10

Precipitating factors of DKA

Answer 10

Infection e.g. pneumonia or URTI
Physiological stress - trauma or surgery
Non adherence to insulin treatment
Drug treatments - steroids

Question 11

DKA investigations

Answer 11

A-E
Cap blood glucose > 11mmol
VBG- metabolic acidosis

Test for ketones:
Urine - 2+
Blood - 3 + mmol
Bloods - LFTs, U+Es, FBC

Question 12

Management

Answer 12

IV 0.9% saline 500ml per 15 mins
Short acting insulin - novarapid whilst setting up FRIII
FRIII - 0.1 unit/kg/hour

Once cap glucose decreases to < 15mmol - give IV dextrose with saline
2-3 hrs after
- give K+

Question 13

Appropriate environment for DKA pt

Answer 13

High dependency ward - to receive 1 to 1 nursing care

Question 14

Assess patients response to treatment

Answer 14

CBG 
Decrease in ketones - less than 0.6mmol/L
Normal pH - more than 7.3
Bicarbonate > 15mmol 
Alleviated symptoms 
Normal GCS

Question 15

Resolution of DKA

Answer 15

Transfer to subcut insulin when eating and drinking

Do not discontinue IV insulin infusion until 30 mins after subcut given

pH - more than 7.3
Blood ketones - less than 0.3 mmol/l
Bicarbonate - more than 15mmol/l

Question 16

Genetic association

Answer 16

HLA-D3 and D4

Question 17

Diagnosis

Answer 17

Symptomatic:
Detected once
- Fasting ≥7mM
- Random ≥11.1mM

Asymptomatic
Detected on 2 separate occasions
- Fasting ≥7mM
- Random ≥11.1mM
- OGTT ≥ 11.1mM

Question 18

Insulin principles

Answer 18

Pt. education about:
- Self-adjustment with exercise and calories
- Abort hypo with sugary drinks or GlucoGel
- Fasting BM before meal informs long-acting insulin
dose.
- Finger-prick BM after meal informs short-acting
insulin dose (for that last meal)

Question 19

Biphasic Insulin Regime

Answer 19

Insulin mixture 30 min before breakfast and dinner

• Rapid-acting: e.g. actrapid
• Intermediate- / long-acting

Question 20

Basal-Bolus Insulin regime

Answer 20

• Night - long-acting e.g. glargine
• Before meal - short acting e.g. lispro

• Adjust dose according to meal size

Question 21

Insulin when ill

Answer 21

• Insulin requirements usually ↑
• Maintain calories
• Check BMs ≥4hrly and test for ketonuria
• ↑ insulin dose if glucose rising

Question 22

DKA pathogenesis

Answer 22

Ketogenesis:
↓ insulin → ↑ stress hormones (glucocorticoids) and ↑ glucagon

↓ glucose utilisation + ↑ fat β-oxidation

↑ fatty acids → ↑ ATP + generation of ketone bodies

Question 23

Addition mx of DKA

Answer 23

Urinary catheter 
NGT if vomiting or ↓GCS
Thromboprophylaxis with LMWH
Refer to Specialist Diabetes Team
Find and treat precipitating factors