Type 1 diabetes mellitus Flashcards
What's this?
What are the aims of management of type 1 diabetes?
○ Prompt diagnosis
○ Encouragement of the appropriate self-management skill set
○ Correction of acute metabolic upsets at diagnosis and thereafter
○ Facilitate long term health and well being
Why is it important to diagnose early?
○ Scotland has 5th highest incidence of Type 1 Diabetes in the world
○ In Scotland 300 children under the age of 15 years are diagnosed with Type 1 Diabetes annually
○ 1 in 4 are diagnosed in DKA
○ Rising to 1 in 3 under the age of 5 years
○ In the UK 10 children die and 10 children suffer permanent neurological disability
How do you make an early diagnosis?
○ THINK – Symptoms - Thirsty - Thinner - Tired - Using the Toilet more - In children under 5 also think □ heavier than usual nappies □ blurred vision □ candidiasis (oral, vulval) □ constipation □ recurring skin infections □ irritability, behaviour change ○ TEST- Immediately - Finger prick capillary glucose test □ If result >11 mmol/l - DO NOT request a returned urine specimen. - DO NOT arrange a fasting blood glucose test. - DO NOT arrange an Oral Glucose Tolerance Test. - DO NOT wait for lab results (urine or blood). ○ TELEPHONE – Urgently - Contact your local specialist team for a same day review
What are the symptoms of diabetic ketoacidosis?
○ Nausea&vomiting ○ Abdominalpain ○ Sweetsmelling,"ketotic"Breath ○ Drowsiness ○ Rapid, deep “sighing” respiration ○ Coma
What are the current strategies to support people with type 1 diabetes?
○ Education
○ Team based DSN, practice nurse, dietitian, podiatrist, doctors.
○ Structured education e.g. DIANE, Dose Adjustment For Normal Eating.
○ Person with diabetes is main team member.
○ Nutrition and Lifestyle management e.g. CHO counting, exercise
○ Skills training e.g. Home blood glucose monitoring, injection technique, hypos
○ Insulin- analogues, pens, pumps
Explain insulin and diabetes
○ Insulin is a polypeptide which is inactivated by the gastrointestinal tract therefore it needs to be injected subcutaneously (usual route) or intravenously (e.g. during illness or surgery)
○ In the subcutaneous fat the Insulin molecule in solution has a tendency to self-associate into hexamers
○ Hexamers need to dissociate into monomers before absorption through the capillary bed. Thus soluble insulin is given 30 mins before eating.
○ Rapid acting analogues do not associate and can be injected just before eating
○ Changing the structure of insulin or binding it to other molecules will change the rate of absorption
○ The amount of insulin injected for meals should balance the carbohydrate intake consumed
What are the types of insulin?
- Rapid acting insulins e.g. insulin lispro, insulin aspart (Humalog, Novorapid ,Apidra)
- Short acting insulins e.g. soluble insulin, actrapid, Humulin S.
- Intermediate acting insulins e.g. Isophane insulin; insulatard, Humulin.
- Long acting insulins e.g. glargine, detemir, degludec
- Continuous subcutaneous insulin infusion (CSII)
Explain insulin regimes
- Suitable for a flexible lifestyle
- Better for shift workers
- Rapid (Short) acting insulin to cover CHO at meals 1 unit per 10g CHO
- Basal long acting insulin as background
Give examples of insulin regimes
- Twice daily
□ Rapid acting mixed with intermediate acting
□ Before breakfast (BB) and evening meal (BT) - Three times daily
□ Rapid acting mixed with intermediate acting BB
□ Rapid acting BT
□ intermediate acting at bedtime BBed - Four times daily
□ Short acting BB BL BT
□ Intermediate BBed or long acting insulin at a fixed time once daily
What do you do if you have blood ketones and your blood sugar level is 14 or above?
- Less than 0.6:
- Normal
- Repeat check after 2 hours to check level isn’t rising
- 0.6-1.4:
- Risk of DKA
- Drink plenty of sugar free fluids
- Give a correction dose of insulin
- Retest blood sugar and ketones 1-2 hourly
- 1.5-2.9:
- Risk of DKA
- As above
- Contact diabetes team for advise
- 3.0 or above
- DKA
- As above
- phone for urgent medical advice: to attend PAU (paediatric assessment unit)
What are the clinical features of hypoglycaemia?
autonomic - Sweating - Palpitations - Shaking - Hunger Neuroglycopenic - Confusion - Drowsiness - Odd behaviour - Speach difficulty - Incoordination General malaise - Headache - Nausea
Explain loss of warnings of hypoglycaemia
- INABILITY TO PERCEIVE NORMAL WARNING SYMPTOMS OF HYPOGLYCEMIA is associated with: □ recurrent severe hypoglycaemia □ long duration of disease □ over tight control □ loss of sweating / tremor
What is the treatment for hypoglycemia?
- All patients treated with insulin or sulfonylureas should be advised to carry carbohydrate with them
- Hypoglycemia can cause coma, hemiparesis and seizures
- If the hypoglycaemia is prolonged the neurological deficits may become permanent
- If able : 15-20g simple CHO
□ 5-7 dextrosol/4-5 Glucotabs
□ 200ml fruit juice - If unable to take oral CHO
□ Out of hospital:
® 1 mg im glucagon
® GlucoGel/ Dextrogel
□ In hospital: 75-80 ml 20% glucose or 150-160 ml of 10% glucose or 25-50 mls 50% dextrose iv
□ Follow-up with long-acting CHO - Hypo box
□ Fruit juice
□ Dextro energy
□ Glucogel
□ 50% Dextrose
□ Hypo management protocol
What are the signs of ketoacidosis?
- Dry mucous membranes
- Sunken eyes
- Tachycardia
- Hypotension
- Ketotic breath
- Kussmaul resp.
- Altered mental state
- Hypothermia
What is the treatment of ketoacidosis?
- Measure glucose / U and E’s / ketones / bicarbonate / arterial blood gas
- Give iv saline (5 l in 24 hours)
- Give iv insulin (drives glucose and potassium into cells)
- Give iv potassium in saline
- May need antibiotics
- Consider heparin, NG tube
- Mortality Rate 2%
