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Medicine block (Y3) > Week 5: Diabetes (3) (Virtual learning) > Flashcards

Week 5: Diabetes (3) (Virtual learning) Flashcards

1
Q

normal BM parameters

A

Between 4.4 and 7.2 mmol/L before meals.

Less than 180 mg/dL (10 mmol/L) two hours after meals.

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2
Q

DKS

A

Mainly T1Dm

  • Significant ketonuria (≥ 2+) or blood ketone > 3mmol/L
  • Blood glucose > 11mmol/L or known diabetes mellitus
  • Bicarbonate < 15mmol/L or venous pH < 7.3

Treatment

  • Insulin- fixed rate intravenous insulin infusion (FRIII) as soon as DKA confirmed
  • Fluids- replace fluid deficit (beware of fluid overload)
  • Potassium- monitor hourly and replace loss
  • Avoid hypoglycaemia – CPG hourly (when <14mmol/l start dextrose
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3
Q

HHS

A

HSS

Mortality is high- requiring senior review

  • Hypovolaemia
  • Marked hyperglycaemia (≥30 mmol/L) without significantly elevated blood ketone levels (<3 mmol/L) or acidosis (pH>7.3, bicarbonate >15 mmol/L)
  • Osmolality ≥320 mosmol/kg (2Na + Gluc + Ur)

Treatment

  • Insulin- FRIII
  • Fluid- follow protocol
  • Potassium- monitor and replace
  • Low molecular weight heparin- prophylactic
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4
Q

Hypoglycaemia in a diabetic

A
  • Many pts will not require admission
  • Usually T1DM, elderly if t2Dm
  • Should considered in any person with diabetes who is unwell, drowsy, unconscious or unable to co-operate
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5
Q

For elderly admitted with hypo consider medication review

A
  • Beware: elderly pts with diabtes who have an HbA1c of less than 7% who are treated with insulin or sulphonylureas
    • Risk of hypo
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6
Q

establishing a diagnosisw of hypoglycemia

A
  • <4mmol/l
  • Signs and symptoms
    • Pallor, sweating, tremor (autonomic)
    • Loss of concentration, behavioural changes, fits, LOC (Neuroglycopenic symptoms)
  • Symptoms harder to recognise in elderly
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7
Q

Causes of inpatient hypoglycaemia

A
  • Inappropriately times diabetes medication
  • Insulin error
  • Use of IV insulin infusion without glucose infusion
  • Acute illness
  • Change in activity e.g. mobilisation after illness
  • Missed or delayed meals
  • Prolonged starvation e.g. vomiting, reduced appetite
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8
Q

Management of inpatient hypoglycaemia

A
  • Prompt treatment
  • Reduce insulin doses
  • Give carbohydrate/ glucose
  • Ensure snacks at bedtime
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9
Q

what to do after treating hypoglycaemia

A
  • Document
  • Maybe refer to specialist team if recurrent
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10
Q

Who needs insulin therapy

A
  • T1DM- complete lack of endogenous insulin- insulin mainstay of treatment
  • T2DM
    • High BM can be controlled with non-insulin therapies e.g. diet, oral and injectable treatments)
    • 50% will require insulin within 6 years due to progressive decline of B cell function
    • Started when glycaemic targets are not met using these therapies or if the pt is symptomatic e.g. rapid weight loss, polyuria, nocturia, gestational diabetes, steroid induce diabetes e.g. dexamethasone
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11
Q

Insulin prescribing

A

All the trainees should comply with insulin prescribing standards to minimise error.

Standards for Insulin prescribing:

  • Correct Brand name – beware of sound alike insulins (NB Humalog v Humalog mix25)
  • Correct device
  • Correct dose (check with pt, GP, etc.)
  • NEVER abbreviate “units” to “u” or “iu” due to risk of 10x overdose
  • Correct time
  • Correctly write on both charts (drug/EPMA and green chart)
  • Correct strength (U100, U200, U300, U500) eg, “(strength 200units/ml)”
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12
Q

example of safe insulin prescription

A
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13
Q

Insulin preparation and admin

A
  • If you need to draw insulin up from a vial or administer insulin using a syringe and needle then this can only ever be done using a standard insulin syringe
    • 1ml syringes – for standard strength insulin (U100) 0.01ml = 1 unit insulin and 1ml = 100 units insulin
    • Otherwise risk of overdose
  • NEVER use a syringe to withdraw insulin from a pen cartridge
  • Insulin is a time critical drug
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14
Q

Indications for Various Rate Intravenous Insulin Infusion (VRIII) (sliding scale)

A

For patients with diabetes who are hyperglycaemic or with hospital related hyperglycaemia who are unable to take oral fluid/food, who are acutely unwell and/or for whom adjustment of their own insulin regimen is not possible. Particularly the following groups of patients:

  • Patients with type 1 diabetes who are unable to eat and drink
  • Patients with type 1 diabetes with recurrent vomiting (exclude DKA)
  • Patients with type 1 or 2 diabetes and severe illness with need to achieve good glycaemic control e.g. sepsis
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15
Q

Monitoring CBGs while on VRIII

A
  • Hourly
  • Aim 6-10mmol/l
  • If above tagrte may need to adjust insulin infusion rate
  • Review need for VRIII on a daily basis
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16
Q

When to switch to subcut insulin from VRIII

A
  • Ensure pt can eat and drink
  • CBG within ranges of 6-10 mmol/l
  • Discontinuous at a meal-time (when usual medication given)
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17
Q

Daily diabetes review and monitoring

A
  • All pts should have a venous plasma glucose measurement anf HbA1c
  • Test for ketones on arrival in pt with diabetes who are unwell, newly diagnosed or has T1DM

For all patients you need to ensure that you:

  • Check the DIABETES CHART daily
  • Check patients FEET and heels daily for pressure damage or ulceration
  • Take ACTION when necessary
  • Use insulin SAFELY
  • TALK to patients, family and carers and staff about INSULIN
  • SPEAK UP if there is a problem
18
Q

bedside monitoring opf CBG

A

Bedside monitor CBG

  • Daily
  • Before each meal and before bed (4 tests)
  • If all test in range, then testing frequency can be reduced
19
Q

footcare in diabetes

A
  • All pt with diabetes should have their shoes, socks and dressings removed on admission  look for evidence of vascular compromise, ulceration and active foot infection and acute charcot arthropathy
    • Diabetics are at higher risk of pressure damage (due to neuropathy) and should have daily feet/heel exam and pressure relief if required
20
Q

Identification of sepsis

A

Vital to recognise the signs of sepsis/infection if a patient is admitted with a diabetes foot emergency and initiate prompt Abx

21
Q

special groups of patients

A

patients on continuous subcut insulin infusions

pregnancy and labor

patients undergoing enteral feeding following a stroke

patient on steroids

22
Q

Patients on continuous subcut insulin infusion (CSII)

A
  • A method of delivering intensive insulin therapy in 10-15% of T1DM
  • Continuous basal infusion of short acting insulin combined with a meal-time boluses of the same insulin
  • Delivered via a small subcut cannula on the abdomen
  • Usually better for pt to continue to self-manage diabetes except when
    • Unconscious or incapacitated
    • Undergoing major general anaesthetic procedure
    • DKA
  • REMEMBER
    • People on CSII do not take long acting insulin
    • Do not cut tubing or disconnect pump from tubing (remaining insulin in tube may infuse quickly risking hypo)
    • Document when removed and where it is stored
23
Q

Pregnancy and labour

A
  • Of the women who have diabetes during pregnancy, it is estimated that approximately 87.5% have gestational diabetes (which may or may not resolve after pregnancy), 7.5% have type 1 diabetes and the remaining 5% have type 2 diabetes.
  • Level of risk to pregnancy in women with pre-existing diabetes increaseds with HbA1c level above 48mmp;/mol
    • Target 4-7mmol/l during pregnancy
  • Risk to woman and development fetus
    • Mischarriage
    • Pre-eclampsia
    • Preterm labour
    • Macrosomnia
    • Stillbirth
    • Congenital malformation
    • Birth injury
    • Perinantal mortality
  • Beware of
    • Steroid admin for lung maturation if risk of premature labour
    • Induction of labour and delivery
    • Specific issues in relation to DKA
24
Q

Patients undergoing enteral feeding following a stroke

A
  • Diabetes doubles risk of stroke
  • Signif no. of stroke patients have diabetes
  • Pt with cerebral damage may be particularly vulnerable to neuroglycopenic effects of hypoglycaemia
  • Avoidance of excessive hyper or hypoglycaemia should eb aspirational in the management of all people with diabetes in hospital
25
Q

Patients on steroids

A
  • Steroid admin modulate carbohydrate metabolism  promoting hyperglycaemia in at risk individuals e.g. T1/2DM, increased risk of T2DM, impaired fasting glucose
  • Therefore steroids can increase blood glucose and pt may require short term insulin injections whilst on them
  • Need to make sure hyperglycaemia is managed when pt is discharged
26
Q

Elderly patients, dementia and end of life care

A

Primary aim is to avoid hypoglycaemia (CBG <4mmol/l) and hyperglucaeima with potential osmotic symptoms (CBG >15mmol/l

  • Pay particular attention to avoidance of hypoglycaemia at night by recommending provision of snacks at bedtime and recuing evening dose of diabetes medication
27
Q

CBG target in the frail

A

CBG target – general inpatient target for frail older patients is 7.8-10mmol/l however this may be individualised and in moderate to severe frailty a higher range may be agreed as appropriate (eg, upto 15mmol/l). For frail older patients undergoing surgery the suggested range is 7-11mmol/l and for patients at the end of life the suggested range is 6-15mmol/l – again individualised where needed as 6-7mmol/l may pose and unacceptable hypo risk when patients in final days of life or with moderate to severe frailty.

28
Q

discharge

A
  • Ensure they are aware of any medication changes ,emergency contact and follow-up plans
  • If pt on insulin vital to ensure the pt or carer is able to admin – may need district nurse support
29
Q

The diabetic foot

Long term effect:

A
  • Prolonged ulceration
  • Ill health
  • Social isolate
  • Risk of re-ulceration
  • Prolonged admission
  • Gangrene
  • Amputation
  • Depression
  • Death
30
Q

diabetic foot problems: deadly triad

A
  • Neuropathy
    • Motor neuropathy
      • Deformity of foot: high arch, hammer toes (more likely to rub)
    • Sensory
    • Autonomic
      • Anhidrosis- dry
      • Reduced sympathetic tone
    • All lead to charcot
  • Vascular
    • Microvascular
    • Macrovascular
  • Trauma
31
Q

assessing the risk for diabetic foot disease

A
32
Q

touch the toes test

A
33
Q

ulceration

A
34
Q

pulses

A
35
Q

gangrene

A
36
Q

peripheral arterial disease progression

A
37
Q

assessing and describing a foot ulcer

A
38
Q

Action required if problem occurs or admitted with a foot problem

A
  • Rapid referral
  • Commence appropriate antibiotics e.g. fluclox
  • Offload affected area
  • Referral for specialist intervention
  • Educate patients/relatives
39
Q

signs of infections

A
40
Q

management of foot ulcer

A
  • Pseudomonas will SMELLLL
  • Debridement important
41
Q

charcots foot

A
  • Warm swollen foot, painful, neuropathy present
42
Q

Charcot treatment

A

Medicine block (Y3) (38 decks)

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