Week 5: Diabetes (3) (Virtual learning) Flashcards
normal BM parameters
Between 4.4 and 7.2 mmol/L before meals.
Less than 180 mg/dL (10 mmol/L) two hours after meals.
DKS
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
HHS
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
Hypoglycaemia in a diabetic
- 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
For elderly admitted with hypo consider medication review
- Beware: elderly pts with diabtes who have an HbA1c of less than 7% who are treated with insulin or sulphonylureas
- Risk of hypo
establishing a diagnosisw of hypoglycemia
- <4mmol/l
- Signs and symptoms
- Pallor, sweating, tremor (autonomic)
- Loss of concentration, behavioural changes, fits, LOC (Neuroglycopenic symptoms)
- Symptoms harder to recognise in elderly
Causes of inpatient hypoglycaemia
- 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
Management of inpatient hypoglycaemia
- Prompt treatment
- Reduce insulin doses
- Give carbohydrate/ glucose
- Ensure snacks at bedtime
what to do after treating hypoglycaemia
- Document
- Maybe refer to specialist team if recurrent
Who needs insulin therapy
- 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
Insulin prescribing
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)”
example of safe insulin prescription
Insulin preparation and admin
- 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
Indications for Various Rate Intravenous Insulin Infusion (VRIII) (sliding scale)
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
Monitoring CBGs while on VRIII
- Hourly
- Aim 6-10mmol/l
- If above tagrte may need to adjust insulin infusion rate
- Review need for VRIII on a daily basis
When to switch to subcut insulin from VRIII
- Ensure pt can eat and drink
- CBG within ranges of 6-10 mmol/l
- Discontinuous at a meal-time (when usual medication given)
Daily diabetes review and monitoring
- 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
bedside monitoring opf CBG
Bedside monitor CBG
- Daily
- Before each meal and before bed (4 tests)
- If all test in range, then testing frequency can be reduced
footcare in diabetes
- 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
Identification of sepsis
Vital to recognise the signs of sepsis/infection if a patient is admitted with a diabetes foot emergency and initiate prompt Abx
special groups of patients
patients on continuous subcut insulin infusions
pregnancy and labor
patients undergoing enteral feeding following a stroke
patient on steroids
Patients on continuous subcut insulin infusion (CSII)
- 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
Pregnancy and labour
- 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
Patients undergoing enteral feeding following a stroke
- 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
Patients on steroids
- 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
Elderly patients, dementia and end of life care
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
CBG target in the frail
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.
discharge
- 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
The diabetic foot
Long term effect:
- Prolonged ulceration
- Ill health
- Social isolate
- Risk of re-ulceration
- Prolonged admission
- Gangrene
- Amputation
- Depression
- Death
diabetic foot problems: deadly triad
-
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
- Motor neuropathy
-
Vascular
- Microvascular
- Macrovascular
- Trauma
assessing the risk for diabetic foot disease
touch the toes test
ulceration
pulses
gangrene
peripheral arterial disease progression
assessing and describing a foot ulcer
Action required if problem occurs or admitted with a foot problem
- Rapid referral
- Commence appropriate antibiotics e.g. fluclox
- Offload affected area
- Referral for specialist intervention
- Educate patients/relatives
signs of infections
management of foot ulcer
- Pseudomonas will SMELLLL
- Debridement important
charcots foot
- Warm swollen foot, painful, neuropathy present
Charcot treatment
