Hypoglycemia, Sick Days/DKA and Hospitalization

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1 Hypoglycemia, Sick Days/DKA and Hospitalization General survival skills for your client with diabetes at home and in Hospital Diabetes Canada guidelines for your client with diabetes while they are in hospital? Presented by,cheryl Fletcher RN,CDE No disclosures

2 Objectives Review of Normal Physiology of Glucose Metabolism Hypoglycemia: Signs, symptoms, prevention and treatment DKA signs, symptoms and prevention Managing illness and when to get help Resources for in hospital management of the client with Diabetes Patient resources

3 When food is consumed, glucose is transported from the stomach to the small intestines Food Carbs Stomach Nutrients Glucose Small Intestines

the transport of glucose into the cells where it is used

4 Nutrients are absorbed from the small intestines into the blood stream Once in the blood stream, insulin facilitates the transport of glucose into the cells where it is used for energy Cells Glucose Insulin Blood Stream Small Intestines

5 Glucagon causes glycogen stores to convert to glucose in response to falling blood glucose. Insulin causes sugar to be transported into cells for energy. As well as converted to glycogen for storage, in response to rising blood sugar. Liver and Glucagon

6 Hypoglycemia Definition Hypoglycemia is defined by 1) the development of autonomic or neuroglycopenic symptoms 2) a low plasma glucose level <4.0 mmol/l (for patients treated with insulin or an insulin secretagogue) 3) symptoms responding to the administration of carbohydrate. The severity of hypoglycemia is defined by clinical manifestations.

7 Severe Hypoglycemia Individual requires assistance of another person. Unconsciousness may occur. PG is typically <2.8 mmol/l.

8 Symptoms of Hypoglycemia Trembling Palpitations Sweating Anxiety Hunger Nausea Tingling Neurogenic (autonomic) Difficulty concentrating Confusion Weakness Drowsiness Vision changes Difficulty speaking Headache Dizziness Neuroglycopenic

9 KEY MESSAGES Prevention of, recognizing and treating hypoglycemia The goals of treatment for hypoglycemia are to detect and treat a low blood glucose (BG) level promptly by using an intervention that provides the fastest rise in BG to a safe level, to eliminate the risk of injury and to relieve symptoms quickly.

10 Hypoglycemia Causes Insulin injection or oral Insulin Secretagogues (Glyburide, Diamicron/Gliclazide, Nateglinide, Repaglinide) Too much medication or medication without carbohydrate intake Increased or unexpected activity Delayed or small meals Alcohol intake

11 Severe Hypoglycemia Other Considerations A1C <6% Hypoglycemia unawareness Autonomic neuropathy Very young and Adolescent children Elderly

12 Prevention Checking blood sugars more often and when having symptoms of a low blood sugar Follow a recommended meal plan May need a carbohydrate snack or a reduction in medication for activity Medication dose may need adjustment (decreased weight, more active lifestyle) ETOH intake with in the national recommendations, eat carb with alcohol intake, check your blood sugars regularly overnight and through the next day, buddy system

13 Signs of Low Blood Glucose Sweating Shaky/trembling Dizziness Sudden hunger Confusion Irritability

14 Treatment for Low Blood Glucose Can happen quickly, so treat quickly Treat with one of these quick sugars: 15 grams of glucose tablets ¾ cup regular pop or fruit juice 8 jelly beans 3 sugar packets 1 tbsp of honey 2 packages of Rockets

15 Severe Hypoglycemia Treatment Requirement: If the person is conscious treatment is : gm CHO of one of these quick sugars: - 5 Dextrose tablets - 1 cup fruit juice or regular pop - 3 packages "Rockets TM - 4 teaspoons honey 2. Wait 15 minutes and check blood sugar again. If blood sugar remains low (<4 mmol/l) then treat again with 15 gm of quick sugar. 3. If it is more than 1 hour before your meal, have a snack of 15 gm CHO and protein i.e. ½ sandwich or cheese & 5 crackers. If the person is unconscious call 911. Be sure to ask the doctor about glucagon for dealing with this situation in the future.

16 What to do Next? Wait 10 to 15 minutes Check blood glucose again If still low, treat again If more than 1 hour until next meal, eat a snack (½ sandwich OR 6 crackers/peanut butter)

17 Driving Guidelines Must be Over 5.0 to drive if on medications that cause low blood sugars Check your blood sugars before you drive Carry quick sugar and carbohydrate snacks in your car Medic Alert

18 Hyperglycemic Emergencies DKA = Diabetic Ketoacidosis HHS = Hyperosmolar Hyperglycemic State Common features: Insulin deficiency hyperglycemia urinary loss of water and electrolytes Volume depletion + electrolyte deficiency + hyperosmolarity Insulin deficiency (absolute) + glucagon Ketoacidosis (in DKA)

19 DKA Signs and symptoms Unexplained hyperglycemia with BG> 14 Thirst, dry mouth,polyuria Abdominal pain/ cramping Feeling short of breath Acetone breath

20 PREVENTION of DKA / HHS Type 1 diabetes Education around sick day management Continuation of insulin even when not eating Frequent monitoring when ill Type 2 diabetes Education around sick day management Frequent monitoring when ill

22 Diabetes Education Centre of St. Joseph s Health Care London For hospital tests and procedures please see reverse SICK DAY Care For Type 2 Diabetes When you are sick, your blood glucose level can change a lot. A sick day plan can help you keep your blood glucose under control when you have fever, vomiting, nausea, diarrhea, coughing or head congestion. MEDICATION Always check with your physician before changing your medication. It is usually recommended to NOT stop taking your diabetes pills or insulin when you are ill. MONITORING It is recommended that you test your blood glucose every 2 to 4 hours. FOOD If you can t eat your usual meal plan, have one serving of food containing 15 grams of carbohydrate every hour while awake. This will help keep your blood glucose from going too low. If you are not able to eat solid foods, take carbohydrate in liquid form (i.e. juice). LIQUIDS Drinking liquids is very important, especially if you are losing fluids due to fever, vomiting, or diarrhea. Let your blood glucose be your guide to choosing liquids. If your blood glucose is over 14.0 mmol/l, drink carbohydrate-free liquids like water, broth or bouillon, sugar-free/caffeine-free soda, or decaffeinated tea that won t raise your blood glucose. If your blood glucose is low, drink carbohydratecontaining liquids like regular soda, milk or fruit juices. Call your health team if: You ve been sick for two days and aren t getting better You ve been vomiting or have had diarrhea for more than 6 hours Your blood glucose stays over 14.0 mmol/l You have chest pain, trouble breathing, &/or dry cracked lips You aren t sure what to do

23 Suggestions for when to get help Illness has lasted 3 or more days especially if there is fever Unable to ingest anything with vomitting/diarrhea for 6 hours would suggest a trip to the ER/Urgent care Blood sugars over 14mmol/L and not correcting with fluids, activity or medication Signs of severe dehydration; cracked lips, very concentrated strong urine Chest pain

24 Blood glucose levels (mmol/l) Ketone bodies in urine* Symptoms** Suggested actions or + + Measure your blood glucose level every 1-4 hours. Drink 250 ml of water every hour. Take 10% extra rapid insulin or use your sliding scale or Correction Factor Check for Ketones: if any unexplained high blood sugar if your blood sugar is above 14 mmol/l or or +++ Measure your blood glucose level every 1-4 hours. Drink 250 ml of water every hour. Take 10-20% extra rapid insulin every 4 hours. Contact your Dr. or go to the hospital if there is no improvement and/or if symptoms of diabetic acidosis appear. if a fruity odor is detected in the breath if abdominal pain is present if nausea or vomiting occurs if you are breathing rapidly and short of breath If a moderate or large amount of ketones register on the test strip, ketoacidosis is present and treatment is required immediately. > 20 or +++ or Go to the hospital. *+ = traces = 0.5 mmol/l ++ = small = 1.5 mmol/l +++ = moderate = 4.0 mmol/l ++++ = large = mmol/l **+ = excessive thirst & excessive urination ++ = diarrhea and nausea +++ = nausea, vomiting and diarrhea ++++ = nausea, vomiting, diarrhea, with or without ketone bodies

26 In-hospital Management 2013 Glycemic targets pre-meal blood glucose (BG) 5-8 mmol/l and random BG <10 mmol/l for the majority of non-critically ill patients BG 8-10 mmol/l for critically ill BG 5-10 mmol/l in the perioperative period Canadian Diabetes Association (2013)

27 DIABETES CANADA Healthcare Provider Tools & Resources

31 THANK YOU!! QUESTIONS?

Going home with Diabetes from the Emergency Department

Going home with Diabetes from the Emergency Department When should I see my health care provider or go to an Emergency Department? You may need to see your health care provider or go to the Emergency Department