Four is the Floor Symptoms can be felt at higher levels if control is poor Worth confirmation using BG meter if at all possible

Transcription

1 Sandra Coats Diabetes Specialist Nurse 1 Hypoglycaemia Hyperglycaemia Diabetes and Illness sick day Diabetic Ketoacidosis HONK/HHS 2 What is Hypoglycaemia BG levels below 4mmol/l. Four is the Floor Floor Symptoms can be felt at higher levels if control is poor Worth confirmation using BG meter if at all possible 3

2 4 Cognitive functions deteriorate at blood glucose <3.0 mmol/l Complex tasks are consistently impaired memory and attention concentration/abstract thought rapid decision making hand-eye coordination Accuracy is preserved at expense of speed Inter-individual differences are common 5 Adrenergic symptoms Sweating Shaking / tremor Palpitations Hunger Tingling lips and tongue Slurred speech Behavioural changes Confusion Aggression Lack of co-ordination Drowsy Coma 6

3 Too much insulin/ Sulphonylurea Inadequate food consumption Increased physical activity Alcohol g of simple CHO 100ml of lucozade or ml of coke/fruit juice or 5 glucose tablets Follow with 10-20g more complex CHO eg bread/crisps/cereal bar Repeat after 10mins if BG still< % of insulin treated individuals have a 3rd party hypo each year Treat with Glucagon-usually effective within 10mins Follow with 20g of simple CHO +40g complex CHO 9

4 Explore cause: e.g. exercise/alcohol/lack of CHO/ poor knowledge Define future strategies to minimise Advise driving guidelines 10 Inability to recognise symptoms Autonomic neuropathy Affects 25% of adults with Type 1 diabetes Associated with strict glycaemic control Prevalence rises with duration of diabetes Risk of severe hypoglycaemia is greater Associated with significant morbidity Range of severity; potentially reversible 11 Aim for less strict control i.e. Do not treat to target Self BG Monitoring is essential Education Refer to specialist 12

5 HYPO BOX: TREATMENT OF HYPOGLYCAEMIA Hypoglycaemia is a blood glucose of 4 mmol/l or less. Wherever possible, check blood glucose level prior to treatment. If patient asymptomatic, repeat test. MILD Patient conscious and able to swallow Trembling, sweating, hungry, tingling, headache, anxiety, palpitations, nausea, forgetfulness Administer 10g 20g fast acting glucose* 3-5 x GlucoTabs (4g glucose per tablet) or 1 x 59ml bottle of Glucojuice MODERATE Patient conscious and able to swallow, but in need of assistance Difficulty concentrating, confusion, weakness, giddiness, drowsiness, unsteady, headache, dizziness, difficulty focusing and speaking STEP 1 Administer 1-2 tubes of GlucoGel*/** (10g glucose per tube) Ensure gag reflex is present. STEP 2 SEVERE Patient unconscious and unable to swallow. Unconscious, fitting Check airways. Place patient in recovery position Intramuscular injection of Glucagon 1mg. (Children weighing less than 25kg 500 micrograms)* Wait 15 minutes and recheck glucose levels, and record. If reading is still below 4 mmol/l, or if no physical improvement, repeat STEP 1 Once patient is conscious, give sips of Glucose Liquid Blast or Lucozade Recheck glucose level every 15 minutes to ensure increase to at least 4 mmol/l ALWAYS FOLLOW UP WITH A SLOWLY DIGESTED/ STARCHY CARBOHYDRATE Check glucose level. Once it is at 4 mmol/l or over and patient is recovered, eat a minimum of 15g slowly digested/starchy carbohydrate. Eg: 1 x slice/sandwich of low GI bread (ideally multigrain or granary); two digestive biscuits, glass of milk, banana, small carton of fruit juice. * British Recheck National Formulary, glucose 2007levels after 15 minutes. NOTE: Insulin should NEVER Linda Burns be omitted Diabetes following Specialist an episode of hypoglycaemia. ** Type 1 Diabetes: Diagnosis and Management of Type 1 Diabetes in children, young people and adults. NICE Clinical Guideline No. 15, July Nurse 13 Blood glucose > 17mmol/l Fatigue Polyuria Polydipsia Blurred vision Increased risk of complications Type 1 Ketones/ risk of DKA Type 2 risk of HONK/HHS 14 Under 0.6 mmol/l - a normal blood ketone value 0.6 to 1.5 mmol/l - indicates that more ketones are being produced than normal, test again later to see if the value has lowered 1.6 to 3.0 mmol/l - a high level of ketones and could present a risk of ketoacidosis. It is advisable to contact your healthcare team for advice. Above 3.0 mmol/l - a dangerous level of ketones which will require immediate medical care. Linda Burns Diabetes Specialist Nurse 15

6 16 Illness (e.g. infection) Over eating CHO food Stress Drugs (e.g. Steroids) Insufficient treatment Injection sites/ technique Frozen or damaged insulin 17 Explore cause optimise treatments/dietary advice/treat illness Education Refer to specialist Aim for appropriate balance in some patients 18

7 Diabetic Ketoacidosis is a serious, acute complication of Diabetes. It carries significant risk of death and/or morbidity especially with delayed treatment. 19 Secondary to insulin deficiency, and the action of counter-regulatory hormones, blood glucose increases leading to severe hyperglycaemia and glycosuria. Glycosuria causes an osmotic diuresis, leading to dehydration and electrolyte imbalance. In the absence of insulin activity the body fails to utilize glucose as fuel and uses fats instead. This leads to metabolic acidosis 20 High BG levels Osmotic symptoms Dry/flushed skin Fatigue/Lethargy/Conscious level Hyperventilation Abdominal pain Nausea/Vomitting Smell on breath ( ketones) Large ketones in blood/urine 21

8 Type 1 diabetes (incl undiagnosed) Young children symptoms often similar to childhood illnesses Pregnant women high ketones can affect the unborn baby Pump users no background insulin if pump fails Adolescents body image, chaotic lifestyle, substance abuse, emotions, growth hormones Substance abusers 22 Urgent referral to acute services Hospital admission DKA protocol High dependency care pcdsn... Recent improvement in morbidity figures thought to be due to HBGM, education and accessibility of expertise 23 Referral to Secondary Care Diabetes Team Education Diabetes Specialist Nurse Psychological services Combined services adolescent/antenatal/pump/renal 24

9 No precise definition - list of characteristics Differs from DKA Can develop over time Older age Type 2 Can be due to physical/psychological stress (Infection, CVA,MI,trauma,bereavement, increased CHO) Mortality rate as high as 15% - higher than DKA BG levels >33mmols/L. Without ketones or acidosis Hyperosmolality > 320mmol/kg Hypovolaemia Coma (sometimes seizures) 25 Urgent referral to acute services I.V. Fluid replacement replace Na I.V. Insulin not always! Caution in rapid rehydration Heart failure HHS Protocol abcd.org.uk/jbds/jbds_ip_hhs_adults.pdf 26 Risk of illness in poorly controlled Diabetes Flu Jab Education/Self management skills Annual/Regular review 27

10 Never omit insulin Check BG 2 Hourly If vomiting anti emetic GP/NHS24 Replace CHO in liquid form 200mls fluid hourly Type 1 check for ketones if BG >16mmol/l Type 1 use fast acting insulin 28