Lynda Astbury Lead Diabetes Specialist Nurse

Lynda Astbury Lead Diabetes Specialist Nurse

WARNING SIGNS AND SYMPTOMS Is patient Feeling unwell? Blood glucose level above 13mmol/L Or higher than the patients day to day readings (even if not eating) Symptoms of underlying infection/virus PRESENCE OF KETONES IN URINE (OR BLOOD KETONE LEVEL RAISED)

QUESTIONS TO ASK Do you have Type 1/Type 2 Diabetes? Have you checked your blood glucose level- what was the result? Have you tested for ketones (urine or blood)- what was the result? Have you done anything to address the problem?

Diabetic Ketoacidosis ( DKA ) Characterised by high blood glucose (usually above 13mmol/l), ketosis and acidosis due to absolute insulin deficiency or ineffective concentration of circulating insulin with concomitant stimulation of counter-regulatory hormones. Affects predominately people with Type 1 diabetes. Very rarely, it can be seen in people with Type 2 diabetes (mostly lean people)

Causes of DKA Infection is the most common cause. Management errors or insulin omissions. Other secondary causes such as MI. No obvious cause in 40%.

Why Do Ketones Develop? Lack of Carbohydrates Not enough glucose to supply the in body s fuel needs Insulin deficiency Liver breaking down fat for fuel- produces ketones

TERMS YOU MIGHT COME ACROSS KETONES - Acid substances formed by liver when body fat is used to provide energy KETONURIA - The presence of acetone and other ketones in the urine KETONAEMIA The presence of ketones in the blood stream KETOACIDOSIS A life threatening condition due to a lack of insulin and the build up of acid substances in the body.

TESTING FOR KETONES Urine testing - Using Ketostix Blood testing - Using Glucomen Areo 2K meter or Freestyle Optium meter B ketone testing strips available for both meters

Treatment guidelines for primary care staff Consider contacting DSN service for further advice/patient support Checks for ketones, level of consciousness, rehydrate (sip sugar free fluids at least 100ml/hr) Consider stat dose short/rapid acting insulin (may need extra insulin every 2 hours)

Continued Treat the underlying infection Refer to secondary care if patient vomiting and unable to keep fluids down Determine the cause and revisit education. Consider referral to DSN service if further review required

Sick day rules Check blood glucose level every 2-4 hours Check ketone level 2-4 hourly Drink at least 100mls fluid every hour (gradually-sips) Give additional doses of insulin every 2 hours according to usual management plan (10% or 20% of total daily dose) Contact DSN service if further advice required

DKA Management, secondary care (As per JBDS guidelines) Rehydration with IV fluids Continuous fixed rate Intravenous Insulin infusion- 0.1unit/kg/hour Continue Lantus or Levemir at usual dose and time Replacement of electrolytes Hourly Capillary glucose if meter reads over 20mmol/l or high send venous blood glucose to the lab hourly

DKA cont... B/G <14mmol/l commence 10% Glucose (125ml/hour) alongside 0.9% Sodium Chloride which needs to be halved to prevent fluid overload Increase Insulin infusion rate by 1 unit/hour increments hourly if: Plasma glucose not falling by at least 3 mmol/hour Venous bicarbonate is not rising by at least 3mmol/hour

DKA cont... Continue fixed rate insulin infusion until: Venous ph >7.3 and Venous Bicarbonate >20mmol/l (Blood ketones <0.3mmol/l) Patient able to eat and drink Restart previous insulin regimen IV infusion should not be discontinued for at least 60minutes after the administration of the subcutaneous dose given in association with a meal

Remember... Treatment of underlying infection if needed All patients admitted with DKA should be referred to the Diabetes Specialist Team for review Patients wearing an insulin pump should be ideally managed by the Diabetes Specialist team

Please note... DKA management guidelines are different to Variable Rate Intravenous Insulin Infusion (VRIII) previously known as Sliding Scale VRIII guidelines should be used for the management of adults with diabetes undergoing surgery and elective procedures If no more than one missed meal avoidance of VRIII is possible. Consider if expected to miss more than one meal

Hyperosmolar Hyperglycaemic State (HSS, previously known as HONK) HSS is characterised by marked hyperglycaemia of > 35mmol/l (usually 50-80mmol/l) and dehydration without significant ketosis and acidosis. It affects people with Type 2 diabetes, usually middle aged or elderly. Less than 1% of people suffer from HSS

Causes of HSS Infection is the most common cause. Drug treatment in high doses, e.g. Glucocorticoid, thiazide diuretics, b-blockers and steroids. Large consumption of glucose drinks. Omissions of insulin or OHAs. Cerebrovascular accident or myocardial infection.

Signs and Symptoms of HSS Severe dehydration Thirst and Polyuria Gradual loss of consciousness Blood sugars 35-100mmol/l

Treatment of HSS Re-hydration Electrolyte replacement (usually isotonic saline) Continuous IV insulin therapy

Re Cap Sick day rules Never stop tablets or insulin. Encourage plenty of fluids. If patient unable to eat, replace meals with sugary fluids, e.g. Fruit juices/ Lucozade etc. Monitor glucose levels more regularly.

Insulin/oral therapy doses may need to be increased. People who normally take oral agents may need to be transferred on to insulin for the duration of illness. If vomiting uncontrollably, the person requires hospital admission to prevent DKA and HONK