diabetes control & acute illness
TRANSCRIPT
Control of blood glucose can be affected in
an acute illness by several ways
Due to Stress response of body glucose
control can be worsened
Loss of appetite , vomiting decrease both
food intake and absorption of OHA
Medications for acute illness can worsen
glucose control. Eg- Steroids
It may lead to HHS or DKA.
Cornerstones of diabetes
management during intercurrent
illness Education of the patient as to the correct
action to take when ill.
Arrangements to monitor blood glucose in patients who do not normally do so - may require education of the patient and/or carer, or involvement of community services.
Patients should Increase the frequency of glucose monitoring to 4-hourly or more as necessary.
Treat the underlying cause of the intercurrent illness sufficiently.
Maintain carbohydrate intake using sugary
drinks or fruit juice, soups or snack foods if
the patient has difficulty eating.
Fluid intake is important and patients should
be advised to have a glass of water every
hour, aiming for 3 litres in 24 hours.
Antiemetics may be useful for symptomatic
treatment of vomiting but establish the likely
cause of the symptoms first and admit if
necessary.
For medico-legal reasons, keep a good
record of how diabetes is being monitored
and your follow-up arrangements.
Advise patients to keep a 'sick-day supply
box' which might contain:
1.Long-life fruit juice
2.Two 2 L bottles of still water
3.Soup
4.Ice-cream
5.box of blood glucose monitoring strips
6.box of ketone strips (if on insulin)
Patients on oral anti-
diabetics The patient should take their tablets
and normal dosage, providing carbohydrate intake continues in solid or liquid form and glucose monitoring continues at least four-hourly.
If glucose level increases beyond 13 mmol/L and/or the patient feels unwell, medical advice should be sought.
Metformin should be stopped if the patient is becoming dehydrated because it can cause lactic acidosis. Hospital admission/sliding scale insulin may need to be considered.
Patients on insulin
INSULIN SHOULD NOT BE STOPPED -
hyperglycaemia can arise from intercurrent
illness irrespective of the patient's calorie
intake
If self blood glucose monitoring is available
and moderate elevations noted patients
should be advised to make adjustments
(increase dose 2-4 units).
Seek Medical help…
They are unable to eat or drink
Have persistent vomiting or diarrhoea
Have a blood glucose higher than 25 mmol/L despite increasing insulin
Have very low glucose levels
Have persistent ketones or large amounts of ketones in the urine
Become drowsy or confused (make sure carers are aware of this)
Any other concern
Hospitalize…. A suspicion of underlying eg myocardial infarction,
intestinal obstruction – admit immediately
Inability to swallow or keep down fluids
Significant ketosis in a type I diabetic despite optimal management and supplementary insulin
Persistent diarrhoea
Blood glucose persistently >20 mmol/L despite best therapy
Any clinical signs of ketosis or worsening condition, eg Kussmaul's respiration, severe dehydration, abdominal pain
The patient who is unable to manage adjustment of normal diabetes care
Patients who live alone and have no support who may be at risk of slipping into unconsciousness
Inward Management
Keep the blood glucose levels in optimal
range (~110mg/dl) with insulin infusion.
Regular blood glucose measurements
(CBS/RBS) and dose adjustments.
Regular check on ketone bodies if blood
glucose 300mg/dl
Manage HHS or DKA accordingly.
Aggressive treatment of concurrent
illness.
Ensure adequate hydration.
Discharge plan.. The A1C test result is valuable in determining
the most appropriate treatment strategy at discharge.
Choose most suitable OHA/Insulin regime or combination. Eg- once-daily basal insulin in combination with oral agents or twice-daily premixed insulin
Patient education on “survival skills” - safe administration of insulin/ basic understanding of meal planning/ recognition and treatment of hypoglycemia
Review the compliance and progress of the illness frequently.