Diabetes for Junior Doctors
Post on 21-Jun-2015
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RMO DIABETES KOREROTania Bailey
Diabetes CNS
OverviewCNS TeamDifferentiation T1DM & insulin treated T2DMQuick word HbA1COHA’s / Insulin profilesInsulin PolicyAcute presentationsHypo/hyper managementIV insulin infusion/Additional s/cPrediabetes??
DIABETES TEAMDr Tom Thompson
Helen Adams / Delia Williams / Tania Bailey
What we do
When to refer
Type 1 or Type 2 on insulin?
Why worry?
how do you know?
HbA1C
OHA’sMetformin – biguanideGlipizide / Gliclazide / Glibenclamide– SUPioglitizone – ThiazolidinedoneAcarbose – Alpha Glucosidase inhibitor
When to discontinue?Timing of dosesrestarting
Insulin Profiles
Insulin profiles
Insulin profilesGlargine / Lantus Glusiline /Apidra
Insulin GuidelinesOptimise diabetes management of hospital inpatients
Additional sub cut insulin algorithms Continue regular insulin ? Adjust usual regime Consider BG targets
IV insulin infusion orders (iio) When? 10% glucose 80mls/hr & Actrapid 50u/50ml NaCl 0.9% ? Kcl → ileus, v & d’s, or NBM → monitoring iio form / drug chart / fluids FBC /algorithm Decision → surg team/anaesthetist Poor control = RBG > 17, mean BG >11, HbA1C
>73mmol/l Preggies & paeds
Acute presentations DKA
Baseline obs ? Aims:
Correct dehydration / electrolyte slowly IV insulin infusion / Dextrose 10% IV ? Cause – education IV insulin / Dextrose 10%
Until ketosis clear or minimal / pH nad Dont be in a rush to feed / Ø vomiting & stable Regular insulin / crossover infusion
Newly dx – ref Lantus Paeds – Starship policy
Mod SeverepH 7-7.24 <7.0
Serum HC03- 10-15 <10
Ketones Urine ++-+++
B hydroxybutyrate
> 1.2 (0.4)
HHS – hyperglycaemia hyperosmolar stateResembles DKABGs usually ↑↑
Rx → as for DKASlow replacement fluidInsulin infusionElectrolyteDVT riskOngoing Rx / usual regime
Notes →Insulin infusions
OT →Infusion starts at point of starvation
Never stop infusion in T1DM →treat / adjust
Infusion not enough prandial cover
If acidotic – keep going!
NaCl 0.9% if BG > 17 mmol/l
dedicated lines
Recommencing usual regimes<24 hrs interruption usual insulin – restart next meal
Infusion overlap 1-4 hrs
>24hrs – morning with overlap 1-4 hrs
Bg’s 5-15 mmol acceptable short term
OHA – resume 1st post op meal
Consider additional s/c
HyperglycaemiaBg >17 mmol/l two or more / repeated? options
HypoglycaemiaBg < 4.0 mmol/l? Treatment
Conciousunconcious? On insulin infusion
Prediabetes – intermediate hyperglycaemia
HbA1C 41-49 mmol/lLifestyle management 3– 6/12Metformin 46-49 mmol/lNo SMBG or retinopathy screeningCVD riskOpportunistic screening
Known IHD/CVA/PVDHx cellulitis / PCOSLong term steroid or antipsychotic RxObese BMI ≥ 30 (27 Indo-Asian)Family hx – Maori, PI, Indo-Asian
Dx planningRx / equipment
Follow up
Opportunistic stuff
Questions?
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