Diabetes for Junior Doctors

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By Tania Bailey Clinical Nurse Specialist

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Diabetes for Junior Doctors

  1. 1. Tania Bailey Diabetes CNS
  2. 2. Overview  CNS Team  Differentiation T1DM & insulin treated T2DM  Quick word HbA1C  OHA’s / Insulin profiles  Insulin Policy  Acute presentations  Hypo/hyper management  IV insulin infusion/Additional s/c  Prediabetes  ??
  3. 3. DIABETES TEAM  Dr Tom Thompson  Helen Adams / Delia Williams / Tania Bailey  What we do  When to refer
  4. 4.  Type 1 or Type 2 on insulin?  Why worry?  how do you know?
  5. 5. HbA1C
  6. 6. OHA’s  Metformin – biguanide  Glipizide / Gliclazide / Glibenclamide– SU  Pioglitizone – Thiazolidinedone  Acarbose – Alpha Glucosidase inhibitor  When to discontinue?  Timing of doses  restarting
  7. 7. Insulin Profiles
  8. 8. Insulin profiles
  9. 9. Insulin profiles  Glargine / Lantus  Glusiline /Apidra
  10. 10. Insulin Guidelines  Optimise 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
  11. 11. 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 Severe pH 7-7.24 <7.0 Serum HC03- 10-15 <10 Ketones Urine ++-+++ B hydroxybutyrate > 1.2 (0.4)
  12. 12. HHS – hyperglycaemia hyperosmolar state  Resembles DKA  BGs usually ↑↑  Rx → as for DKA  Slow replacement fluid  Insulin infusion  Electrolyte  DVT risk  Ongoing Rx / usual regime
  13. 13. 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
  14. 14. 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
  15. 15. Hyperglycaemia  Bg >17 mmol/l two or more / repeated  ? options Hypoglycaemia  Bg < 4.0 mmol/l  ? Treatment  Concious  unconcious  ? On insulin infusion
  16. 16. Prediabetes – intermediate hyperglycaemia  HbA1C 41-49 mmol/l  Lifestyle management 3– 6/12  Metformin 46-49 mmol/l  No SMBG or retinopathy screening  CVD risk  Opportunistic screening  Known IHD/CVA/PVD  Hx cellulitis / PCOS  Long term steroid or antipsychotic Rx  Obese BMI ≥ 30 (27 Indo-Asian)  Family hx – Maori, PI, Indo-Asian
  17. 17. Dx planning  Rx / equipment  Follow up  Opportunistic stuff Questions?

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