4 Your turn: Vomiting + diarrhoea Flu Exam time Infection Having surgery Chicken poxRecovering from an illnessStart of a new school termIn groups, discuss the scenariosWould you anticipate:BG levels to go up?BG levels to go down?No impact on BG levels?
5 Relationship between illness & hyperglycaemia InfectionIncreased secretion of cortisol and glucagonHigh blood glucose levelsIncreased insulin resistanceDecreased immune functionDecreased wound healingIncrease in inflammatory factors
6 Illness Fever/ Infection Nausea/ Vomiting Increases the need for insulin % ↑ over 24 hoursDecreased appetite may ↓ amount of insulin neededRisk of DKA from insulin deficiencyDifficulty in retaining nutrients due to nausea / vomiting / diarrhoeaDecreased appetite may decrease amount of insulin neededRisk of low blood glucose levelsIn gastroenteritis, slower emptying of stomach may contribute to hypos
7 Management - Blood glucose testing Frequent monitoring facilitates optimal managementBG should be monitored at least every 3-4 hours, including overnightSometimes, frequency might need increasing to every 1-2 hours
8 Ketones ‘Starvation’ v. ‘insulin deficiency’ Ketones produced by the liver from fatty acids that are used as an alternative energy sourceAs ketone levels become more seriously elevated, then ketoacidosis (or DKA) may occurSymptomsacetone (or pear-drop) smelling breathabdominal painNausea / vomiting
9 Urine strips measure acetoacetate (AcAc) Blood strips measure beta-hydroxybutyrateEnables earlier identification & treatmentNormalises sooner than AcAc preventing hypoglycaemia from over insulin treatment
10 Your turn – when to get help? BG high x2, no ketonesTemp 36.7°, sore throatKetones increasing/ persistent despite ↑ insulinBG <4mmols but tolerating fluidsBG high x2, + ketonesTemp 40°, rash, high BGVomiting and unable to tolerate fluids for 2 hoursBG <4mmols & drowsyBG high, child confused, abdo painIn groups, discuss the scenariosDecide:When would you feel it safe to manage at home?When do you feel you would need advice?When would you head straight to A&E?
11 When to get help Repeated vomiting / unable to tolerate fluids Increasing level of ketonesIncreasing BG levels despite additional insulinInability to reverse hypoglycaemiaLaboured breathingSevere or unusual abdo painConfusion or deterioration of well beingParental concern? Possibility of underlying infection requiring AB
12 Managing at home Treat current illness ?GPSymptom treatmentTest & document every couple of hoursBlood glucose levelsKetone levelsMaintain hydrationHigh BG’s, fever, ketones and glucose in urine will ↑ fluid lossSmall amounts frequentlyJuice/ oral rehydration solutionsDrinks containing glucose if BG low
13 Insulin adjustmentMay have increased insulin requirements during the incubation period of an infection (few days before the physical symptoms)Increased need for insulin may continue several days after the illness has passed, due to insulin resistanceNEVER STOP THE INSULINInsulin may need to be increased or decreased
15 Insulin adjustmentEasiest to adjust short acting insulin according to BGHumalog, NovoRapid or ApidraChange the correction/ sensitivity ratio?Low BG levels will ↑ sensitivity to insulinHigh BG levels will ↓ sensitivity to insulinCorrection dose can be calculated using:unit / Kg body weight every 2-3 hours5 - 10% of the total daily insulin dose every 3-4 hours100 rule (1 unit of insulin will reduce BG by X mmols/L)
16 Additional insulinCalculate a current correction ratio for your child using one of the methods
17 Blood ketones Urine ketones <5.5 5.5-10 10-14 14-22 >22 <0.6 Negative - traceNo insulin↑ insulin for next meal if BG highGive extra 5% of TDD or 0.05 U/kgGive extra 10% of TDD or 0.1 U/kgTrace-smallCheck again in 2 hoursStarvation ketonesExtra CHOGive extra 5-10% of TDD or U/kgSmall-moderateStarvation ketonesGive 5-10% of TDD or U/kgRepeat if neededModerate-largeStarvationExtra CHO. May need IV glucoseExtra CHO Give extra 5% of TDD or 0.05 U/kgGive extra 10-20% of TDD or 0.1 U/kg.Repeat dose after 2 hours if ketones do not decrease>3.0LargeAs aboveRisk of ketoacidosis
23 Stress & Diabetes Impact very individual Mild stress can lower BG’sHowever, stress often raises BG’sHard to evaluate as different from day-todayWhen body is exposed to stressRelease of AdrenalineStone age “fight or flight” responseIncreased blood glucoseLiver releases more glucoseDecrease movement of glucose into cells
24 Causes of stress in every day life Mental stress:New schoolExamsConflict at homeDeath of loved onesDiabetes as a stressorFeeling aloneWorrying about the futurePhysical stress:Illnessinfection
26 Helpful strategiesImpact of stress might not be obvious until change in BGAdjust insulinBolus - Remember to evaluate active insulinTemp basal rates on CSIIEvaluate relationship between emotions & blood glucose levelsUse the comments section on BG charts to recordLook for patternsUse of CGMPlan ahead to minimise impactE.g. School exams
27 Helpful strategies – who else can help? Share feelings, worry and guiltCoping skillsGrey et al.demonstrated that preventive strategies such as teaching coping skills(1999,2000) to adolescents with type 1 diabetes in order to better prepare them for stressful life events led toimprovements in glycemic controlImprovements in quality of lifethe improvement was maintained over timeRole of Psychology
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