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Managing sick and stress days

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Presentation on theme: "Managing sick and stress days"— Presentation transcript:

1 Managing sick and stress days
Rebecca Thompson RSCN, BSc, MSc Nurse Consultant – Diabetes, UCLH

2 Aims: Review the effect of sick days on diabetes
Review the effect of stress on diabetes To identify potential strategies To review the effectiveness of strategies

3 Sick Days

4 Your turn: Vomiting + diarrhoea Flu Exam time Infection Having surgery
Chicken pox Recovering from an illness Start of a new school term In groups, discuss the scenarios Would you anticipate: BG levels to go up? BG levels to go down? No impact on BG levels?

5 Relationship between illness & hyperglycaemia
Infection Increased secretion of cortisol and glucagon High blood glucose levels Increased insulin resistance Decreased immune function Decreased wound healing Increase in inflammatory factors

6 Illness Fever/ Infection Nausea/ Vomiting
Increases the need for insulin % ↑ over 24 hours Decreased appetite may ↓ amount of insulin needed Risk of DKA from insulin deficiency Difficulty in retaining nutrients due to nausea / vomiting / diarrhoea Decreased appetite may decrease amount of insulin needed Risk of low blood glucose levels In gastroenteritis, slower emptying of stomach may contribute to hypos

7 Management - Blood glucose testing
Frequent monitoring facilitates optimal management BG should be monitored at least every 3-4 hours, including overnight Sometimes, 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 source As ketone levels become more seriously elevated, then ketoacidosis (or DKA) may occur Symptoms acetone (or pear-drop) smelling breath abdominal pain Nausea / vomiting

9 Urine strips measure acetoacetate (AcAc)
Blood strips measure beta-hydroxybutyrate Enables earlier identification & treatment Normalises sooner than AcAc preventing hypoglycaemia from over insulin treatment

10 Your turn – when to get help?
BG high x2, no ketones Temp 36.7°, sore throat Ketones increasing/ persistent despite ↑ insulin BG <4mmols but tolerating fluids BG high x2, + ketones Temp 40°, rash, high BG Vomiting and unable to tolerate fluids for 2 hours BG <4mmols & drowsy BG high, child confused, abdo pain In groups, discuss the scenarios Decide: 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 ketones Increasing BG levels despite additional insulin Inability to reverse hypoglycaemia Laboured breathing Severe or unusual abdo pain Confusion or deterioration of well being Parental concern ? Possibility of underlying infection requiring AB

12 Managing at home Treat current illness
?GP Symptom treatment Test & document every couple of hours Blood glucose levels Ketone levels Maintain hydration High BG’s, fever, ketones and glucose in urine will ↑ fluid loss Small amounts frequently Juice/ oral rehydration solutions Drinks containing glucose if BG low

13 Insulin adjustment May 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 resistance NEVER STOP THE INSULIN Insulin may need to be increased or decreased

14 Changes in insulin sensitivity over 24 hours

15 Insulin adjustment Easiest to adjust short acting insulin according to BG Humalog, NovoRapid or Apidra Change the correction/ sensitivity ratio? Low BG levels will ↑ sensitivity to insulin High BG levels will ↓ sensitivity to insulin Correction dose can be calculated using: unit / Kg body weight every 2-3 hours 5 - 10% of the total daily insulin dose every 3-4 hours 100 rule (1 unit of insulin will reduce BG by X mmols/L)

16 Additional insulin Calculate 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 - trace No insulin ↑ insulin for next meal if BG high Give extra 5% of TDD or 0.05 U/kg Give extra 10% of TDD or 0.1 U/kg Trace-small Check again in 2 hours Starvation ketones Extra CHO Give extra 5-10% of TDD or U/kg Small-moderate Starvation ketones Give 5-10% of TDD or U/kg Repeat if needed Moderate-large Starvation Extra CHO. May need IV glucose Extra CHO Give extra 5% of TDD or 0.05 U/kg Give extra 10-20% of TDD or 0.1 U/kg. Repeat dose after 2 hours if ketones do not decrease >3.0 Large As above Risk of ketoacidosis

18 Beware of “Insulin Stacking”

19 ABCC CSII & increase in DKA Assess Bolus via pump Check
Change + Injection (Blood glucose – 10) ÷ correction ratio = dose of insulin

20 Additional strategies using insulin pump therapy
Use temporary basal rates Percentages easier Increase by % for feverish illness Decrease to 50-75% for vomiting/ diarrhoea

21 Temporary Basal in action
Duration of Temporary Basal Rate

22 Stress Days

23 Stress & Diabetes Impact very individual
Mild stress can lower BG’s However, stress often raises BG’s Hard to evaluate as different from day-today When body is exposed to stress Release of Adrenaline Stone age “fight or flight” response Increased blood glucose Liver releases more glucose Decrease movement of glucose into cells

24 Causes of stress in every day life
Mental stress: New school Exams Conflict at home Death of loved ones Diabetes as a stressor Feeling alone Worrying about the future Physical stress: Illness infection

25 Relationship between stress and glycaemic control
Relationship between stress and glycemic control. From Ref. 21. Lloyd C et al. Diabetes Spectr 2005;18: Copyright © 2011 American Diabetes Association, Inc.

26 Helpful strategies Impact of stress might not be obvious until change in BG Adjust insulin Bolus - Remember to evaluate active insulin Temp basal rates on CSII Evaluate relationship between emotions & blood glucose levels Use the comments section on BG charts to record Look for patterns Use of CGM Plan ahead to minimise impact E.g. School exams

27 Helpful strategies – who else can help?
Share feelings, worry and guilt Coping skills Grey 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 to improvements in glycemic control Improvements in quality of life the improvement was maintained over time Role of Psychology

28 Questions?

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