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.

A little bit on calculating Insulin

dose

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.

Thank You!!