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RMO DIABETES KORERO Tania Bailey Diabetes CNS

Diabetes for Junior Doctors

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By Tania Bailey Clinical Nurse Specialist

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Page 1: Diabetes for Junior Doctors

RMO DIABETES KOREROTania Bailey

Diabetes CNS

Page 2: Diabetes for Junior Doctors

OverviewCNS TeamDifferentiation T1DM & insulin treated T2DMQuick word HbA1COHA’s / Insulin profilesInsulin PolicyAcute presentationsHypo/hyper managementIV insulin infusion/Additional s/cPrediabetes??

Page 3: Diabetes for Junior Doctors

DIABETES TEAMDr Tom Thompson

Helen Adams / Delia Williams / Tania Bailey

What we do

When to refer

Page 4: Diabetes for Junior Doctors

Type 1 or Type 2 on insulin?

Why worry?

how do you know?

Page 5: Diabetes for Junior Doctors

HbA1C

Page 6: Diabetes for Junior Doctors

OHA’sMetformin – biguanideGlipizide / Gliclazide / Glibenclamide– SUPioglitizone – ThiazolidinedoneAcarbose – Alpha Glucosidase inhibitor

When to discontinue?Timing of dosesrestarting

Page 7: Diabetes for Junior Doctors

Insulin Profiles

Page 8: Diabetes for Junior Doctors

Insulin profiles

Page 9: Diabetes for Junior Doctors

Insulin profilesGlargine / Lantus Glusiline /Apidra

Page 10: Diabetes for Junior Doctors

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

Page 11: Diabetes for Junior Doctors

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)

Page 12: Diabetes for Junior Doctors

HHS – hyperglycaemia hyperosmolar stateResembles DKABGs usually ↑↑

Rx → as for DKASlow replacement fluidInsulin infusionElectrolyteDVT riskOngoing Rx / usual regime

Page 13: Diabetes for Junior Doctors

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

Page 14: Diabetes for Junior Doctors

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

Page 15: Diabetes for Junior Doctors

HyperglycaemiaBg >17 mmol/l two or more / repeated? options

HypoglycaemiaBg < 4.0 mmol/l? Treatment

Conciousunconcious? On insulin infusion

Page 16: Diabetes for Junior Doctors

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

Page 17: Diabetes for Junior Doctors

Dx planningRx / equipment

Follow up

Opportunistic stuff

Questions?