DIABETES SURGICAL BOLT-ON

Presented by: Phil Mannall

Inpatient DSN

DIABETES SURGICAL BOLT-ON

SUBJECTS TO DISCUSS:• T1 & T2 DM• DIABETES & NUTRICIAN• THERAPEUTIC BL. GL. LEVELS• HbA1c• HYPOGLYCAEMIA

• DIABETES ORAL MEDS & INSULIN

• SAFE ADMINISTRATION OF INSULIN

• SLIDING SCALES

AGENDA

What Is Diabetes?

• Diabetes mellitus is a disorder in which the blood sugar level is persistently raised above the normal range.

• Normal blood glucose range:» 4 – 7 mmol/l

• The abnormality is caused by an absolute or relative lack of insulin, secreted from the pancreatic β-cells.

Diabetes mellitus = ‘flowing over with sweet urine’

• Diabetes (Greek) means ‘siphon’ or ‘fountain’• Mellitus (Latin) means ‘sweet like honey’• The most obvious sign of diabetes is passing a

lot of urine. Early physicians in Egypt and India tasted the urine and noted it was very sweet (1500 BC and 400 BC).

• In many languages, like Finnish and German, the condition is actually called ‘sugar disease’

How Is Diabetes Diagnosed?

The person may experience some or none of the following symptoms:

• Frequent urination, even at night (polyuria)• Excessive thirst (polydipsia)• Tiredness and weakness (fatigue)• Constant hunger (polyphagia)• Blurred vision• Weight loss• Dry, itchy skin (pruritis), boils• Genital irritation/thrush/urinary infections

DIABETES SURGICAL BOLT-ON

Diagnostic Criteria for Diabetes• Patient showing symptoms of diabetes: • Random venous plasma glucose ≥ 11.1 mmol/l OR• Fasting venous plasma glucose ≥ 7.0 mmol/l

• Asymptomatic patient:• Two samples, either random or fasting, taken on different days, are

needed to confirm diagnosis• These blood values refer to blood taken from a vein and tested in the

laboratory. Capillary blood values by a finger prick test on the ward are about 1.0 mmol/l lower. A meter reading is not sufficient to diagnose diabetes.

(WHO Diagnosis and Classification of Diabetes Mellitus 1999)

Diagnostic Criteria for Diabetes

Patient showing symptoms of diabetes:

Random venous plasma glucose ≥ 11.1 mmol/l OR

Fasting venous plasma glucose ≥ 7.0 mmol/l

Asymptomatic patient:

Two samples, either random or fasting, taken on different days, are needed to confirm diagnosis

These blood values refer to blood taken from a vein and tested in the laboratory. Capillary blood values by a finger prick test on the ward are

about 1.0 mmol/l lower. A meter reading is not sufficient to diagnose diabetes.

(WHO Diagnosis and Classification of Diabetes Mellitus 1999)

What Is Type 1 Diabetes?

• Type 1 Diabetes happens when the β-cells in the pancreas are destroyed by the body’s own immune system. They stop making insulin and blood glucose levels rise.

• Type 1 Diabetes usually comes on suddenly, within a few months or weeks. The person is typically young (<30 years) and thin.

• The missing insulin must be given every day for lifetime in order to survive.

DIABETES SURGICAL BOLT-ON

What Is Type 2 Diabetes?

•Type 2 Diabetes happens when the pancreas is not making enough insulin, or the body is not able to use insulin properly (insulin resistance).•Type 2 Diabetes appears most often in middle-aged and older adults. Often not diagnosed until 10-15 years after the onset.•These people should aim to lose weight, be more active.•They may require tablets, and because Diabetes is a slow onset disorder may require insulin in the future.

DIABETES SURGICAL BOLT-ON

What Causes Diabetes?

TYPE 1:Inherited genetic susceptibility: HLA genes which initiate the

immune attack against β-cellsEnvironmental factors: viruses, early use of cow’s milk in

infancy, toxins in smoked fish/potatoes, low exposure to sunlight and low Vitamin D level

Autoimmune response: pancreatic cells destroyed by own lymphocytes (circulating islet cell antibodies, insulin antibodies, and

GAD antibodies)Highest incidence in Finland, rare in Africa

DIABETES SURGICAL BOLT-ON

What Causes Diabetes?

• TYPE 2:Genetic factors: possibly several genes, leading to

inherited apple-shape body with abdominal (visceral) fat layer; genes in certain ethnic groups (South-East Asians, Afro-Caribbeans, American Indians, Mexicans)

Environmental factors: small birth weight, rapid weight gain in babyhood, sedentary lifestyle, large calorie intake, obesity

Highest incidence in India, Hispanic people in USA, and Black Americans

How Is Diabetes Treated?

• Type 1: need insulin for life; some doctors also prescribe Metformin tablets, especially to people who have raised fasting glucose levels, or who need large amounts of insulin.

• Type 2: all patients benefit from dietary advice and increase in physical activity; need to start on oral tablet (OHA) or a combination of two/three, if glucose levels still high; most Type 2 patients need insulin, if they live long enough.

Eating, Drinking and Diabetes(1)

• There are no ‘forbidden’ foods for diabetics• There is no ‘diabetic diet’! No ‘diabetic yoghurts, ice-

cream, marmalade, or jam’!• People with diabetes follow same healthy eating

principles as everyone should do: Avoid sugary puddings, cakes, biscuits Reduce saturated/animal fats – trim off fat, use low-fat

alternatives, avoid pastries and pies Avoid sweetened drinks and fruit juices – use ‘No added

sugar’ drinks or diet drinks Do not add salt in cooking, use herbs and spices Do not buy ‘diabetic foods’ – sorbitol is high in calories –

they are expensive, cause diarrhoea, taste foul

Eating, Drinking and Diabetes (2)

• Brown bread or wholemeal bread is no better than white bread – whole-grain bread is preferable

• Eat at least 5 portions of fresh fruit and vegetables a day (frozen or tinned are OK)

• Cut down your portion sizes – keep a diary of what you eat for a week or two!

• Eat foods with low GI index – such as , pulses, lentils, brown pasta, and nuts

• Drink plenty of fresh water – 2-3 litres a day• In Type 2 diabetes, eat 3 small meals a day – to

avoid large increases in post-meal blood glucose

Eating, Drinking and Diabetes (3)

• Avoid ready meals and take-aways• Use olive oil in cooking, have at least two meals of oily fish

(salmon, herring, mackerel, sardines) per week• Alcohol (any wine or beer) in moderation is protective to your

blood vessels. Do not go for ‘low-alcohol’ beers – they are high in sugar. Do not choose ‘low-sugar’ beers – they are high in alcohol. Use the ordinary varieties 1-2 units a day for women 2-3 units a day for men REMEMBER: alcohol can lead to weight gain! REMEMBER: if you take insulin or tablets, alcohol causes hypos

within 6-12 hours – always have food with alcohol

Tablets In Type 2 Diabetes

• Also called oral hypoglycaemic agents -(OHAs) or antihyperglycaemic agents

1. Insulin secretagogues increase insulin secretion from β-cells

2. Insulin sensitizers decrease insulin resistance

3. Inhibitors of glucose absorption slow down glucose absorption from the gut

ORAL HYPOGLYCAEMIC AGENTS

Class of drug Name Action Side effects Contra-indications

Biguanide MetforminMetformin SR

Lowers liver glucose output, increases glucose use in muscles and fat

Nausea, vomiting and diarrhoea

Renal failure (serum creatinine>150)Liver or heart failure

Sulphonylurea Gliclazide /also MR

GlimepirideGlipizide

Stimulates pancreas to secrete more insulin (second-phase release)

Weight gain and hypos

Renal impairment, except Gliclazide and Tolbutamide

Thiazolidine-dione Pioglitazone

Lowers insulin resistance, helps to preserve β-cells, lowers BP and lipids

Fluid retentionWeight gain

Heart failureHepatic or renal impairment

OHAs In Type 2 Diabetes (1)

• INSULIN SECRETAGOGUES:

1. Sulphonylureas (Gliclazide, Glimepiride, Glipizide) increase ‘second-phase’ insulin release (10-120 minutes) after a meal. They are taken with a meal. Can cause hypoglycaemia, which can be severe.

I

OHAs In Type 2 Diabetes (2)

• INSULIN SENSITIZERS:

1. Metformin reduces hepatic glucose production, increases glucose uptake by muscles, and reduces appetite. Helps to lose weight, no hypos.

1. Thiazolidinediones/ Glitazones ( Pioglitazone) increase insulin sensitivity especially in fat tissue; improve lipid problems; lower blood pressure; redistribute abdominal fat to peripheral subcutaneous fat layers. Can cause weight gain and oedema. Take 4-6 months to show full effect.

Which OHA(s) to choose?

• SULPHONYLUREAS:

Glipizide up to 20mg od Glimepiride up to 6mg od

2nd phase insulin secretion hypos, weight gain, NOT in renal

failure Gliclazide up to 160mg bd Gliclazide MR 30mg –up to

120mg od

• METFORMIN/ METFORMIN SR up to 1G bd

First-line in all Type 2 diabetes patients; hepatic glucose out-put; fasting and post-prandial BG; glucotoxicity; FFAs; insulin requirement; appetite; weight gain; allows β-cell recovery; endothelial function; no hypos on its own

Abdominal discomfort, diarrhoea; slow release formula better toleratedNOT in renal impairment (if creatinine > 130), NOT in cardiac or respiratory failure; NOT 48 hours before or after IV contrast medium for radiological investigations

Combination Therapy With Insulin And OHAs

• Until recently, insulin was introduced in Type 2 Diabetes as a last resort after serious deterioration in glucose levels

• Insulin is now discussed with the patient on diagnosis, and the progressive loss of β-cells and hence insulin secretion is explained

• NICE guidelines now recommend HbA1c target of ≤ 7%, except in the elderly and very frail

• Insulin is now introduced when HbA1c is around 8% and there is still some residual insulin secretion

Insulin Therapy With Tablets In Type 2 Diabetes

• Start with OD basal insulin, e.g. glargine, detemir, or insulatard, together with metformin; this will suppress glucose production from the liver at night-time and control fasting BG level; metformin will keep the required insulin dose lower and help control weight and improve blood cholesterol. Continue sulphonylurea also to keep insulin dose low

• When post-meal glucose ‘spikes’ start to appear, BD pre-mix insulin, e.g. NovoMix 30, or Humalog Mix 25, can be introduced, together with Metformin

• Later basal bolus regimen with three rapid-acting pre-meal injections and OD glargine/detemir is preferred for younger patients with less predictable daily routines

• To keep insulin dosages lower, some diabetologists now add thiazolidinedione, such as pioglitazone, which sensitizes tissue cells to insulin. It enhances the utilisation of both endogenous and exogenous insulin. (Not yet licensed in the UK.)

INSULINS

• Human insulin is manufactured using genetic DNA methods in E.Coli bacteria or yeast

• Animal insulins are extracted from the pancreas of pigs (porcine) or cows (bovine) and purified. Some people still prefer to use them, as they feel human insulins made them lose their hypo-awareness

• Analogue insulins are made using DNA recombinant technology in bacteria to make a few changes in the human insulin structure

National Patient Safety AgencyRapid Response Report

Safer Adminstration of Insulin

For IMMEDIATE ACTION by all organisations in the NHS and independent sector.

– 1. All regular and single insulin (bolus) doses are measured and administered using an insulin syringe or commercial insulin pen device. Intravenous syringes must never be used for insulin administration.

– 2. The term ‘units’ is used in all contexts. Abbreviations, such as ‘U’ or ‘IU’, are never used.

– 3. All clinical areas and community staff treating patients with insulin have adequate supplies of insulin syringes with subcutaneous needles, which staff can obtain at all times.

– 4. An insulin syringe must always be used to measure and prepare insulin for an intravenous infusion. Insulin infusions are administered in 50ml intravenous syringes

– 5. A training programme should be put in place for all healthcare staff (including medical staff) expected to prescribe, prepare and administer insulin. An e-learning programme is available from: www.diabetes.nhs.uk/safe_use_of_insulin

– 6. Policies and procedures for the preparation and administration of insulin and insulin infusions in clinical areas are reviewed to ensure compliance with the above.

Types Of Insulins By Their Action

CategoryRapid-acting Short-

actingIntermediate-acting

Long-acting

Biphasic

Type Analogue Regular ‘Soluble’

IsophaneNPH (Neutral Protamine Hagedorn)

Analogue Pre-mix insulins

Examples NovoRapidHumalogGlulisine Soon to

(Apidra) come !

ActrapidHumulin S

InsulatardHumulin I

Glargine (Lantus) Detemir

NovoMix 30Humalog Mix 25, Mix 50Mixtard 30/40/50Humulin M3/M5

Onset 5–20 min 30 min 1-2 hrs 30 minutes but, in repeated dosing, the onset disappears

30 min

Peak 0.5-2 hrs 1-3 hrs 4-8 hrs No peak 2-8 hrs

Duration 3–5 hrs 4-8 hrs 12-18 hrs Glargine 24 hDetemir 16-20 hours

12-18 hrs

Where Should Insulin Be Injected?

• Insulin should be injected into subcutaneous fat tissue, not in the muscle

• Suitable sites: Abdomen below navel and both sides of the navel Upper outer thighs below trochanter Lower outer aspect of upper arms below deltoid Buttocks

Short- and rapid-acting insulins are best injected in the abdomen, long-acting in the thighs or buttocks.

Glargine can be injected in any of the sites The actual injection spot in each site must be rotated

for every injection to avoid lipos from forming

Insulin injection sites

Timing Of Insulin Injections

• Rapid-acting analogues – NovoRapid and Humalog - can be given just at the start of a meal, or if BG is very low, even after the meal

• Short-acting Actrapid or older pre-mixes, Mixtard 30 (Disc. Dec. 2010 and Humulin M3, should be given 20-30 minutes before eating

• Analogue mixes, NovoMix 30, Humalog Mix 25/50, can be given at the start of the meal

Where Should Insulin Be Kept?

• Do not keep live insulin pens in the fridge! • Do not leave the pen near heat (radiator, cooker,

car glovebox) or in sunlight.• Only spare cartridges need to be in the fridge.

Vials must be marked with date of starting – discard in a month.

• Always remove pen needle after injecting, fit a new needle on the pen just before the next injection.

What Is Hypoglycaemia ?

What Is Hypoglycaemia ?

Hypoglycaemia means blood glucose <4.0mmol/l although in many people with diabetes hypos can occur >4.0 mmol/l. Please check with patient/carersHypo is caused by insulin or sulphonylureasPoor renal function can lead to hypos in Type 2 diabetic patients, as some SU tablets and insulin are not secreted by the kidneys and build upWhen BG falls below 3.5 mmol, glucagon, epinephrine and nor-epinephrine – counterregulatory hormones – are released to make the liver release glucoseThis causes the ‘autonomic’ signs of a hypo: sweating, trembling, pounding heart, and hunger

Hypoglycaemia And Hypoglycaemia Unawareness(2)

• If BG continues to fall to 3.2 – 2.8 mml/l, cognitive brain function starts to deteriorate. Symptoms of this ‘neuroglycopenia’ include: confusion, visual disturbances, drowsiness, odd or aggressive behaviour, speech difficulty, tingling in the lips and tongue.

• If BG falls still below 1.5 mmol, coma develops. Children and elderly may have convulsions or transient hemiplegia.

• Unfortunately, people who have had diabetes for years or who suffer from frequent hypos, lose their hypo awareness: the autonomic symptoms do not develop until the brain dysfunction has started, and the person can no longer take any action to correct the low blood sugar.

• A training programme of avoiding hypoglycaemia with regular blood glucose testing and regular snacks can often restore hypoglycaemia warning symptoms.

What Causes Hypoglycaemia ? (3)

What Causes Hypoglycaemia? (3)

• Too much insulin or sulphonylurea, especially if renal or liver function is impaired and/or appetite poor

• Too little food or a missed meal• Vigorous, prolonged exercise hours earlier• Inappropriate giving time of insulin, e.g. rapid-acting NovoRapid

given too early and meal delayed• Gastroparesis, which causes delayed digestion and absorption of

food• Inappropriate type of insulin, e.g. Insulatard given at bedtime,

reaching peak action around 3 am, when no food taken! Pre-mixed Mixtard 30 given am, hypo likely if lunch delayed

• Sudden increase in skin temperature after injection, e.g. hot bath, sauna, sunbathing

• Alcohol intake without food – alcohol will stop the liver from releasing glucose for hours afterwards

• Drugs, such as betablocker (propranolol and sotalol), can reduce hypo awareness and delay recovery from hypo

HYPO GLYCAEMIA FLOWCHART

How To Treat A Hypo? (1)

– 3-4 Dextrosol (1 tablet = 3g glucose) tablets plus a drink of water

– 100 ml Lucozade– 100 ml Orange juice– 1 tube Glucogel

– ALL THESE WILL RAISE BG ABOUT 2-3 mmol IN 10-20 MINUTES. RETEST BLOOD SUGAR IN 10 MINUTES. HAVE A SANDWICH, 2 BISCUITS, A BANANA OR YOUR NEXT MEAL, IF IT IS DUE

– Do NOT overtreat a hypo. Use this guide as a prescription! Otherwise, severe hyperglycaemia will follow leading to a vicious cycle.

How To Treat A Moderate to Severe Hypo (2)• If not able to swallow safely or too confused, DO NOT PUT

ANYTHING IN THE MOUTH! RISK OF ASPIRATION INTO LUNGS!

• Glucagon 1 mg IM or SC – will raise BG by 2-3 mmol in 10-15 min. Easy to give even to an agitated person; does not need IV access; does not damage veins; does not overtreat hypoglycaemia. After 30 min, give 2-3 biscuits, a sandwich, a yoghurt, or a meal.

• IV Dextrose 20% 75-80ml - will raise BG by 8-10 mmol in 5 min. Needs a cannula; difficult to manage in a patient who is restless or fitting; overtreats the hypo

• DO NOT USE DEXTROSE 50% - VERY VISCOUS, DIFFICULT TO PUSH INTO CANNULA; DAMAGES PATIENT’S VEIN; CAUSES SEVERE NECROSIS IF EXTRAVASATES!

What Is ‘Rebound Hyperglycaemia’ ?

What Is ‘Rebound Hyperglycaemia’ ?

Answer• Rebound hyperglycaemia:

high blood sugar following a severe hypo and with little insulin left in the body, esp. in the morning. Glucagon and epinephrine release glucose from the liver too effectively, the person over treats the hypo, and even lowers the next insulin dose! Result: rebound hyperglycaemia.

Question.

Where would you find the guideline for Perio-operative management of patients with Diabetes?

Where would you find the guideline for Perio-operative management of patients with Diabetes?

• Answer

On the intranet.

Type in ‘Diabetes’ in the search window and scroll down to find all the guidelines for Diabetes in hospital management.

Sliding Scale Insulin And After

• NOTE: Intravenous sliding scale insulin is given to treat Diabetic ketoacidosis (DKA) and Hyperosmolar non-ketotic state (HONK), but also to give insulin replacement peri-operatively or during serious intercurrent illness (MI, stroke, or pancreatitis). The insulin sliding scale may be the same, but the IV fluid regimen will differ.

• In DKA, after the initial fall in BG to 15 mmol/l, N.Saline should be replaced with 5% Dextrose infusion to keep BG around 10-15 mmol/l. It is important to provide the body with insulin and glucose for fuel, in order to clear the ketones.

• Once ketones have cleared from the urine (trace or negative) and the patient is able to eat and drink, transfer to sc insulin.

• IV SOLUBLE INSULIN HAS A HALF- LIFE OF 4-6 MINUTES ONLY – AFTER THAT THE PATIENT WILL HAVE VIRTUALLY NO INSULIN AND BLOOD SUGAR WILL RISE DRAMATICALLY IF S/C INSULIN HAS NOT BEEN GIVEN AT THE RIGHT TIME BEFORE STOPPING THE IV SLIDING SCALE INSULIN!

How to stop Sliding Scale Insulin correctly?

• Stop IV sliding scale around a meal time after giving sc insulin, depending on the type of the sc insulin, as follows:– NovoRapid,Humalog, Actrapid or Humulin S – stop Sliding

scale ½ hour later

– Insulatard or Humulin I – stop Sliding scale 1 hour later

– Glargine or Detemir – stop Sliding scale any time but check with a doctor if a small dose of soluble insulin might be needed if BG rises above 13 mmol/l in the first 24 hours

– If uncertain, contact Diabetes Specialist Nurse

What Is DKA? What Is HONK?

• Diabetic keto-acidosis (DKA) is an acute emergency in a person with Type 1 diabetes, rarely in Type 2. Over a day or two, hyperglycaemia, ketonaemia, acidosis, and dehydration develop, due to lack of sufficient insulin and the release of counter-regulatory stress hormones (glucagon, epinephrine, norepinephrine and cortisol). Typical symptoms are thirst, polyuria, abdominal pain, nausea, vomiting, air hunger, and drowsiness. Ketones appear in urine. Hypotension, tachycardia, and hypothermia follow.

• Hyper-osmolar non-ketotic state (HONK) develops in Type 2 diabetes, often the elderly, and is similar to DKA, with gross hyperglycaemia (BG ≥50 mmol/l), severe dehydration, confusion, and even coma, but without significant ketosis. Ketones are not formed as there is some insulin secretion left in the patient with Type 2 diabetes. Infection is often present, history of feeling unwell for weeks, drinking sugary fluids for thirst, and often taking diuretics for hypertension. There is a serious risk of thrombosis, MI, or stroke. HONK is a condition with high mortality.

What Are Ketones?

• Ketones are produced in the liver when the body has to break down fat for energy. We all make ketones if we have been without food for some time. A person with diabetes makes ketones if they do have not have enough insulin, even though glucose levels are high in the blood stream. The body cells are starving as there is not insulin to let glucose inside the cells. Brain, heart, muscles and kidneys can use ketones for energy, but increasing ketones make the blood acidotic (<7.3, which is normal). Most enzymes stop working when keto-acidosis develops, coma and death will follow unless treated urgently.

What Is HbA1c?

• HbA1c means glycosylated or glycated haemoglobin and shows the average blood glucose level over the past 2-3 months.

• Glucose binds to the protein, haemoglobin, in the blood, causing it to become glycosylated. The higher the average blood glucose is over the life cycle of red blood cells (appr.120 days), the higher the percentage of them that become coated with glucose, i.e., the higher the % of HbA1c.

• Normal range is 4.6-6.0%.• The goal of diabetes treatment is to achieve HbA1c <7% to

reduce the risk of complications, but every patient needs a personal target goal set for them, depending on their individual circumstances (age, overall health, employment, social circumstances). Generally, HbA1c consistently >8% means that treatment action or change should be taken.

Useful websites on diabetes

• www.diabetes.org.uk• www.yorkshirediabetes.com• www.diabetesuffolk.com• www.diabetes-healthnet.ac.uk• www.nelh.nhs.uk/nsf/diabetes/default.htm• www.nice.org.uk• www.diabetesresource.com• http://care.diabetesjournals.org• www.idf.org• www.diabetesonestop.com• www.medscape.com• www.diabetescare.warwick.ac.uk• www.diabetesnow.co.uk• www.cgsupport.nhs.uk/disn/

References used in this handbook

The following websites have been accessed to obtain guidelines for diabetes management in individual NHS Trust Hospitals and nationally:

• www.webdem.org/pubstaff.asp• www.nottinghamdiabetes.nhs.uk• www.yorkshirediabetes.com• www.nice.org.uk• www.idf.org/home

THANK YOU FOR LISTENING

QUESTIONS ?