Managing sick and stress days Rebecca Thompson RSCN, BSc, MSc Nurse Consultant – Diabetes, UCLH.
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Transcript of Managing sick and stress days Rebecca Thompson RSCN, BSc, MSc Nurse Consultant – Diabetes, UCLH.
Managing sick and stress days
Rebecca Thompson RSCN, BSc, MScNurse Consultant – Diabetes, UCLH
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
SICK DAYS
Your turn:
In groups, discuss the scenarios
Would you anticipate: BG levels to go up? BG levels to go down? No impact on BG
levels?
Vomiting + diarrhoea Flu Exam time Infection Having surgery Chicken pox Recovering from an
illness Start of a new school
term
Relationship between illness & hyperglycaemia
Illness
Fever/ Infection Increases the need for insulin - 25-50% ↑ over 24 hours
Decreased appetite may ↓ amount of insulin needed
Risk of DKA from insulin deficiency
Nausea/ VomitingDifficulty in retaining nutrients due to nausea / vomiting / diarrhoea Decreased appetite may decrease amount of insulin needed Risk of low blood glucose levelsIn gastroenteritis, slower emptying of stomach may contribute to hypos
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
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
Urine strips measure acetoacetate (AcAc) Blood strips measure beta-hydroxybutyrate
Enables earlier identification & treatment Normalises sooner than AcAc preventing
hypoglycaemia from over insulin treatment
Your turn – when to get help?
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?
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
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
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
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
Changes in insulin sensitivity over 24 hours
0
0.5
1
1.5
2
2.5
3
6 8 10 12 14 16 18 20 22 24 2 4 6
Clock Time
Rel
ativ
e In
suli
n S
ensi
tivi
ty
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: 0.05 - 0.1 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)
Additional insulin
Calculate a current correction ratio for your child using one of the methods
Blood ketones
Urine ketones
<5.5 5.5-10 10-14 14-22 >22
<0.6 Negative - trace
No insulin 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
0.6-0.9 Trace-small
Check again in 2 hoursStarvation ketonesExtra CHO
Starvation ketonesExtra CHO
Give extra 5% of TDD or 0.05 U/kg
Give extra 5-10% of TDD or 0.05-0.1 U/kg
Give extra 10% of TDD or 0.1 U/kg
1.0-1.4 Small-moderate
Starvation ketonesExtra CHO
Starvation ketonesExtra CHO
Extra CHOGive 5-10% of TDD or 0.5-1.0 U/kg
Give extra 10% of TDD or 0.1 U/kg
Give extra 10% of TDD or 0.1 U/kgRepeat if needed
1.5-2.9 Moderate-large
StarvationExtra CHO. May need IV glucose
StarvationExtra CHO Give extra 5% of TDD or 0.05 U/kg
Extra CHOGive extra 10% of TDD or 0.1 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 aboveRisk of ketoacidosis
As above Extra CHOGive extra 10% of TDD or 0.1 U/kg
Give extra 10-20% of TDD or 0.1 U/kg.Repeat dose after 2 hours if ketones do not decrease
Beware of “Insulin Stacking”
CSII & increase in DKA
ABCCAssess
Bolus via pump
CheckChange + Injection
(Blood glucose – 10) ÷ correction ratio = dose of insulin
Additional strategies using insulin pump therapy
Use temporary basal rates Percentages easier Increase by 150-200% for feverish illness Decrease to 50-75% for vomiting/ diarrhoea
Temporary Basal in action
Duration of Temporary Basal Rate
STRESS DAYS
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
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
Relationship between stress and glycaemic control
Lloyd C et al. Diabetes Spectr 2005;18:121-127
Copyright © 2011 American Diabetes Association, Inc.
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
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
Questions?