Dr : Reem Murad

Sick days " refer to periods of minor intercurrent illness that require changes to the person's usual self management practices.

What happens in Sick days the body reacts by releasing hormones to fight infection. But these hormones raise blood sugar levels and work against insulin. even a minor illness can lead to dangerously high blood sugar. This may cause life-threatening complications, such as DKA or a hyperosmolar state

Key Principles of Sick Day Management 1. Stress to the person with diabetes the need to continue insulin or diabetes medications 2. Ask the person with diabetes to monitor glucose and ketone levels more frequently 3. Ensure person with diabetes has adequate support 4. Provide advice on maintaining hydration and carbohydrate intake 5. Supervise supplemental insulin or glucose lowering medications to manage hyperglycemia and ketosis 6. Manage the underlying illness 7. Provide advice on prevention of hypoglycaemia 8. Discontinue home management of sick days if condition deteriorates or fails to respond to increased insulin

1. Stress to the person with diabetes the need to continue insulin or diabetes medications But Metformin may need to be ceased with onset of intercurrent illness.  Gastrointestinal illnesses may cause hypoglycemia for individuals treated with insulin, sulphonylureas or glitinides. In this instance these medications may need to be reduced according to blood glucose and ketone levels.

2. Ask the person with diabetes to monitor glucose and ketone levels more frequently Type 1 diabetes Blood glucose : two hourly or more frequently if blood glucose < 4.0mmol/L-(70mg/dl) or significant ketones present Ketones : two to four hourly when blood glucose is >15.0 mmol/L( 270mg/dl) and/or signs of illness present. For greater accuracy blood ketone testing is preferred.

Type 2 diabetes Blood glucose - two to four hourly, more frequently if blood glucose < 4.0mmol/L-70mg/dl.

3. Ensure person with diabetes has adequate support Ensure person with diabetes has a support person with them and knows when the condition can no longer be managed at home. For those in assisted accommodation ensure carers have the knowledge, skills and equipment to provide sick day management.

4. Provide advice on maintaining hydration and carbohydrate intake Recommend frequent volumes of fluids to prevent dehydration. As a guide, mls every hour is suggested. Encourage person with diabetes to maintain oral carbohydrate intake to reduce risk of hypoglycemia and maintain energy requirements. If unable to consume food the recommendation is: Carbohydrate containing fluids if blood glucose < ( 270mg/dl) Carbohydrate free fluids if blood glucose ( 270mg/dl) Rehydration solutions (eg Gastrolyte) can help replenish fluid and electrolytes lost through vomiting, diarrhea or dehydration. Rehydration solutions have a relatively low concentration of carbohydrate therefore additional carbohydrate may be required. Care should be taken with hypertonic or sweetened fluids if diarrhea occurs. Sweetened fluids may require dilution up to 1-5 times for optimum absorption.

Drink Lots of Fluids Water Club soda Diet soda (caffeine-free) Tomato juice Chicken broth

If vomiting no drink or eat anything for 1 hour. Rest, but not lie flat. After 1 hour, let him take sips of soda every 10 minutes.

Eating If the stomach is upset, eat small meals. Try carbohydrates, such as: Bagels or bread Cooked cereal Mashed potatoes Noodle or rice soup Gelatin (such as Jell-O)

When the pt is sick, he should try to eat the same amount of carbohydrates that he normally does If possible, follow the regular diet. If having a hard time swallowing, eat soft foods. If he has already taken his insulin and cannot eat, drink enough liquids with the same amount of carbohydrates If cannot keep food or liquids down send him to the emergency room for IV treatment.

5. Supervise supplemental insulin or glucose lowering medications to manage hyperglycaemia and ketosis Type 1 diabetes Type 2 diabetes

Type 1 diabetes Supplemental doses of rapid or fast acting insulin should be administered : in addition to the usual insulin dose given straight away given as a percentage of the usual total daily dose supplemental insulin doses can be given 2-4 hourly, medical care should be sought if no improvement in blood glucose or ketones after 2 supplemental doses. Individuals with insulin pumps can develop ketosis and DKA more quickly because there is no background reservoir of long acting insulin. Always check for technical problems with the pump and advise use of pen or syringe for supplemental insulin dose.

Increase insulin 1 unit extra insulin per 50 mg/dl if blood glucose is above 250 mg/dl and no ketones or ketones are small or 10% of total daily dose if blood glucose over 250 mg/dl and no ketones or ketones are small 1 unit extra insulin per 25 mg/dl if blood glucose is abov 250 mg/dl and ketones are moderate to large 20% of dose if blood glucose is over 250 mg/dl and ketone are moderate to large

Type 2 diabetes No medication : May require the addition of sulphonylureas or insulin temporarily Treated with glucose lowering agents: 1. If not on maximal dose of sulphonylureas or glitinides consider increasing 2. Increasing other glucose lowering agents is not recommended 3. May require supplemental quick acting insulin 4... Metformin must be stopped if vomiting, diarrhea, difficulty breathing or serious illness Treated with mixed insulin : May require supplemental quick acting insulin

6. Manage the underlying illness The inter current illness needs to be diagnosed and treated. Symptoms from the illness need to be differentiated from the symptoms of hyperglycemia, hypoglycemia or ketoacidosis. The use of sugar free medicines is not essential.

7. Provide advice on prevention of hypoglycemia nausea, vomiting or diarrhea may cause hypoglycemia. Follow regular recommendations for treatment of hypoglycemia. A reduction in, insulin (by 20-50%) or glucose lowering medications may be required. Consider "Mini dose" glucagon :A smaller dose than the standard recommendation for treatment of hypoglycemia is used to maintain glucose levels above 72 mg/dl, in people with gastroenteritis or reduced carbohydrate intake. Care in individuals who are malnourished e.g. frail older people as glucagon may not be effective.

8. Discontinue home management if condition deteriorates or fails to respond to increased insulin indication for seeking medical attention : Blood glucose - does not improve despite 2 supplemental insulin doses Ketones - are moderate to heavy (urine) / > 270 mg/dl (blood) or present and not decreasing with supplemental insulin Signs of DKA or HHS - such as vomiting, drowsiness, confusion, disorientation, hyperventilation, dehydration or severe abdominal pain

Vomiting - is persistent especially if frequent for more than 2-4 hours or becomes blood or bile stained Severe dehydration severe Hypoglycemia Too unwell Unclear diagnosis Extremes of age - children under 2 years or frail older people If unable to carry out above guidelines e.g. impaired cognitive/physical ability or too sick

TARGET GLUCOSE LEVELS FOR HOSPITALIZED PATIENTS Intensive care unit: 80–110 mg/dL General medicine and surgical units: preprandial 90– 126 mg/dL; postprandial 180 mg/dL The glycemic control is aimed to achieve a fasting plasma glucose of < 140 mg % and post prandial plasma glucose of < 200 mg %.

Principles of Diabetes Management in Hospitals improve the glycaemic control reduce complications Reduces mortality Reduces morbidity Lowers the incidence of wound infections Reduces hospital length of stay Enhances long-term survival

Determinents of the management plan in the hospital 1. Type of DM 2. Treatment: diet, oral antidiabetic drugs, insulin 3. Metabolic status 4. Vascular status: cardiac, renal, cerebral 5. Surgery: Type: emergency or elective Minor or major procedure Type of anesthesia Post operative oral intake

elective surgery of minor nature Usually aim for morning surgery and to be first on the list. Usually preferable to be admitted the day before surgery. Type 1patients can be admitted 2-3 days prior to surgery to achieve satisfactory control.

Emergency surgery In emergency surgery it is deal to use intravenous insulin infusion. 26

Minor surgery For minor surgery the antidiabetic drugs and insulin are stopped on the day of surgery, once the surgery is over and the patient is permitted to resume oral feeds the antidiabetic drugs are started with half the dose which the patient was originally taking, on the second post operative day full dose of the oral drugs and or insulin are started.

Type of Diabetes Type 2 diabetic patients controlled with diet or oral agents, 1-The patient with well-controlled diabetes receiving submaximal dosages of oral agents usually will manage to maintain satisfactory perioperative glycemic control without the medications when taking no calories in orally. 2-In contrast, the patient with poorly controlled diabetes receiving maximal oral therapy will need to have insulin therapy initiated..

Oral Medications Oral antidiabetic medications are usually stopped in severe sick days and the day of surgical intervention and resumed with oral food intake As a replacement, insulin is used for the short term If fasting blood glucose levels are greater than 180 mg/dL,

Metformin is usually stopped before surgery Before using intravenous contrast agents metformin is not resumed until actual hospital dismissal because of its potential for severe adverse events in patients who may be dehydrated, undergo surgical intervention

Thiazolidinediones may predispose to edema and congestive heart failure and are frequently stopped during hospitalization.

Sulfonylureas: are long-acting medications have significant potential for causing hypoglycemia in hospitalized patients

Meglitinides, have a shorter duration of action, may be safer to use than sulfonylureas. However, both meglitinides and sulfonylureas can be used in the stable hospitalized type 2 DM patient with caution to avoid hypoglycemia.

Type 1 diabetic will need basal insulin at all times, and only the mealtime insulin should be withheld. patients using pumps or long-acting basal insulin may continue with their regular doses. For patients on intermediate-acting insulin (NPH) with some postprandial effect, the dose should be reduced by one third to one half. Correction-dose insulin may be used every 4 to 6 hours as necessary, and an insulin infusion is recommended if a prolonged NPO status is anticipated.

Type 2 DM Using Insulin the procedure is short : (e.g., endoscopy ) and does not interfere with meal timing can delay insulin injection till after the procedure, (In most situations of surgical interventions )insulin is provided in a reduced dose to avoid hypoglycemia but in a way to continue adequate control. In most situations, the patient is fasting, and only basal insulin is provided (1/2-2/3 dose of NPH) until the patient recovers and is able to eat. In patients who have a complicated hospital course, further adjustments of the original regimen are needed.

The intravenous insulin route is superior to the subcutaneous route (Basal / Bolus insulin)

The Insulin InfusionThe Insulin Infusion Many Protocols Exist DIGAMI van den Berghe Portland protocol Markovitz Yale Protocol Stamford Protocol Duke Protocol Leuven: University of Washington: Atlanta Medical Center: Glucommander : Clarian

KEY POINTS: INPATIENT MANAGEMENT OF DIABETES 1. Evidence shows that glycemic control in hospitalized patients improves outcomes 2. Insulin is the best agent for management of hyperglycemia in hospital patients. 3. Physiologic (basal-bolus) dosing is the preferred approach in this population. 4. Use of sliding-scale insulin alone to control blood sugars should be avoided.

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