Hypoglycaemia is a blood glucose level of below 4 mmol/l. 4 is the floor

Mags Bannister Diabetes Nurse Consultant Hypoglycaemia Mags Bannister Diabetes Nurse Consultant

What happens now in clinical practice re hypo’s?

Mild Hypoglycaemia Sweating Dizziness Trembling Tingling hands,feet,lips or tongue Hunger Blurred vision Difficulty in concentration Palpitations Occasional headaches

Causes of hypoglycaemia Too much insulin/sulphonylurea  Extra activity e.g. shopping, DIY, gardening, sexual activity or sport  Insufficient food  (particularly CHO’s) Delayed or missed meal  Poor injection technique/change of site  Change of routine  Alcohol Heat - hot weather/sauna/hot bath  

Autonomic Neuroglycopenic Malaise Sweating Palpitations Shaking Hunger Confusion Drowsiness Speech difficulty In coordination Atypical behaviour Diplopia (double vision) Nausea Headache

Severe Neuroglycopenia Mild Neuroglycopenia Cognitive dysfunction Blood glucose level Autonomic activation Release of counter Regulation Hormones Sweating Tremor Palpitations Blurred vision Severe Neuroglycopenia Unconsciousness/Coma Aggression Staggering Death

Mild “hypo” - treatment 6-7 Dextrose tablets Glucochek 6 sugar lumps 4 teaspoons of sugar 100mls Lucozade 15 - 20 grams rapid acting CHO Eat next meal if due OR Have a snack, e.g. banana/bread /biscuits etc Ref The hospital management of hypoglycaemia in adults with diabetes mellitus 2010

SEVERE HYPOGLYCAMIA Requires third party assistance Odd behaviour e.g. rudeness/laughter (appear to be drunk when not) Aggressive behaviour Confusion UNCONSCIOUS

Severe hypo glycaemia Take immediate action EAT NEXT MEAL if due OR Glucose in liquid form LUCOZADE min 100mls lemonade/cola/ribena- 200mls EAT NEXT MEAL if due OR TAKE A SNACK

If unable to take anything orally 999 Give GLUCAGON injection - I.M (can take 15mins to take effect) OR I.V. Dextrose 150mls 10% or 75mls 20% If necessary repeat Ref The hospital management of hypoglycaemia in adults with diabetes mellitus 2010 Re-check blood glucose in 10 minutes after IV glucose if still below 4mmols repeat When blood glucose above 4.0mmls give long acting carbohydrate Monitor blood glucose levels

Which Patients with Diabetes are at Risk of Hypoglycaemia TYPE 1 ALL Type 2 If treated with a sulphonyurea ( gliclazide or glimepiride) If treated with Insulin If treated with a combination that includes either or both or the above

Prevention Ensure Staff understand the mode of action of the treatment prescribed Discuss timing & dose of oral therapy/insulin Educate Staff how to prevent/recognise hypo symptoms

Prevention Ensure patients are aware of the correct/safe treatment of hypos Discuss the acceptable blood glucose levels for the individual patients needs Maintain good glycaemia control without compromising patient safety

Hyperglycaemia and illness management

High Blood glucose levels What blood glucose levels cause concern? What would you do if a patients blood glucose levels were running high?

Illness Infection Steroids Stress High Blood glucose levels Poor appetite Poor fluid intake

Steroid treatment Fasting blood glucose levels will often be within normal range 5-10mmols/l Pre-tea and bed time readings can be >20mmols/l Blood glucose levels rapidly increase Insulin maybe need when on steroid treatment but not at any other time

DIABETIC KETOACIDOSIS Type 1 DM A state of severe, uncontrolled diabetes due to insulin deficiency and increased counter regulatory hormones. High blood glucose levels (PG>11 mmol/l Moderate ketonuria (3mmol/L or over 2+on urine stick) Acidosis (arterial pH<7.30 & serum bicarb< 15mmol/L.) Usually Type 1 Ref: The management of Diabetic Ketoacidosis in adults NHS Diabetes 2010

DKA Lack of insulin Reduced glucose uptake Increased liver glucose output Breakdown of fat Hyperglycaemia Ketosis Glycosuria Reduced pH, vomiting, ketonuria, hyperventilation Osmotic diuresis Loss of water, change in electrolytes Dehydration Electrolyte imbalance, acidosis Tachycardia, hypotension Impaired consciousness, coma

Hyperosmolar Hyperglycaemic State HHS Type 2 DM Severe hyperglycaemia (PG>33.3 mmol/L) Profound dehydration (-10L) No ketosis/acidosis (pH>7.3) Middle-aged/elderly Insidious onset (days/weeks) Often undiagnosed Type 2 Mortality 15- 20%

HHS Lack of insulin Reduced glucose uptake Increased liver glucose output Hyperglycaemia Glycosuria Osmotic diuresis Loss of water, change in electrolytes Dehydration Tachycardia, hypotension

HYPERGLYCAEMIA – Sick Day Rules Never stop taking insulin or tablets (metformin and SGLT2i should be omitted if dehydration a risk) Monitor more often Type 1 – test Urine or Blood for ketones Encourage more Fluids (sugar free) Rest Vomiting – if accompanied by rapid deep breathing + drowsiness – dial 999 If BG persistently raised – insulin dose may be increased temporarily

If unable to eat - replace solid food with alternatives such as Amount CHO content Soup (thickened or creamed) 200mls 15grams Milk 10 grams Pure fruit juice 100mls Lucozade 60mls Build up/ Complan 1/3rd serving Milk pudding /Custard 75g or ½ pot

Accessing Advice Diabetes Specialist Nursing team Horton Park Centre Monday to Friday 01274 323728 8.30-12.30 and 1.30-5.30 Emergency on call 7.30-8.30am and 5.30pm- 9pm Saturday and Sunday and Bank Holidays 7.30am -9pm 01274 494194

Information needed when ringing DSN Patients name , DOB and NHS number Current treatment Type of diabetes Blood glucose levels Ketones level if indicated Any signs of illness/infection

Questions