1. Diabetes Specialist Nurse
Managing Illness
Haley Faulds
Diabetes Specialist Nurse

2. Aims By the end of the session you will be able to describe:
How illness affects blood glucose levels and potentially leads to DKA
Why insulin should never be stopped even if not eating
Sick day rules
When to test for ketones
Understand when to give a correction dose.
When to seek guidance and help
When you have diabetes its important to know how to cope when you ae unwell
You should be aware of the effects of illness on your diabetes and know what to do about it
To be able to bring down your blood glucose levels safely
By the end of this session today you will be able to describe……….

3. How about if your blood glucose levels are really high?
What symptoms do you experience when you are ill or have a high blood glucose levels?
Thirsty
Peeing more
Tired
Blurred vision
Nausea
How about if your blood glucose levels are really high?
Vomiting
Cramps
Abdominal pain
Illness is likely to upset usual blood glucose levels and lead to symptoms like those mentioned on this slide

4. How does illness affect blood glucose levels ?
The bodies defence mechanism is to fight illness and infection
Stress hormones are made and released
Stress hormones trigger release of stored
glucose
Stored glucose is released into blood stream
This happens even if you are off your food
More insulin is then needed in the body
If you don’t have more insulin body will start to burn fat as an alternative energy source
High blood glucose levels make you pee more +- fever can lead to dehydration making the situation worse
You might need to manage your diabetes a bit differently when you are sick

5. Can you remember what ketones are?
Illness can cause resistance to insulin which increases blood
glucose levels and can bring about ketone production
If your blood glucose is higher than usual you need more
insulin otherwise your body wont be able to use glucose for
energy and will start to break down fat instead.
When your body needs more energy it will use fat to
produce this energy and ketones are produced.
They gradually build up and make the blood more acidic
If sick day rules aren’t followed this build up of ketones
can lead to DKA.
What does Ketones in the blood mean?

6. What is DKA? Has anybody had DKA? At diagnosis ?
Diabetic Ketoacidosis This is a serious and life threatening complication of diabetes.
Has anybody had DKA?
At diagnosis ?
The only treatment for DKA is hospital admission for intravenous fluids and insulin.
DKA can be prevented if detected early
Its Important to take action and follow sick day rules when you are ill!

7. So what are the sick day rules?
GOLDEN RULE
1) NEVER STOP TAKING YOUR LONG ACTING (basa INSULIN (Lantus, Glargine, Tresiba)
The body is working hard to fight infection and
often requires extra insulin to provide the extra “fuel”.
Practical steps to take when unwell

8. 2) Keep checking BG levels 1-4 hourly
Blood sugars can go UP or DOWN during illness .
Blood glucose levels can be very unpredictable, checking where you are will give you the information you need to take action appropriately
Don’t guess?

9. 3) Check your blood ketone levels
If you are ill you might not easily realise that your symptoms relate to DKA and not your illness so that’s why its important to check your blood glucose and ketone levels.
What is the normal ketone level ?
< 0.6 mmol/l

10. If BG >14mmol/L and you have a negative ketone check
Ketones
If BG >14mmol/L and you have a negative ketone check
take your usual correction dose.
Continue with your usual amount of background insulin
Drink plenty of water and sugar-free fluids.
Try to identify cause of high blood glucose level and seek treatment if necessary.
You should continue to test for ketones every 1-2 hours if your blood glucose levels remain above 14 mmol/l.
If you have a positive ketone test, treat this immediately.
Ketones can be measured in urine by ketostix or in blood by using a ketone meter, and it is recommended that you test your blood or urine for ketones if your blood glucose levels are over 14 mmol/l. It is also advisable to check the expiry date on urine and blood strips before use.
If your blood glucose levels remain above 14 mmol/l, but you have no ketones,

11. Positive ketone check
Take rapid acting insulin asap. If a pump user give a pen injection
Drink plenty of water and sugar-free fluids.
Test blood glucose and ketones every 30 mins-
1 hours and repeat a doubled correction dose
until blood is negative to ketones.
Try to identify cause of high blood glucose level and seek treatment if necessary.
Contact your diabetes team if:
high glucose and ketones levels persist.
if you are vomiting and or feel dehydration
Continue with your usual background insulin.
What is your correction dose

12. General advice for injection regimen
Test blood glucose at least 1-2 hourly
If LOW then have sugary drinks hourly to help prevent BG dropping- prevent hypoglycaemia (<4mmol/L).
Drink plenty of fluids – (sugar-free), prevent dehydration.
If BG <8mmol/L and not eating, omit fast acting insulin.
If BG >8mmol/L and not eating you will need some fast acting insulin (Bolus of Novorapid).

13. Advice for Insulin Pump users
Test blood glucose at least 2 hourly
Drink plenty of fluids – (sugar-free),
Prevent dehydration.
If BG<8mmol/L and not eating Do not give insulin bolus.
If BG >8mmol/L and not eating they need bolus via the pump (fast acting insulin pump will calculate dose based on BS level and correction ratio.
A temporary basal rate be used to prevent blood glucose rising too high or dropping too low.

14. Ketones (Insulin Pump)
If blood ketones <0.6
Give correction dose bolus via the PUMP.
Recheck blood sugar and blood ketones in 1 hour.
If blood ketones >0.6
Give correction dose of Novorapid immediately via insulin pen device NOT the Pump.
Change cannula and set.
Monitor blood sugars regularly. (seek advice diabetes team.UCS/Drs

15. Insulin Pump users
Blood sugar can rise very quickly if there is any problem with the pump or cannula.
If the cannula becomes blocks or kinks - you will not be receiving insulin and you wont have an insulin reserve in your body. (Insulin pump has Novorapid in it only)
If Blood Sugar above 14 mmol/l
Check Blood Ketones
Just as reminder ketones can build up if they is a problem with the pump delivery of insulin

16. 4) Keep eating and drinking 5) Stay hydrated
Drinks lots of non-sugary drinks to keep well hydrated
If you cannot eat meals as normal try regular small snacks
If you are unable to eat try drinks that are sugary .
You can still obtain carbohydrate from sources such as Lucozade, fizzy soft drinks, squashes and milky drinks.
You will need to take a quick acting insulin to cover them.
If you cant keep food/drink down try sipping drinks, best to let go flat and at room temperature
If you are vomiting seek medical advice immediately

17. Call diabetes team if: Your not sure what to do next
Keep being sick or unable to drink anything
Blood glucose levels remain above 14.0 mmol even after extra insulin
Ketones levels stay > 1.5 even after you have taken extra insulin
You have stomack pains feel SOB or are drowsy
You have a fever/temperature
Blood glucose level is low all the time or if you are unsure.

18. Remember some medicines affect blood glucose levels
Prevention of illness
Annual flu vaccine
Checking vaccines needed before going to University
Remember some medicines affect blood glucose levels
Paracetamol cant be used with
Libre, Dexcom G4 and G5.
Should be aware medicines to prevent illness such as

19. Have you had any experience of managing your diabetes whilst unwell
Have you had any experience of managing your diabetes whilst unwell? What problems did you experience and how did you deal with them?

20. Scenarios Amy ,16 years old, type 1 diabetes uses insulin injections
BBQ last evening, had some diarrhoea before bed.
Woken up feeling a bit sick. Wants to go back to sleep, what should she do?
Her blood glucose is 6.2 mmols?
Amy wakes up again at 11am, now feeling really quite sick. Amy checks her blood glucose and her blood glucose is 4.2 mmols.
What should she do?
Amy really doesn’t want to eat anything?
At bedtime Amy has been unwell all day and off her food, should she still have her Glargine at bedtime?
Pay special attention to nausea and vomiting. May not be a stomach bug could be DKA?.
Omit insulin, check ketones in presence nausea even if BG ok
Needs to prevent hypo and keep starvation ketones from building by having some CHO how ever she feels she could tolerate it.
Always have basal insulin.

21. John is 17 years, type 1 and uses an insulin pump.
John has a really sore throat and feels like he has a temperature.
John checks his blood glucose level before breakfast. His blood glucose is 15.8 mmols.
What should he do next?
When should he call for advice?
Dehydration is made worse by a fever
Severe dehydration and high blood glucose levels can be serious
Pen injection then cannula change
Drink water
Check BG and ketones mins

22. Any questions? Learning zones