1. Managing Sick Days and Hospital Stays Mike Heile MD Orlando, CWD July, 2011

2. What can raise blood sugars besides SUGAR? STRESS ILLNESS MENSES PREGNANCY MEDICATIONS –Steroids –Atypical antidepressants/antipsychotics –Niacin, HCTZ –Etc. VACCINES

3. Management Sick Days More frequent BG monitoring More aggressive treatment hyperglycemia Keep hydrated Treat underlying condition Ketone testing ? Gastroenteritis –Hyperglycemia in general –Post meal hypoglycemia ?

4. MEDICATIONS AND EFFECTS ON DIABETES/MANAGEMENT STEROIDS, ETC. SUGAR IN COUGH SYRUPS SENSOR BG READINGS METER BG READINGS

5. DIABETIC KETO-ACIDOSIS (DKA) CAUSED BY A SEVERE LOW OR NO INSULIN LEVEL IN DM1 RISK INCREASES WITH ILLNESS BLOOD ACID LEVEL RISES DUE TO HIGH SUGARS AND NO INSULIN SYMPTOMS INCLUDE NAUSEA, VOMITTING, ABDOMINAL PAIN, FATIGUE DIAGNOSED CLINICALLY AND AT HOME BY USING FINGER STICK KETONE TESTING (PREFERABLY) OR URINE KETONE STRIPS.

6. DKA CONTINUED TREATMENT: –Fluids –Insulin –Ketone monitoring –More frequent blood glucose monitoring (takes longer to get rid of ketones than to fix hyperglycemia) –Treat underlying illness if present –When to get to hospital PREVENTION

7. SURGERY NPO –PUMP –MDI WEARING PUMP DURING SURGERY

8. HOSPITAL STAYS Dka dx Choose hospital/team that can follow diabetes effectively Illness/stress usually requires higher insulin requirements Diet/menu Dont stop pump therapy

9. CASE STUDIES LAURA –Sick day-stomach virus SARAH –Pump and severe high sugars PETER –Pre-op for tonsillectomy

10. LAURA 10 years old DM1 for 5 years on MDI (shots)

11. LAURA (cont) Sudden onset fevers/chills/muscle aches HOW WILL THIS LIKELY AFFECT HER SUGARS?? Sugars very high (300+) WHAT SHOULD SHE DO? -Doctor? -Extra testing -More insulin as needed -More fluids -? ketone testing (when) -others?

12. LAURA (cont) Getting better in general but 2 days later notices sugars still very high in mornings and post meals. WHAT SHOULD SHE DO?? -raise background/meal insulin? -wait it out -continue more testing/correcting

13. SARAH 16 years old DM1 12 years now A1C usually 9-10 range On a pump Tests 3x/d on average Felt really sick hours after soccer game-sugar 350mg/dl WHAT MAY HAVE HAPPENED?

14. SARAH (cont) Pump site fell out? Pump malfunction? Out of insulin? Stress/exercise related hyperglycemia? Over did it with carbs pre soccer to avoid low? Doesnt test enough anyway and was very high already prior to soccer? HOW WOULD YOU TREAT AND/OR PREVENT EACH OF THESE?

15. Pump site fell out Test ketones (finger stick preferably) Ketones and able to drink/eat? Correct BG with syringe Put new site in Push fluids, maintain good BG Follow ketones to resolution Ketones and vomitting everything up? Hospital

16. EXERCISE INDUCED HIGH CHECK SITE/PUMP CHECK KETONES- usually negative this scenario IF NEGATIVE GIVE CAREFUL CORRECTION THRU PUMP (may need less for exercise induced high) PUSH FLUIDS AND FOLLOW SUGARS CLOSELY

17. TOO MANY CARBS PRE SOCCER CORRECT CAREFULLY MONITOR CAUTIOUSLY TEMP BASAL PRE EXERCISE NEXT TIME TESTING BEFORE/DURING/AFTER EXERCISE

18. HOW TO AVOID DKA TEST AT LEAST 4-6X/D NEVER MISS INSULIN DOSES OR LEAVE PUMP SITE IN TOO LONG ALWAYS TEST KETONES WITH UNEXPLAINED HIGHS, NAUSEA, VOMITTING, ETC. FIND AND CORRECT KETONES QUICKLY AS DISCUSSED EARLIER

19. PETER 12 year old DM1 3 years. Frequent strep throat Needs tonsillectomy/adenoidectomy Needs to be NPO the 12 midnight before surgery and cannot eat next morning HOW DO THEY DO THIS?

20. PETER (cont) Basal/Long acting insulin tuning pre surgery (overnight and morning) Drop insulin basal or long acting dose night before surgery. HOW LONG? Check / consider active insulin on board before bed night of surgery Avoid large insulin boluses pre bed time Over-night testing night of surgery (especially on pump)

21. CONCLUSION More things raise blood sugars than sugar Sick days and hospital stays require extra knowledge and attention in DM1 but are not overly difficult DKA can be avoided