1. Managing sick and stress days
Rebecca Thompson
RSCN, BSc, MSc
Nurse Consultant – Diabetes, UCLH

2. 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

3. Sick Days

4. Your turn: Vomiting + diarrhoea Flu Exam time Infection Having surgery
Chicken pox
Recovering from an illness
Start of a new school term
In groups, discuss the scenarios
Would you anticipate:
BG levels to go up?
BG levels to go down?
No impact on BG levels?

5. Relationship between illness & hyperglycaemia
Infection
Increased secretion of cortisol and glucagon
High blood glucose levels
Increased insulin resistance
Decreased immune function
Decreased wound healing
Increase in inflammatory factors

6. Illness Fever/ Infection Nausea/ Vomiting
Increases the need for insulin % ↑ over 24 hours
Decreased appetite may ↓ amount of insulin needed
Risk of DKA from insulin deficiency
Difficulty in retaining nutrients due to nausea / vomiting / diarrhoea
Decreased appetite may decrease amount of insulin needed
Risk of low blood glucose levels
In gastroenteritis, slower emptying of stomach may contribute to hypos

7. 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

8. 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

9. Urine strips measure acetoacetate (AcAc)
Blood strips measure beta-hydroxybutyrate
Enables earlier identification & treatment
Normalises sooner than AcAc preventing hypoglycaemia from over insulin treatment

10. Your turn – when to get help?
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
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?

11. 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

12. 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

13. 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

14. Changes in insulin sensitivity over 24 hours

15. 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:
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)

16. Additional insulin
Calculate a current correction ratio for your child using one of the methods

17. Blood ketones Urine ketones <5.5 5.5-10 10-14 14-22 >22 <0.6
Negative - trace
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
Trace-small
Check again in 2 hours
Starvation ketones
Extra CHO
Give extra 5-10% of TDD or U/kg
Small-moderate
Starvation ketones
Give 5-10% of TDD or U/kg
Repeat if needed
Moderate-large
Starvation
Extra CHO. May need IV glucose
Extra CHO Give extra 5% of TDD or 0.05 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 above
Risk of ketoacidosis

18. Beware of “Insulin Stacking”

19. ABCC CSII & increase in DKA Assess Bolus via pump Check
Change + Injection
(Blood glucose – 10) ÷ correction ratio = dose of insulin

20. Additional strategies using insulin pump therapy
Use temporary basal rates
Percentages easier
Increase by % for feverish illness
Decrease to 50-75% for vomiting/ diarrhoea

21. Temporary Basal in action
Duration of Temporary Basal Rate

22. Stress Days

23. 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

24. 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

25. Relationship between stress and glycaemic control
Relationship between stress and glycemic control. From Ref. 21.
Lloyd C et al. Diabetes Spectr 2005;18:
Copyright © 2011 American Diabetes Association, Inc.

26. 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

27. 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

28. Questions?