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Managing Sick Days and Hospital Stays

Managing Sick Days and Hospital Stays . Mike Heile MD Orlando, CWD July, 2011. What can raise blood sugars besides SUGAR?. STRESS ILLNESS MENSES PREGNANCY MEDICATIONS Steroids Atypical antidepressants/antipsychotics Niacin, HCTZ Etc. VACCINES. Management Sick Days.

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Managing Sick Days and Hospital Stays

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  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 • Don’t 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? • Doesn’t 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

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