Hypoglycaemia

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

2. Hypoglycaemia Mags Bannister Diabetes Nurse Consultant

3. What happens now in clinical practice re hypo’s?

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

5. 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

6. AutonomicNeuroglycopenicMalaise Sweating Palpitations Shaking Hunger Confusion Drowsiness Speech difficulty In coordination Atypical behaviour Diplopia (double vision) Nausea Headache

7. 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

8. 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

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

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

11. 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

12. 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

13. 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

14. 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

15. Hyperglycaemia and illness management

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

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

18. 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

19. DIABETIC KETOACIDOSISType 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

20. 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

21. Hyperosmolar Hyperglycaemic StateHHSType 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%

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

23. 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

24. If unable to eat - replace solid food with alternatives such as

25. 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 Monday to Friday 7.30-8.30am and 5.30pm- 9pm Saturday and Sunday and Bank Holidays 7.30am -9pm 01274 494194

26. 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

27. Questions