Managing sick and stress days

Rebecca Thompson RSCN, BSc, MScNurse Consultant – Diabetes, UCLH

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

SICK DAYS

Your turn:

In groups, discuss the scenarios

Would you anticipate: BG levels to go up? BG levels to go down? No impact on BG

levels?

Vomiting + diarrhoea Flu Exam time Infection Having surgery Chicken pox Recovering from an

illness Start of a new school

term

Relationship between illness & hyperglycaemia

Illness

Fever/ Infection Increases the need for insulin - 25-50% ↑ over 24 hours

Decreased appetite may ↓ amount of insulin needed

Risk of DKA from insulin deficiency

Nausea/ VomitingDifficulty in retaining nutrients due to nausea / vomiting / diarrhoea Decreased appetite may decrease amount of insulin needed Risk of low blood glucose levelsIn gastroenteritis, slower emptying of stomach may contribute to hypos

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

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

Urine strips measure acetoacetate (AcAc) Blood strips measure beta-hydroxybutyrate

Enables earlier identification & treatment Normalises sooner than AcAc preventing

hypoglycaemia from over insulin treatment

Your turn – when to get help?

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?

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

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

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

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

Changes in insulin sensitivity over 24 hours

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0.5

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1.5

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2.5

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6 8 10 12 14 16 18 20 22 24 2 4 6

Clock Time

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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: 0.05 - 0.1 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)

Additional insulin

Calculate a current correction ratio for your child using one of the methods

Blood ketones

Urine ketones

<5.5 5.5-10 10-14 14-22 >22

<0.6 Negative - trace

No insulin 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

0.6-0.9 Trace-small

Check again in 2 hoursStarvation ketonesExtra CHO

Starvation ketonesExtra CHO

Give extra 5% of TDD or 0.05 U/kg

Give extra 5-10% of TDD or 0.05-0.1 U/kg

Give extra 10% of TDD or 0.1 U/kg

1.0-1.4 Small-moderate

Starvation ketonesExtra CHO

Starvation ketonesExtra CHO

Extra CHOGive 5-10% of TDD or 0.5-1.0 U/kg

Give extra 10% of TDD or 0.1 U/kg

Give extra 10% of TDD or 0.1 U/kgRepeat if needed

1.5-2.9 Moderate-large

StarvationExtra CHO. May need IV glucose

StarvationExtra CHO Give extra 5% of TDD or 0.05 U/kg

Extra CHOGive extra 10% of TDD or 0.1 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 aboveRisk of ketoacidosis

As above Extra CHOGive extra 10% of TDD or 0.1 U/kg

Give extra 10-20% of TDD or 0.1 U/kg.Repeat dose after 2 hours if ketones do not decrease

Beware of “Insulin Stacking”

CSII & increase in DKA

ABCCAssess

Bolus via pump

CheckChange + Injection

(Blood glucose – 10) ÷ correction ratio = dose of insulin

Additional strategies using insulin pump therapy

Use temporary basal rates Percentages easier Increase by 150-200% for feverish illness Decrease to 50-75% for vomiting/ diarrhoea

Temporary Basal in action

Duration of Temporary Basal Rate

STRESS DAYS

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

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

Relationship between stress and glycaemic control

Lloyd C et al. Diabetes Spectr 2005;18:121-127

Copyright © 2011 American Diabetes Association, Inc.

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

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

Questions?

rebecca.thompson@uclh.nhs.uk