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SICK DAY MANAGEMENT IN
Dr Anton Harding Paediatric Endocrinologist
Victoria Stevenson RN, CDE
Austin Health, Heidelberg & Royal Childrens Hospital, Victoria
Tuesday 26 August 2014
DISCLOSURES Dr Anton Harding
6 YEAR OLD BOY
6yo boy t1DM, basal bolus insulin short acting tds
and intermediate acting nocte
Fever, cough, sore throat with anorexia refusing
Paracetamol, 2hourly BGLs 10-16
Fluids, increased insulin - BGLs 6-8
Started to eat next day, fever continued, required a
further increase in insulin doses
25 YEAR OLD MALE ADMITTED IN
Type 1 diabetes admitted with BGL of 2.4 post hot
weather, eating less, taking usual insulin.
Has hypoglycaemic unawareness, hypo BGLs 2/wk, HbA1c 6.1%
Lives with watchful family
Was still driving!
33yo first pregnancy, 1st TM routine test BGL 8s,
diet management 6s
2nd TM BGL 9-11, started basal bolus insulin
with good response
Gastro illness at 34w vomiting, diarrhoea
Hydralyte, monitoring BGL 2hourly and
Improved in 24 hours
45 YEAR OLD MUM, T1DM ON
2030 Changed line & reservoir
2200 BG of 16.7mmol/L, ate ice cream and bolused
Wanted to void overnight but slept on
0630 BG18mmol/L, ketone strips OOD, vomited x3
0900 Called ambulance (& was lectured!), went to GP
BG 19.4 with large urine ketones
Admitted with evolving DKA (pH 7.35, HCO3 22,
BKL 3.7) HbA1c 8.7%
68 YEAR OLD UNWELL MAN
T2DM for 6years on 1g metformin bd with good BGLs of 7-9 Developed flu symptoms (fever, cough, sneezing, nasal
congestion) Saw usual GP and advised:
to increase fluids increase AC/PC testing, report if BGLs > 12 Panadol and over the counter flu medication Call clinic if other symptoms develop Continue metformin unless dehydration occurs
BGLs 8-13 which returned to normal in 3 days.
88 YEAR OLD CHINESE MATRIACH ADMITTED IN
A HYPERGLYCAEMIC HYPEROSMOLAR STATE
Type 2 diet treated
Non English speaking, lives with daughter
suffered an unwitnessed fall
10/7 Hx of increasing confusion, extreme fatigue,
polyuria (every 2 hours), unsteady, recurrent falls
Fiercely independent, significant sugar/soft drink
intake, refused GP visit
BGL 30.2mmol/L, urine ketones +, BKL
0.7mmol/L Osmolality 356 mosmol/kg
AIMS OF WORKSHOP Understand the clinical evidence supporting the local and
international sick day management guidelines.
Learn more about an Australian review on the effectiveness of ambulatory ketone monitoring to prevent DKA. The findings will guarantee to challenge your current thinking.
This workshop will keep you abreast of the current consensus and guidelines on creating and implementing a sick day management plan.
The place of sick day management plans in self-management of diabetes
Current guidelines and evidence
Myths and misconceptions a review of the evidence base for ambulatory monitoring of ketones
Realities proactive management of blood glucose levels is key to good control on sick days
THE AIMS OF SICK DAY MANAGEMENT To avoid
diabetic ketoacidosis (DKA) hypoglycaemia hyperglycaemic hyperosmolar state (HHS) reduce hospitalisations reduce absenteeism from school and work reduce cost of illness to the community reduce anxiety in family/friends improve early contact with the diabetes team demonstrate effective action when unwell recover as soon as possible prevent the re-occurrence of an illness
EVIDENCE FOR EARLIER INTERVENTION Better outcomes when timely interaction with HPC
Prevention of DKA & HHS with better communication, education & medication
24 hour phone support significant reduction in presentations with DKA, 31 patients (83 contacts), 2 with DKA
(Farrell & Holmes-Walker, 2011)
ADMISSIONS OVER A DECADE (WRIGHT, 2009) Factors contributing to
Number of Admissions Percentage of
Poor control and
Missed insulin dose
Alcohol abuse 25 9.0
Vomiting or diarrhoea
Family problems 11 4.0
Other 3 1.1
BGLS ON THE RISE
Hyperglycaemia occurs in 1 hour
Ketone production begins in 3 hours
DKA may occur in 4 Hours
Patient education is critical
Walsh, J & Roberts 2000, Pein, P. Hinselmann, C, Pfitzner et al 1996
HYPERGLYCAEMIC HYPEROSMOLAR STATE (HHS)
1% of all primary diabetes-related admissions
Usually affects middle aged or older people
Infection most common precipitating factor
Symptoms evolved over days to weeks
2/3 of episodes of HHS occur in people not known to have diabetes
MANAGEMENT OF HYPOGLYCAEMIA DURING ILLNESS Illness associated with nausea, vomiting or diarrhoea
Pregnant women with type 1 and type 2 diabetes are at increased risk
Routine hypoglycaemic management is recommended
ie 15-30 grams of glucose is recommended for the
conscious individual experiencing hypoglycaemia
People with type 1 diabetes should have a glucagon kit (in date) for severe hypoglycaemia. Support team need how when and how to use it.
LOCAL AND INTERNATIONAL GROUPS
ADEA www.adea.com.au APEG/ADS/NHMRC www.apeg.org.au NZ www.diabetes.org.nz ADA www.diabetes.org IDF www.idf.org ISPAD www.ispad.org Canadian DA- www.diabetes.ca UK NICE guidelines www.diabetes.org.uk LWPES/ESPE
THE EFFECTIVENESS OF AMBULATORY BLOOD
KETONE MONITORING IN THE PREVENTION AND
MANAGEMENT OF KETOACIDOSIS IN TYPE 1
A SYSTEMATIC REVIEW
JANUARY 1993- SEPTEMBER 2012
Victoria Stevenson, Seham Girgis, Armita Adily, Anton Harding, Jane Speight, Jeanette
Ward, Maarten Kamp
Thanks to Roche Australia for an unrestricted education
Diabetes ketoacidosis is life threatening Two thirds of patients hospitalised have type 1 diabetes International organisations support ambulatory capillary
blood and urine ketone monitoring as components of clinical practice and self management
Using a systematc review, we wanted to determine the quantity and quality of existing evidence of ketone monitoring in people with t1DM
1. IN PEOPLE WITH TYPE 1 DIABETES, HOW EFFECTIVE IS AMBULATORY KETONES MONITORING?
The retrieved evidence is by no means definitive. We do not know whether ambulatory ketones monitoring is effective in preventing DKA or reducing the likelihood of serious clinical incidents such as DKA related hospitalisation.
It remains unclear whether ketones monitoring is at all necessary in ambulatory settings with the availability of precise glucose monitoring.
Urinary ketone monitoring during sick days is embedded in clinical practice recommendations and patient selfcare regimens, but the evidence of beneficial impact is uncertain.
Addition or substitution of urinary ketone monitoring by blood ketone monitoring is unjustified with the extant evidence.
In summary, this question has not yet been sufficiently researched to provide definite conclusions.
2. IS AMBULATORY KETONE MONITORING ASSOCIATED WITH AN IMPROVEMENT IN PSYCHOSOCIAL OUTCOMES IN PEOPLE WITH TYPE 1 DIABETES OR THEIR CAREGIVERS? (E.G. CONFIDENCE IN DIABETES MANAGEMENT, DIABETES RELATED DISTRESS, IMPACT ON SCHOOL OR UNIVERSITY OR OTHER EDUCATIONAL OBLIGATION, WORK ATTENDANCE AND ABSENTEEISM)
Unknown The available evidence comprises only one study which did not measure any of these required psychosocial outcomes (Laffel et al., 2006) A singleitem question about satisfaction with blood ketone monitoring was asked only of those randomised to receive it and the wording of the item is not available The sample size of patients of whom this item was asked was small (possibly only 40 participants but not reported exactly by the authors)
3. IN PEOPLE WITH TYPE 1 DIABETES, WHAT IS THE EVIDENCE OF A DIFFERENTIAL EFFECT BETWEEN AMBULATORY BLOOD KETONE AND URINE KETONE MONITORING FOR THE PREVENTION AND MANAGEMENT OF DKA?
Findings: Evidence to date is not yet compelling.
4. IN PEOPLE WITH TYPE 1 DIABETES OR THEIR CAREGIVERS, WHAT IS THE EVIDENCE OF A DIFFERENTIAL EFFECT BETWEEN AMBULATORY BLOOD KETONE AND URINE KETONE MONITORING IN PSYCHOSOCIAL OUTCOMES?
Evidence to date is not yet compelling.
The evidence about the effectiveness of ambulatory urine and blood ketone monitoring in prevention and management of DKA is not yet comp