By Tania Bailey Clinical Nurse Specialist

1. Tania Bailey
Diabetes CNS

2. Overview
 CNS Team
 Differentiation T1DM & insulin treated T2DM
 Quick word HbA1C
 OHA’s / Insulin profiles
 Insulin Policy
 Acute presentations
 Hypo/hyper management
 IV insulin infusion/Additional s/c
 Prediabetes
 ??

3. DIABETES TEAM
 Dr Tom Thompson
 Helen Adams / Delia Williams / Tania Bailey
 What we do
 When to refer

4.  Type 1 or Type 2 on insulin?
 Why worry?
 how do you know?

5. HbA1C

6. OHA’s
 Metformin – biguanide
 Glipizide / Gliclazide / Glibenclamide– SU
 Pioglitizone – Thiazolidinedone
 Acarbose – Alpha Glucosidase inhibitor
 When to discontinue?
 Timing of doses
 restarting

7. Insulin Profiles

8. Insulin profiles

9. Insulin profiles
 Glargine / Lantus
 Glusiline /Apidra

10. Insulin Guidelines
 Optimise diabetes management of hospital inpatients
 Additional sub cut insulin algorithms
 Continue regular insulin
 ? Adjust usual regime
 Consider BG targets
 IV insulin infusion orders (iio)
 When?
 10% glucose 80mls/hr & Actrapid 50u/50ml NaCl 0.9%
 ? Kcl → ileus, v & d’s, or NBM → monitoring
 iio form / drug chart / fluids FBC /algorithm
 Decision → surg team/anaesthetist
 Poor control = RBG > 17, mean BG >11, HbA1C >73mmol/l
 Preggies & paeds

11. Acute presentations
 DKA
 Baseline obs ?
 Aims:
 Correct dehydration / electrolyte slowly
 IV insulin infusion / Dextrose 10% IV
 ? Cause – education
 IV insulin / Dextrose 10%
 Until ketosis clear or minimal / pH nad
 Dont be in a rush to feed / Ø vomiting & stable
 Regular insulin / crossover infusion
 Newly dx – ref
 Lantus
 Paeds – Starship policy
Mod Severe
pH 7-7.24 <7.0
Serum HC03- 10-15 <10
Ketones Urine ++-+++
B hydroxybutyrate > 1.2 (0.4)

12. HHS – hyperglycaemia
hyperosmolar state
 Resembles DKA
 BGs usually ↑↑
 Rx → as for DKA
 Slow replacement fluid
 Insulin infusion
 Electrolyte
 DVT risk
 Ongoing Rx / usual regime

13. Notes →Insulin infusions
 OT →Infusion starts at point of starvation
 Never stop infusion in T1DM →treat / adjust
 Infusion not enough prandial cover
 If acidotic – keep going!
 NaCl 0.9% if BG > 17 mmol/l
 dedicated lines

14. Recommencing usual regimes
 <24 hrs interruption usual insulin – restart next meal
 Infusion overlap 1-4 hrs
 >24hrs – morning with overlap 1-4 hrs
 Bg’s 5-15 mmol acceptable short term
 OHA – resume 1st post op meal
 Consider additional s/c

15. Hyperglycaemia
 Bg >17 mmol/l two or more / repeated
 ? options
Hypoglycaemia
 Bg < 4.0 mmol/l
 ? Treatment
 Concious
 unconcious
 ? On insulin infusion

16. Prediabetes – intermediate
hyperglycaemia
 HbA1C 41-49 mmol/l
 Lifestyle management 3– 6/12
 Metformin 46-49 mmol/l
 No SMBG or retinopathy screening
 CVD risk
 Opportunistic screening
 Known IHD/CVA/PVD
 Hx cellulitis / PCOS
 Long term steroid or antipsychotic Rx
 Obese BMI ≥ 30 (27 Indo-Asian)
 Family hx – Maori, PI, Indo-Asian

17. Dx planning
 Rx / equipment
 Follow up
 Opportunistic stuff
Questions?