Insulin Treatment. J A O Hare. Bones, Brains & Blood Vessels

Transcription

1 Insulin Treatment J A O Hare Bones, Brains & Blood Vessels

2 Indications for Insulin Treatment Diabetic Ketoacidosis Diabetics with unstable acute illness ICU Gestational Diabetes: diet failure Type 2 diabetes: after oral agent Failure Optimise Hyperalimentation? Myocardial infarction and stroke

3 Starting Insulin Type 1 Diabetes(Non-Ketotic) Basal: suppression of hepatic glucose output Intermediate or long acting insulin Post Prandial glucose peaks soluble or analogue

4 How to Start S.C. Insulin Injection Type 1 DM unstressed units Kg e.g. 80 Kg 60 units day 2 injections 60% in am..40% pm e.g. 36 units am 24 units pm

5 Insulin Types Animal Beef and Pork (obsolete) Human Recombinat DNA Analogues Short Acting Insulin aspart,lispro Long Acting Insulin Glargine, Detimer

6 Insulin Regimens for Type 1 DM Basic: Mixed fixed b.d (am and pm) Mixed Flexible: Soluble and NPH b.d Mixed Flexible 3 injections am: sol/nph(breakfast) sol(dinner) NPH(bed) 4 injections: pre meal: soluble anolog + Ultratard or Glargine (bed)

7 Insulin Time-Action profiles Hrs.

8 Major operations Stop Oral Agents at least 2 days before hand Schedule Early in day 5% Dextrose infusion Separate I.V. Infusion as 50 U in 50 mls saline Hourly monitoring with sliding scale

9 I.V. Sliding scale for Unstable DM Soluble human Insulin (Actrapid) only If glucose Mol/l Insulin units/hour >4-6 1 >6-8 2 > > > >20 6 >25 Review Scale 50 units soluble in 50 mls N Saline separate IV Dextrose 5 5 at 50 to 100 mls /Hour as required

10 Sliding Scale Insulin. subcutaneous 40 Insulin units Sensitive Normal Resitant Glucose mmol/l

11 Minor operations (<1 hour) Fast Overnight 5 % Dextrose infusion + 10 KCl Half of usual Intermediate acting Insulin Sub-Cutaneous Sliding scale on 2 hourly values Usual p.m. insulin if eating

12 Hypoglycaemia The short term problem!

13 Hypoglycaemia Symptoms Sweating Trembling Weakness Hnxiety Hunger Signs Diaphoresis Tremor Strong pulse Slowed mentation

14 Causes of Hypoglycaemia Meals missed Exercise Alcohol Dose errors Inappropriate insulin administration Recovery from temporary insulin resistance Increasing insulin sensitivity Combined therapy delayed Effects Deliberate

15 Increasing Insulin Sensitivity Honeymoon Weight loss/dieting Cancer Adrenal Insuffiency Steroid withdrawal Coeliac Renal Failure Poor to good control! Compliance!

16 Hyoglycamemic Unawareness Diminished adrenergic response Glucorecptor failure Commoner in long duration Worseded by repeated hypoglycaemia Reversible

17 Oral glucose drinks Glucagon I.V. Glucose Treating hypos

18 Avoiding hypoglycaemia Appropriate insulin regimen Adapting to circumstances Monitoring Patient education

19 Renal failure Creatinine > 400 Half usual requirements Some Type 2 patients stop insulin!

20 Decreasing insulin sensitivity Hypocaloric Diets Cancer Advanced Heart Failure Withdrawl of Steroid treatment Addison disease Advanced renal failure

21 Case1 16 year old male new onset glucose 18 ketone + manage? Oral rehydration Mixtard b.d. 0.4 units/kg

22 Insulin Resistance

23 Insulin Resistance (>1 unit /Kg body weight) Acute Illness Obesity Recent Persisting Hyperglycaemia Steroid Treatment Adolescence Pseudo = non-compliance Rare Syndromes

24 Case 2 58 year old female thin 70 Kg loosing weight, thirsty 10 years of type 2 on tablets Glucose 18 no infection or meds Insulin insultard bd unit/kg

25 Case 3 Male type 1 male 30 years age 48 Acute cholylithiasis septic Glucose 35, ketones +2, ph 7.2 I.V, Insulin infusion by sliding scale with saline and Potassium through surgery

26 Case 4 35 year female Praeder Willi syndrome 140KG on 200 Mixtard b.d poor veins glucose 15 no ketones Acute cellulitis 250 mixtard b.d + top up sc actrapid with sliding scale units 6 hourly Feeding restraint

27 Case 5 78 year old coma type 2 for 5 years on sulphonyluria Glucose 102 no ketones ph 7.31 Na 118 K 3.8 urea 20 Nnormal saline alternating with dextrose saline up to 10 litres over 3 days avoid too rapid correction of sodium Insulin at 2-5 units hour I.V. Return To Tablets

28 Case 6 35 year old type 1 x17 years new proliferative retinopathy No test results, usual HBa1c 9% Demands to go on the insulin pump as seen in promotional video? Hypo awareness? Willingness to test adjust and follow diet on conventional therapy

29