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T1DM (ii) - Coggle Diagram
T1DM (ii)
Initial tx
if in DKA...
urgent admission + tx
intensive educational programme
basic pathophysiology of DM
insulin injection technique + sites
Diet
reduced refined carbs
carb counting to allow calculation of insulin dose required
adjusting for exercise
sick day rules
blood glucose monitoring
recognising + txing hypoglyc
where to get advice
available organisations
how to correct any sugar > 10 by extra SA insulin
MDT
paediatrician
diabetes nurse specialist
dietician
psychologist
social worker
support groups
liaise with school
Insulin
made using recombinant DNA technology or from modified pork insulin
rapid-acting
insulin lispro (Humalog)
insulin glulisine (Apidra)
insulin aspart (novorapid)
v long acting
insulin detemir (Levemir)
insulin glargine (Lantus)
short-acting
onset in 30-60mins, peaks @ 2-4hrs, duration up to 8hrs
give 15-30mins before meals
e.g. Actrapid, Humulin S
intermediate acting
onset 1-2hr, peaks @ 4-12hrs
isophane insulin (e.g. insulatard + Humulin I)
Predetermined mixed preparations
can be given by continuous infusion (pump) or injected (basal-bolus)
subcut injection sites: upper arm, ant/lat thigh, buttocks, abdo
rotation essential to prevent lipohypertrophy or lipoatrophy
shortly after presentation there is still some pancreatic reserve so insulin requirements minimal - "honeymoon period" - requirements will increase
Diet
healthy diet recommended with high complex carbs + <30% fat
should be high in fibre to provide sustained glucose release
minimal refined carbs - cause rapid swings in glucose levels
blood glucose monitoring
keep a diary
aim = 4-6, but more realistic is 4-10 in children + 4-8 in adolescents
adolescents tend to test v infrequently
Continuous glucose monitoring sensors (CGMS)
subcut or transcut
allow detection of unexpected asymp nocturnal hypoglyc
blood ketone testing must be done during infections
HbA1c
guide of glucose control over previous 6-12wks
check x3/yr
level correlates with risk of later comps
Misleading in sickle cell anaemia (reduced RBC lifespan) + thalassaemia (HbA) molecule abnormal
aim: 58 (7.5%) or less
Managing hypos
sx when <4
hunger, tummy ache, sweatiness, faint, dizziness, seizures, coma, pallor, irritability, behaviour changes
glucose tabs / sugary drink
oral glucose gel (e.g. glucogel) quickly absorbed from buccal mucosa
glucagon IM injection kit
after give the child food (biscuit/sandwich) to ensure glucose levels don't drop again
can usually be predicted/explained (missed meal, heavy exercise)
if unconscious bring to hosp + give IV glucose
aim: anticipate + prevent
Managing DKA
fluids
IV insulin infusion
do not stop until 1hr after subcut insulin given
K
acidosis
should correct once insulin + fluids given, if not give bicarbonate
try find an underlying cause (e.g. infection)
Long term tx
Aims
normal growth + development
maintain normal home + school
good diabetic control
encouraging children to become self-reliant
avoidance of hypos
prevention of long term comps
BP: check once a yr
Renal disease: screen for micoalbuminuria annually in teens
check eyes annually after 5 yrs with DM or from puberty
foot care
screen for coeliac + thyroid disease