Approach to the Management of Diabetes Mellitus - Management of Intercurrent Illness in Type 1 Diabetes

MANAGEMENT OF INTERCURRENT ILLNESS IN TYPE 1 DIABETES

Author:

The initial draft of this chapter was prepared by Marianne Beckstead, RN, MN, CDE and Carolyn Lawton, RN, MScN, CDE

People with diabetes are more susceptible to common infections such as those of the skin, soft tissue, urinary tract, pneumonia and bacteremia
Acute illness affects metabolic control
Increased blood glucose may result from release of counterregulatory hormones
Failure to administer supplemental insulin may lead to Diabetic Ketoacidosis (DKA)
The risk for DKA with concurrent illness is a result of insufficient insulin to regulate ketone production, as seen in Figure 14.1, and can result in life threatening consequences
Sufficient insulin must be administered to reestablish glucose and lipid homeostasis
In mild illness without substantial counter-regulatory responses and if caloric intake is reduced by nausea, vomiting, diarrhea etc., insulin requirements may decline if the blood glucose level is falling

14.2 Pathogenesis of Hyperglycemia in Illness

Hyperglycemia and ketonuria during illness results from activation of counter-regulatory (stress) hormones leading to relative insulin deficiency resulting in the following metabolic derangement: See Figure 14.1.

14.3 Management

Blood ketone testing is an essential skill for all patients with type 1 diabetes during periods of intercurrent illness. It is the preferred method over urine ketone testing as it quantifies beta-hydroxybutyric acid the predominant ketone body.

Most illness can be managed by following the following principles:

Check blood glucose and blood ketones every 4 hours around the clock.
Do not omit insulin, the dose will likely need adjustment (see Table 14.1).
Underlying illness must be treated.
Rapid acting or fast acting insulin should be available for supplementation during illness.
Pump users should inject insulin using syringe or pen to treat hyperglycemia and check for pump malfunction.
If the patient is unable to tolerate a regular diet then sugar-containing fluids should be substituted (see Table 14.2 for suggested replacement).
The physician/health care team should be consulted during illness.
Fever generally increases insulin requirement and should be investigated for the presence of a bacterial illness.
Emergency department assessment is indicated if the person is unable or refuses to take fluid supplements or vomits twice or more in 8 - 12 hour time span, if ketones persist despite taking supplemental insulin.
See Table 14.1 for insulin dosage adjustment for intercurrent illness

TABLE 14.1 Adult Patient Guidelines for Sick Day Management (reprinted with permission)6
Guidelines for insulin dose adjustments when sick with flu or a fever but tolerating fluids or food (adults only): Test BG and blood ketones every 4 hours, all day and night. If blood ketones >3.0 mmol/L at any time, go to the ER immediately; you need IV insulin and fluids. If you are not able to drink fluids without vomiting, go to the ER. You may require IV insulin and fluids. The TDD formula is used to help determine how much extra rapid or fast insulin is needed. Add up the number of units of insulin (all kinds) you usually take each day (use baseline or usual doses). Your TDD =______ units Calculate 10% = ____ , 15% = _____ , and 20% =____ of your TDD Follow the chart to decide how much extra rapid or fast insulin to take every 3 to 4 hours, in addition to your usual baseline insulin doses. If you are not eating as usual, replace the usual carbohydrate with sugar-containing fluids.
BG (mmol/L)	Blood ketone (mmol/L)	Action required * *Note: Person is able to take fluids	Extra insulin dose
<3.9	-	No extra insulin required Decrease dose of premeal insulin as directed Contact care team if vomiting occurs
4.0–16.0	<0.6	Use same insulin dose (and scale) as for non-sick days
4.0–16.0	>0.6	Take a 10% supplement of fast or rapid insulin every 4 h, as needed, all day and night, in addition to normal baseline insulin doses
>16.0	<0.6	Take a 10% supplement of fast or rapid insulin every 4 h, as needed, all day and night, in addition to normal baseline insulin doses
>16.0	>0.6–1.4	Take a 15% supplement of fast or rapid insulin every 4 h, as needed, all day and night, in addition to normal baseline insulin doses
>16.0	>1.5–3.0	Take a 20% supplement of fast or rapid insulin every 4 h, as needed, all day and night, in addition to normal baseline insulin doses Contact your care team as soon as possible

Patients should be encouraged to have on hand sick day supplies, which include:

Blood glucose meter and glucose and ketone test strips
Rapid acting or Fast acting insulin
Thermometer
Acetaminophen (if no contraindication, for treating fever)
Sugar-free cough drops and syrup
Emergency medical contact phone number
Local 24 hour pharmacy phone number

Prevention

In adults with diabetes consideration should be given to influenza vaccination and immunization against pneumococcus.

TABLE 14.2 Sugar Containing Fluid Diet
The following each contain 15g of carbohydrate:
3/4 cup orange juice 1/3 cup grape juice 3/4 cup regular soft drink/pop 1/4 cup regular Jello 1 ½ Popsicles (3 sticks) 1/2 cup sugar sweetened Kool-Aid	6 soda crackers 1 slice toast 2 digestive cookies 3/4 cup applesauce 1/3 cup sherbet 1/2 cup vanilla ice cream

References

Booth, G. & Fang, J. Diabetes in Ontario An ICES Practice Atlas. June 2003. Institute for Clinical Evaluative Sciences, Toronto, 2001.
Kitabchi, A. E., Umpierrez, G. E., Murphy, M. B., Barrett, E. J., Kreisberg, R. A., Malone, J. I. et al. Management of hyperglycemic crises in patients with diabetes. Diabetes Care 2001; 24(1): 131-153.
American Diabetes Association. Hyperglycemic Crises in Patients with Diabetes Mellitus. Diabetes Care 2003; 26(suppl 1): S109-117.
Booth, G. Short-Term Clinical Consequences of Diabetes In Adults. Chpt 7p 68-106, In Gerstein H., Haynes R.B (eds). In Evidence-based Diabetes Care (2001).. Hamilton: BC Decker Inc.
Umpierrez, G. E., Murphy, M. B., & Kitabchi, A. E.Diabetic ketoacidosis and hyperglycemic hyperosmolar syndrome. Diabetes Spectrum 2002; 15(1): 28-36.
Canadian Diabetes Association. Building competency in diabetes education: Advancing practice 2003. Chapter 2: 60-62.
Daneman D., Frank M. Managing intercurrent illness in the child with diabetes. Clin Diab 1984;2(1):1-7.
American Diabetes Association. Hyperglycemic crises in patients with diabetes mellitus. Diabetes Care 2002 25: S100-S108.
Canadian Diabetes Association Clinical Practice Guidelines Expert Committee. Canadian Diabetes Association 2003 Clinical Practice Guidelines for the Prevention and Management of Diabetes in Canada. Can J Diabetes 2003;27(suppl 2): S53-54.
Registered Nurses Association of Ontario. Best Practice Guideline for the Subcutaneous Administration of Insulin in Adults with Type 2 Diabetes. (in press 2004)