Download Sick Day rules renal presentation

Western
Sussex
Hospitals
NHS
Foundation
Trust
SICK DAY GUIDANCE
SARA DA COSTA
NURSE CONSULTANT,
DIABETES
Type 2 Sick day rules
KEY POINTS:
Why and when do we need
“Sick day guidance”?
What is the general and specific
advice, according to type
of diabetes?
What are the risks of “Sick day
guidance”?
Why do we need Sick day
guidance?
• When we are ill, our bodies will respond to fight infection, and we
need to manage other symptoms eg dehydration, +/- medical care
• People with long term conditions, are particularly vulnerable to acute
illness, which can also destabilise their co-morbidities
• Knowing this, one of our aims as clinicians is to reduce the risk of
avoidable harm to our patients, so sick day guidance is important
• We know that people with CKD, heart failure or those taking certain
medications, are at increased risk of AKI
• When ill, people with diabetes will often experience hyperglycaemia,
which can cause and be compounded by dehydration, and can lead
to keto-acidosis
When do we need Sick day
guidance?
When we are sick!
For the duration of the illness,(may be acute or
chronic episode) but not when well.
How sick do we have to be?
NHS Highland (2015) definition of acute illness
is
• Pyrexia , fevers , sweats & shaking & D &V
(not minor)
• Infection or sepsis
• Clinically ill – require admission
• Post surgery or post procedure
What risks does illness bring to patients
with renal disease and diabetes?
Better control of both conditions improves resilience to illness
and outcomes.
RENAL:
• People with mild and moderately low kidney function are at
greater risk of developing kidney damage during periods of acute
illness such as infection eg flu or gastroenteritis( leading to AKI) ;
also associated with ESRF
DIABETES:
• During illness, insulin resistance increases, increasing insulin
requirements
• Additionally, stress hormones cause glucose levels to rise,
leading to hyperglycaemia, and if untreated, HONK & DKA
• Illness in both of these conditions can lead to unplanned
admissions, as well as greater risk of death in short and long
term, and are largely PREVENTABLE if guidance is known
• (And used by clinicians)
General Guidance during illness
RENAL
• During acute inter-current illness, particularly with disturbed fluid
balance, certain drugs are advised to be temporarily discontinued,
• e.g NSAID’s -may increase risk of AKI by impairing renal autoregulation
• Hypotensive agents (ACE,ARB’s)- reduce systemic BP
• Diuretics – exacerbate hypovolaemia
DIABETES
• Drugs may also accumulate as a result of reduced kidney function in
AKI, increasing risk of side effects
• Metformin- increased risk of lactic acidosis in high risk patients
• Sulphonylurea-increased risk of hypoglycaemia; care with insulin
• SGTLT2- exacerbate hypovolaemia
Education is key- patients need to be advised as to how to manage
their own medication should they become unwell ( this doesn’t relate to
clinical management of known or suspected AKI by clinicians)
General guidance during illness
• Avoid dehydration as can exacerbate hypotension, hyperglycaemia.
• Drink plenty of water and sugar-free fluids
• (n.b specific advice required if fluid restrictions in place)
• If you are unwell, your blood glucose may rise higher than usual
• Continue your insulin, even if you are not eating- replace the
carbohydrate in meals with milky drinks, soup, yoghurt or fruit juices
• Check BS more frequently, and if Type 1 diabetes, or ketosis –prone
Type 2’s, check ketones
• If symptoms are worsening eg BS rising, ketones rising, or vomiting,
seek prompt medical advice e.g GP or A&E.
Do not sleep it off!
Type 1 Sick Day guidance
• Continue insulin even if not eating; check blood for glucose every 1-2
hrly and ketones every 2-4 hrly
• Use the advice on your regimen advice sheet to increase insulin
according to your BS (and ketone) levels e.g. basal bolus below
Blood glucose level
Insulin dose
13-17 mmols/L
Add 2 extra units to each
dose rapid insulin
17-22 mmols/L
Add 4 extra units to each
dose rapid insulin
More than 22 mmols/L
Add 6 extra units to each
dose rapid insullin
NB Insulin resistance in illness means more insulin is needed, and in
the absence of sufficient insulin, body fat is broken down to supply
energy, and ketones are formed which
accumulate to cause DKA
Type 1 on Insulin pump sick day
guidance
• Follow advice in pump booklet re fluids, food, BS and ketone testingtables are included with specific dosing advice
•
•
•
•
•
•
If BS are rising, check pump to ensure it is working e.g
Check no air in tubing
Change the cannula and check the site is not inflamed
Temporarily increase basal rate
Try to identify cause of high BS and seek treatment
If you suspect pump is not working or if this advice is not successful,
give correction boluses by your insulin pens
• Contact GP or A&E if vomiting occurs
• Contact pump company for technical support, and DSN helpline in
hours for advice
Type 2 Sick day rules
• If on Metformin, sulphonylurea, SGLT2, or GLP1 discontinue
temporarily or permanently (renal function will determine latter)
• Review insulin doses and increase if hyperglycaemic, but decrease if
hypoglycaemia occurs, which can happen with low egfr
(<30mmols/L)
• Ensure Metformin remains withheld in cases of sepsis, cardiac
problems or pre scan preparation.
• Advise fluids, food and increased blood glucose testing.
• Nb Some Type 2 patients are ketosis –prone and are often on insulin;
ensure they can ketone test and know to do so if hyperglycaemic ie
BS remaining >13-15 mmols/L ( individual targets apply, consider
other co-morbidities, capability, quality of life)
• If insulin-treated, may need to increase doses, or may need to start
insulin, temporarily or permanently
• Will need agreed next steps and plan to review
Risks of Sick day guidance
• Education is key- when to use guidance, and when to stop!
• Risk is that patients and clinicians do not restart treatments, causing
poor glucose or blood pressure control, with increased health risks
• Reduced adherence to drug treatment, which may have been
incorrectly described as “nephrotoxic”
• Drugs may not be titrated back to previous levels when AKI has been
treated or excluded from diagnosis
• Issues related to removing medication from dossette boxes causing
confusion
Summary
• Diabetes and renal disease require complex management during illness
• Patient and clinician education is key, alongside useful and relevant
information being provided in a timely manner
• Knowing what to do when ill, and what to change, and when and where
to gain advice is important in keeping people well and safe
• Planning for return to health or previous level of health is an important
and often overlooked part of sick day guidance
Recommendations
• Make time for adequate patient and carer education before patients
are ill if at all possible.
• Provide useful information, which shows what do and when. (specific
handouts)
• Ensure clear collaborative planning with clinicians- when to restart
treatments, when stop completely, and what alternatives to use
• Communicate these strategies and information to other clinicianschanges are often made in acute care but advice regarding next steps
is often late, or absent.
References
• Sick day guidance in patients at risk of Acute Kidney
Injury: an interim position statement from the Think
Kidneys Board
Griffith K et al Version 8:13 November, 2015.
• NHS Managing diabetes during inter-current illness in the
community February 2013
• WSHT Diabetes team guidelines for Illness for Type 1 and
Type 2 diabetes
• Websites- Think Kidneys , DUK.
Western
Sussex
Hospitals
NHS
Foundation
Trust
End slide
Thank you, etc.