All diabetic patients should increase their monitoring of blood glucose—patienta with type 1 diabetes should also start urine ketone measurements—during suspected or acute illness. Often glycemia values will increase before there are signs! and symptoms of a developing illness. Patients need to be given specific instructions on how to monitor and adjust their therapy during periods of illness ("sick-day rules").
Blood glucose shouJd be checked every 2 to 4 hours, or unti] the symptoms diminish.
Urine ketones should be tested at least every 4 hours during acute illness. Increased insulin is often needed (10—20%). This must be stressed with patients who often want to reduce or eliminate their dosage because they are vomiting and not eating, and do not understand the body's need for more insulin when under stress, even if carbohydrate intake is decreased. Insulin omission is a common cause of diabetic ketoacidosis (DKA). Adequate hydration is critical. Patients should drink 8 ounces of calorie-free fluids (e.g., water, broth, or diet drinks) every hour while they are awake. Also useful are fluids that contain electrolytes, such as canned clear soups, bouillon, consomme, and sports drinks. A "sipping diet" consisting of 15 grams of carbohydrates, such as Gatorade every 1 to 2 hours, can be effective in patients widi nausea and vomiting. Caffeine is a diuretic and should be avoided. Antiemetics or i.v. fluids may also be needed. Many over-the-counter cough and cold medications contain sugar and alcohol, and can increase blood glucose. Advise patients to use sugar-free preparations if available.
Most situations can be managed by phone if the patient is monitoring and reporting his status. However, patients are often reluctant to contact their
Cl, o u provider until symptoms are severe. They should be instructed to contact their provider when:
Diarrhea persists for more than 24 hours or occurs five limes or more. Blood glucose levels are higher than 300 mg/dl on two consecutive measurements which do not respond to insulin. They observe moderate or large ketones.
They have unexplained chest pain and/or difficulty in breathing. They should be seen for medical evaluation if:
They are unable to tolerate fluids or have persistent vomiting or diarrhea. They report progressive weakness.
They are experiencing rapid and labored respirations or other significant difficulty in breathing. There is a change in mental status.
Moderate or large urinary ketones do not improve after 12-24 hours of treatment.
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