59F DIABETES 10YRS, RENAL FAILURE 10 MONTHS, UNCONTROLLED BLOOD SUGARS 10 DAYS. TELANGANA PAJR.
04-11-2024
This is an online E Log book to discuss our patient's de-identified health data shared after taking her signed informed consent.
Here we discuss our patient's problems through series of inputs from available global online community experts with an aim to solve those patients clinical problems with collective current best evidence based inputs.
In this case the patient is 59 Yr old female with Diabetes since 10yrs. She is also suffering with Renal failure since 10 months. Since 10 days her blood sugars are uncontrolled and was advised to be admitted in the hospital.
PPM 3 - Did you check the morning sugars?
PA - No madam. Will check in the evening.
06-11-2024
PPM 1 - What is the current treatment for her diabetes that she's on?
PPM 3 - 6U actrapid TID sir.
PPM 1 - Let's make it 8U TID from today. What's her Serum Creatinine?
PPM 3 - Creatinine 2 sir.
PA - Sugar value is 405
PPM 1 - Thrice and ask them to share the blood sugars 2hrs after every meal today thrice.
PPM 3 - @PA please give the patient 8U and share the sugar values 2 hrs of taking food.
PA - Okay madam.
PPM 1 - 👍
PA
PPM 1 - After 8U @PPM3?
PPM 3 - Yes sir
07-11-2024
PA - Fasting sugar
PPM 3 - What was the sugar value yesterday afternoon and night?
PA - 400 madam
PPM 3 - How much Insulin did you give?
PA - 8U
PPM 3 - 👍. Give 10U.
PA - Okay
PPM 3 - Did you check sugar levels 2 hrs after food?
08-11-2024
PA - 368
PPM 3 - Give 12U actrapid.
PA - Okay madam
PPM 1 - Please share her entire Insulin dose regime provided yesterday.
PPM 3 - 10U TID sir.
PPM 1 - Serum Creatinine? So 12U TID today?
PPM 3 - Creatinine 2 sir.
They are able to monitor GRBS only in the morning sir.
PPM 1 - While we are attempting to change the regular insulin dose in +2 increments isn't it mandatory for them to monitor it atleast 2hrs after every input?
Can they afford a CGM device?
PPM 3 - PA is not available all the time to check the sugars as he has to go for work.
So only Fasting sugars are checked.
PPM 1 - Who else is there in her house? @PPM4 current system challenges for you to talk about on 28th! Perhaps @PPM3 may also like to attend and share her PaJR experience and other patients there?
09-11-2024
PPM 1 - Fasting?
@PPM3 he needs to check her 3 am blood sugar to rule out Somogyi!
PPM 3 - OK Sir, but now shall we continue with 12U or increase to 14U sir?
PPM 2 - Somogyi has been reliably discredit and disproved. Only learnt it recently myself. It's always Dawn's apparently.
PPM 1 - The fasting is high either because she had nocturnal hypoglycemia or she needs additional NPH at night!
For deciding the pre breakfast Insulin you need to look at yesterday's two hours post breakfast values assuming the other variables like diet and exercise are constant. Till then it may be safer to continue 12U.
PPM 2 - Can they afford analog Insulin Sir? Lantus or Semglee?
PPM 1 - @Meta AI share one paper that suggests nocturnal hypoglycemia is not a major reason for fasting hyperglycemia citing valid searchable references and sharing their data in PICO format taking care to share only the absolute values.
Meta AI- Here's a paper that suggests "Nocturnal Hypoglycemia is not a major reason for fasting Hyperglycemia paper"
Nocturnal hypoglycemia does not predict fasting hyperglycemia in type I Diabetes by Danne. et.al. (2013), Reference- Danne.,T.,Kordonouri, O & Holder, M(2013).
Nocturnal hypoglycemia does not predict fasting hyperglycemia in type I Diabetes.
Journal of Clinical Endocrinology and Metabolism, 98(11), 4336-4342.doi 10.1210Ijc 2013-2341.
PICO FORMAT:
P (Population): 127 patient's with type I Diabetes.
I (Intervention): Continuous glucose monitoring (CGM) for 14 days.
C (Comparison): None
O (Outcome): Incidence of nocturnal hypoglycemia (<70mg/dl) and fasting hyperglycemia (>130mg/dl).
DATA:
•27% of patients experience nocturnal hypoglycemia.
•55% of patients had fasting hyperglycemia.
•No significant correlation between nocturnal hypoglycemia and fasting hyperglycemia (r=0.12, p=0.17).
This study suggests that nocturnal hypoglycemia is not a major predictor of fasting hyperglycemia in patients with type I Diabetes.
PPM 1 - @Meta AI The study design isn't too inspiring to make such a claim in the title.
Meta AI- You are right , the study design and results may not entirely support the titles conclusive claim. Here's why.
1. OBSERVATION STUDY:
The study is observational which makes it difficult to establish causality.
2. Small sample size:127 patients is a relatively small sample size for making broad conclusions.
3. Short Duration: 14 day CGM monitoring may not capture long term patterns.
4. Correlation vs causation: The lack of significant correlation(r=0.12) doesn't necessarily rule out nocturnal hypoglycemia's impact on fasting hyperglycemia.
Definitions: The thresholds for nocturnal hypoglycemia (<70mg/dl) and fasting hyperglycemia (>130mg/dl) might be debated.
A more nuanced title might reflect the study's limitations and findings, e.g.
"Nocturnal Hypoglycemia Not Strongly Associated with Fasting Hyperglycemia in Type I Diabetes A 14 Day CGM Study".
PA - Sir the patient is having fever. She is feeling very weak and no relief with Dolo 650.
PPM 3 - How much is the GRBS?
PA - Not checked.
PPM 1 - Ask the PA to check her temperature every 4hrs and share here.
PA - At this hour in the night no RMP is available as it is village.
PPM 1 - Every pharmacy has a digital thermometer that the PA can purchase.
10-11-2024
PA - Fasting sugar is 590.
PPM 3 - Please give the patient 14U now before breakfast.
PA - OK madam.
PPM 1 - Please ask him to share the sugars 2hrs after the 14U.
PA - 👍
PPM 1 - Ask him to give 4U of actrapid subcutaneously right now alongwith 4U NPH mixed after drawing the actrapid first @PPM3 and share the values again here after 2hrs or before lunch.
PA - Isophane
PPM 1 - 👍
PPM 3 - Did you check the sugars @PA?
She is having fever. Tomorrow should we bring her to the hospital?
PPM 3 - 👍
PPM 1 - When was this NPH and repeat actrapid given?
PPM 3 - 10.45am
PPM 1 - Sugars not checked at 1.45pm? How much Insulin given before lunch? What time was lunch?
PPM 3 - Before lunch what was the dose of Insulin?
11-11-2024
PPM 1 - What was the Insulin dose before breakfast, before lunch, before dinner?
Insulin actrapid 10U +Insulin isophane NPH 6U after giving please share blood sugars after 2hrs.
PA - 14U sir. We are coming to the hospital. The patient is having temperature.
PPM 3 - Please give 6U isophane Insulin also.
PA - 👍
PPM 1 - @PPM3 she needs admission in AMC and fever charting 4hrly alongwith hemogram, urine CUE and blood and urine culture sensitivity.
PPM 1 - @PPM3 she needs admission in AMC and fever charting 4hrly alongwith hemogram, urine CUE and blood and urine culture sensitivity.
PPM 3 - OK Sir.
PA - We are at the hospital. Where should the patient be admitted?
PPM 4 - Please take the OP slip and go to room 76.
PPM 1 - 👍 who is our PG in the OPD currently? Anyone in this group?
PPM 4 - PPM 3 sir.
PPM 1 - 👍
Reviewing the patient here now.
BP - 90/60
Temperature - Febrile low grade.
Plan - Admit
Sugar profile to adjust Basal bolus.
Temperature charting 4 hrly.
Start Amoxicillin as per previous urine culture sensitivity on October 24 during last admission.
PA - Sugar value 490 sir.
PPM 3 - Have to check after 2hrs of food.
PA - Yes madam.
PPM 1 - How much Insulin was given this morning?
PA - 14U sir.
PPM 1 - At what time? What about NPH?
PA - Now it is 527.
PPM 3 - Morning 14 HAI and at lunch 14 HAI sir.
PPM 1 - Yes she was also supposed to add NPH 6U in the morning. It's supposed to be twice daily.
PPM 3 - Yes sir we will add. Shall we give 6U HAI now sir?
PPM 1 - 👍
In such situations when the patient's sugar evaluations are being done without any fixed interval period, at least one can just give some 4-6U of subcutaneous Insulin actrapid to stem the tide till the actual dose and monitoring schedule regularised.
PA - Sir what should we give her for eating?
PPM 5 - Today hemogram report sir.
PPM 3 - Pre dinner GRBS 209 sir.
PPM 1 - 👍 Can add NPH 4U at dinner alongwith the pre dinner actrapid Insulin dose like yesterday.
PPM 3 - Post dinner GRBS 357 sir.
12-11-2024
PPM 3 - 2 am GRBS 287
7 am GRBS 302
PPM 6 -
PPM 3 - Post breakfast GRBS 570
PPM 1 - Pre breakfast Insulin?
PPM 3 - it is 302, given 14 HAI and 6 NPH.
PPM 1 - 👍. Can start her on IV Insulin hourly with monitoring to control immediately if there's any anxiety due to the slower communication over this platform. She actually may have needed 20U HAI although we can even increase the NPH now by +2 for longer term benefits. @PPM6 what antibiotic has been started? Amoxyclav? Or IV Monocef?
PPM 3 - Amoxyclav sir.
PPM 1 - Oral?
PPM 3 - Yes sir.
PPM 1 - Today's counts?
PPM 3 - 15,500, yesterday count was 14000
PPM 1 - Start her on hourly subcutaneous 4-6U with hrly blood sugar monitoring.
PPM 3 - @PPM6 inform the sister and post hrly GRBS.
PPM 6 - OK madam.
PPM 1 - Will the sister listen to him unless one of the interns tell them?
PPM 3 - 12pm GRBS is 343.
PPM 7 - Can the patient be put on DAPA or Acarbose or both?
PPM 1 - They are weak drugs with not much efficacy to reduce blood sugars. What are the Insulin dosages and further values obtained since post breakfast GRBS 570.
PPM 1 - They are weak drugs with not much efficacy to reduce blood sugars. What are the Insulin dosages and further values obtained since post breakfast GRBS 570.
PPM 3 - 6U actrapid given at 11am when the GRBS was 570. At 12pm 4U actrapid given when GRBS is 343.
PPM 1 - 👍. 1 pm would be pre lunch so we need to factor in the lunch calorie input. How much Insulin did she take before yesterday's lunch?
PPM 3 - 14U sir.
PPM 1 - What was the value after 2hrs yesterday? No NPH given yesterday morning I guess?
PPM 3 - Post lunch sugar value is 527 sir.
Yes sir yesterday NPH was not given.
PPM 7 - OK Sir My mom is a chronic diabetic (>27yrs). She has just lost vision in her right eye due to diabetic retinopathy. Was on both Lantus and Actrapid, taking a total of 60U/day alongwith OHAS. Since last 4 months she has been put on DAPA, gliptin and metformin. Her Insulin dosage has come down to just 26U of Lantus. These days her FBS is around 85-90 and RBS hovers around the 125-130 mark. Was just thinking if DAPA would work in our patient as well as it can be used in CKD.
PPM 1 - Because we have given 6U NPH today we can expect some post lunch help from that. So instead of giving 14U should we use 10U to be on the safe side?
If we had a better data about your patient we could possibly correlate that the current control is more due to Renal failure than DAPA. Either way if it doesn't help, the post lunch a lot we can still continue the hourly 4U to bring down the sugars?
PPM 2 - I wouldn't worry that much about in hospital hypoglycemias. There is a huge safety net and she requires high doses of insulin anyway?
PPM 1 - 👍
PPM 7 - OK Sir thank you.
PPM 1 - I am more worried about the safety net! @PPM7 what was her Serum Creatinine? While in your patient the strategy to support insulin therapy with the drugs that you mention could be alright, in this particular patient we also have a current transient situation due to her sepsis and hence we need to focus more on insulin driven control in this crisis phase.
PPM 7 - Serum Creatinine 1 and EGFR 61.
PPM 1 - 👍
PPM 5 - Sugar value 281mg/dl
PPM 1 - After how much time after lunch?
PPM 3 - Pre meal sir. Given 12U actrapid.
PPM 1 - 👍
PPM 3 - 3 pm GRBS is 319 sir. Giving 4U actrapid.
PPM 5 -
PPM 3 - 4 pm GRBS 269 sir.
PPM 1 - 👍
PPM 6 - 7 pm GRBS 195mg/dl
PPM 1 - Pre dinner insulin plan?
How much NPH yesterday night?
Can keep the same dose or +2.
Pre dinner actrapid depending on her dinner.
PPM 3 - Yesterday 4 NPH sir.
PPM 1 - 👍
13-11-2024
PA - Fever 101.
PPM 3 - Morning GRBS 151 sir.
PPM 1 - 👍
PPM 5 - Giving 12U HAI and 6U NPH sir.
PPM 1 - 👍. Keep sharing the glucose values. Share the updated fever chart @PPM3.
PPM 6 -
PPM 1 - @PPM3 Amoxyclav oral appears to be working in vivo? How's she feeling subjectively?
PPM 3 - No Sir she has 2 fever spikes 100F.
PPM 1 - Yes but the amplitude is less isn't it? How's her subjective improvement?
PPM 5 - GRBS at 7pm 71mg/dl.
GRBS at 9.30pm is 121mg/dl
PPM 1 - 👍
PPM 5 - GRBS at 10pm 156, 2am 147, 7am 171.
PPM 1 - Today's chart update @ PPM3.
PPM 6
PPM 5 - 2 fever spikes since yesterday sir. Subjectively she is better sir. Sugars are also under control.
PPM 1 - Please share the fever chart. Just checking the file right now: No temperature records in the file after this point! @PPM3 @PPM5? Is it because the patient improved subjectively? So sisters stopped recording? Also no urine culture in the file?
PPM 5 -
PPM 1 - Was she already on antibiotics Amoxicillin when the urine culture was sent? @PPM3 did we change the antibiotics since admission?
PPM 3 - No Sir after sending cultures she was started on Amoxyclav.
PPM 1 - 👍
16-11-2024
16-11-2024
PPM 1 - Was the temperature reading data stored some where other than the file as we couldn't locate it yesterday afternoon when we tried to complete the chart ourselves?
PPM 5 - It's in the sister's hand over book sir.
PPM 1 - 👍
PPM 6
PPM 1 - Stop night NPH! @PPM3 I think we didn't plan the night NPH here as we knew the dangers of her renal failure inducing hypoglycemia. Did she have any symptoms at midnight?
PPM 5 - Yes sir sweating, sir.
PPM 1 - 👍 Looks good.
19-11-2024
PPM 1- What's the 2 hours post breakfast today?
So she's currently on NPH twice a day?
PPM 3 - 275 sir post breakfast'
PPM 1 - Pre lunch?
Let's increase all by +2
PPM 3 - Okay sir. Pre lunch 140 sir.
PPM 3 - How much insulin did you give yesteday night?
PA - 10 HAI 4 N.
PPM 1 - Too well controlled! Can reduce N by 2U.
PPM 3 - @PA please give the patient 10 HAI and 2 NPH.
21-11-2024
21-11-2024
PA -
PA - Fasting sugar value.
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