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 3 - Please give the patient 8U Insulin. 

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.
Ragi for the patient. 

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
PA - 
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 1 - @PPM3 let's add 6U  of NPH tomorrow  to her night actrapid.  Can take 14U before breakfast. 

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 - Explained to them sir.

PPM 1 - 👍 

PPM 3 - Did you check the sugars @PA?

PA - Sugar level. Post lunch.
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
PA - Fasting sugar level. 

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 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.
Relatively  well preserved. 
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 1 - 👍 

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 1 - Share yesterday's all Insulin doses and outcomes and today's increment plan.

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 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 1 - Thanks.  
How's the patient feeling subjectively now? Can you meet me now in the ICU?

PPM 5 - 
15-11-2024
PPM 1 - 👍  Subjectively how is she feeling since admission?

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
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- 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 1 - 👍 Looks good.

19-11-2024
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
PA - 
PPM 3 - Please give the patient 12 HAI and 2 NPH.

23-11-2024
PA -  Fasting sugar value. 
PPM 1 - 👍









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