Part 25: Maintenance treatment and what to do and what to avoid

1. Maintenance treatment:

+ If the patient is awake and able to eat, continue eating as usual.

+ If unable to eat (vomiting, intolerance...): Intravenous infusion of 10% Glucose at a dose of 1500-200 ml/24 hours (150-200g Glucose) until plasma glucose concentration returns to normal after several hours. Do not give high doses because the body can only tolerate a maximum of 1.5g glucose/hour.

+ Blood sugar monitoring is often based on the half-life of hypoglycemic drugs (Insulin, Hypoglycemic Sulfamide, etc.). Treatment must exceed the duration of action of hypoglycemic drugs.

+ Check electrocardiogram especially for elderly patients, coronary artery disease, hypertension.

THINGS TO DO

Handle immediately

No waiting for blood sugar results

Direct intravenous pump

Glucose ≥ 20%

Glucagon

Follow up after re-

Electrocardiogram of elderly patients

THINGS TO AVOID

Taking too long a medical history

Waiting for blood sugar results

Intravenous drip

Glucose ≤ 10%

Calm down if you struggle

Do Not Track

No ECG check

2. Treat the cause:

2.1. Related to diabetic patients:

+ Identify the conditions that appear: missed meals, foods containing little sugar, overdose of insulin, excessive physical activity but forgetting to replenish energy. Combined use of a drug that has the potential to increase the effect of hypoglycemic sulfamide drugs

+ Need to change treatment instructions:

- Change or reduce insulin dose, hypoglycemic sulfonamide dose.

- Adjust the energy composition of each meal appropriately.

- Adjust meal times, add snacks between main meals.

+ Sulfamide hypoglycemic drugs should not be prescribed for patients over 70 years old, especially drugs with a very long half-life (Chlopropamide).

+ Kidney failure and liver failure (increased sensitivity to hypoglycemic drugs).

+ Combining some drugs increases the effect of hypoglycemic drugs or by reducing the daily dose of drugs.

+ Do not apply ideal blood sugar balance standards in diabetic patients over 60 years old.

+ Attention should be paid to the Somogyi phenomenon causing secondary hyperglycemia in the morning due to hypoglycemia at night.

2.2. Treatment of diseases that cause hypoglycemia:

- Insulin-secreting pancreatic tumors: Surgery, Diazoxide (oral or intravenous) 300-1200 mg/day + diuretics. Octreotide subcutaneously 100-600 mg/day. Chemotherapy with Streptozotocine-5 fluoro uracile. Antihypoglycemia with glucose infusion and additional Sandostatine treatment.

- Extra-pancreatic insulin-secreting tumors: Surgery, treatment of hypoglycemia (difficult) with glucose infusion, continuous subcutaneous infusion of glucagon using an intermittent pulse pump.

- Patients with gastric bypass surgery: Educate patients and relatives about the signs and treatment of hypoglycemia. Glucagon and hypertonic glucose are always available at home. Divide meals into many equal portions. Reduce the type of rapidly absorbed sugar. Foods that combine protein and carbohydrates.

VIII. RESERVATIONS

+ It is necessary to educate diabetic patients and their relatives about hypoglycemia as well as how to handle hypoglycemia.

+ Treatment of hypoglycemia must be immediate, on the spot, using all possible measures before transferring the patient to the hospital. Do not wait for blood sugar results.

+ Note the hypoglycemic effect of some drugs when combined.

+ Avoid the idea that “sugar is the enemy” for diabetic patients.

+ The motto "DO NOT EAT, DO NOT USE HYPOGLYCEMIA MEDICINES. IF YOU USE HYPOGLYCEMIA MEDICINES, YOU MUST EAT" should be applied to all diabetic patients./.

C. CHRONIC COMPLICATIONS IN DIABETIC PATIENTS:

Chronic damage in diabetes is divided into two types: large blood vessel damage and small blood vessel damage.

1. Large blood vessel damage:

- Cerebrovascular disease: Diffuse cerebral atherosclerosis, hypertension causes stroke. The rate of stroke in diabetics is 2-4 times higher than in non-diabetics. The important characteristic of stroke due to diabetes is multiple cerebral infarctions, which are easy to recur, causing disability or death.

- Coronary artery disease: Diffuse coronary fibrosis, along with autonomic nerve damage, causes diabetic patients to have threatened coronary artery disease or myocardial infarction without typical clinical manifestations such as angina. Patients with threatened or infarcted diabetes may only feel tired, have low blood pressure, and then die. This is a characteristic that needs to be noted in diabetic patients.

- Vascular disease of the limbs: Diffuse fibrosis, along with hypercoagulability, causes ischemia, embolism, and limb necrosis. Along with peripheral nerve damage, it is the leading cause of amputation and disability in the United States.

2. Small blood vessel damage:

- Diabetic retinopathy: Diabetic retinopathy has many levels: non-proliferative, pre-proliferative, proliferative, retinal hemorrhage and exudation, along with an increased risk of cataracts, causing blindness. Diabetic retinopathy accounts for 21-36% of type 2 diabetes patients and the risk of affecting vision is 6-13% (according to IDF 2005).

- Diabetic kidney disease: Glomerular fibrosis causes diabetic kidney disease, the earliest is the appearance of microalbumin (beginning of kidney disease), then the appearance of macroalbumin (actual kidney disease). If not treated, it will gradually progress to kidney failure at various levels. Kidney disease accounts for about 20-30% of diabetic patients (according to IDF 2005).

- Peripheral neuropathy: Peripheral nerve damage causing paresthesia, numbness, loss of sensation, loss of ability to adjust, postural hypotension, foot deformities, ulcers, gangrene is the leading cause of amputation in the US.

- Autonomic neuropathy: Parasympathetic nerve damage causes rapid heart rate, intestinal paralysis causing constipation alternating with diarrhea. Bladder nerve damage causes difficulty urinating, urine retention causes infection...

Doctor Nguyen Van Hoan (Director of Nghe An Endocrinology Hospital)