Computer generated transcript

Warning!
The following transcript was generated automatically from the content and has not been checked or corrected manually.

Hi and welcome back to the Prescribing in Surgery series. Um, my name is Hermione. If you haven't met me before, um, today we're gonna be covering diabetes medications, but before we start, we have a guest with us, uh, Daniel, who's going to give us a few words and he's from the BMA. So I'll just hand you over to him for a little bit. Thank you for my, uh, just share my screen real quick. Um. Ok, cool. There you go. All right. Uh, I'm sure everybody you're watching is, is a membership. Um, so, so don't worry too much about this. Um, but yeah, for anyone who anyone who's not currently, um, if you use that link that I put in the chat and also the QR code on the screen, um, if you join slash rejoin the BMA, er, you'll get your first month membership free. Um, this is a bit of an exclusive for, for mind the bleep. Um, so yeah, you won't find this online anywhere else. Um, so yeah, take advantage of it if you're watching that on repeat as well, it, it should still work. Um, as long as it's not sort of five years in the future. Um, so yeah, go, go for it. Um, so yeah, I'll talk ti just a tiny bit before you start the session. So, um, mainly giving a bit of an update on sort of what's the lay of the land is at the moment. Um, in terms of strikes, not, not too much, um, to, to update you with, um, on this current day. Um, but yeah, just, just a reminder of what, what we do. Um We obviously your union um when time has passed, we sort of get a bit of confusion between um us and, and, and indemnity companies. So people like MDU mps. Um So, yeah, so it's just always worth reminding that um we're sort of the non clinical side of things. Um So anything sort of pay related, um sort of relationships between colleagues, that kind of thing. Um It's us, anything clinical is, is um sort of a MD mps sort of side of things in indemnity. So three ways of looking at us as your union, um we can help on an individual level. So things like your contract um contract checking, I'll, I'll go on to, to looking at so your individual sort of side of stuff, um local issues. So say you're a group of F two S um you were sort of facing a similar um rotor problem or something along those lines. Um We have people on the ground every trust, so we can help, um, sort of trust level. So that's sort of the local side of things. Um, and then obviously on a national level there's what's going on with the strike. So, yeah, 33 ways of looking at, looking at how, how we, how we can help you. Um, so yeah, just a bit of an update on, on what's going on at the moment. Obviously, today is the final day for, um, the re ballot for Juniors. Um So the cut off date for sending the the envelopes back was um Friday. So yeah, we should have an announcement on, on that result. Um early next week, I'd imagine. Um we, we, we have them counting pretty quickly. Um So yeah, so, so tomorrow is the final day. Um It's looking like like it's gonna be AAA A a big turnout once again, obviously, the last two re ballots. Um w what, sorry, the last Reba and the ballot for that um were, were similar. Um I can't give you any news on any strike date scores cos we don't have the mandate as we speak, but obviously next week when we get that mandate back, um that means we can start planning um more strikes if, if the government continues to not talk to us. So I imagine the next round of strikes would be at the end of April at the earliest. Cos we always have to give sort of a free week um notice period, I am consultant. So, but that's just my take on it. It doesn't necessarily mean there will be any strikes at the end of April. By the way, it's just you can sort of tell, everybody can sort of tell by the the pattern of things how things have been going. Um So the consultants are, are currently voting on an improved pay offer as well. There was that marginal no vote um in January, I think it was 51% to 49%. So uh uh and improved offers come in. So we imagine that will go through. Um They haven't till the third of April to vote on that. Um And then, yeah, that would be sort of the first um I wanna say first domino because it's, it's different what, what's going on with the consultants, the juniors there, there's sort of needed tweaking whereas we're looking to sort of overhaul pay and look for something a lot bigger um in terms of percentages for, for, for juniors. Um But yeah, so, so keep an eye on on the consultants um pay offer. So again, we should have results pretty quickly after the third of April um on, on whether that's it. Yes, voting for that offer. Um So yeah, just, just quickly, just round off of just a, a few other things that we can, we can help you with day to day. So there are some of the sort of frequently asked questions that we, that we get on the screen. Um We, we solve, we solve pretty much every, every case that comes in within three months or 85% of, of of cases. Um 22,000 new doctor cases, junior doctor cases alone. Sorry, we managed in 2023. Um So yeah, so just think about the first point of call um for any issues you might have. I know that um hr s aren't always very forthcoming with, with answering queries and, and sorting things out to you so you can get as well. We do have people on the ground. Um, every trust across the country contract checking. I mentioned this earlier. 25% of the contracts we checked last year were, were wrong in some way often it's the wrong pay. Um So even if you've got your contract now and you're quite happy with it, you can just send it to us any time and we'll just check and if there is anything and you are owed anything, um, then then we can help get, get you any money back or, or get that contract changed. Um Retrospectively. Um It doesn't necessarily matter if you've signed the contract because if you're given something wrong, then it should have been wrong in the first place. So you're not buying just because you've signed it, we negotiate the contracts for, um, for doctors in the UK for better or worse. Um So we know what should be in them and we didn't, we didn't negotiate them just so they could be tweaked and, and you could be tricked. Um So yeah, so always worth getting it checked. Um Ro checking as well should be more standard. I'm sure if you, you'd know by now if you wrote was possibly incorrect, but again, it's something that we can check and, and look over if, if you're unsure, you just wanna expect to get it checked. Um BMA library. So BMA library has moved entirely online now. We also used to have the library um in Central London, but everything's sort of turned into. Um it's a, it's an E library essentially now, but you can still go to BMA House if, if you're a London based um to sort of the study space and whatnot, clinical key, that's AAA point of care tool. Um breaks down um conditions, gives you videos, links to all journals and books related to anything. Um So yeah, really useful to, to use standalone app. Um It's his own thing, but you log in through, through your BMA credentials. We run a series of webinars as well. Um throughout the year which, which you can watch B MJ learning obviously um obviously free as part of part of your membership and the B MJ, it's worth knowing that if you wanna switch the BM Js off, you can do just by giving us a quick call and saying I'd rather read them online because you have access to them now, especially explor at all. Um So yeah, it is essentially a psychometric test. Um If you guys are thinking about um what, what specialty to go into? This is essentially um a, a little test which will, which will break down at the end. Um All the specialties that was to you according to the answer you've given um and it gives you lots of pie charts and, and, and graphs and reasoning why such specialties will suit you. Um We've got a good wellbeing service um confidential, of course, of, of the, of the trust uh that you, that you're working at. Uh the unique thing about this webbing service is that you can speak to either a counselor or, or a peer support doctor. Um So somebody who's perhaps been through similar situations to you and, and is a doctor themselves. Um So yeah, free to use um for everybody, regardless of whether you're a membership, a member or not. That's it. Um I'll, I'll let you get on the session, I'll pass you back to Hermione. Um And yeah, thanks for listening and yeah, that's it. Thank you very much. Ok, great. So I can get going with this now. So just a few things to say about today, there are lots of guidelines on diabetes and they do vary from trust to trust. Um So just to be um aware, you should always check your local policies and follow your hospital guidelines. Um And the other thing says, I know sometimes it can feel a little bit one sided with these webinars. So to address that if you have any questions or any discussion points, please put that in the chat and we can do our best to explain any of the answers. This is the calendar for the next half of the series. So just a note here that there are two weeks off, um, until the next webinar, which is on the ninth of April. Um, before we start, I thought we'd just go back to basics with insulin and other oral hypoglycemic medications. Um, so type one diabetes occurs when your pancreas makes small amounts or no amount, no insulin. Um, just to recap on that, it's a hormone producing in your pancreas that helps you store your sugar from your food. Um And obviously, if you don't have any, you're not making any, then we need to replace it. So that's what we do with insulin. Um, just providing exogenous insulin to prevent your hyperglycemia. This is some of the brands that are commonly used. So the short acting ones, um, up here in Scotland, we use Novorapid. Um, but there are plenty of other ones, intermediate acting acting ones. Uh HumuLIN is the one that I'm most common with. Uh, but there's plenty of other ones and long acting ones here, Lantus, Levemir and Tresiba. And again, just to recap on the modes of insulin as well. So we've got the pens that have premeasured amounts of insulin, um, insulin pumps which are automated and syringes which are sometimes used um to draw up the specific amount. Ok? And then just to recap this graph, which I'm sure you will see in plenty of times as well, just to remind you of the durations of various insulins. So rapid acting, that's what it says on the label. Um It acts very quickly within 5 to 10 minutes. Uh So we normally use this before meals. So it's the insulin that patients will need just before meals as a quick burst of insulin to deal with the carbs from the upcoming meal. Um And in hospital, this is the kind of insulin that we prescribe um before meals. Um and it's dose dependent on their blood glucose and how many carbs they're eating. Um So for example, you might be prescribing two units of novorapid before breakfast. Um short acting is very similar to rapid acting, but it takes a little bit longer to work, which you can see here. Um Normally 30 minutes to an hour. Um and normally if you're taking a rapid or short acting insulin, you'll also be taking a background insulin. Um So that's either intermediate or long acting insulin. Um So if we start with intermediate acting, uh you can take this once or twice a day, usually in the morning and the evening, long acting insulin is slower than that. So it takes 1 to 2 hours to work. Um, and again, you normally take it once or twice a day. And a good thing to know about these background insulins is that they're commonly used in type two diabetics as well. Um, who sometimes have enough insulin on their own. Uh, but they need a sort of top up. So they have this morning and evening regime. Um, and there are such things as mixed insulins which you probably heard of before. Um, and they're a mix of the intermediate insulins alongside your shorter acting ones. So it can be taken before meals. And brand names include things like HumaLOG, just so you're aware before we get started. Um, one more slide before we get into the questions that summarizes most of the type two diabetic medications that we see in hospital. Um, so not only are there different rules for them with surgery but they also have different side effects and contraindications. Er, so it's just a chart to be aware of. Ok. So into the first case, we've got a 56 year old lady who's admitted for an elective cholecystectomy following a diagnosis of gallstones. The surgery is planned for tomorrow afternoon. Um, so she will be fasted for both breakfast and lunch. Past medical history includes bilary colic and meniere's disease. She takes atorvastatin insulin and betahistine and that's her insulin regime. So the question is on the day before the surgery, what insulin regime would the patient get? Ok. So we've got a few answers here. So the answer here was a, um, the key with this question is that it is the day before the surgery. So we can assume she's still eating and drinking normally. Um, we continue the rapid acting, um, as it's normal and we give 80% of the long acting insulin, which is why it's 12 units. Ok. Any questions about that. So just to recap on this, this is uh, the B NF, it's got the page on diabetes, drugs and surgery, which is very useful. Um It's advising us here to give 80% of the normal background insulin. So that would be naught 0.8 times 15, which is what gives us our 12 for our 12 units of Lantus. Ok. Ok. So moving on same case, the patient's been given 80% of her Lantus dose and her normal short acting incident the day before we're now on the day of the surgery and her blood glucose is 5.6. She's due to go into surgery around 2:30 p.m. And so she has fasted for at least 12 hours before. So a few things about this before answering the question and feel free to put this in the chat. What were we thinking about with this surgery? So we need to think about when the surgery is. So how many meals are being missed and what her blood glucose have been like and what her normal regime is and just to recap you of her previous um regime, it's novorapid four units, three times a day and Lantus 15 units once daily. So the question for this is on the day of the surgery, what insulin regime would you prescribe? So I'll put that up in the poll now. Great. So the answer here is e so again, we're giving 80% of the Lantus. So that makes it 12 units instead of 15. And we're stopping the short acting insulin because she's gonna be fasting for 12 hours. So she'll miss at least tw uh two meals, sorry. Um And we're gonna start a variable rate insulin infusion. So this just shows where we've got this information from again, the B NF. So the key things to consider here are the fasting time here. It says that you'll need a variable rate insu insulin infusion if they're missing more than one meal or if their diabetes is poorly controlled. Um below that. So still keeping the patient on 80% background insulin. And then on the right hand side, we have some information about variable rate in insulin infusions, which we're gonna spend some time going through in a little bit. Does that all make sense? Any questions? Ok. So we're gonna talk a little bit about variable rate insulin infusions um because they're quite a hot topic in the surgery. So it's really worth getting a solid understanding of them if we start from the beginning, um with what they are, um it's an IV insulin infusion of a variable rate according to um regular capillary blood glucose measurements. With the aim of controlling serum glucose levels within a specific range. So it's also important to remember that they must be accompanied by an infusion of fluid containing glucose. And that's to prevent hypoglycemia in that shell. If you start a her insulin infusion, you've gotta make sure you've got a bag of fluids with glucose alongside it. And that makes sense. If you think that the patient's probably gonna be fasting or not eating, normally, you're gonna need to give them some glucose or they'll have an H A hypo. Ok? Um, indications for viral rate, insulin infusions. So anyone with diabetes or high blood glucose sugars, sorry, anyone with diabetes or high blood sugars in hospital who can't take any fluids or flu food, anyone who's fasted for a prolonged period of time. So anyone going in for a, a prolonged surgery, if they're vomiting or ill by mouth. So this could be found with an obstruction, for example, and anyone with severe illness where it's difficult to manage their sugars. So your classic patient is one who's septic or perhaps um a hypoactive delirium. So I've made a quick table to cover the pros and cons pros. Obviously, you are able to manage blood sugars with which aids with your clinical outcome er cons, they need hourly CBG S and it can cause hypos or hyperglycemia fluid overload and electrolyte imbalances. However, if we try and manage the variable insulin infusions, um you hopefully don't need to worry too much about those. And then this is just the B NF guideline. So it tells you how you're making up an insulin um infusion. So you're gonna uh put in the insulin with some sodium chloride. This would not be a nurse doing this. Um And you need hourly BMS for the 1st 12 hours. Um and you can change the rate of insulin according to the BMS. And we're aiming between 6 to 10 minimal per liter. OK. So this shows a trust guideline for a variable rate insulin infusion. I've said it before and I'll say again, always use your own guidelines. Um But this one is nice because it gives you some indications which we've covered. So it's also used in a CS with poor glycemic control and after strokes. Um But here we're focusing on surgery. Um There are a few exclusions to know about on the right hand side. So ICU pregnancy peds and people with DK or HHS. And there's some guidance at the top here, just remind us to continue using our background insulin at 80% get diabetes involved if you have any concerns um and the contents of the infusion. So here they are using actrapid. So you dilute 50 units of that with 50 mL of naught 0.9% saline. So your concentration is one unit per mill. Again, some trusts use different insulins um but actrapid is quite common and then on the bottom left, there is some guidance on fluids to give alongside. So this varies the most between trusts. Um Normally it's a mix of sodium chloride with some dextrose plus or minus some potassium, er depending on the level. Um in Scotland, we normally give naught 0.9% saline with 5% dextrose. Um And then we add the KCL in alternating bags of fluids. So just double check what your guidelines say for that. Um And final note on TPN. So if a patient is on TPN, er, they don't need to have the same number of regular bags of fluids because they'd be receiving glucose and electrolytes in that TPN. Um And then just say we normally set the rate between 7 to 100 mils per hour for the fluid. So here they've said 80 mil per hour. So that's your fluids that gonna be running alongside your variable rate and insulin infusion. Ok. And just to run over setting uh them up. So we've mentioned you can use different fast acting insulins and you make it up to a concentration of one unit per meal. Of note, they have to be changed every 24 hours. Um So they are quite intensive for the nurses. Um and the variable rate insulin infusion needs to be prescribed, there's usually a pre specific prescription chart for them as well and important to touch on. There are three different rates that you can normally have. Er, the standard, one is the one in the middle. You can have a reduced rate for those who are on, who are insulin sensitive or have a reduced clearance. So, those with renal or heart failure or frail elderly patients, um, and then there's a higher rate for those who are insulin resistant. So on the pres prescription chart, depending on your blood glucose, um results, it may recommend that you move someone up or down a scale. Uh So for our protocol, if the blood glucose is more than 11 on two consecutive readings, then you'd want to be switched to a higher regime. And the specifics of the of these range from trust to trust. So for example, another trust recommends increasing the scale if the glucose is more than 12 for three consecutive readings. So just get familiar with your own guideline as always. And again, there's lots of monitoring required every hour for the 1st 12 hours at least. And we like to use a dedicated Cannula for the variable rate insulin infusion. So they're gonna always need at least two Cannulas in one for that variable rate insulin infusion and one for the fluids. And it's important to know that you'll need to be ordering daily bloods. Um cos they need to use and these done to just check their electrolytes aren't arranged. Mm sorry. Um And finally I know I've just touched on it but just to mention again that um you don't need to be giving the exact same number of fluids with glucose. Um if you had a any kind of enteral or parenteral feeding, so anything via um an NGN J A peg. Um and it's really important to be extra vigilant if patients are coming off enteral or parenteral feeding because if it's stopped, it can then lead to a hypo cos they're no longer receiving that glucose. Um So they would then need to have a mixed bag started. Ok. This just shows you what some of the protocols look like and what they recommend for dosing. So below four, we want to be treating hypoglycemia apologies in the middle there. We can see the dosing varies slightly uh depending on the scale and what your um CBG S are. And this just shows us what the monitoring sheets look like. And obviously it won't be all the same but something similar to this. Um So it has where your CBD S are recorded, which scale and how much insulin they're being given. Um And then you'd also have to have the prescription alongside that before we move on about any questions about variable insulin infusions. No. Ok, great. We'll move on then. Ok. So this is part C so our lady has been converted onto a variable rate insulin infusion and she undergoes surgery. Um So her surgery is successful and postoperatively, she has some vomiting and nausea. She's prescribed some morphine sulfate and some Ondansetron, she remains on the variable rate insulin infusion and her BMS and ketones are normal. So our next question is, when should she be converted back to regular short acting insulin from the variable rate insulin infusion? Ok, great. So lots of people got the answer here. Um The answer is c um if anyone has any questions about this, please let us know. But um essentially we need to ensure that she's eating and drinking properly um, before she can come off it. Um And this is a really good flow chart that just shows when we should be switching people from a variable weight into an infusion back to the normal regime. So the first question is if they're eating and drinking without nausea and vomiting and the concern here is that if they're vomiting, obviously, that's an issue for glucose control. If they're nauseated, we've gotta wonder if they're actually gonna be eating properly. Um So if you're eating and drinking well, um with no nausea or vomiting, then you can be switched back um for her, she was on insulin. So the guidance here suggests we resume her normal long acting so she can go back to her 15 units. Um We should continue the variable rate insulin infusion until an hour after she's received her insulin to make sure she's covered and we can resume her short acting with the next meal. And again, from trust to trust, I'm sure they'll have something similar to this that you can look up if you ever forget. And this is just to reassure you all that, this information can be found on the B NF if you're not sure what's going on. So it gives you your conversions back from er, variable rate insulin infusions and when to start them. OK. Moving on to case two. So here we've got a 48 year old male who's admitted with necrotizing fasciitis of the leg. Um and recurs urgent debridement under general anesthetic. These are his obs so he's got a temperature, he's tachycardic and he's got a bit of hypertension. There. Past medical history include type two diabetes, hypertension and angina and drugs history. He takes a gliclazide, 80 mg, amLODIPine, 10 mg, GTN as needed. Aspirin, 75 mg and atorvastatin. So the question here is, what would you do with the gliclazide? So it sounds like an emergency, sad, isn't it? So I'll put this pole up for you. Mm OK. So you got a bit of a spread here for answers. So the correct answer is d so we're gonna want to withhold the gliclazide from the morning of the surgery. So, unfortunately, his medication chart is not reviewed and he receives his gliclazide whilst an inpatient two days postoperatively, he becomes nauseated and fatigued. He's got some blurred vision and a new headache. Um, so looking at his abs here, he's pale, shaky and weak. He's got a irregular heart rate and is tachycardic. He's mildly hypertensive and has new confusion. Chest is clear and no temperature. What is the likely cause of his presentation? Ok. So it looks like quite a lot of you got this one right. The answer here is c so, um, these are classic symptoms of hyperglycemia. So he hasn't got a temperature. Um So the first line of call wouldn't be sepsis in my and he's got his confusion. He's got irregular heart, ra heart rate. He's pale, shaky and weak and he's been given his gliclazide when he shouldn't have been. So again, we've got a slide here showing the B NF. So this is linking our sulfonal ura. So our glycoside in this scenario, um associated with hypos if they're not admitted on the day of surgery. Um So these are some of the symptoms of hypos to be aware of in our patients case, it's very severe, severe um because he's got this new arrhythmia. Um So he would need urgent IV glucose. It's just a sort of show you how much of a effect these drugs can have if we don't give them on the right day. Ok. So case three, we've got a 37 year old female, she's admitted for an elective minor operation in the ent department. She's having a tonsillectomy and should be able to be discharged home on the same day. She has asthma and type two diabetes and her drugs include salbutamol and SITagliptin. So the question here is, what changes would you want to make to her diabetes medications during the surgical period? So, the pole is now. Ok. So the answer here is d so he'd want to give it as normal apologies. So, I've got a horrible cough. So, anyone in the chat, which oral hypoglycemic agent is this? Does anyone know what type of drug a SITagliptin is? Yeah, exactly. So it's DPP four inhibitor. So, um this is one of the drugs that we can continue as normal. So as the fasting time is short, this is a minor procedure, some agents can be continued. So here this is B NF shows our DPP four inhibitors and our G LP one receptor agonist can be taken as normal. Ok. So moving on to case four, got a 42 year old female who's presenting with appendicitis. So she's admitted for surgery and uh for the following afternoon and she fasts from midnight. She's type two diabetes, obesity, hypertension and iron deficiency anemia. She takes ferrousfumarate, ramipril and Metformin twice a day looking at her blood. So she's mildly anemic. She's got a raised white cell count and C RP. So it looks like she's got an infection and urea is normal. Creatinine is raised, eg fr is down. So how would you manage her glycemic control. OK. So that Paul is now in the chat as well. OK, great. So, oh, so you got this one right? A is the answer here. So we want to stop the Metformin before the fast and we want to start a variable rate insulin infusion. So the important factor here to have recognized is her low renal function. So her creatinine is very high, 100 and 91 and her EGFR is only 28. So I think this question warrants some explaining. We've got the management of Metformin um here and it varies based on a few factors. So we've got renal function. We've got the length of the fast and the regime of Metformin. So once daily versus twice daily or three times a day. So um guidelines from the BNF here on the right hand side. So if you've got a good renal function and a short fast, you can actually continue the Metformin. If you've got a long, fast or reduced renal function, then you need to withhold the Metformin. So this is the case for our patient and only if they're on a BD regime, um which is withheld, then you need to start a variable rate insulin infusion. And our concern for the lady here is lactic acidosis due to the accumulation because of her renal impairment. OK. Any questions about that? OK. So question five here, we've got an 81 year old gentleman who's had a fall. He's admitted with a ne a feur fracture. He is due to undergo surgery tomorrow. All of his medica medications are continued and he has started on morphine, sulfate, paracetamol and codeine. He's got congestive heart failure. He's got type two diabetes, co PD, osteoarthritis and depression. Here is a list of his meds including fursemide dapagliflozin foster inhaler, salbutamol, cholecalciferol, sertraline and alendronic acid. And our question is what medical issue are we concerned about postoperatively? Given all these medications have been continued during the surgical period? Ok. So the answer here is b it is euglycemic ketoacidosis. So, the SGL T two inhibitors are the main culprits for you glycemic ketoacidosis during surgery. Um So they should always be admitted and only restarted when a patient is stable and eating and drinking is normal. And this is from the B NF. Um just highlighting that issue just to run through your glycemic ketoacidosis. So, symptoms are similar to DK A. So you can get nausea and vomiting abdominal pain, but sometimes they can have no symptoms as well. Trial of signs that we're looking for. So, normoglycemic, they have metabolic acidosis. So they're gonna have a low Ph and they're gonna have reduced serum bicarb and they're gonna have raised ketones. Um And we manage it similarly to DK A. So you gotta follow your local trust protocol as always. But um yeah, in essence, we're stopping the offending drug. So we wanna stop the SGL T two inhibitor um, we continue the background insulin and we give them fluids and insulin and we want to monitor their BMS and their electrolytes and replace as needed. Ok. So the final case, I think we have here, oh, maybe not. Um, next case even, er, is a 32 year old female who's been in hospital for an appendicectomy. So she's type one diabetes which is usually controlled solely by insulin before meals. So that uh rapid acting, her insulin has restarted postoperatively when she is eating and drinking postoperatively, she is reviewed and is found to be hyperglycemic. So on examination, she's maintaining her own airway, she's got equal air entry, she's warm, well perfused. Her cap refill time is normal. Heart sounds pure and regular pulse. G CSE G CS is 15 out of 15 and her capillary blood glucose is found to be 18.5. Abdomen is soft, non tender calves are soft, non tender. So in this case, we've got a patient who's hyperglycemic maybe cos that incident has been withheld. So how are we gonna manage her hyperglycemia? Yeah. Ok. So I think most people have answered and the answer here would be c so we want to give four units of novorapid. Mhm. So this just explains my thinking in this scenario. So again, correctional doses can be varied from trust to trust and depends on which agent you're using. Um but with this guideline as her blood glucose is more than 18.1 she's gonna need four units. Um So as a general rule, one unit of rap, rapid, a rapid acting um should aim to drop the blood glucose by about 2 to 3. So that would bring her BM down to about 10. So this flow chart also just explains how to manage an onw patient with hypoglycemia. So we always wanna check the ketones and rule out DK A and HHS. And if the patient is well, then you can give correctional doses, um, you can always get diabetic help. Um If you wanna change their sort of background or basal insulin, just a summary of what we've covered today. Um, always use your own trust guidelines and if you are struggling in hospital, um, the diabetes teams are always on a bleep so they can come and review your patients and help change any of the medications as well. And these are my references as well. Um And uh looks like the feedback forms have been sent to the group chat. Thank you. Um So thank you for filling them in as always, really appreciate your feedback. Um And we look forward to doing some more sessions with you in the coming weeks. Thank you very much for.