Aeromedical Concerns for the diabetic patient

TC4 AVMX 721 Sundaresan Maiyalagan 15th May 2012

Content Overview
Introduction Current definition and classification of Diabetes Complications and its implications for aeromedical transfer Aeromedical concerns with management of blood glucose levels General advice for passengers flying with diabetes

Introduction
171 million people in the world with diabetes mellitus (DM) in the year 2000 and this is projected to increase to 366 million by 2030 8.3 percent of the U.S. Population In Mauritius the prevalence is as high as 15% (2004 survey) Multiple associated complications and co-morbidities Heterogeneous population with a varied range of disease spectrum

Current definition and classification

Current definition and classification

Complications and its Implications for Aeromedical Transfer

Acute consequences of impaired glycemic control Hypoglycemia, Ketoacidosis and hyperosmloar non-ketotic hyperglycaemic coma Stiff Joint Syndrome and associate difficult laryngoscopy
Cardiovascular complications - Silent MI, Cardiomyopathy Diabetic Sensory and Autonomic Neuropathy Diabetic Retinopathy and Cerebral Complications Diabetic Nephropathy

Impaired wound healing and immunity

Complications and its Implications for Aeromedical Transfer

Diabetic Autonomic Neuropathy effect on various organs Cardiovascular Resting tachycardia Exercise intolerance Orthostatic hypotension Silent myocardial ischemia GI Esophageal dysmotility Gastroparesis diabeticorum Constipation Diarrhea Fecal incontinence

Complications and its Implications for Aeromedical Transfer

Diabetic Autonomic Neuropathy effect on various organs
Genitourinary Neurogenic bladder (diabetic cystopathy) Metabolic Hypoglycemia unawareness Hypoglycemia-associated autonomic failure Sudomotor Anhidrosis Heat intolerance Gustatory sweating Dry skin

Complications and its Implications for Aeromedical Transfer

Diabetic Autonomic Neuropathy effect on various organs
Pupillary Pupillomotor function impairment (e.g., decreased diameter of dark adapted pupil) Argyll-Robertson pupil like phenomenon

Respiratory Impaired response to hypoxia and hypercapnia

Aeromedical Concerns With Management Of Blood Glucose Levels

Oral Hypoglycaemic Drugs and Insulin administration

Blood Glucose monitoring

Aeromedical Concerns With Management Of Blood Glucose Levels

Oral Hypoglycaemic Drugs and Insulin administration
Timing Maintaining bioactivity of insulin Insulin pumps and aeromedical transfer
Picture of the Minimed Paradigm 722 (Insulin pump device, Medtronic)(A), with the continuous blood glucose monitor (C) and transmitter (D), and the infusion set (B).

Aeromedical Concerns With Management Of Blood Glucose Levels

Oral Hypoglycaemic Drugs and Insulin administration
Timing Maintaining bioactivity of insulin Insulin pumps and aeromedical transfer
(Bruce R King et al . Diabetes Care 34: 1932-33, 2011

The cartridge should only contain 1.5 ml of insulin Disconnect the pump before takeoff At cruising altitude, take the cartridge out of the pump and remove air bubbles before connecting After the plane lands, disconnect the pump and prime the line with 2 units. Then reconnect the pump. During flight emergencies involving cabin decompression, disconnect insulin pump.

Aeromedical Concerns With Management Of Blood Glucose Levels Blood Glucose monitoring
Availability Variability

Effect of altitude on glucometer performance

Patricia L Brubaker. Adventure Travel and Type 1 Diabetes. Diabetes CARE 2005; 28 (10): 2563-72

Aircraft regulations regarding use of Continuous Glucose Monitoring devices

General advice for passengers flying with diabetes

Two blood glucose monitoring devices, with extra batteries, packed in separate bags Enough insulin, syringes, lancets, and test strips to last the entire trip For pump users, enough pump supplies for the entire trip, extra batteries, and supplies of long-acting insulin (ultralente or glargine) and regular or rapid-acting insulin analog (lispro or aspart) and syringes for use in case of pump malfunction or battery failure Prescription medicines (including a glucagon emergency kit), for diabetes and other medical conditions

General advice for passengers flying with diabetes

Simple carbohydrate sources, such as glucose tablets, gels, candy, and nondietetic soft drinks to relieve symptoms of hypoglycemia Complex carbohydrate sources, such as breakfast bars, cheese crackers, granola bars, and trail mix to serve as snacks when meals are missed or delayed Regular insulin or short-acting insulin analogs for treating high blood glucose and for sick-day management even if these are not part of the patients regular regimen Identification (diabetes identification card, Medic Alert necklace or bracelet)

General advice for passengers flying with diabetes

Insurance papers (Confirm before travel what medical coverage is available from the insurer in the event of a medical problem abroad.) Medications for vomiting and diarrhea A first aid kit, including analgesics, antibiotic and antifungal creams, bandages, sterile gauze, and adhesive tape

Conclusion
In conclusion, patients with DM are a heterogeneous population, but there are key areas where the aeromedical team must focus and be prepared with regards to type of diabetes, the associated complications, management of blood sugar levels and the effects of aeromedical transfer

on these areas in order to ensure a safe and effective

aeromedical transfer of patients with diabetes.

Thank You
TC4 AVMX 721 Sundaresan Maiyalagan 15th May 2012