1: Endocrine - DKA, T1DM, T2DM, MODY Flashcards
What is the criteria for DKA in children
Acidosis:
- Bicarbonate >15
- pH <7.3
Ketonaemia:
- Serum ketones >3
- Urine ketones: ++
What type of diabetes occurs in children
T1DM
What is a method to remember triggers of T2DM
5I’s
What are 5 triggers of diabetes mellitus
Infection Intercurrent illness Intoxication Infarction Insulin withdrawal
What are 5 symptoms of diabetes mellitus
- Abdominal pain
- Nausea and vomiting
- Kussmaul breathing - with acetone breath
- Dehydration
- Reduced consciousness
What should happen to a child with blood-glucose >15 and symptoms DKA
Refer to paediatric acute assessment unit
when should a child with known diabetes be referred for DKA assessment
Measure capillary glucose if:
- Polydipsia
- Polyuria
- Excessive fatigue
- Tiredness
and symptoms DKA
what defines mild dehydration in DKA
3% weight-loss
what defines moderate dehydration in DKA
5%. weight-loss, reduced skin tutor, dry mucous membranes
what defines severe dehydration in DKA
8% weight-loss
Sunken-eyes
Reduced capillary refill
Explain DKA
- Absence of insulin causes lipolysis
- FFA produced enter ketongenesis to form ketone bodies
- Ketones reduce pH of blood causing metabolic acidosis
What investigations are required for diagnosis of DKA
- Capillary blood-glucose
- Serum ketones (B-hydroxybuterate) or urinary ketones
- Venous blood gas
What are criteria for admitting DKA patient to HDU
- Under 2-years
- pH <7. 1
What is first-line for management for DKA
Fluid resuscitation
How should fluid be replaced and why
Replace fluids over 48h, any quicker than this increases risk of cerebral oedema
What time-frame should resuscitation fluid be replaced in cerebral oedema
48 hours
How is ‘maintenance fluid’ calculated in DKA
(Maintenance + Fluid Deficit)/48
What is fluid deficit for mild DKA
5%
What is fluid deficit for moderate DKA
10%
What should be added to maintenance fluid in DKA
KCl (Potassium) 20mmol/500ml
When is insulin given in DKA
1h after fluids started
Why is insulin not given earlier than one-hour
Increases risk of cerebral oedema
What insulin is given
Actarapid 0.1 unit/Kg/h
What is done when glucose drops below 14
Continue 5% dextrose and insulin
When is IV insulin stopped in DKA
Ketones less-than 1 and can tolerate oral food
In which population does cerebral oedema only tend occur
Children with DKA
What are 5-symptoms of DKA
- Drop in HR
- Increase in BP
- Headache
- Agitation
- Oculomotor palsy
- Unequal pupils
How is cerebral oedema in DKA managed
20% Mannitol
What is T1DM
Autoimmune condition caused by production autoantibodies to B-islet cells
What age does T1DM tend to present
5-7 years and prior to adolescence
What is a risk factor for T1DM
FH
Explain symptoms of T1DM
- Polyuria
- Polydipsia
- Lethargy
- Nocturnal enuresis
- Weight loss
What is a common symptom of T1DM in children
Nocturnal enuresis
How may T1DM present
DKA
How soon should a child with suspected T1DM be seen in secondary care
If suspect a child to have T1DM requires same-day referral to paediatric diabetes team
What is the diagnostic criteria for T1DM
Child with symptoms requires one-of:
- Fasting plasma glucose >7
- Random plasma glucose > 11.1
- OGTT > 11.1
If no symptoms, what is the diagnostic criteria for T1DM
Requires two of:
- Fasting plasma glucose >7
- Random plasma glucose > 11.1
- OGTT > 11.1
What value of fasting plasma glucose diagnoses T1DM
> 7
What value of OGTT and RPG diagnoses T1DM
> 11.1
What test is not appropriate for diabetes in young-people
HbA1c = it is NOT used to diagnose T1DM or young-people
Explain use of C-peptide to diagnose T1DM
C-peptide should not be used in the first instance to diagnose T1DM
What is conservative management for T1DM
Advice on:
- Diet and exercise (dietician)
- Taking insulin
- Sick day rules
- Monitoring BG
How often should a child with T1DM have dental exams
Regularly
How often should a child with T1DM have dental reviews
2-years
What vaccines should all individuals with T1DM be offered
Pneumococcal
Annual Influenza
If someone is ill, how often should they monitor their blood glucose
4-hrly
What are the sick day rules for T1DM
Continue taking insulin
Why should insulin NOT be stopped if ill
Illness increases glucocorticoids, which increases blood-glucose. If stopped can precipitate DKA
How is T1DM managed
Insulin
What are the three three insulin regimens for T1DM
- Mixed daily bolus regimen
- Novomix
- Continuous SC insulin
Explain multiply-daily basal bolus insulin regimen
- Short-acting insulin is given TDS 1h prior to meals
- Long-acting insulin is given once
Explain second insulin regimen
Novomix (Intermediate acting insulin) given twice a day
What is continuous subcutaneous insulin
A pump is fitted that gives continuous SC insulin
When is continuous SC insulin recommended
Children and adults over 12-years
What regimen is offered first to children with T1DM
Multiple daily-dose basal bolus regimen
What are insulin requirements in childhood
0.5 Units/Kg
What are insulin requirements in puberty
1.2- 2.0 Units/Kg
What are insulin requirements post- puberty
0.7 - 1.2
What 4 things do children with T1DM need to be monitored for
- Thyroid disease
- Diabetic retinopathy
- A:Cr
- HTN
When does monitoring for thyroid disease occur
Diagnosis until adult care
What does monitoring for A:Cr, diabetic retinopathy and HTN occur in T1DM
> 12-years
What are 3 acute-complications of T1DM
- Hypoglycaemia
- DKA
- Delayed puberty
Explain microvascular complications
Can occur in childhood and adolescence. But, rare to occur before puberty
What are microvascular complications
Renal: Diabetic nephropathy, microalbuminaemia
Eyes: Diabetic Retinopathy
NS: Peripheral Neuropathy, Autonomia Neuropathy
What are mascrovascular complications of diabetes
CHD
Stroke
What 3 conditions are associated with T1DM
- Thyroid
- Coeliac
- Addison’s
What is T2DM
Condition due to peripheral tissue insulin resistance
Explain age T2DM tends to present in
- Rare to present in children. However, it is increasing due to obesity epidemic
What are 3 risk-factors for T2DM
Obesity
FH
Asian or Afro-carribean
Explain identifying T2DM symptoms in young-patient
If symptoms present in young patient, assume T1DM unless strong indicators otherwise:
- FH T2DM
- Features to suggest insulin resistance (acanthosis nigricans)
- Obese
- Asian or Afro-carribean
- No insulin requirement after remission phase
What are 5-features that will make you strongly consider this is T2DM
- Obese
- Asian or Afro-Carribean
- Strong family history T2DM
- Features insulin resistance (acanthosis nigricans)
- No insulin requirement following remission phase
Explain conservative management
Diet and exercise
Weight loss if obese
Influenza and pneumococcal vaccine
What is first-line medical management for T2DM
Metformin
Define MODY
Onset of T2DM in individuals before age 25
Which age defines limit for MODY
Less than 25
Explain ‘clinical presentation of someone with MODY’
Symptoms diabetes
Less than 25
Often strong FH
No ketosis at presentation
What is the most common type of MODY
MODY 3
What gene is mutated in MODY3
HNF1a
When does MODY-3 present
Adolescence
What does MODY3 increase risk of
Hepatocellular carcinoma
What is the second most-common type of MODY
MODY 2
What is mutated in MODY 2
Glucokinase
When does MODY 2 present
Early childhood
What is the prevalence of MODY 5
Rare
When does MODY 5 occur
Post-Puebertal
What is MODY 5 associated with
Liver and Renal Cysts
What are MODY treated with
Sulphonylureas
