Diabetes Flashcards
Define
Classification:
o Type 1 → 96% of DM children – destruction of pancreatic β1 cells
o Type 2 → insulin resistance, usually in older children and obesity related
o Type 3 → other – genetic defects, infections, drugs, pancreatic exocrine deficiency (CF), endocrine disease
o Type 4 → GDM
Neonatal hypoglycaemia = jittery and hypotonic baby; RFs:
1. IUGR
2. Maternal DM
3. Premature Hypothermia
4. Neonatal sepsis
5. Inborn errors of metabolism
6. Labetalol (pre-eclampsia)
Signs and symptoms
Early signs – often occur over a few weeks…
Most common ‘classical triad’:
* Polydipsia
* Polyuria
* Weight loss
Less common:
* Secondary enuresis
* Skin sepsis
* Candida (and other infections)
Type-2 specific:
· Acanthosis nigricans (sign of insulin resistance; ‘tanning’ in skin folds i.e. neck and axillae)
· Skin tags
· PCOS
Late signs / DKA:
- Acetone breath
- Vomiting
- Dehydration
- Abdominal pain
- Kussmaul breathing
- Hypovolaemic shock
- Drowsiness
- Coma and death
Hypoglycaemia (after insulin):
* Sweating
* Pallor
* CNS irritability
Investigations
OGTT = 75g oral glucose -> 2 hours later measure blood glucose
Whole blood fasting plasma glucose ≥6.1mmol/L
Impaired Glucose Tolerance (IGT):
* Fasting <7.0 mmol/L
* OGTT 7.8-11.1 mmol/L
Impaired Fasting Glucose (IFG) – only if fasted:
* Fasting 6.1-7.0 mmol/L
* Investigations – diagnosis of hypoglycaemia
* Blood glucose
* Other (growth hormone, IGF-1, cortisol, insulin, C-peptide, fatty acids, ketones, etc
Management
3 types of insulin therapy:
**1st line -> Multiple Daily Injection Basal-Bolus: **injections of short-acting insulin before meals, with 1 or more separate daily injections of intermediate acting insulin or long-acting insulin analogue
2nd line -> Continuous SC Insulin Infusion (insulin pump): programmable pump / insulin storage device that gives regular or continuous amounts of insulin (usually rapid- acting insulin or short-acting insulin)
- If appropriate; often child needs to be older and in control of the diabetes
One, Two or Three Insulin Injections Per Day: injections of short-acting insulin or rapid-acting insulin analogue mixed with intermediate-acting insulin
Educational programme for parents and child:
Basic pathophysiology of diabetes:
* Body attacking its own pancreas
* Depleted ability to produce insulin
Insulin injection method and sites:
Types of insulin:
* Long acting -> Glargine, Determir
* Short acting -> Lispro, Glulisine, Aspart
Sites: antero-lateral thigh, buttocks, abdomen
Rotate sites frequently to avoid lipohypertrophy
Method: gently pinch up skin and inject at a 45-degree angle (avoid IM)
* Not too deep (IM) and not too shallow
Blood glucose prick monitoring (glucose, ketones):
* ≥5 capillary blood glucose a day (fasting = 4-7mmol/L; after meals = 5-9; driving = >5)
Ongoing real-time continuous monitoring with alarms for children with:
* Frequent severe hypoglycaemia
* Impaired hypoglycaemic awareness
* Inability to recognise/relay symptoms of hypoglycaemia (i.e. cognitive disability)
* HbA1c checked ≥4x per year (last 6-12 weeks overview)
Healthy diet and exercise:
* Carbohydrate counting education from diagnosis and to family members (DAFNE)
* 5 fruit and vegetables a day
* Regular exercise (with insulin adjustment)
‘Sick-day rules’ during illness to prevent DKA:
Explain symptoms of DKA:
* Nausea/vomiting Abdominal pain
* Hyperventilation
* Dehydration
* Reduced consciousness
Check blood ketones when ill or hyperglycaemic
Recognition and treatment of hypoglycaemia:
* Can be very individual (i.e. feeling ‘wobbly’, feeling sick)
* Can develop/vary with age
* Help and advice: Offer 24hr helplines and voluntary groups (‘Diabetes UK’, DAFNE)
· Access to mental health services (e.g. psychologist often part of the MDT)
· School is often very involved (nurse aware)
Annual monitoring from 12yo for diabetic retinopathy, nephropathy and hypertension
· Macrovascular complications -> HTN, CHD, CVD
· Microvascular complications -> retinopathy, nephropathy, neuropathy
MDT = paediatrician, PDSN (specialist nurse), psychologist, school, (GP)
Management (DKA) – hyperglycaemia, ketonuria, acidosis (1-year incidence of 3.6% in those with T1DM):
o Causes – anything to raise the bodies need for insulin (thus the lack of insulin can -> DKA)
Discontinuation / not enough insulin (i.e. anorexic T1DM that want to lose weight)
Drugs – steroids, thiazides, SGLT-2 inhibitors
Physiological stress – pregnancy, trauma, surgery
Investigate:
* Blood gases, blood glucose
* Plasma osmolarity – will be hyper-osmolar (like in HONK/HHS; but is much higher in HHS) >29
* Management = fluid replacement -> IV insulin -> tx underlying cause
* Lower rate fluid replacement than usual due to risk of cerebral oedema
· Management (hypoglycaemia) -> treating this depends upon the patient’s consciousness:
o I.E. from too much insulin (± skipped meal) N.B. care with IV dextrose as hypertonic
o Oral glucose (e.g. Coca-Cola -> banana) -> glucose gel to gums / IM glucagon -> IV glucose (e.g. dextrose)
· Diabetes in adolescence:
o Teenagers are more resistant to treatment as they find out they don’t have to always obey parents and be okay
o Interference:
Biological factors:
· Insulin resistance 2nd to growth and sex hormone secretion
· Growth and pubertal delay if diabetes control is poor
Psychological factors:
· Reduced self-esteem (i.e. impaired body image)
Social factors:
· Different from peer group Hypoglycaemia (emphasise differences)
· Increased risk from alcohol, smoking, drugs
Vocation plans (can’t be a pilot)
· Separation from parents more complex
· Transition vs. transference of care in children with chronic health conditions:
o Transitional care = joined adult and paediatric care (16-22yo) clinics -> much better care!
o Transference = immediate transfer of care to the adult team
Management of HHS
Management (HHS): HHS (Hyperosmolar, Hyperglycaemic State) / HONK (Hyperosmolar, Non-Ketotic) State
Symptoms:
* Weakness, leg cramps and visual disturbances
* N&V (less than in DKA)
* MASSIVE DEHYDRATION (e.g. dry membranes, confusion & lethargy)
* Focal neurological symptoms (seizures in up to 25% à coma in ~10%)
Investigations:
* Bloods – no hyperketonaemia, no acidosis
* Serum osmolarity will be >320mOsmol/kg (normal 275-295)
* Same causes as DKA
Management (drugs):
(1) Diet & exercise
(2) Oral monotherapy – metformin
1st line = Biguanide / Metformin (sensitises cells to insulin)
(3) Oral combination
2nd line = sulphonylurea (increases insulin secretion of cells) – for non-obese T2DM
Glibenclamide Chlorpropamide Tolbutamide
3rd line = a-glucosidase inhibitor (inhibits carbohydrase) – for post-prandial hyperglycaemia
· Acarbose
(4) Oral + injectable incretin mimetics
(5) Oral + insulin
(6) Insulin
Define DKA
Management of DKA
(1) Emergency Management:
- ABCDE
- Emergency fluid resuscitation:
Shocked -> 20mL/kg bolus (over 15 minutes) -> + 10mL/kg bolus if required (max 40mL/kg)
Not shocked -> 10mL/kg bolus (over 60 minutes)
o Investigations (i.e. blood glucose, FBC, U&Es, blood gas, ketones) and full clinical assessment (inc. weight, GCS)
(2) Fluid management:
o (1) Deficit = ((deficit x weight x 10) – initial bolus if non-shocked) à replace over 48 hours
§ Mild DKA pH <7.3 -> 5% fluid deficit
§ Moderate DKA pH <7.2 -> 7% fluid deficit
§ Severe DKA pH <7.1 -> 10% fluid deficit
(2) Maintenance requirement: or use the 4-2-1 method…
First 10kg = 100mL/kg/day
Next 10kg = +50mL/kg/day
Every kg above 20kg = +20mL/kg/day
(3) Requirement of fluids – ensure 20mmol of KCl per 500mL saline (i.e. 40mmol per litre):
Requirement = deficit (- bolus in non-shocked children) + maintenance
(4) Insulin / dextrose therapy after 1-2 hours of IV fluid replacement: Insulin Dose = IV 0.05-0.1 units/kg/hour
-Start dextrose when <14mmol/L; change to SC insulin and then oral fluids if child starts to resolve
-Monitor with ECG to identify hypokalaemia (ST depression, prominent U waves, flattened P waves)
Monitoring during therapy – monitor every hour; every 30 minutes if severe DKA or child <2yo:
* Hourly -> CBG, vital signs, fluid balance (input/output), GCS, ± ECG
* At 2 hours, every 4 hours à glucose, U&Es, blood gas, beta-hydroxybutyrate
