diabetes

Question 1

what is a big risk in DKA + how does it present + how managed?

Answer 1

cerebral oedema
irritability, agitation
headache
↓HR + ↑BP

careful fluid correction to avoid
may need CT head
mannitol or hypertonic NaCl

Question 2

DKA - what to counsel family on (ie precipitants)

Answer 2

illness
growth spurt
insulin omission

Question 3

DKA - presentation

Answer 3

ketone breath
breathing rapid → kussmaul
thready pulses, hypotn, tachy etc
polydipsia + uria
weight loss + tiredness
N+V + abdo pain
reduced LOC

fever not normal - ?sepsis

Question 4

DKA - investigation + mgmt (no known DM)

Answer 4

cap glucose

>11 - immediate referral paeds

Question 5

DKA - investigation + mgmt (known DM)

Answer 5

blood ketones - high - immediate referral paeds

Question 6

DKA once referred to paeds - investigations + diagnosis

Answer 6

cap glucose
cap ketones
cap/venous pH
bicarbonate

diagnosis - acidosis or ketonaemia/ketonuria

Question 7

DKA - management once in paeds

Answer 7

inform senior

oxygen

monitor - obs, BG, pH, bicarb, U+Es; ECG (hypoK); fluid balance + dehydration; GCS + neuro

fluid + insulin therapy

Question 8

fluid + insulin therapy in DKA (patient UK + NICE)

Answer 8

1 - 0.9% NaCl replacement; then maintenance (add 40mmol/L KCl)
2 - IV insulin infusion 1-2h after fluids begin - 0.1U/kg/hr
3 - when BG 15 switch fluids to 0.45% NaCl + 5% glucose + 40 KCl

replace fluids over 48h, or consider reducing when alert, tolerating oral fluids, ketosis resolving
stop insulin when clinically well

Question 9

another risk of DKA other than cerebral oedema + how to manage

Answer 9

hypokalaemia - why should monitor ECG
consider pausing insulin
discuss w critical care

Question 10

what are the insulin regime options for T1DM?

Answer 10

basal bolus - daily long acting + pre-meal short acting
continuous infusion (pump) - short acting

Question 11

BG targets for T1DM

Answer 11

waking, fasting + premeal - 4-7

postmeal - 5-9

Question 12

BG monitoring in T1DM

Answer 12

at least 5 cap BGs/d

more if ill, exercise

Question 13

mild-mod hypoglycaemia - mgmt

Answer 13

oral fast acting glucose (10-20g)
recheck BG in 15min
repeat glucose if still low
then oral long acting carb

Question 14

severe hypoglycaemia - mgmt

Answer 14

in hosp - 10% IV glucose
not in hosp - glucogel/IM glucagon
assistance if no improvement in 10 mins

Question 15

monitoring for complications of T1DM

Answer 15

annual thyroid
annual retinopathy from 12y
annual HTN from 12y
annual albuminuria from 12y

Question 16

DKA - investigations in kids (patient UK)

Answer 16

screen:
cap - blood glucose

bloods - near-pt ketones, glucose, renal function, U+E (deranged, AKI), VBG (acidosis, ↓bicarb) + FBC/LFTs
urine - glucose, ketones + MCC

rule out cause - ~blood/urine cultures, CXR, CSF, throat swabs etc

Question 17

where should swabs be taken on in sepsis of unknown cause in kids? what else to do?

Answer 17

blood, urine, throat

CXR??

Question 18

DKA - management (patient UK)

Answer 18

A - NG - prevent asp pneumonia
B - 100% oxygen by face mask
C - cannulate, fluids, cardiac monitor
D - GCS, monitor hourly neuro, comatose - ?cerebral oedema (treat + PICU)

Question 19

assessing dehydration in kids

Answer 19

CRT
weak - pulse
eyes - sunken
skin - turgor
membranes - dry mucous
hands - cool peripheries

oliguria + hypotension (late signs)

CRT; weak eyes, skin, membranes, hands; OH

Question 20

DKA - monitoring in kids (patient UK)

Answer 20

obs + fluid chart
ECG - ~K imbalance
cap + venous glucose
cap ketones (urine if not)
cerebral oedema - headache/GCS, ↑BP, ↓HR - mannitol IV + ICU
U+Es

Question 21

DKA - once resolved

Answer 21

continue IV fluids till drinking + tolerating food

when blood ketones <1, change to subcut insulin