Diabetes/DKA Flashcards
What viruses can trigger T1DM?
Coxsackie B virus and enterovirus
Ideal body glucose
4.4-6.1
What produces glucagon?
Alpha cells in islets of langhan
How do children with diabetes often present?
DKA
What is DKA?
When pancreas can;t produce enough insulin to maintain basic blood glucose regulation
Symptoms of diabetes
Polyuria
Polydipsia
Weigh tloss
Apart from DKA how else can children with T1DM present?
Seondary enuresis
Recurrent infections
How long are symptoms present before DKA presentation?
1-6 weeks before
Bloods need to do after new diagnosis of T1DM?
FBC, renal profile (U+E) and a formal laboratory glucose
Blood cultures
HbA1c
Thyroid function tests and TPO to test for ass AI thyroid disease
antiTTG antibodies - coeliac
INsuline antibodies, anti-GAF antibodies and islet cell antibodies
What to test for ass with direct destruction of the pancreas>
INsuline antibodies, anti-GAF antibodies and islet cell antibodies
Management of T1DM in children?
SC insulin regimes
Monitoring dietary carbohydrate intake
Monitoring blood sugar levels on waking, at meals and before bed
Monitorung for and managing complications, long and short term
What can continous insulin injections into same spot cause?
Lipodystrophy
What is lipodystrophy?
SC fat hardens and prevents normal absorption of insulin if further injections into this area
Why should patients inject in different areas each time for treatment>
Risk of lipodystrophty
How often is the cannula of an insulin pump replaced?
2-3 days
How does a child qualify for an insulin pump on the NHS?
> 12 years
Have difficulty controlling HbA1c
Advantages of insulin pump
Better blood sugar contil
More flexibility with eating
Less frequent injections
Disadvantages of insulin pump?
Difficulties difficult learning to use
Attached at all times
Blockage in infusion set
Small risk of infection
Two types of insulin pump
Tethered pump
Patched pump
What are tethered insulin pumps?
Replaceable infusion set and insulin attached to belt or waist with a tube conneciting pump to infusion site. Contols on pump iteslf
What are patch pumps?
Sit directly on skin without visible tubes
When run out of insulin entire pathc pump disposed of and new pump attached
Short term complications related to immediate insulin and blood glucose management
Hypoglycaemia
Hyperglycaemia + DKA
Typical symptoms of hypoglycaemia
Hunger
Tremor
Sweating
Irritability
Dizziness
Pallor
Severe:
Reduced consciousness, coma and death
How is hypoglycaemia treated?
Combination rapid acting glucose eg lucosade and slower acting carbohydrates eg biscuits or toast to maintain
Treatment for severe hypo when losing consciousness
IV dextrose and IM glucagon
What solution can be given IV in hypoglycaemia?
10% dextrose solution
eg 2mg/kg bolus then 5mg/kg/hr infusion
Causes of hypoglycaemia except T1DM
Hypothyroidism
Glycogen storage disorders
Growth hormone deficiency
Liver cirrhosis
Alcohol and fatty acid oxidation defects - MCADD
What is a common complication of diabetes treatment?
Nocturnal hypoglycaemia
How is nocturnal hypoglycaemia dianosed and treated>
Morning blood glucose is raised - continous glucose monitoring overnight
Treated by altering the bolus insulin regimes and snacks at bedtime
How much does one unit of novorapud reduce sugar levels by?
4 mmol/l
3 groups of long term complications of hyperglycaemia
Macrovascular
Microvascular
Infection related complications
Macrovascular complications of hyperglycaemia
- Coronary artery disease
- Peripheral ischaemia causes poor healing, ulcers and “diabetic foot”
- Stroke
- Hypertension
Microvascular complications
Peripheral neuropathy
Retinopathy
Kidney disease, especially glomerulosclerosis
Microvascular complications
Peripheral neuropathy
Retinopathy
Kidney disease, especially glomerulosclerosis
Infection related complications
UTI
Pneumonia
Skin and soft tissue infections, particuarly in feet
Fungal infections, particuarly oral and vaginal candiadiasis
Infection related complications
UTI
Pneumonia
Skin and soft tissue infections, particuarly in feet
Fungal infections, particuarly oral and vaginal candiadiasis
What is HbA1c measuring?
Glycated haemoglobin
Glucose attached to haemoglobin inside cells
How long does the HbA1c reflect glucose levels of?
3 months
How often do you monitor HbA1c in diabetes?
3-6 months
What bottle is HbA1c measured with?
Red top EDTA bottle
How does flash glucose monitoring work?
Sensor on skin measures glucose level intersistitial fluid in subcutaneous tissue
5 minute lag behind body glucose
How does flash glucose monitoring work?
Sensor on skin measures glucose level intersistitial fluid in subcutaneous tissue
5 minute lag behind body glucose
Why is capillary blood glucose necessary aswell as flash glucose monitoring to monitor glucose?
CBG - finger prick testing - 5 minute lag between actually blood glucose and amount on flash glucose monitoring
Why is capillary blood glucose necessary aswell as flash glucose monitoring to monitor glucose?
CBG - finger prick testing - 5 minute lag between actually blood glucose and amount on flash glucose monitoring
What is ketogenesis and when does it occur?
Supply of glucose/glycogens stores exhausted
During prolonged fast or low carb diets
Liver converts FA to ketones
What is ketogenesis and when does it occur?
Supply of glucose/glycogens stores exhausted
During prolonged fast or low carb diets
Liver converts FA to ketones
What causes DKA?
Inadequate insulin -> Hyperglycaemic ketosis -> metabolic acidosis that can’t be buffered sufficiently after a while (bicarb from kidneys used up)
Main problems in DKA
Ketoacidosis
Dehydration
Potassium imbalance
Why does DKA cause dehydration?
Hyperglycaemia overwhelms kidneys -> filtered into urine, drawing water out with it -> polyuria and dypsia
What is important to correct when treating DKA?
Hypokalemia that will be triggered by insulin treatment
Why does insulin treatment in DKA cause hypokalemia?
Serum potassium - high or normal, kidneys balance excreted with blood
Total body potassium low as not absorbed into cells
Therefore when treated with insulin not enough potassium in blood to be absorbed - hypokalemia
What is the priority in DKA treatment?
Fluid resuscitiation - correct dehydration, electrolyte disturbance and acidosis
Only then treat with insulin
What are children with DKA at high risk of developing as a complication?
Cerebral oedema
What are children with DKA at high risk of developing as a complication?
Cerebral oedema
What causes cerebral oedema in DKA?
Dehydration and blood sugar conc - move from intracellular space in brain to EC space
Brain cells shrink -> rapid correction with fluids and insulin
Rapid shift in water from EC space to IC space in brain cells -> oedematous -> cell death
What shoudl be monitored hourly after DKA treatment in children?
Neurological observations = GCS
Cerebral oedema
Red flags after treatemtn for DKA
Headaches
Altered behaviour
Bradycardia
Changes of consicousness
Managmenet for cerebral oedema
Slow IV luids
IV mannitol
IV hypertonic saline
Presentation of DKA?
- Polyuria
- Polydipsia
- Nausea and vomiting
- Weight loss
- Acetone smell to their breath
- Dehydration and subsequent hypotension
- Altered consciousness
- Symptoms of an underlying trigger (i.e. sepsis)
Criteria for diagnosis of DKA
Hyperglycaemia >11 mol/l
Ketosis >3mmol/l
Acidosis pH <7.3
Two pillars for correcting DKA in children?
1) Correct dehydration evenly over 48 hours
Corrects hyperglycaemia and ketones
2) Give fixed rate insulin infusion
Allows absorption of glucose and stops keton production
Other important principles behind DKA treatment thatn that 2 pillars
Careful administration of fluid bolus to treat shock (mindful of cerebral oedema risk)
Treat underlying triggers (antibiotics for septic patients)
Prevent hypoglycaemia (with IV dextrose once blood glucose <14 mmol/l)
Add potassium + monitor serum potassium
Monitor for signs of cerebral oedema
Monitor glucose, ketones and pHassess progress and determine when to switch to SC insulin
Other important principles behind DKA treatment thatn that 2 pillars
Avoid fluid bolus
Treat underlying triggers
Prevent hypoglycaemia
Add potassium
Monitor for signs of cerebral oedema
Monitor glucose, ketones and pH
When can you not give a child potassium in DKA treatment?
If potassium above upper limit of normal only add to IV fluids after patinet has passed urine or until potassium has fallen to within upper limit of normal range - 5.5mol/l
Parameters for severity of DKA
Mild DKA – venous pH 7.2- 7.29 or bicarbonate < 15 mmol/l. Assume 5% dehydration
* Moderate DKA – venous pH 7.1-7.19 or bicarbonate < 10 mmol/l. Assume 5%
dehydration
* Severe DKA – venous pH less than 7.1 or serum bicarbonate < 5 mmol/l. Assume 10%
dehydration
Parameters for severity of DKA
Mild DKA – venous pH 7.2- 7.29 or bicarbonate < 15 mmol/l. Assume 5% dehydration
* Moderate DKA – venous pH 7.1-7.19 or bicarbonate < 10 mmol/l. Assume 5%
dehydration
* Severe DKA – venous pH less than 7.1 or serum bicarbonate < 5 mmol/l. Assume 10%
dehydration
Parameters for severity of DKA
Mild DKA – venous pH 7.2- 7.29 or bicarbonate < 15 mmol/l. Assume 5% dehydration
* Moderate DKA – venous pH 7.1-7.19 or bicarbonate < 10 mmol/l. Assume 5%
dehydration
* Severe DKA – venous pH less than 7.1 or serum bicarbonate < 5 mmol/l. Assume 10%
dehydration
Should the bolus be counted in the calculated fluid deficit if used to treat DKA shock?
No - should be counted seperately
What should all children with DKA who are not in shock recieve if IV fluids indicated?
Initial 10ml/kg bolus 0/9% NaCl over 30 mins
What is the maximum bolus given to children with DKA in shock?
10ml/kg over 15 mins 4 times, reassessing after each
Then consider ionotropes
What level of potassium means insulin treatment is deferred?
<3 - wait until over 3 to treat with insulin
Life threatening complications of DKA
Cerebral oedema
Hypokalemia
Aspiration pneumonia
Inadequate resuscitation
Symptoms of presenting DKA
Clinical dehydration
acidotic respiration
* drowsiness
* abdominal pain/nausea/vomiting
Initial investigations for DKA
Blood glucose
* FBC, Urea and electrolytes (electrolytes on blood gas machine give a guide until accurate results
available) and CRP
* Blood gases (venous or capillary)
* Ketones - Near patient blood ketones (beta-hydroxybutyrate) testing should be used.
* If able to obtain sufficient blood, send new diagnosis investigations (HbA1c,TFT,
Coeliac screen)
What features of sepsis could present with DKA?
Fever
hypothermia
Hypotension
Refractory acidosis/lactic acidosis
High lactate
What do you keep an eye out for on DKA exam?
Cerebral oedema
Infection
Ileus
When should a child be nursed with one to one nursing with DKA?
Under 2
Severe DKA - pH <7.1
Dehydration deficit assumed in mild and moderate DKA
5%
Dehydration deficit assumed in severe DKA
10% volume
Should non shocked patients fluid bolus be subtracted form total calculated fluid deficit?
Yes
How long should deficit be replaced for in DKA with maintenance fluids?
over 48 hours
Fluid calculation for DKA
Hourly rate = ((deficit-initial bolus))/48hrs) + maintenance per hour
Why do people need to wee before give potassium with fluids if above upper limit for potassium?
Confirm not becoming anuric
How long after starting IV fluids wait to start insulin infusion?
1-2 hours
What do rate give insulin infusion dose at?
0.05 or 0.1units/kg/hr
What to do if child already on insulin?
For children and young people on continuous subcutaneous insulin infusion (CSII) pump
therapy, stop the pump when starting intravenous insulin.
* For children who are already on long-acting insulin, you may wish to continue this at the usual
dose and time throughout the DKA treatment, in addition to the IV insulin infusion, in order to
Therefore start an intravenous insulin infusion 1-2 hours after beginning
intravenous fluid therapy.
Use a soluble insulin infusion at a dosage between 0.05 and 0.1 units/kg/hour.
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shorten length of stay after recovery from DKA.
* ISPAD guidelines suggest that starting an appropriate dose of long acting background insulin in
newly diagnosed patients alongside the intravenous infusion should be considered. The BSPED
working group felt this was an issue to be agreed locally and did not feel there was strong evidence
or consensus either way.
When consider giving bicarbonate in DKA?
. Only consider
bicarbonate if there is life threatening hyperkalaemia or in severe acidosis with impaired myocardial
contractility
When is there a risk of VTE in DKA?
Be aware that there is a significant risk of femoral vein thrombosis in young and very sick children with
DKA who have femoral lines inserted. Line should be in situ as short a time as possible. Thromboembolic
prophylaxis should be considered in young people >16 years (in line with NICE guidance), in young
women taking the combined oral contraceptive pill and sick patients with femoral lines, following
discussion with an Intensive Care Specialist.
Medical reviews need to be done with DKA?
At 2 hours after starting treatment, and then at least every 4 hours, carry out and record the results of
the following blood tests -
* glucose (laboratory measurement)
* blood gas (for pH and pCO2)
* plasma U&E – ensure samples are sent URGENTLY to lab
* finger-prick (near patient) blood ketones
* strict fluid balance including oral fluids and urine output, using fluid balance charts (urinary
catheterisation may be required in young/sick children)
* hourly capillary blood glucose measurements (these may be inaccurate with severe
dehydration/acidosis but are useful in documenting the trends. Do not rely on any sudden changes
but check with a venous laboratory glucose measurement)
* capillary blood ketone levels every 1-2 hours
* hourly BP and basic observations
* hourly level of consciousness initially, using the modified Glasgow coma score
* half-hourly neurological observations, including level of consciousness (using the modified Glasgow
coma score) and heart rate, in children under the age of 2, or in children and young people with a pH
less than 7.1, because they are at increased risk of cerebral oedema
* reporting immediately to the medical staff, even at night, symptoms of headache, or slowing of
pulse rate, or any change in either conscious level or behaviour
* reporting any changes in the ECG trace, especially signs of hypokalaemia, including ST-segment
depression and prominent U-waves
* twice daily weight; can be helpful in assessing fluid balance
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A doctor should carry out a face-to-face review at the start of treatment and then at least every 4
hours, and more frequently if:
* children are aged under 2 years
* they have severe DKA (blood pH below 7.1)
* there are any other reasons for special concern.
At each face-to-face review assess the following:
* clinical status, including vital signs and neurological status
* results of blood investigations
* ECG trace
* cumulative fluid balance record.
Corrected sodium calculation
= measured sodium + (glucose-5.6)/3.5
How to manage suspected cerebral oedema
Hypertonic saline - 2.7% or 3% 2.5-5ml/kg over 10-15 mins
OR
mannitol - 20% 0.5-1g/kg over 10-15 mins
Should not be delayed
Early manifestations of cerebral oedema
- headache
- agitation or irritability
- unexpected fall in heart rate
- increased blood pressure.
What signs mean immediately treat for cerebral oedema?
deterioration in level of consciousness
* abnormalities of breathing pattern, for example respiratory pauses &/or drop in SaO2.
* oculomotor palsies
* abnormal posturing
* pupillary inequality or dilatation
Management of cerebral oedema other than IV
1/2 maintenance fluids
Slow deficit over 72 hrs
Urgent anaestheic help
Consider excluding other diagnoses with CT
4 Ts of diabetes
Thinness
Toiletting
Tired
Thirst
Drug induced DKA
Thyroxine
Steroids
Tacrolimus
Endocrinopathies causing diabetes
Cushing syndrome
hyperthyroidism
Infections causing diabetes
Rubella
CMV
Cocksakie virus
Syndromes screened reguarly for diabetes
Downs
Turners
Kilnefelter
Wolfran *DIDMOAD
Diagnostic levels for diabetes
> 11.1 mmol/L
fasting - >7mmol/L
2 hour oral GGT 11/1
HbA1c >48
Why cant diagnose diabetes when child is ill
When body under stress cortisol released -> increased glucose levels
Stages type 1
1 - multiple islet antibodies, normal blood glucose, pre symptomat
Stage 2 - multiple IAs, raised glucose, presymptomatic
Stage 3 - limited islet antibodies, raised blood gluose, sympomtatic
Stage 4 - long standing type 1
What % T1DM diagnosed inder 15?
50-60%
Peaks diagnosis in chuldren
4-6 years
10-14 years
Peak incidence in winter and autumn
Peaks diagnosis in chuldren
4-6 years
10-14 years
Peak incidence in winter and autumn
How much of paediatric diabetes does type 1 account for?
90%
What genes increase risk of diabetes?
HLA-DR3/4
Unusual symptoms diabtets
Secondary enuresis
Recurrent thrush
Vomitting - GE
Abdominal pain - acute abdomen
Hyperventilation 0 asthma.pneumonia
Chronic weight loss (anorexia_
Management of T1DM
Near normal blood glucose/HbA1c
Prevent DKA
Avoid severe hypos
QOLM
Maintain normal growth and development
MDT support
Surveillanve and prevention of micro/maxrovascular complications
Complications diabetes
Renal damage
Retinopathies
Vasculopathies
Neuropathies
Stroke/MI
IHD
Autonomic symptoms of hypo
Hunger
Sweaty and clammy hands
Ttembling and shaking
Anxiety
Pallor
Nausea
Nurogenic symptoms hypo
young children -> naughty
Severity of hypoglycaemia
Mild/Grade 1 - patient aware and can treat themselves
Moderate/Grade 2 - child requires assistance from others can be treated by oral therapy
Severe/Grade 3 - Semi/uncosncois, assestance needed from others needing IV therapy - covulsions
What to do in sevree hypo
IM glucagon
Glucagon to give if unconscious under vs over 12
Under - 0.5mg
Over 12 - 1mg
Alternative to IM glucagon
IV dextrose - 10% dextrose
Why dont give 20% dextrose IV?
Sclerosing agent - damages vein that its given in
How can give insulin if not injected SC?
Periotnneal infusion
Foot care
Wide toe shoes
Dont walk bare foot - cant feel as much, risk of infection
Why doesnt insulin work when children are ill?
Increased cortisol and adrenaline levels cause increased glucose - insulin needs to be increased when child is unwell
Ass conditions with T1DM
Coeliac
Hypo/erthyroidism (much more common hypo)
Social problems
Alcohol - loose weight, poor control
Drug abuse - appetite stimulating
Smoking - NEPHROPATHY, NEUROPAHTY, RETINOPATHY AND CVS
Eating disorder - higher incidence, diabulimai
Psychiatric prolemns
Typical T1DM symptoms
Polyuria
Nocturia
New onset enuresis
Polydipsia
Unintentional weight loss
Fatigue
Blurred vision
Extreme hunger
Irritability/mood changes
Peak age of T1DM diagnosis
9-14
Reasons for hyperglycaemic episodes
Not using enough insulin, not injecting insulin properly or using expired insulin, insulin pump tubing/cannula dislodged
Not following your diabetes eating plan or incorrectly carbohydrate counting
Being inactive
Having an illness or infection
Using certain medications, such as steroids
Being injured or having surgery
Experiencing emotional stress, such as family conflict or workplace challenges
What causes hypoglycaemic episodes?
Too much insulin
Incorrect carb counting
Not eat enough
Postpoining or skipping meal or snack
Increasing exercise/physical acticity without eating more/adjusting meds
Drinking alcohol
DKA presentation
increased thirst, polyuria, recent unexplained weight loss or excessive tiredness and any of the following: nausea or vomiting abdominal pain hyperventilation dehydration reduced level of consciousness.
What is monitored in children with T1DM from 12 years?
Diabetic retinopathy annually
ACR ratio - kindery disease annually
HPTN annually
Anual foot assessment
What is screened for at diagnosis of T1DM?
Thyroid disease and annually thereafter
Coeliac disease - after if symptoms arise
Three basic types of insulin regimens
Multiple daily injection basal–bolus insulin regimens
Continuous subcutaneous insulin infusion (insulin pump therapy):
One, two or three insulin injections per day: these are usually injections of short-acting insulin or rapid-acting insulin analogue mixed with intermediate-acting insulin.
What does multiple daily basal bolus regime look like
: injections of short-acting insulin or rapid-acting insulin analogue before meals, together with 1 or more separate daily injections of intermediate-acting insulin or long-acting insulin analogue.
What type of insulin is normally administered by cont SC therapy
Rapid acting insulin analogue or short acting insulin
What do the injections of insulin that can be taken contain?
Short acting insulin or rpaid acting insulin analogue mixed with intermediate acting insulin
What is ideal HbA1c level
<48 mmol/mol
When strongly sus T2DM in children
have a strong family history of type 2 diabetes
* are obese
* are from a Black or Asian family background
* do not need insulin, or need less than 0.5 units/kg body weight/day after the
partial remission phase
* show evidence of insulin resistance (for example, acanthosis nigricans)
When suspect diabetes that is not T1 or T2 eg monogenic or mitochondrial
diabetes in the first year of life
* rarely or never develop ketones in the blood (ketonaemia) during episodes of
hyperglycaemia
* associated features, such as optic atrophy, retinitis pigmentosa, deafness, or
another systemic illness or syndrome
How distinguish between T1DM and T2DM
C-peptide
What do people with T1DM have immunisations against?
annual immunisation against influenza, starting when they are 6 months old.
* immunisation against pneumococcal infection, if they are taking insulin or oral
hypoglycaemic medicines
What can happen after initial insulin treatment in T1DM
Honeymoon period where more sensitive to insulin so dont need as high a dose
What can do when exercsie to avoid hypo
Eat carb heavy foods before (if <7 glucose)
Monitor blood sugar before and after to adjust insulin accordingly
Target plasma glucose
fasting plasma glucose level of 4 to 7 mmol/litre on waking
* a plasma glucose level of 4 to 7 mmol/litre before meals at other times of the
day
* a plasma glucose level of 5 to 9 mmol/litre after meals
* a plasma glucose level of at least 5 mmol/litre when driving
How to treat mild/mod hypos
Give oral fast-acting glucose (for example, 10 to 20 g) (liquid carbohydrate may
be easier to swallow than solid).
* Be aware that fast-acting glucose may need to be given in frequent small
amounts, because hypoglycaemia can cause vomiting.
* Recheck blood glucose levels within 15 minutes (fast-acting glucose should
raise blood glucose levels within 5 to 15 minutes), and give more fast-acting
glucose if they still have hypoglycaemia.
* As symptoms improve or blood glucose levels return to normal, give oral
complex long-acting carbohydrate to maintain blood glucose levels, unless the
child or young person is:
－ about to have a snack or meal
－ having a continuous subcutaneous insulin infusion
How to treat hypos in hospital
10% intravenous glucose if rapid
intravenous access is possible. Give a maximum dose of 500 mg/kg body
weight (equivalent to a maximum of 5 ml/kg)
IM glucagon or conc oral glucose solution if dont have IV access
Advice around alcohol
- eat food containing carbohydrate before and after drinking
- monitor their blood glucose levels regularly, and aim to keep the levels within
the recommended range by eating food containing carbohydrate.
When is ACR raised
> 3
3-30 = microaluminuria
Over = proteinuria
LOOK AT NICE MANAGMENT AGAIN TO CHECK HAVE EVERYTHING
Mouth condition often contracted in diabetes
Peridonitis
Why does diabetes cause recurrent thrush??
What advise to paretns and the children who have T2DM diaetes?
Weigth loss and benefits of exercise reduces hyperglycaemia and CVS risk
How often monitor HbA1c in children with T2D,?
Every 3 months
What complications of T2DM monitor for?
HPTN and dyslipidemia at diagnosis
ACR at diagnosis
All annually aswell
What measure when testing for dyslipidemia
HDL + non HDL cholesterol
total cholesterol
TGs
