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Year 5 - Paediatrics > Diabetes in a child > Flashcards

Diabetes in a child Flashcards

1
Q

GP sees Sam who is 25kg and 8 years old. He presents with polyuria and polydipsia. His urine dipstick is +ve for ketones and glucose and his BM is 35mmol/L. What is the immediate management?

A

Send to paediatric A&E for treatment of diabetic ketoacidsis. No further investigations are required.

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2
Q

What is the first line of action for treating diabetic acidosis in a child who is hypotensive, tachycardic and has delayed capillary refill (3sec)?

A

Treat for SHOCK first.

  1. Give a fluid bolus of 20ml/kg* over an hour
  2. Monitor vital signs for improvement
  3. If no improvement, give another fluid bolus
  4. Monitor vital signs again

This is new protocol - used to be calculated by weight but a study showed that giving this much to all children was safe and did not cause cerebral oedema.

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3
Q

Once the child has been treated for shock successfully, what is done to manage diabetic ketoacidosis?

A

Work out the maintenance fluids:

  1. 100ml/kg for the first 10kg
  2. 50ml/kg for the next 10kg
  3. 20ml/kg for the rest of the weight

This is the maintenance dose for a 24 hour period.

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4
Q

The child also has dry mucous membranes and increased skin turgor. How do you calculate what fluid intake is needed to account for the level of dehydration?

A

Look at the pH (correction index)

  1. pH <7.1 = severe (10%)
  2. pH 7.1-7.2 = moderate (7%)
  3. pH 7.2-7.3 = mild (5%)
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5
Q

What is the formula used to calculate the fluid deficit from dehydration? What time is this given over?

A

Fluid deficit = weight(kg) x dehydration level (%) x 10(ml)

This gives the fluid deficit that should be corrected over 48 hours.

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6
Q

What is the fluid rate equation for diabetic ketoacidosis?

A

Fluid rate = [2(maintenance fluids total*) + fluid deficit total]/48hrs

*NB: x2 MF because the MF is only given for 24 hours from its calculation (ml/kg/day)

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7
Q

What electrolyte abnormalities might occur in diabetic ketoacidosis ?

A

Pseudohyponatraemia - do nothing

Hypokalaemia - usually corrected by adding 20mmol of K+ per litre of fluid BUT in DKA you give 40mmol/L of saline*

*NB- do not give K+ in renal failure

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8
Q

When do you start to give insulin in DKA?

A

After 1 hour of fluids

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9
Q

What is the rate of insulin given in paediatric DKA?

A

0.05-0.1 units/kg/hr

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10
Q

What type of insulin is used in paediatric DKA?

A

Actrapid IV- short half-life and fast acting

NO SLIDING SCALE in paeds

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11
Q

When do you start to give 5% dextrose in DKA management?

A

Once the blood glucose falls to 12mmol/L (must monitor carefully)

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12
Q

Once insulin Actrapid has been started, what shoud be monitored and how often?

A
  1. BM every 1hr
  2. Blood ketones every 2-4hr
  3. GCS - check for cerebral oedema
  4. Vital signs
  5. Blood gas
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13
Q

Why is the 5% dextrose given in DKA treatment?

A

Stop ketosis (from fat breakdown for energy)

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14
Q

What three things are given once the glucose has reached 12mmol/L?

A

0.9% saline + 5% dextrose + K (40mmol/L)

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15
Q

When should you start subcutaneous injections of insulin?

A

ASAP once the child is alert

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16
Q

What insulin regimen is used in children?

A

Basal bolus ONLY

17
Q

Name 3 baseline insulins used in children.

A
  1. Insulin glargine (Lantus) - must be given at the same time each day
  2. Insulin detemir (Levemir)
  3. Insulin degludec (Treciba) - can be given at any time if a dose is missed

Act within 6 hours, peak within 12 hours, disappear within 24hrs

18
Q

Name a bolus insulin used in paediatrics.

A

Novorapid - usually given 3 times a day 15min before each meal.

Acts within 15mins, peaks at 2 hours and disappears within 4 hours.

19
Q

How many units of insulin do children with diabetes receive each day?

A

0.5 -0.7 units/kg/day* = total daily dose

  • 40-50% of this is the basal insulin
  • The remaining 50-60% is split between each bolus insulin.

e.g. a 25kg child could be receiving 12.5units/day. This would consist of 6 units of basal insulin and 2 units of the basal doses (assuming 3 meals a day).

NB: the hospital dose was much higher as it was per hour.

20
Q

What is the definition of DKA?

A
  • pH <7.3
  • BE high
  • Bicarbonate low
  • CO2 low
21
Q

What other investigations would you do for a child whose first presentation of diabetes is DKA?

A
  • Thyroid function tests*
  • HbA1c
  • Coeliac screen*
  • Islet cell antibodies
  • Venous blood glucose
  • U&Es

*increased risk of other autoimmune conditions with T1DM

22
Q

What is the aetiology of DKA?

A
  1. Not enough insulin therefore glucose not taken up by cells and remains in the bloodstream causing hyperglycaemia
  2. Once the renal threshold is overcome then glycosuria occurs.
  3. Glucose draws water out with it causing polyuria which causes dehydration
  4. Body cannot utilise glucose therefore uses fatty acids instead. The breakdown product of these are ketones causing acidosis
  5. Acidosis causes base excess increase and loss of bicarbonate as bicarbonate (alkaline) tries to neutralise ketones (acidic)
23
Q

How long is the initial admission after DKA?

A

2-3 days in order to teach child and parents how to manage their condition

24
Q

What is the difference between ICR and ISR?

A

ICR - insulin carbohydrate ratio - equals the number of grams of carbohydrate that 1 unit of rapid-acting insulin will cover.

ISR - insulin sensitivity ratio - tells you how many points, in mg/dL, your blood sugar will drop for each unit of insulin that you take

25
Q

How many units of insulin are required to cover 50g of carbohydrates?

A

ICR = 1:10

So for every 10g you need 1 unit of rapid acting insulin.

Therefore, 5 units.

26
Q

Who is involved in the management of diabetic children?

A
  • Diabetic nurses
  • Psychologists
  • Doctors
27
Q

What is the cut-off for hypoglycaemia in a diabetic patient? What can be given to prevent this?

A

<4 mmol/L is hypoglycaemia IN DIABETIC PATIENTS ONLY

Glucagon may be given if unconscious, otherwise sugary snack.

28
Q

What is hypoglycaemia in a child who is not diabetic?

A

<2.6 mmol/L

29
Q

What is the “honeymoon phase” in diabetes?

A

When the pancreas suddently starts making insulin

Here you would reduce the ICR/ISR from for example 1:10 to 1:8.

30
Q

What does follow up of diabetic patients involve?

A

4 appointments per year at least + 8 contacts per year in addition

4 HbA1c measurements i.e. every 3 months because this is the time for Hb turnover to occur.

31
Q

What additional investigations for complications are carried out in diabetes at the annual review?

A
  • Thyroid function
  • Coeliac screen
  • Height and weight
  • Feet
  • Only after 12 years:
    • Albumin to creatinine ratio
    • Retinopathy
    • BP
  • Questionnaire
    • About eating habits, school, mental health
32
Q

What 3 types of devices can help with the management of diabetes?

A
  1. Insulin pump - different amount of insulin delivered every hour; can press button every time a meal is eaten; BUT still have to measure BM prior to administration of bolus.
  2. Flash glucose monitoring e.g. Libra device - usually at least 5 readings must be taken during a day (3 meals, bed and morning); press to get result. BUT not accurate if very high or low levels.
  3. Continuous glucose monitoring - sensor gives a real time waveform of glucose even when not testing. This is a closed-loop system i.e. pump and sensor are connected together.
33
Q

Apart from type 1 diabetes, what are the other causes of diabetes?

A
  1. T2DM
    1. obesity
    2. South Asian/African
    3. acanthosis nigricans present
    4. manage with lifestyle changes
    5. more FH of diabetes than in T1DM
  2. Monogenic
    1. single gene defect in pathway of secretion
    2. may have other associated features
  3. Secondary
    1. related to conditions of the pancreas
    2. e.g. cystic fibrosis, steroids (e.g. for leukaemia), tacrolymus (renal transplant patients)
34
Q

What is the definition of DKA?

A
35
Q

Is fever possible in DKA?

A

It is not part of DKA so consider a different diagnosis

36
Q

What is the mortality with cerebral oedema?

A

25%

37
Q

Name 4 complications of DKA.

A
  1. Hypokalaemia
  2. Cerebral oedema
  3. Aspiration pneumonia (if comatose)
  4. Inadequate resuscitation causing brain injury from ischaemia
38
Q

What are the signs and management of cerebral oedema?

A
39
Q
A

Year 5 - Paediatrics (91 decks)

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