Endocrinology Flashcards
What are the clinical presentations of diabetic ketoacidosis in children?
Abdominal Pain
Respiratory distress - Kussmaul’s breathing
Vomiting
Dehydration - decreased skin turgor, dry mucous membranes
Tachycardia
Tachypnoea
Pear breath
Confusion
Drowsiness
Reduction in consciousness/ loss of consciousness
What are the complications of diabetic ketoacidosis?
Hyperglycemia Hyperketonemia (metabolic acidosis) Osmotic diuresis (hypoperfusion) Severe vomiting Dehydration (fatal) Obligatory loss of electrolytes Greater stress hormone production More severe insulin resistance Cerebral oedema
How do we investigate diabetic ketoacidosis?
Bedside: basic obs, general exam, abdominal exam, cardiological exam, neuro exam, respiratory exam
Bloods: CBG, Ketone levels, Blood glucose, CB Glucose (2 hourly), beta-hydroxybutyrate (>=3mmol/L), U&Es, renal function tests
Other: GCS, body height and weight (calculate dehydration)
How do we classify DKA?
The severity of DKA is categorized by the degree of acidosis:
Mild DKA: venous pH of <7.3 and/or a HCO3 level of <15 mmol/L
Moderate DKA: venous pH of <7.2 and/or a HCO3 level of <10 mmol/L
Severe DKA: venous pH is <7.1 with or without a HCO3 level <5 mmol/L.
How do we manage DKA?
From A&E
1) Admission to inpatient ward/ICU
2) A - able to maintain airway
B - Oxygen
C - IV access, fluids deficit replacement, insulin administration, correction of electrolyte imbalance, maintenance of glucose levels at normal range
D - GCS/Neurological screen for cerebral oedema, painkillers for abdominal pain, consider NG tube if still vomiting?
E - General examination
3) SEPSIS 6 Screen Sometimes sepsis can contribute to the hypoperfusion and acidosis IV fluids Oxygen Abx Take urine dip Blood cultures Lactate levels
Monitoring every 2 hours
Involve seniors - Registrar
Screen for Diabetes Mellitus Type 1
How can we investigate Diabetes Mellitus T1?
Random blood sugar test.
This is the primary screening test for type 1 diabetes. A blood sample is taken at a random time. A blood sugar level of 200 milligrams per deciliter (mg/dL), or 11.1 millimoles per liter (mmol/L), or higher, along with symptoms, suggests diabetes.
Glycated hemoglobin (A1C) test. This test indicates your child’s average blood sugar level for the past 3 months. An A1C level of 6.5% or higher on two separate tests indicates diabetes.
Fasting blood sugar test. A blood sample is taken after your child hasn’t eaten (fasted) for at least 8 hours or overnight. A fasting blood sugar level of 126 mg/dL (7.0 mmol/L) or higher suggests type 1 diabetes.
What are the visible signs of cerebral oedema?
Restlessness Irritability Increased drowsiness Cranial nerve palsies Abnormal pupillary responses Headache slow heart rate (HR) rising blood pressure (BP) recurrence of vomiting.
What are the diagnostic criteria of cerebral oedema?
Diagnostic criteria of cerebral edema include abnormal motor or verbal response to pain, decorticate or decerebrate posture, cranial nerve palsy, and abnormal respiratory patterns (grunting, tachypnoea, apnoea, Cheyne-Stokes respirations). Major criteria include altered sensorium, sustained deceleration of HR (decrease by >20 beats/min) and age-inappropriate incontinence. Minor criteria include vomiting, lethargy, diastolic BP < 90 mm Hg, headache, and age <5 years
How should cerebral oedema be managed?
Treatment of cerebral edema should be prompt and immediate. 0.5-1 g/kg of mannitol should be administered intravenously over 10-15 min, and should be repeated if there is no initial response in 30 min to 2 h. Hypertonic saline (3%) with suggested dose of 2.5-5 mL/kg, administered over 10-15 min, may be used as an alternative to mannitol, especially if there is no initial response to mannitol.
What fluid therapy do we give for DKA?
Check if anything has been given already Replacement (dehydration corrections) Usually over 24 hrs – maintenance + %dehydration Estimate % lost Weigh child if possible 1kg lost = 1000ml lost Estimate weight loss if possible 10*weight*%dehydration = correction Add correction onto maintenance fluids over 24 hrs
Resuscitation
10ml/kg 0.9% NaCl (plasmalyte) over <10 minutes
Sometimes 20ml/kg acceptable too i.e. for shocked pts
Smaller boluses: Neonatal DKA Cerebral oedema Trauma Cardiac pathology – heart failure
Consider maintenance fluids too: Remember 3 categories of fluid Maintenance – 0.9% NaCl + 5% Dextrose 100mls/kg/day for each first 10 kg 50mls/kg/day for next 10kg 20ml/kg/day for next kg
You always give dextrose in maintenance because otherwise they will become hypoglycaemic
Normal saline or Ringer lactate is used over a period of 4-6 h. Consequently, maintenance fluids are used. Usually, half normal saline (0.45%) with potassium chloride is given depending on the state of hydration and electrolyte levels. Fluid therapy is usually planned for a period of 48 h. However, a child may improve earlier than 48 h. Normal circulation is often achieved in 12 ± 6 h. When the child becomes stable, fluids can be given orally, and subsequently insulin can be given subcutaneously. In cases of mild DKA, no bolus is needed. The main principle of fluid therapy is to never infuse fluids more than 1.5-2 times the normal daily requirement. Moreover, constant monitoring and assessment of hydration is absolutely essential.
Potassium replacement therapy is used when the total body potassium deficit is nearly ~3-6 mmol/kg. If the patient is hypokalemic, start potassium replacement at the time of initial volume expansion and before starting insulin therapy. Otherwise, start replacing potassium after initial volume expansion and concurrent with starting insulin therapy. If the patient is hyperkalemic, defer potassium replacement therapy until urine output is documented.
In DKA, rehydration alone reduces BG. Insulin therapy is used to restore normal metabolism, to suppress lipolysis, ketogenesis and normalize BG. A low dose of intravenous (IV), insulin infusion is considered to be safe and effective. Insulin infusion should be initiated 1-2 h after starting fluid replacement therapy; that is after the patient has received initial volume expansion. The dose of insulin should usually remain at 0.05-0.1 unit/kg/h, at least until resolution of DKA viz. pH <7.30, serum HCO3 levels <15 mmol/L and beta-hydroxybutyrate levels <1 mmol/L. No IV bolus is required to be given because it may worsen hypokalemia or precipitate cerebral edema. As long as possible, the physician should minimize the time on IV insulin infusion, and optimal doses of insulin should be used to avoid severe hypokalemia. BG should be gradually lowered at a rate of 50-100 mg/dL. When BG level falls to 250 mg/dL, 5% glucose is added to IV fluid. Furthermore, 10% or 12.5% glucose may be needed while continuing insulin infusion to correct metabolic acidosis. Furthermore, 2 hourly subcutaneous or intramuscular short-acting insulin may also be used if facilities for IV infusion are not available.
What are blood glucose targets?
Fasting blood glucose of 4-7mmol/L on waking
Random plasma glucose 4-7 mmol/L pre-prandial
Plasma glucose 5-9 mmol/L post-prandial
How should type 1 diabetics be advised regarding blood glucose monitoring?
> =5 capillary glucose tests/day
Continuous glucose monitoring for:
Frequent, severe hypoglycaemia
Impaired hypoglycaemia awareness with severe consequences
Barriers to recognising or communicating sx of hypoglycaemia
In diagnosed type 1 diabetics how many clinic appointments a year should they have?
4 and HbA1c should be checked each time
Albumin:creatinine ratio to check for nephropathy
What vaccines should be offered to type 1 diabetics?
Normal schedule + pneumococcal
From what age do we screen for retinopathy, nephropathy and blood pressure?
12 years
