diagnosis and management of Diabetes mellitus and DKA

diagnosis and management of Diabetes mellitus and DKA

1. Diabetes Mellitus in children 2021

2. Outline Definition Epidemiology Diagnosis Pathophysiology Clinical Presentation Investigations Management

3. Definition A chronic metabolic disorder characterized by hyperglycemia Caused by deficiency of insulin or its action Manifested by abnormal metabolism of carbohydrates, protein and fat

4. Epidemiology Diabetes is the most common endocrine problem Is a major health hazard worldwide. Incidence is alarmingly increasing worldwide Incidence of childhood diabetes range between 3=50/100000

5. Etiological classification of Diabetes mellitus Type1 diabetes Beta cell destruction Immune mediated Type2 diabetes Insulin resistance Other types MODY Endocrinopathies: Cushing disease Drug or Chemical induced: Glucocorticoids Infections: CMV Genetic : Down’s syndromes Neonatal diabetes mellitus : transient, permanent

6. Type 1 Diabetes: Etiology Autoimmune Genetic factors Autoimmune factors Environmental factors

7. Genetic factors Evidence of genetics is shown in Familial clustering High concordance rate in twins 30% for identical twins 85% NT1DM don’t have family history Specific genetic markers Increased frequency of certain histocompatibility antigens i.e. HLAs DR3 & DR4 Higher incidence with genetic syndromes or chromosomal defects

8. Auto immune Factors Circulating antibodies against beta cell and insulin Immunofluorescent antibodies and lymphocyte infiltration around islet cells Evidence of immune system activation: circulating immune complexes with high IgA and low interferon levels. Association with other autoimmune diseases.

9. Environmental Factors Seasonal variation Suspicion of environmental agents causing disease which is confirmed by case control experimental animal studies.

10. Environmental SUSPECTS Viruses Coxaskie B MUMPS RUBELLA REO VIRUSES Nutrition and dietary factors cow’s milk protein Contaminated sea food

11. Other modifying factors The counter regulatory factors Glucagon Cortisol Catecholamines Thyroxin GH and somatostatin Sex hormones EMOTIONAL STRESS

12. Pathophysiology The main functions of insulin Reduce blood glucose by: inhibiting glycolysis Inhibiting gluconeogenesis Increasing glucose uptake by cells 2.Inhibiting fat breakdown 3.Inhibiting protein breakdown

13. Insulin deficiency will lead to: Hyperglycemia: increase glucose` -osmotic diuresis-polyuria-dehydration-Compensatory polydipsia Proteolysis- wt loss-polyphagia Lipolysis: increased fatty acids and accumulation of Acetyl Co-A-Liver-Ketone bodies-ketonemia-ketonuria and metabolic acidosis

14. Clinical presentation Peak age 5-7 puberty Classical symptom triad: Polyuria, polydipsia weight loss DKA Accidental diagnosis

15. Diagnosis RBS >200mg/dl /11mmol with poly symptoms FBS>126mg/dl HBA1C Target <7.5{58mmol/ml Urine: glucosuria or ketonuria if DKA Remember acute infections in non diabetic children may cause hyperglycemia with out ketosis *starvation can cause ketosis

16. Natural history Diagnosis and initiation of insulin Period of metab olic recovery Honeymoon phase State of total insulin dependency

17. Complications of diabetes Acute/immediate DKA Hypoglycemia Chronic/late Microvascular Retinopathy Nephropathy Neuropathy Macrovascular Ischaemic heart disease and stroke

18. 1.Hypoglycemia Symptoms related to sympathetic discharge sweating, tremulousness and hunger More severe symptoms related to glucose deprivation to the CNS

19. 2. Diabetic Ketoacidosis hyperglycemia BG>200mg/dl (>11mmol/l Ketonemia and ketonuria>or=2+ Metabolic acidosis (pH<7.3,Bicarbonaate <15meq/l Severity of DKA By degree of acidosis Mild : venous PH<7.3 or Serum Bicarbonate< 15mmol/l Moderate : <7.2 , HCO3<10mm0l/l Severe: < 7.1 , HCO3<5mmol/l

20. Diabetic Ketoacidosis Assessment History known diabetic: Omission, Infection Suspected diabetic: poly symptoms, wt loss, abdominal pain ,vomiting B. Examination: assess for dehydration, kussmaul’s breathing ,fruity breath ,mental status and current wt

21. DKA C. Laboratory tests Check blood glucose, blood gas, electrolytes Urinalysis for glucose and ketones

22. Management of DKA Goals of treatment of DKA Correct dehydration Correct acidosis and reverse ketosis Restore blood glucose to near normal Monitor for complications of DKA and its treatment Identify and treat any precipitating event

23. Management of DKA Fluid Assume 5-10% dehydration dictated by clinical examination Give 10-20meq/kg bolus of N/S or Rl over 1hr Then replace the remaining deficit and maintenance fluid requirement over 36-48hrs Add 5% glucose to the fluid when BG drops to 250-300mg/dl

24. DKA management B. Insulin Started after the initial bolus is completed if hemodynamically stable IV insulin is preferred 0.1/kg per hour insulin as continuous drip C. Glucose Measure hourly Rate of fall should not exceed 80-100mg/dl/ hr If>100mg/dl/ hr add 10%glucose As BG approaches 250-300mg/dl, add D5to IVF regardless of rate of fall

25. D. Electrolytes Potassium Risk of hypokalemia during DKA management 20-40meq/l of k+ after patient has passed urine check 2hrly 2. Sodium 0.9% or ½ NS for rehydration serum Na+ rises as BG falls 3. Bicarbonate rarely used for severe DKA with caution

26. Treatment goals Prevent death and alleviate symptoms Achieve biochemical control Maintain growth and development Prevent acute complications Prevent late onset complications

27. Management Elements Insulin replacement 0.75-1u/kg daily a. Divided between short acting regular insulin &intermediate acting, Lente in a 1:3 proportion 2/3 am/ 1/3 pm b. Multiple 3 to 4 doses of regular insulin before meals supplemented with once or twice daily intermediate insulin source Recombinant human insulin: less immunogenic

28. Management Elements 2. Diet A meal plan that promotes normal growth and wt gain Avoid simple sugars encourage fibers and complex carbohydrates 55-30-15, Carb-Fat-Protein Equivalent calories 20-10-20-10-30-10 Must be eaten on time

29. 3.Exercise regular exercise Should be encouraged Caution for hypoglycemia No restriction on individual or organized athletic programs 4. Education Techniques of insulin injection Home BG monitoring Recognition and treatment of hypoglycemia Recognition of DKA Meal plan Sick day management

30. Management elements 5. Psychological support and Counseling of patient and family 6. Medical follow up Regular follow up Every 3-4 months

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