DM and DKA in Pediatrics Age group by Berhanu Wale.pptx

By Berhanu Wale

1. Common endocrine disorders in pediatrics age group 5/14/2024 1

2. By the end of this unit, the students will be able: Define what the disorder (disease) is Identify the etiology and/or risk factor State the pathophysiology Describe the clinical manifestation List the differential diagnosis Select the appropriate investigation Explain the complication Use the appropriate treatment 5/14/2024 2 For each disorder Objectives

3. Diabetes is a metabolic disease characterized by hyperglycemia. Result in defects in insulin secretion or action. Forms and the etiology of diabetes: Type 1 diabetes mellitus (T1DM) or juvenile diabetes: Results from absolute deficiency of insulin secretion. Because of pancreatic β-cell damage. Further divided into: Type 1A, which is immune mediated. Type 1B, which is typically idiopathic. The most common form of DM in pediatrics age group. 5/14/2024 3 Insulin is a hormone made by the beta cells in the pancreas, facilitates the movement of glucose from the blood to the cells so it can be used. Diabetes Mellitus #1

4. Etiology of type 1 DM: Immune mediated: T- cell mediated destruction of insulin producing beta cells. Genetic factors: Mutation in human leukocyte antigen (HLA) gene. Environmental factors: Viral infection e.g., congenital rubella syndrome. Dietary factors: Vitamin D repletion. Duration and timing of breastfeeding. Introduction of cow’s milk, … etc. 5/14/2024 4 But, definitive data and conclusive evidence are lacking. Diabetes Mellitus #2

5. Diabetes Mellitus #3 Type 2 diabetes mellitus (T2DM): Results from relative deficiency, resistance or both. Etiology: obesity, T2DM f amily history, hypertension, dyslipidemia. Other types of diabetes: Atypical diabetes: form of diabetes do not neatly fit T1DM/ T2DM. Neonatal diabetes: presenting in the first six months of life. Gestational diabetes: occur in pregnancy in younger women. 5/14/2024 5 Epidemiology of diabetes: T1DM has a bimodal distribution, with one peak. At 4 to 6 years of age and in early puberty (10 to 14 years of age).

6. Clinical presentation: Hyperglycemia without acidosis is the most common presentation. Common: polydipsia, polyuria, weight loss, tiredness & bed wet. Less common: polyphagia, blurred vision, skin infection, … etc. Diabetic ketoacidosis (DKA): the 2 nd most common presentation. Polydipsia, polyuria and weight loss plus Fruity-smelling (acetone/sweet smell) breath and Neurologic findings (drowsiness, lethargy, … etc.) Kussmaul respiration (deep, rapid, labored). Frequent vomiting, abdominal pain, dehydration, … etc. 5/14/2024 6 Diabetes Mellitus #4

7. Criteria for the diagnosis of diabetes Symptoms of diabetes: Polyuria, polydipsia, unexplained weight loss AND Casual (random) plasma glucose of > 200 mg/dl or greater, OR Fasting (for at least 8 hours) plasma glucose > 126 mg/dl, OR Plasma glucose of > 200 mg/dl 2 hours after oral glucose challenge Glucose load, 1.75 g/kg (maximal dose of 75 g), OR HbA1c of > 6.5% 5/14/2024 7 The biochemical criteria for DKA are: Hyperglycemia Venous pH <7.3 or bicarbonate <15 mmol/l Ketosis (ketonemia and ketonuria ( ≥2+) ) Diabetes Mellitus #5

8. Classification of DKA 5/14/2024 8 Mild Moderate Severe Venous PH < 7.3 < 7.2 < 7.1 Serum bicarbonate < 15 mmol/L < 10 mmol/L < 5 mmol/L Clinical Oriented (alert) But fatigued Kussmaul respirations Oriented But sleepy, arousable Kussmaul or depressed respirations Sleepy to depressed sensorium to coma Shock Diabetes Mellitus #6

9. Prediabetes: Impaired fasting glucose: fasting glucose 100-125 mg/dL. Impaired glucose tolerance: 2 hour postprandial glucose 140 - 199 mg/dL. Hemoglobin A1c (HbA1c) values of 5.7 – 6.4% 5/14/2024 9 Prediabetes is used to identify individuals with abnormalities in blood glucose homeostasis who are at increased risk for the development of diabetes. Prediabetes is not a clinical entity, but rather a risk factor for future diabetes and cardiovascular disease. Diabetes Mellitus #7

10. Management: DKA is a medical emergency and needs correction of the clinical and chemical changes to prevent the associated complications. Fluid therapy: replacement + maintenance. Manage hyperglycemia: insulin therapy + dextrose in IV fluid. Manage electrolyte and acid – base disturbance. Treat infection with broad spectrum antibiotics. Consider and treat fatal complication e.g., cerebral edema. Close monitoring. Transition to routine subcutaneous insulin therapy. 5/14/2024 10 Diabetes Mellitus #8

11. Fluid therapy: Paradigm: d eficit replacement plus maintenance fluids . If DKA with shock or severe circulatory collapse: Normal saline 20 mL/kg IV bolus infused as quickly as possible. Additional 10 mL/kg boluses once or twice if needed. If DKA without shock, but dehydration is ≥ 5%: Normal Saline (LR) 10 ml/kg IV over 1 hour. 2 nd hour until DKA resolution ( 0.45% NaCl) : IV rate = 85 ml/kg + 2(maintenance) – bolus divide by 47 hrs. Once the blood glucose level is < 250 mg/dl, add 5% dextrose. Dehydration should be slowly corrected over 48 hours 5/14/2024 11 Diabetes Mellitus #9

12. Example: The type and amount of fluid for a 30 kg child with DKA, but have no shock: For first hour: 10 ml × 30 kg = 300 mL of 0.9% NS or RL. For the second and subsequent hour: = (85 ml × 3o kg) mL + 2 (1700 mL) – 300 mL 47 hour = 120 mL per hour of 0.45% NaCl. Drop (flow) rate: Total volume * drop factor = 120 mL * 20 = 40 gtt. Time in minutes 60 minutes 5/14/2024 12 Diabetes Mellitus #10

13. Insulin treatment: After shock management & fluid replacement therapy . Started 1 to 2 hours after initiating fluid therapy as earlier onset of insulin treatment has been associated with cerebral oedema. IV infusion rate: 0.1 unit/kg/hour short acting (regular) insulin. Via syringe pump: Dilute 50 units insulin in 50 ml Normal Saline, 1 unit = 1 ml or Use a side drip (if a syringe pump is unavailable): Put 50 u nits of insulin in 500 ml of Normal Saline, 1 Unit = 10ml. For example: a 25 kg child should receive 2.5 units per hour: 2.5 ml per hour of the syringe pump solution, OR 25 ml per hour of the side drip solution. 5/14/2024 13 Diabetes Mellitus #11

14. Potassium replacement: K+ replacement is needed for every child in DKA. Measure blood potassium level as part of the initial assessment. 20 mEq/L potassium phosphate and 20 mEq/L potassium acetate. Bicarbonate therapy: Generally should not be used in children with DKA. Has been associated with the development of cerebral injury. The rapid correction of acidosis with bicarbonate therapy may result in hypokalemia. Monitoring: Vital signs, neurologic status, fluid status & metabolic state. 5/14/2024 14 Diabetes Mellitus #12

15. Transitioning to subcutaneous insulin : Once the DKA has been adequately treated (hydration corrected, glucose controlled, ketones cleared) the child can be transitioned to subcutaneous insulin and the first SC dose of short-acting insulin should be given 1 - 2 hours before stopping the insulin infusion. Insulin dose: Pre-pubertal children: 0.7 to 1 IU/kg/day. During puberty: 1 to 2 IU/kg/day. Regimens (both short-acting and intermediate-acting insulin) : Twice-daily insulin. Basal bolus (the preferred option): with main meals + qd or bid. 5/14/2024 15 Diabetes Mellitus #13

16. Initiating therapy in a child not in DKA: Day 1: short-acting (regular) insulin 0.1 U/kg every second hour until blood glucose is < 200 mg/dl, then every 4 - 6 hours. Day 2: total daily dose 0.5 - 0.75 U/kg/day. Schedule: 2/3 in the morning. 1/3 in the evening. Insulin type: 1/3 short acting: Regular insulin. 2/3 intermediate acting: Lent and NPH insulin. 5/14/2024 16 Example: For a 36 kg child who is started on 0.5 U/kg/day, the total daily dose is 18 Units. Morning (2/3 of 18 units): 12 units. Lente (2/3 of 12 units): 8 units Regur (1/3 of 12 units): 4 units Evening (1/3 0f 18 units): 6 units. Lent (2/3 of 6 units): 4 units Regular (1/3 of units): 2 units Diabetes Mellitus #14