Unit 8_Diabetes in Children and DKA .pptx

Undergraduate medicine

1. Diabetic ketoacidosis Definition :Is a potentially life threatening acute complication of T1DM characterized by a biochemical triad of hyperglycemia , (200 mg/dl) , ketonaemia ( ketonuria ) and acidemia (pH<7.3) 2/24/2020

2. Pathophysiology of DKA Insulin Adrenaline Glucagon GH Cortisol 2/24/2020

3. The Pathophysiology of Diabetes and acute complication(DKA) 2/24/2020

4. DKA clinical classifications * Mild:-Oriented, alert but fatigued * Moderate :- Kussmaul respirations; oriented but sleepy; arousable * Severe :- Kussmaul or depressed respirations; sleepy to depressed sensorium to coma 2/24/2020

5. DKA category by the severity of acidosis 2/24/2020

6. Who is at risk to develop DKA? Newly diagnosed type 1 DM patients. Those who are under 5 years of age. Patients with poor glycemic control. Patients who develop stress because of infection or trauma. 2/24/2020

7. DKA Management protocol General Resuscitation Measure A= If comatose inert NGT and maintain the airway B= Give oxygen by face mask for patients with severe circulatory impairment or shock C= Insert IV cannula and take blood sample and if the child is in shock give 20 ml/kg of 0.9 % normal saline to the maximum of 30 ml/kg depending on the response of the child over 30 minutes 2/24/2020

8. DKA Management protocol Physical Examination Perform a clinical evaluation to confirm the diagnosis and take weight for calculation Vital signs Assess the degree of dehydration Look for signs of cerebral edema Neurological assessment using GCS 2/24/2020

9. DKA Management protocol Investigation Collect blood sample to do – RBS, Ketone, electrolytes (K +), CBC Urine analysis – Check glucose, ketones and WBC Blood gas analysis – PH, Bicarbonate ECG-to see signs of hypo or hyperkalemia Blood or urine culture if there is sign of infection 2/24/2020

10. Specific Management Principle of DKA 1.Expand intravascular volume 2.Rehydration therapy 3.Potassium replacement therapy 4.Insulin therapy 5.Avoid complications ( Hypoglycemia, Cerebral edema and Hypokalemia ) 6.Treat precipitating factors 7.Follow up Refer to Annex 3 and 5 2/24/2020

11. Hypoglycaemia Commonly called ‘hypo’ Occurs when the blood glucose level is too low but it can also occur when the blood glucose is not particularly low. Is one of the most common acute complications of diabetes May cause mild, moderate or severe symptoms Limitation in the management of diabetes Effective treatment and prevention are the keys 2/24/2020

12. Criteria for Hypoglycemia A hypo is a blood glucose level of 3.9mmol/L (70 mg/dl) or less Awareness of symptoms depend on background values/age Symptoms due to hormonal responses ( adrenargic ) or ANS which will come first Neuroglycopenia occurs at values <2.5 mmol /l will come later 2/24/2020

13. Risk Factors Too little or a delayed meal/skipped meal Too large dose of insulin Age ( younger children, adolescents, long duration diabetes ) Low HbA1c levels( Increased risk of hypoglycemias unawareness) Recent /frequent hypoglycemias (store in the liver depleted) 2/24/2020

14. Risk Factors When awareness of hypo is reduced During sleep Increased activity or exercise (the rest of the day and during the night after heavy exercise) New site for injection Gastroenteritis After alcohol(adolescents) 2/24/2020

15. Symptoms from the body/ Autonomic and adrenergic symptoms Trembling Rapid heart rate and Pounding heart (palpitations) Cold Sweats Pallor, numbness in the limbs, fingers and tongue Hunger and/or nausea. Irritability Anxiety 2/24/2020

16. Neuroglycopenia difficulty concentrating Headache blurred or double vision disturbed colour vision difficulty hearing slurred speech poor judgement and confusion dizziness and unsteady gait tiredness nightmares inconsolable crying loss of consciousness seizures. 2/24/2020

17. Classification of severity Mild Recognition and self treatment Usually ≤ 3.9 mmol /l(70mg/dl) Moderate ≤ 3.9 mmol /l Aware of symptoms Needs assistance to take care of themselves Severe Loss of consciousness (coma), convulsion, marked confusion and Usually <2.5 mmol /l 2/24/2020

18. Hypoglycemia unawareness Neuroglycopenic symptoms without having warning Signs and symptoms People may notice that you have the signs and symptoms This may be very dangerous for the patient as this may lea permanent neurologic injury or death 2/24/2020

19. Glucostat Is the blood glucose level to experience symptoms of hypoglycemia. When there is high blood glucose level for a couple of days signs and symptoms of hypoglycemia will occur at a high glucose level (High level hypoglycemia) 70-80 mg /dl(4-4.5 mmol/l) When it has been low for several days they will experience symptoms at lower blood glucose (low level hypoglycemia)< 65 mg/dl ( < 3.5 mmol /l) 2/24/2020

20. Management of Hypoglycemia Identify hypoglycaemia Symptoms Blood glucose values Treat the hypoglycaemia Teach child how to recognize and manage hypoglycaemia Determine cause (when possible) 2/24/2020

21. Practical Instructions to treat Hypoglycemia 1.Test the blood glucose 2.If the blood glucose is less than 65-70 mg./dl have a sweet to eat preferably glucose tablets 3.If the person is conscious but difficult to chew give glucose gel or honey 4.If the person is unconscious or has seizure give glucagon injection (dose 0.1-0.2 mg/10 kg sc / im ) 5.Don’t take any physical exercise until all symptoms of hypoglycemia have vanished 6.don’t leave the child alone until the hypoglycemia symptoms are over. 7.look for additional factors which can aggravate hypo 2/24/2020

22. Management of Hypoglycemia … Feed the child Rapid acting carbohydrate e.g. sweetened drinks, fruit juices, glucose in water, sweets. Enough to make symptoms go away, don’t over treat . Follow up with regular meal or snack If has severe symptoms Not able to eat Glucagon or IV glucose Oral rapid acting foods; glucose, sugar or honey 2/24/2020

23. Treatment 2/24/2020

24. Prevention Of hypoglycaemia Determine cause Too much insulin Too little food - carbohydrates Increased activity Illness Helps to avoid future hypoglycaemia 2/24/2020

25. Prevention Of hypoglycaemia Remind about the symptoms and causes of hypoglycaemia. Help to identify risk factors e.g. age , longer duration of diabetes , higher doses, etc. Repeated episodes of hypoglycaemia should result in specific advise to prevent recurrences. 2/24/2020

26. Nocturnal Hypoglycaemia Very worrying for parents – can limit management Is more likely to happen if the child was very active during day time and eat poorly or is unwell Check BG level before bed, occasionally during night 2/24/2020

27. Hypoglycaemia Unawareness If there is a period where too many hypos or frequent overnight hypoglycaemia. Body re-sets its response (adrenalin) I ncreases the risk of severe hypoglycaemia Contact clinic for advice – adjust insulin 2/24/2020

28. Unexplained hypoglycaemia Check for:- Coeliac Disease Addisons disease 2/24/2020

29. Recommendations 2/24/2020 Maintain blood glusose levels above 3.9mmo/L Aim to prevent hypos – education about risks, symptoms, monitoring (c hild, parent, all involved with care) Wear identification (bracelets) Have quick acting carbohydrate available Hypoglycaemia management protocol

30. Recommendations ( cont ) Glucagon should be accessible if it is possible Contact clinic if there is hypoglycaemia unawareness to adjust BG goals If unexplained hypoglycaemia or frequent consider possibility of coeliac or Addison’s disease 2/24/2020

31. Routine Diabetic care Goals of Diabetic care 1.Goals of Diabetic care 2.Components of Care 2/24/2020

32. Goals of Diabetic Care Eradicate symptoms. Prevention of acute complications Hypoglycaemia Diabetic ketoacidosis Optimum growth and pubertal development Normal schooling Prevention of long term complications 2/24/2020

33. Components Routine Care 1.Insulin Therapy 2.Home blood glucose testing 3.Use of HbA1c to monitor the glycemic control 4.Dietary Advice 5.Monitoring the growth using growth chart 6.Diabetic education is vital 2/24/2020

34. Management - who? Multi-disciplinary team Physician, nurses Diabetes educator Dietician Social worker Psychologist 2/24/2020

35. Insulin therapy is a must in children diabetes 2/24/2020

36. Insulin Human insulin Produced by recombinant DNA technology/semi-synthetic method Usually U-100 concentration. Different types of insulin classified by their duration of action 2/24/2020

37. Onset of action 30-60 minutes 5-15 minutes 1-2 hours 1-3 hours Peak of action 2-4 hours 1-2 hours 5-7 hours 4-8 hours Duration of action 6-8 hours 4-5 hours 13-18 hours 13-20 hours Insulin Soluble-Regular Lispro-Aspart NPH/ Lente Glargine- Detemir Insulin Preparations Kinetics following s.c. injection 2/24/2020

38. Short acting regular insulin Onset=30-60 minutes Peak=2-4 hours Duration=4-8 hours Given 30 minutes before meal Actrapid , Humulin R 2/24/2020

39. Rapid acting analogues Onset: 15 minutes Peak: 30 min-3 hours Duration: 3-5 hours Given 15 minutes before food NovoRapid , Humalog, Apidra Time (min) 1320 1200 1080 960 840 720 600 480 360 240 120 330 300 270 240 210 180 150 120 90 60 30 -30 Serum insulin (pmol/L) Insulin profile NovoRapid ® , adolescents aged 13–17 years NovoRapid ® , children aged 6–12 years HI, adolescents aged 13–17 years HI, children aged 6–12 years 2/24/2020

40. Intermediate- acting insulin Onset: 2-4 hours Peak: variable Duration: 10-18 hours Not related to meals Usually twice daily Sometimes 3-4 times/day NPH, Insulatard, Monotard, Protaphane, Humulin N 2/24/2020

41. Insulin profiles Slide no 41 2 4 6 8 10 12 14 16 18 20 22 24 Hours Plasma Insulin Levels Detemir Aspart, lispro, glulisine NPH Regular 2/24/2020

42. Mixing insulin Fixed ratio combination insulin Combination of short and long acting insulin Most commonly 30% and 70% combination E.g. Actraphane , Mixtard 30 Two peaks of action Often used in twice daily regimens Self-mixed combinations Mixed regular/rapid insulin with NPH in syringes Create own mix to suit patient 2/24/2020

43. Insulin therapy No perfect insulin preparation Choice of insulin individualised to give as physiological insulin profile as possible (using basal/bolus) Need proper storage of insulin Compliance with treatment regimen is key to success 2/24/2020

44. Insulin regimens Twice daily regimen Mix of short acting and long acting before breakfast and supper Multiple daily injections Intermediate or long acting insulin twice daily Short acting insulin with each meal 2/24/2020

45. Blood glucose testing 2/24/2020

46. Blood glucose testing patterns Patterns determined by Availability of strips- at home Insulin regimen injections per day Level of control of the glucose-poor control more frequent testing Patient factors- activities, food and stress Pattern changed to get useful information Blood glucose information is used to help patient and family to adjust the insulin dose if strips are available Identify times when at risk for hyper- or hypoglycaemia Needs patient records of food and insulin for readings to be valuable! 2/24/2020

47. Dietary advice Principles Need to have a healthy diet Amount and proportions appropriate for age and growth Carbohydrate content of food matched with insulin regimen Understanding of how to match insulin with food is the key Best done with the assistance of a dietician If the child with diabetes is growing at the same rate as other children that is a powerful indicator of the adequacy of treatment 2/24/2020

48. Dietary review Taken at the time of diagnosis Review regularly (annually) Review food patterns, activities and insulin regimen regularly Growth and stage of puberty can be influenced by diet 2/24/2020

49. Use of HbA1c Is an objective indicator of glycemic control and predicts both acute and chronic complications of diabetes 2/24/2020

50. What is HbA1c Red blood cells contain Haemoglobin Glucose sticks onto Hb  HbA1c HbA1c reflects average blood glucose over 2-3 months (half life of RBC) High glucose = increased HbA1c Non diabetics: 4-6.4% (normal range) 2/24/2020

51. What does it tell us Measure of the average blood glucose Correlates with risk of long-term complications Rising HbA1c requires action Ideal HbA1c < 6.5% fix slide pix Add EAG table vs A1c??? 2/24/2020

52. Age Pre meal BG level(mg/dl) 30 days average BG level (mg/dl) Target HbA1c <5 years 100-200 180-250 7.5–9.0 5-11 years 80-150 150-200 6.5–8.0 11-15 years 80-130 120-180 6.0–7.5 15-18 years 70-120 100-150 5.5-7 Different Target BG and HbA1c level at different Age 2/24/2020

53. HbA1c Vs estimated average glucose 2/24/2020

54. 54 2/24/2020 Date

55. Quality of care indicators Quality of care indicators are the tools used to assess the long term control of diabetes. Long term monitoring is aimed both at the affected person and at a clinical service. 2/24/2020

56. Patient indicators Indicators Measurement Growth Height, weight and BMI Puberty Blood pressure Age at menarche, breaking voice Once in a year Acute complications No of admissions for DKA Frequency of severe hypoglycaemia Social adjustment Schooling Number of clinic visits in last 12 months Number of hospitalizations in last 12 months Missed school days due to diabetes Food security 2/24/2020

57. Clinic indicators Indicator Measurement Prevalence Number of children in your clinic Acute complications Frequency of severe hypoglycaemia Frequency of severe hypoglycaemia in <5 year old children Supplies Interruptions in insulin therapy Prevention of microvascular complications Screening for comorbidity % of patients tested for proteinuria % of patients tested for HbA1c % of patients with recorded BP % of patients with recorded lipids Thyroid disorders, celiac 2/24/2020

58. Growth Monitoring Growth can be affected by diabetes, i.e. insufficient insulin dosing can cause stunted growth even if blood glucose levels seem fine (Mauriac syndrome) Normal growth is indicator of adequate diabetes care 2/24/2020

59. Measurements Measure height and weight at each clinic visit, once every three months, at least twice a year Record in medical chart and plot on growth chart  2/24/2020

60. Use Growth charts Can use population specific charts Center for Disease Control (CDC) charts or WHO growth chart Charts specific for boys and girls and for different age ranges Height, weight, BMI 2/24/2020

61. Diabetic Education Is the keystone of diabetes care It is providing the person with the knowledge and skills needed - To perform diabetes self care , -To manage crises and -To make lifestyle changes - T o successfully manage the disease ’’. 2/24/2020

62. Diabetic Education The DCCT provided unequivocal evidence that intensification of management reduces micro-vascular complications and that intensification requires effective diabetes self-management. 2/24/2020

63. Diabetic Education • Children and adolescents, their parents and other care providers should all have easy access to and be included in the educational process 2/24/2020

64. Diabetic Education Diabetes education should be delivered by health care professionals with a clear understanding of the special and changing needs of young people and their families as they grow through the different stages of life 2/24/2020

65. Diabetic Education Educators (doctors, nurses, dieticians and other health care providers ) should have access to continuing specialized training in diabetes education and educational methods • Diabetes education needs to be a continuous process and repeated for it to be effective 2/24/2020

66. Primary (Level 1) education At diagnosis: Survival skills 1. Explanation of how the diagnosis has been made and reasons for symptoms 2. Simple explanation of the uncertain cause of diabetes. No cause for blame. 3. The need for immediate insulin and how it will work 4. What is glucose? - normal BG levels and glucose targets 2/24/2020

67. Primary (Level 1) education 5. Practical skills - insulin injections - blood and/or urine testing and reasons for monitoring 6. Basic dietetic advice 7. Simple explanation of hypoglycemia 8. Diabetes during illnesses. Advice not to omit insulin—prevent DKA 9. Diabetes at home or at school including the effects of exercise 2/24/2020

68. Primary (Level 1) education 10. Identity cards, necklets , bracelets and other equipment 11. Membership of a Diabetes Association and other available support services 12. Psychological adjustment to the diagnosis 13. Details of emergency telephone contacts 2/24/2020

69. Secondary (level 2) continuing educational 1 . Pathophysiology, epidemiology, classification and metabolism 2. Insulin secretion, action and physiology 3. Insulin injections, types, absorption, action profiles, variability and adjustments 2/24/2020

70. Secondary (level 2) continuing educational 4. Nutrition—food plans; qualitative and quantitative advice on intake of carbohydrate, fat, proteins and fiber; coping with special events ; growth and weight gain; ‘‘diabetic foods’’; sweeteners and drinks 2/24/2020

71. Secondary (level 2) continuing educational 5. Monitoring, including glycated hemoglobin and clear (agreed) targets of control 6. Hypoglycemia and its prevention, recognition and management including glucagon 7. Intercurrent illness, hyperglycemia, ketosis and prevention of ketoacidosis 8. Problem solving and adjustments to treatment 2/24/2020

72. Secondary (level 2) continuing educational 9. Goal setting 10. Micro and macro-vascular complications and their prevention. The need for regular assessment 11. Exercise, holiday planning and travel, including educational holidays and camps 12. Updates on research. 2/24/2020

73. Diabetic Education Continuing education will take place most often in an outpatient setting and has to be interactive Group education may be more cost effective and enhanced by peer group Depend on individual age and maturity 2/24/2020

74. FOLLOW UP Regular follow up is important . The follow up includes:- Check for the symptoms of hyper and hypoglycemia Check for injection site swelling and infection. BP measurement and Growth monitoring. Check the records of blood glucose testing. Younger children and those who have poor glycemic control to be seen in a shorter intervals. Every 3months to do HbA1c, Every 12 months – Thyroid Function tests , test for celiac disease and Lipids profile Screening for microvascular complications. 2/24/2020

75. End of Unit - 8 2/24/2020