Type 1 Diabetes Mellitus

Transcription

1 Type 1 Diabetes Mellitus Imprtant Pints in Histry Plyuria, thirst and plydipsia Plyphagia Weight lss Vmiting Abdminal pains Onset f enuresis in a previusly tilet trained child. New presentatin r acute episde in knwn diabetic? What is the usual insulin requirement? Any precipitating factrs? Any fcus fr infectin? Diagnsis is made when: Symptms + randm bld sugar (RBS) >11.1mml/L (>200mg/dl) Or Fasting BS >7mml/l (126mg/dl) (Cnversin: 1 mml/l glucse apprximately = 18 mg/dl) In the absence f clear symptms, diagnstic testing shuld be repeated n a separate day. Treatment cnsists f: Lifelng insulin dependency with multiple daily injectins A healthy eating plan Regular physical activity Diabetic Ketacidsis Diabetic Ketacidsis (DKA) = Hyperglycaemia RBS >15 r 270mg/dl + ketnuria + acidsis (if bld gas available ph <7.3 r bicarbnate <15 mml/l) Imprtant Pints n Histry & Examinatin Vmiting, abdminal pain, flushed cheeks Ketacidtic smell f breath. Dehydratin Rapid, shallw breathing (Kussmaul breathing) Reduced cnscius level Abdminal rigidity may mimic appendicitis r pancreatitis. Assess Severity f dehydratin usually apprximately 7.5% dehydrated. D nt crrect abve this withut cnsultant decisin. Level f cnsciusness Evidence f infectin Relevant Investigatins Bld sugar (>15mml/l r >270 mg/dl) Urine Glucse high > 3-5%; Ketnes high +++ r ++++ (If available capillary bld gas & Urea and Electrlytes) Screen fr infectin i.e. Bld culture, urine dipstick, cnsider FBC.

2 Acute cmplicatins Cerebral edema (& Raised ICP) Thrmbsis, haemrrhage. Hypkalaemia (secndary t insulin) can lead t Cardiac arrest. Acute renal failure Management f Diabetic Ketacidsis *******Crrect acidsis and high bld sugars slwly ******* 1. ABCCCD Give O2 t patients with circulatry impairment r shck 2. Fluid Replacement: Insert large IV cannula, if nt pssible intra-sseus access IV Fluids are the Mst Imprtant Resuscitatin Measure. Start either Nrmal Saline r Ringer s Lactate. Fluid requirement = (Maintenance) plus (deficit) Crrect ver 48 hrs t avid cerebral edema Deficit (litres) = % dehydratin x weight (kg) x 10. D nt calculate abve 7.5% Give 10mls/kg blus 0.9% Nrmal saline nly if shck is present. (d NOT give further fluid bluses withut discussing with the cnsultant n call) DO NOT include the blus fluids in this calculatin unless >20ml/kg have been given Write the calculatin in the ntes. Child weighing 20kg n admissin in shck in DKA and 7.5% dehydrated Example 1 x 10 mls/kg Blus needed t crrect shck = 200mls Maintenance = 1500ml /day (1.5L) Deficit = 20 kg x 7.5% x 10 = 1.5 L Requirement (ver 48 hurs) = Maintenance ( ) + Deficit (1.5) 4.5 litres/ 48 hurs = 94 mls/hr 3. Insulin Therapy Insulin shuld be shrt acting, sluble ( clear ) This can be given intravenusly via syringe pump (preferred chice) r subcutaneusly START INSULIN 1 HOUR AFTER STARTING IV FLUIDS IV insulin: Start IV at 0.05 units/kg/h. Use a syringe pump - dilute 50 units shrt-acting [sluble] insulin e.g. Actrapid in 50 ml nrmal saline, 1 unit = 1 ml (E.g. fr a 25kg child give1.25 ml/hr. =1.25 units per hur)

3 D nt give an insulin blus Ensure a slw drp in glycaemia <3-5mml/l/h Once RBS < 15 mml/l ( mg/dl) change fluid t 0.9% NaCL & 5% dextrse. D nt reduce rate f insulin (t make this fluid add 100ml f 50% glucse t every litre f 0.9% saline.) If bld glucse levels start t rise rather than fall cnsider whether need t increase rate f fluids (recalculate % dehydratin) r whether need t increase insulin t 1u/kg/h Subcutaneus insulin: Cmmence 0.1u/kg SC shrt acting/sluble insulin. Recheck bld glucse after ne hur. Repeat hurly until bld glucse is falling. When falling give 0.1units/kg1-2 hurly. Ensure a slw drp in glycaemia <3-5mml/l/h Once RBS < 15 mml/l ( mg/dl) change fluid t 0.9% NaCL & 5% dextrse. (T make this add 100ml f 50% glucse t every litre 0.9% saline.) 3. Ptassium replacement Ptassium replacement is needed fr every child in DKA if they are passing urine. Add KCL t IV fluids (20 mml t each 500ml bag). If K+ <2.8 r >6, ECG mnitring advisable. When t switch t maintenance insulin therapy: Stp insulin infusin r 2 hurly SC regime when ketsis is reslving, the child is fully alert and ral fluids are tlerated withut nausea r vmiting. ph shuld be > 7.3. The first dse f subcutaneus insulin shuld be given 1-2 hurs befre stpping insulin infusin. 4. Onging management: Mnitr bld glucse levels hurly and when patient is stable every 2 hrs. Cnsider NGT n free drainage fr child wh is uncnscius Check each urine passed fr glucse and ketnes as a guide t recvery IV fluid shuld be cntinued until the child is drinking well and able t tlerate ral feeds. The Urine shuld be ketne free. Please infrm the Diabetes Nurse/ team fr patient educatinal supprt 5. Treatment f infectin: Infectin can be a precipitant f infectin. It can be difficult t exclude as the white cell cunt can be high due t stress and acidsis. Fever is a mre reliable sign. If infectin is suspected treat with brad spectrum antibitic e.g. Ceftriaxne. 6. Cerebral edema This is a rare but fatal cmplicatin f DKA. Signs include headache, vmiting, irritability, slwing heart rate and rising bld pressure, reduced cnscius level, seizures. Neurlgical signs e.g. unequal pupils, psturing. Risk factrs include: Yung age, first presentatin, early start f insulin, t rapid drp in glycaemia, t much IV fluid. TREAT URGENTLY Exclude hypglycaemia as a cause fr change in neurlgical state. Reduce the rate f fluid administratin by ne third Give mannitl 0.5-1g/kg/d ver 20 minutes and repeat if there is n initial respnse in 30 mins t 2 hurs

4 Hypertnic 3% saline 5ml/kg ver 30 minutes is an alternative Elevate the head f the bed t 30 degrees Cnsider intubatin Cnsider neur-imaging t rule ut ther intra-cerebral causes f neurlgical deteriratin 7. Initial Maintenance Insulin Requirements nce DKA has reslved and the child is drinking and eating Calculate the ttal daily dse f insulin nce the child is stable. Fr new diabetics this is usually u/kg/day, but bear in mind their insulin requirement ver the previus 24 hurs. Children can have an initial hneymn perid where they require less insulin. Initial ttal daily dse u/kg/d. Tw thirds ( 2 / 3) f the ttal dse given befre breakfast and ne third ( 1 / 3) befre evening meal. At each injectin 2/3 rd is intermediate acting and 1/3 rd is shrt acting, Child weighing 36kg Example Fr 0.5u/kg/d ttal daily dse f insulin = 18 units AM (pre breakfast) PM (pre evening meal) Shrt acting (Sluble) 4 2 Intermediate acting (Lente ) 8 4 Lng term management f diabetes: Attend Diabetes clinic (Friday mrning) nce a mnth when glycaemic cntrl is stable. At each clinic review the fllwing: 1. Investigatins: - Height and weight - Fasting bld sugar - Review f injectin sites t review signs f lipdystrphy - Ft examinatin fr neurpathy, infectins and ulcers (annually). - Bld pressure (annually ver 12 years) - HBA1c (at least annually, ideally three times per year) - Urine dipstick. If prteinuria check creatinine & urea. If persistent albuminuria cnsider ACE inhibitrs & Renal Review. - Ophthalmlgy review (annually) 2. Assess fr Hypglycaemic awareness and Hyperglycaemic symptms: Ncturia? Thirsty? A gd guide f bld sugar cntrl is hw many times the child has t pass urine vernight. Hyp symptms: sweating trembling, tachycardia, drwsiness, cnfusin Treatment: Glucse in frm f refined sugars e.g. sb 3. Bld Glucse mnitring: Check whether have glucmeter and ensure prvided with.. number f sticks each clinic Review bld glucse mnitring bklet Patterns f bld glucse levels (BGLs) are mre imprtant than a single BGL

5 Shuld test strips be scarce, it is best t test at different times f the day a few days a week rather than the same time each day. If pssible, test regularly befre and tw hurs after breakfast and all ther meals, and peridically vernight at 3am (checking fr hypglycaemia). Recmmended target bld sugar range: Befre meals: 4-7mml (72-126mg/dl) After meals: 5-10mml/l (90-180mg/dl) At bedtime: 10mml (180mg/dl) At 3am: 5-8mml/l ( mg/dl) Hypglycaemia = bld glucse <3.9 mml/l (70mg/dl) Onging insulin requirements: Pre-pubertal children (utside the partial remissin phase) usually require IU/kg/day. During puberty, requirements may rise abve 1 and even up t 2 U/kg/day. In any child requiring ver 1.5u/kg/d cnsider pr treatment cmpliance as a strng pssibility. Cnsider admissin t fr 2 days t review regime. (On day 1 f admissin the nurses shuld administer the insulin and check RBS s 4 hurly. Check injectin technique, injectin sites and diet) The crrect dse f insulin is that which achieves the best attainable glycaemic cntrl, withut causing bvius hypglycaemia, and resulting in nrmal grwth and develpment. Insulin adjustment: Review bld sugar bklet, HBA1c & symptms t guide alternatin f regime. DO NOT INCREASE INSULIN BASED ON AN ISOLATED HIGH BGL IN CLINIC as this may be a rebund frm hypglycaemia in the middle f the night If a pre-meal BGL is always high, the preceding dse f intermediate acting insulin (lente) may be insufficient. If the pre-meal BGL is always lw, the previus dse f intermediate insulin (lente) may be t high. If a pre-meal BGL is smetimes very high and at ther times very lw, either insulin, fd r exercise are nt cnsistent and shuld be reviewed. If the BGL 2 hurs after the meal is t high, the previus meal dse f shrt-acting (regular) insulin may be t lw. If the BGL 2 hur s pst-meal is t lw, the previus meal dse f shrt-acting (regular) insulin may be t high. NB the level f bld glucse can rise in the early mrning, s care shuld be taken if increasing the evening intermediate dse as ncturnal hypglycaemia may g unnticed which can be dangerus. HBA1c: HBA1c (glycated haemglbin) prvides infrmatin abut the average bld glucse levels ver the past 2-3 mnths. The target HbA1c fr all age-grups is < than 7.5% Check HBA1c at least nce yearly (ideally 3 times yearly) Educatin: Patient educatin is the crnerstne f gd glycaemic cntrl Diet Imprtance f regular meals

6 Avid refined sugars e.g. Sb, cke, fanta, any sugar in tea, cakes and biscuits Encurage cmplex carbhydrates e.g. cereals and a high fibre diet Encurage the whle family t adpt this healthy diet Insulin Keep in a cl place (ideally a fridge; if unavailable place insulin in a small clay pt, then place small pt int a larger pt cntaining water evapratin f the water will cl the inner pt) Rtate injectin sites t prevent erratic insulin absrptin frm lipdystrphy. Use the stmach, thighs, buttcks and upper arms Hypglycaemia awareness Hyp Symptms: sweating trembling, tachycardia, drwsiness, cnfusin Treatment: Glucse in frm f refined sugars e.g. 200ml (half a cup) sweet juice eg sb fllwed by 10-15g f a slw acting carbhydrate eg Nsima Sick day rules Increase fluid intake D nt stp insulin even if unable t eat Seek medical attentin if child is unable t drink r breathing fast r drwsy Exercise Mnitr fr cmplicatins: Pr glycaemic cntrl may lead t grwth failure & puberty delay Retinpathy resulting in visual lss Diabetic nephrpathy causing hypertensin and renal impairment Neurpathy causing pain, parathesia, muscle weakness, autnmic dysfunctin Macrvascular disease causing cardiac disease, strke and peripheral vascular disease with limb lss, imptence Hypthyridism can develp Cnsider anti-hypertensives if bld pressure is cnsistently > 95th centile (see table fr nrmal bld pressures ) r > 130/80 mmhg. Reference: Glbal IDF Guidelines.pdf British Sciety f Paediatric Endcrinlgy DKA Guidelines Other rarer types f diabetes: Type 2 diabetes usually presents in adulthd, but can present in adlescents, particularly if verweight and inactive. There may be a family histry. The cnditin may respnd t a healthy diet & weight reductin.. Malnutritin related diabetes and fibrcalculus pancreatpathy. (May present with abdminal pain and calcificatin n X-ray r ultrasund. Nenatal diabetes (presenting in the first 6 mnths f life)