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Acute presentations of diabetes

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1 day history of lethargy shortness of breath ... Nurseries should minimise sedentary activities at playtime and provide healthy meals ... – PowerPoint PPT presentation

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Title: Acute presentations of diabetes


1
Acute presentations of diabetes
  • Dr Debbie Matthews
  • Consultant Paediatric Endocrinologist
  • Newcastle Hospitals NHS

2
Emma
  • Presented at 10 months of age referred by GP
  • 3 day history of vomiting poor feeding
  • 1 day history of lethargy shortness of breath
  • O/E pyrexial 38C, shocked, dehydrated (c7),
    tachypnoeic RR 70. Poorly responsive, modified
    GCS 8

3
Investigations
  • Na 131, K 5.2, urea 12.2, creatinine 123
  • FBC Hb 13.1, WCC 13.8, Plts 244
  • Blood culture no growth
  • CXR ? Hyperexpanded, lungfields clear
  • What other investigations would you do?

4
Diabetic ketoacidosis
  • Hyperglycaemia (BG gt11mmol/L)
  • Ketonaemia
  • Acidosis (pHlt7.3, HCO3 lt15mmol/L)
  • Glycosuria
  • Ketonuria

5
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6
Management of diabetic ketoacidosis (1)
  • General Resuscitation A, B, C
  • If shocked, give 10ml/kg of 0.9 saline as bolus
    and repeat as necessary
  • Assess degree of dehydration
  • Ix include BG, blood gas, UE, bicarbonate, FBC,
    osmolality

7
Management of diabetic ketoacidosis
(2) Conscious level
  • Half hourly neurological observations
  • If in coma or deteriorates-
  • Record GCS or AVPU scale
  • Transfer PICU
  • Consider instituting treatment for cerebral
    oedema

8
Management of diabetic ketoacidosis (3) Degree
of dehydration
  • 3 just detectable
  • 5 dry mucous membranes
  • 7.5 sunken eyes, ?skin turgor, poor CRT
  • 10 poor perfusion, thready pulse
  • Use recent weight

9
Management of diabetic ketoacidosis (4) Full
examination
  • Weight
  • ? Evidence of cerebral oedema
  • ? Infection
  • ?Ileus

10
Management of diabetic ketoacidosis (5) Consider
PICU if-
  • Severe acidosis pHlt7.1, marked hyperventilation
  • Severe dehydration with shock
  • ? GCS
  • Suspected cerebral oedema
  • lt2 years of age

11
Management of diabetic ketoacidosis
(6) Observations
  • Strict fluid balance including urine output
  • Half hourly neuro obs initially
  • Hourly capillary BG monitoring
  • Weigh bed or twice daily weight

12
Management of diabetic ketoacidosis (7) Fluids
  • Fluid to be given over 48 hours
  • (48hrs maintenance deficit) - resuscitation
    fluid
  • Initial fluid 0.9 saline 20mmol KCl per 500ml
  • Once BG lt14mmol/l, change to 0.45 saline 5
    dextrose 20mmol KCl
  • Check UE blood gas every 2-4 hours

13
Potassium in DKA
  • Total body potassium depleted in DKA
  • Plasma levels low, normal or high
  • Levels fall when insulin is given
  • Give 20mmols/l per 500 mls

14
Insulin therapy in DKA
  • Essential to switch off ketogenesis reverse
    acidosis
  • Delay start of insulin therapy for c 1 hour while
    rehydration fluid is running
  • Continuous low dose insulin infusion is preferred
    method for treating DKA

15
Insulin therapy in DKA (2)
  • 50 units Actrapid in 50mls 0.9 saline via
    syringe pump.
  • Starting dose of insulin 0.05u/kg/hr
  • If plasma glucose remains gt 20, review dose and
    consider increasing to 0.07 or 0.1u/kg/hr
  • If BG falls by gt5mmol/l/hr or to lt 14mmol/l,
    change to 0.45 saline 5 dextrose KCl

16
Insulin therapy in DKA (3)
  • If BG is 4-6mmol/l change to 0.45saline 10
    dextrose with added potassium
  • If BG falls lt4mmol/l, give bolus of 2ml/kg 10
    dextrose and then continue as above. Retest BG
    after 30 minutes
  • If BG remains low, discuss with Consultant. It
    may be appropriate to reduce the insulin infusion
    although not to stop it

17
Changing to subcutaneous insulin
  • Child may still have urinary ketones
  • Child should be able to tolerate oral food/fluids
  • Discontinue insulin infusion 10-60 minutes after
    the first subcutaneous injection, depending on
    type of insulin used

18
General Comments
  • Remember children can die from DKA
  • They can die from-
  • Cerebral oedema
  • Hypokalaemia
  • Aspiration pneumonia

19
Signs symptoms of cerebral oedema
  • Headache and slowing of pulse rate
  • Change in neurological status restlessness,
    confusion, drowsiness, incontinence
  • Specific neurological signs cranial nerve
    palsies, abnormal posturing
  • Rising BP
  • Reduced SpO2

20
Management of cerebral oedema
  • Exclude hypoglycaemia
  • Give mannitol 0.5g/kg stat over 15 minutes.
    Repeat after 2 hrs if no response
  • Nurse with head elevated to 450
  • Restrict IV fluids to 2/3 maintenance and replace
    deficit over 72 hours
  • Transfer to PICU
  • Arrange CT scan to exclude other pathology

21
Summary
  • DKA is serious complication of diabetes and can
    be fatal
  • Metabolic abnormalities need to be reversed
    slowly over 48 hours
  • The insulin deficiency needs to be corrected by
    continuous insulin infusion

22
Other acute presentations of diabetes mellitus
  • "Walking wounded"
  • Incidental finding of hyperglycaemia or
    glycosuria
  • These may be non-diabetic
  • Early diabetes
  • Non-Type 1 diabetes

23
Chronic Management of Type 1 Diabetes mellitus
  • Dr Debbie Matthews
  • Consultant Paediatric Endocrinologist
  • Newcastle Hospitals NHS

24
Aims of treatment
  • No symptoms day to day
  • Good general health
  • Normal growth puberty
  • Normal school peer group relations
  • Prevention of long term complications

25
Patient Pathway from diagnosis
  • 12 year old girl admitted as emergency from GP
    with 3/52 H/O polyuria, polydipsia and weight
    loss
  • Blood glucose 25mmol/l.
  • Otherwise well
  • How will you manage this patient?

26
How????
  • Multidisciplinary team
  • Paediatrician with special interest
  • Diabetes specialist nurse
  • Dietitian
  • Psychologist
  • Input from GP, SW, school teachers, sports
    coaches
  • Support from family critical

27
Insulin molecule is found in hexamers
28
Insulin Preparations
  • Rapid acting insulin analogues
  • Short acting (soluble)
  • Intermediate
  • Long acting analogues

29
Rapid acting insulin analogues
  • Novorapid
  • Amino acid at B28 has aspartic acid
    substituted for proline which prevents hexamer
    formation and speeds up action

30
Long acting insulin analogues
  • Insulin Glargine
  • Formulated at pH4 and injected as
    water-soluble.
  • At pH7, forms hexamers precipitates under
    skin. Gradually released in biologically active
    form.
  • Claimed to be "peakless"

31
Injection devices
32
Insulin administration
  • Abdomen gt Arm gt Bottom
  • Timing of insulin-
  • rapid-acting
  • basal

33
Insulin regimens
  • Insulin doses 0.5-1.0u/kg/d
  • Up to 1.5u/kg/d in puberty
  • Frequency from once daily to multiple injections
  • CSII (continuous subcutaneous infusion of insulin)

34
Minimed Insulin pump
35
Blood testing
36
Blood testing
  • Pre-prandial aim 4-8
  • Post-prandial aim lt10
  • Number of tests per day
  • What about night-time monitoring?
  • CGMS

37
Advantages of continuous blood glucose monitoring
38
Patient with insulin pump and continuous blood
glucose monitor
39
Food Carbohydrate Counting
  • Healthy eating
  • Diet more flexible with multiple injection
    regimens and CSII
  • DAFNE

40
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41
"Hypos"
  • "Four is the floor"
  • Recognition of symptoms
  • Pre-school children suffering significant hypos
    may be at risk of longterm neurocognitive
    dysfunction
  • "Dead-in-bed"
  • Alcohol

42
Treatment of hypos
  • Dextrose tablets or lucozade
  • Give 10g CHO Wait 15 mins. If still symptomatic,
    repeat.
  • Give long-acting CHO when no longer symptomatic
  • Glucagon

43
Glucagon kit
44
Treatment of high blood glucose levels
  • Exercise
  • Novorapid/ Humalog
  • The "100 Rule"

45
Exercise
  • Blood testing
  • Effects of exercise on blood glucose
  • Effect of exercise on insulin sensitivity

46
Monitoring of diabetes
  • Glycaemic control
  • HbA1c
  • Blood glucose results
  • Annual review for associated conditions and late
    effects
  • Other concerns
  • EDUCATION

47
HbA1c
48
Other conditions associated with Type 1 diabetes
  • Coeliac disease
  • Thyroid disease
  • Addisons disease
  • Other autoimmune conditions

49
Normal jejunal biopsy and biopsy in coeliac
disease
50
Longterm complications of diabetes relevant to
children young people
  • Risk of complications is related to duration of
    condition glycaemic control. Some genetic
    component
  • Macrovascular disease
  • Microvascular disease
  • Eyes
  • Kidneys
  • Nerves

51
Complications seen in adolescents with Type 1
diabetes
  • Background retinopathy
  • Microalbuminuria
  • Painful peripheral neuropathy
  • Autonomic neuropathy

52
How????
  • Education
  • Support
  • Empowerment

53
Unusual forms of diabetes in children young
people
  • Maturity onset diabetes in the young
  • Type 2 diabetes
  • Steroid-induced diabetes
  • Cystic fibrosis related diabetes
  • Others eg mitochondrial disease, Friedreich's
    ataxia

54
Maturity onset diabetes in the young
  • Misnomer - not Type 2 diabetes
  • Hereditary, monogenic, usually dominant.
  • Mutations in genes causing disruption of insulin
    production or release
  • Usually act like mild T1DM but variable
  • MODY3 is most common (HNF1a mutation)
  • Many forms can be treated with oral hypoglcaemic
    agents

55
Maturity onset diabetes in the young (2)
  • When to suspect MODY and not T1DM-
  • Diagnosis of DM lt 6 months of age
  • FH of diabetes with 1 parent affected
  • Persistence of low insulin requirements
    (lt0.5U/kg/d)
  • Absence of autoantibodies or H/O autoimmune
    disease in family

56
Type 2 Diabetes Mellitus
  • Patients overweight, especially around abdomen
  • Ethnic background (Afro-Caribbean, Asian)
  • Family history (but polygenic inheritance, not
    monogenic)
  • Associated problems eg hypertension, PCOS

57
Causes of Type 2 diabetes
58
Type 2 Diabetes (2)
  • Typically present with thirst, polyuria,
    infections eg thrush, boils, tiredness
  • Often strong FH T2DM
  • c5 present with DKA
  • 90 have acanthosis

59
Acanthosis nigricans
60
Type 2 diabetes (3)
  • Diagnosis of T2DM with oral glucose tolerance
    test
  • Elevated HbA1c, absence of autoantibodies
  • Treatment is with lifestyle measures, metformin,
    sulphonylureas, glitazones or insulin
  • Becoming more common in young people

61
The Obesity Epidemic
  • Dr Debbie Matthews Consultant Paediatric
    Endocrinologist Newcastle Hospitals NHS

62
  • Energy stores Energy intake minus
    Energy expenditure
  • In children, some of energy stores used for growth

63
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64
Definition of Obesity
  • The definition of obesity in adults is a
    BMIgt30kg/m2
  • BMI is not static in children and varies
    according to sex. BMI centiles needed
  • UK National BMI percentile classification . Uses
    85th 95th percentiles of 1990 UK data as
    cutoffs for overweight obesity
  • International Obesity Taskforce. Centile curves
    drawn that at age18 pass through BMI 30

65
Key Facts on Obesity
  • Obesity is one of the major public health issues
    in the developed world
  • In 2003, 22 ? 23 ? were obese. By 2010, will
    increase to 33 ? 28 ?.
  • Childhood obesity in 2-10 year olds in England
    has risen from 9.9 in 1995 to 14.3 in 2004

66
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68
Increasing prevalence of obesity in England
69
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70
Childhood obesity in Newcastle
  • 4287 children in Newcastle were height weight
    measured at school entry or Year 6 in 2006.
  • 29.5 children were overweight or obese
  • 17.5 children were overweight
  • 12 children were obese

71
What are the reasons for the increase in
childhood obesity in the UK?
  • Environmental
  • Less exercise
  • Food high in fat and simple sugars
  • Effect of poverty
  • What about genetics and any underlying pathology?

72
Lifestyle issues in children
73
The "School run"
74
What are the reasons for the increase in
childhood obesity in the UK?
  • Environmental
  • Less exercise
  • Food high in fat and simple sugars
  • Effect of poverty
  • What about genetics and any underlying pathology?

75
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78
What are the reasons for the increase in
childhood obesity in the UK?
  • Environmental
  • Less exercise
  • Food high in fat and simple sugars
  • Effect of poverty
  • What about genetics and any underlying pathology?

79
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80
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81
Leptin deficient child pre and post treatment
with leptin
82
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83
Healthy Eating Stall in School
84
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86
Healthy Weight, Healthy Lives
  • A Cross Government Strategy for England
  • New 372 million strategy to help everyone lead
    healthier lives
  • Published in Jan 2008 by Alan Johnson Ed Balls
    (Sec of State for Children, Schools Families)
  • Targets Early Years, Schools food, sport
    physical activity, planning, transport Health
    Service

87
Healthy Weight, Healthy Lives (2)
  • National Child Measurement Programme
  • Healthy Schools Programme
  • Food in Schools Programme
  • School Fruit Vegetable Scheme
  • Physical Education, School Sport and Club Links
    Programme

88
Obesity Strategy for Newcastle upon Tyne
  • Obesity is more common in lower socioeconomic and
    socially disadvantaged groups
  • Obesity almost 4x more common in Asian than in
    white children
  • Target to halt by 2010 (from 2004 baseline) the
    year-on-year increase in obesity in children
    lt11yrs

89
Obesity Strategy for Newcastle upon Tyne (2)
  • Nurseries should minimise sedentary activities at
    playtime and provide healthy meals
  • Healthy Schools Programme
  • Mothers encouraged to breast feed
  • Teach Cooking skills (community food projects
    throughout city)
  • Encourage Physical activity (On the Go)

90
  • Is it Working???
  • "Lost Generation"
  • Current parents are the first generation to have
    a life expectancy greater than their children
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