SICKDAY MANAGEMENT

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SICK-DAY MANAGEMENT
Children With Diabetes Friends for Life
Conference Orlando, FL July 23 27, 2008
H. Peter Chase, MD Professor of
Pediatrics University of Colorado Denver Barbara
Davis Center for Childhood Diabetes
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DIABETES EDUCATION The cornerstone for optimal
care and outcome.Apple pie and Motherhood

• New-onset (1-3 days)
• Daily phone contact, one week, one month every
  three months
• Understanding Diabetes 15,000 copies/year
  The Pink Panther Book
• The First Book (Synopsis of big book)
• 53,000 copies last year

(available 1-800-695-2873 or free on the
internet at www.barbaradaviscenter.org)
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SICK-DAY MANAGEMENT

• People with diabetes get sick just like anyone
  else.
• Average 6 known infections per year in
  children.
• Four main concerns
• I. Dehydration
• II. Hyperglycemia (high BG)
• III. Ketones (DKA)
• IV. Hypoglycemia

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I. DEHYDRATION
(loss of body fluids)

• Can occur in anyone if fluid intake is not
  adequate.
• More likely with diabetes because the glucose
  pulls water out of the body for excretion in the
  urine (cant excrete sugar cubes).
• Diabetes is the only disease in which someone can
  be dehydrated and still pass much urine.
• The higher the BG, the more water that is
  pulled out of the body.
• Vomiting and not drinking adequate fluids add to
  the problem.
• A good physical sign to look at is often the
  dryness of the tongue.

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DEHYDRATION/VOMITING
1) May need a medicine to stop
vomiting Phenergan children over age 2
years Zofran oral 2) Fluids Start slowly
Pedialyte, juice, water BG lt100 Fluids with
sugar popsicles, jello, etc. - Gradually
increase to requirement of 1 oz/yr of
age/hour for up to age 16 yrs. 3) The fluids
help to wash-out sugar and ketones, to restore
circulation, BP and other parameters. 4) Solid
foods When no further vomiting (e.g. crackers,
banana, soup, what child wants)
Understanding Diabetes page 178
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II) HYPERGLYCEMIA (High blood sugar)

• Many infections cause release of cortisone which
  raises BG (e.g. Mumps).
• Make sure ketones are not present.
• Give usual insulin plus extra injections or
  boluses every 2 hours. Use usual correction
  factor (most common is 1 unit/50 mg/dl over 150).
• Frequent blood sugars is a key.

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III. KETONES (DKA)

• MUST CHECK KETONES WITH ANY ILLNESS (even
  vomiting one time) OR IF HIGH BG (e.g.
  gt300mg/dl).
• Education about ketone testing is the most common
  deficiency in families referred to our Center.
• If ketones build up DKA.
• DKA is the number one cause of death in children
  with diabetes.
• DKA is almost completely preventable in a
  properly trained family.
• (Understanding Diabetes, Chapter 15, page 163)

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WHAT CAUSES KETONES?

• INFECTIONS number 1. Due to fat breakdown to
  supply extra energy and secondary to increased
  cortisol.
• MISSED INSULIN ? fat breakdown.
• PUMP INSERTION DISLODGING.
• NOT ENOUGH INSULIN.
• TRAUMATICE STRESS ON BODY.
• Understanding Diabetes page 164

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WHERE DO KETONES COME FROM?

• Fatty Acids and
  Glycerol
• Acetyl-CoA
• 
  Oxaloacetate
• Hydroxybutyric acid (?-OHB) TCA Cycle
  for energy
• Acetoacetic acid (AcAc)
• Acetone

Fat
Liver
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HOW TO CHECK FOR KETONES

• MUST ALWAYS HAVE A METHOD IN THE HOME and ALONG
  ON TRIPS.
• Urine test cheapest not as accurate as urine
  may not reflect current status. Ketostix? good
  for 6 months once bottle opened (get
  foil-wrapped!).
• Blood meter PrecisionXtra?
• More expensive most accurate gives the exact
  level at time of testing.
• Many families do only if cant get urine or if
  urine test high.
• More apt to do (93) than urine (53) when ill.

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COMPARISON OF BLOOD and URINE KETONES
Blood (mmol/L) Urine lt 0.6 negative 0.6
to 1.5 small to moderate 1.6 to
3.0 usually large 3.0 go directly to
the E.R. Very large
Understanding Diabetes page 30
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The Annual ADA Standards of Care states Blood
Ketone testing methods that quantify ß-HBA, the
predominant ketone body, are available and are
preferred over urine ketone testing for
diagnosing and monitoring ketoacidosis.
ADA Clinical Practice Recommendations Jan, 2003
Position Statement Diabetes Care, S107, 2003
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?-hydroxybutyrate is a better indicator of
metabolic status when detecting and treating DKA


Schade DS, Eaton RP Special Topics in Endo and
Metab 198241-27
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Old Paradigm Check urine ketones New Paradigm
Check blood ?-OHB

• Blood ?-OHB tells you how you are doing at
  the time of the test
  (Urine may have been in
  bladder for hrs)
• Urine ketone levels may not accurately reflect
  the severity of the problem
• A person may not be able to void
• Some (teens) give false urine test results

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New Paradigm Check blood ?-OHB (cont.)

• Some people are too ill/exhausted to do the urine
  test
• Urine ketone strips spoil after opened x gt6
  months
• Urine strips check for AcAc, whereas the more
  important ketone is ?-OHB
• Use of blood ?-OHB test may save an ED visit or a
  life!

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If Money/Insurance Is a Problem

• Can test urine ketones
• (If a sample can be obtained)
• Skip the blood ketone test if the urine test is
  negative, trace or small
• Use the blood strips anytime the urine test is
  moderate or large

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Why are ketones dangerous?

• Acidosis ensues as ketones build up
• ? - Hydroxybutyric acid (?-OHB) is the main
  ketone
• Glucose is high dehydration
• Potassium is lost ? ? GI motility
  ? vomiting
• The acid state of the body interferes with
  body metabolism

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Diabetic KetoAcidosis (DKA)

• 160,000 Admissions to private hospitals/year
• Cost over 1 billion annually
• 65 lt19 years old
• Main cause of death in children with diabetes
  (approximately 85)
• Cerebral edema in 69 of deaths

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Signs of DKA

• Increased urination
• Stomachache, vomiting
• Fruity odor to breath
• Dry mouth and tongue
• Drowsiness
• Deep breathing
• Coma
• Death (very rare if treated early)

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Denver DKA Data (ED or Hospitalization) (Rewers,
Chase, et al JAMA 2872511,2002)

• Definition an episode of DKA leading to an ED
  and/or hospital admission
• 1243 children living in metro Denver with known
  type 1 diabetes (not new onsets)
• 3994 person years of f/u (1/1/1996-12/31/2002)
• Infancy to age 19 yrs
• Incidence 8 per 100 patient-years

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TREATMENT
(Directions from Understanding Diabetes page 167)

• ?-OHB level (mmol/L)
• 0.6 1.5 Take 10 of total daily insulin dose
  every 2 hrs ? fluids Call HCP.
• gt 1.5 3.0 Take 20 of total daily insulin
  dose every 2 hrs ? fluids. Must call HCP.
• gt3.0 Go to ED.

available www.barbaradaviscenter.org or call
1--800-695-2873
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TREATMENT Mild Ketones

• A much more common problem than severe DKA.
• Almost every child with diabetes has 1-4 times
  annually after the honeymoon period is over.
• By definition Able to be handled in the home
  setting usually with telephone help from the
  HCP. Always take phone numbers on trips!
• Small - moderate urine ketones or blood ketone
  level lt3.0 mmol/L.

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Mild Ketones Denver Data on Phone Management

• Chase et al
• Ped in Review 11297, 1990
• Arch Pedriatr Adolesc Med 152672, 1998
• 57 children, ages 1 18 yrs.
• Small ketones 4 pts
• Moderate ketones 22 pts
• Large ketones 31 pts.
• Time to resolution Mod 4.1 Hrs
• Lge 4.5 Hrs
• Four children ED and/or Hospital (6)

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Sick Day Management Study

• Goal To evaluate the impact on hospitalizations
  of a blood
• ß-hydroxybutyrate (ßOHB) test vs. urine
  ketone tests
• Design
• 123 participants, ranging in age from 323 years
• 61 participants randomized to use blood ßOHB
  measurements using the Precision Xtra Advanced
  Diabetes Management System
• 62 participants randomized to use traditional
  urine acetoacetate measurement using Ketostix
• All participants were trained on their sick-day
  guidelines
• Data collected included episodes of illness, ER
  visits, hospitalizations, blood glucose testing
  frequency, ketone testing frequency and A1c
  (glycohemoglobin)

From Laffel et al, Poster 426-P, presented at
ADA Scientific Sessions, San Francisco June 2002
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Testing for Ketones When ill

• 123 Adolescents randomized
• 62 to blood ?OHB
• 61 to urine ketone testing
• Sick Days Checked for Ketones
• ?OHB 304 91
• Urine K 279 56

(Laffel L et al, Diabetes 51,426P,2002)
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Summary Study Findings

• Participants managed with blood ßOHB ketone test
  during sick days were 46 less likely to require
  an ER visit
• Participants managed with blood ßOHB ketone tests
  during sick days were 64 less likely to be
  admitted to the hospital
• 70 of those participants testing blood ßOHB
  reported they would check blood ketones more
  often than urine ketones

(Laffel L et al, Diabetes 51,426P,2002)
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Directions in Understanding Diabetes regarding
blood ?-OHB (page 166)
?-OHB level (mmol/L) lt 0.6 Normal 0.6 to 1.0
Take extra insulin fluids 1.0 to 1.5
Same call HCP 1.5 to 3.0 Call HCP STAT
gt 3.0 Go to ED
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CASE EXAMPLES 11 yo ? Mom calls (1000 am)

• Home from school with fever
• Rapid-strep test positive yesterday
• Treatment with penicillin
• BG 380 mg/dL ?-OHB 1.3 mmol/L
• Usual AM insulin 4 H/12 NPH 700pm 4H/20
  Lantus
• (40 units total per day)
• Plan 4 units H every 2 hrs until ?-OHB lt0.6
• Encourage fluids (juice if BG lt150)

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CASE EXAMPLES 4 yo ? GI flu
700 am Mother phoned emesis x 5 thru
night 1st void since 9 pm BG 180 mg/dL
Urine ketones Large ? Take extra insulin
? Advice Do blood ?-OHB level 715 am Blood
?-OHB 0.3 mmol/L (normal) Advice No extra
insulin Usual dose fluids 900 am Urine
ketones neg feeling fine
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CASE EXAMPLE 14 yo? Pump failure
Time ?-OHB Art. pH BG (mg/dL) 11 am gt
6.0 7.02 1042 230 pm 5.7 7.2 409 5
pm 3.0 7.23 267 730 pm 1.7 7.34 162 830
pm 0.2 7.45 119
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CASE EXAMPLES Diabetes Camp
700 am 4 children with moderate urine ketones,
which one(s) need to go to the
infirmary? ?-OHB level (mmol/L)
1 10 yo ? BG 276/mod 0.3 2 13 yo ?
BG 303/mod 0.5 started menses 3 9 yo
? BG 240/mod 1.7 upset stomach 4 9 yo
? BG 320/mod 0.4 URI, Homesick
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III) KETONES SUMMARY

• DKA is a serious illness and complication of
  diabetes.
• Checking serum ?-OHB early (and often when
  elevated) and implementing proper treatment can
  lead to early resolution and MAY BE LIFE-SAVING!
• Use of blood ?-OHB testing likely saves money in
  the prevention and treatment of severe DKA.

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SICK DAY MANAGEMENT IV. HYPOGLYCEMIA

• When treating Dehydration (I above) or Ketones
  (III above), must add fluids with sugar when the
  BG is lt150 mg/dl (lt8.3 mmol/L) (Ketones may still
  be present and need to continue giving insulin
  every 2 hours to turn ketone production off so
  must keep BG up in safe range).
• Pedialyte,? Gatorade, Jello, Popsicles are
  examples of early liquids in Table 4, page 179.
• Solids (when ready) might include soup,
  crackers, bananas, apple sauce (page 179).
• Frequent checks of BG (and/or CGM) are essential.

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IV HYPOGLYCEMIA
A Low Dose of Glucagon
(page 178 Understanding Diabetes)

• NOT the larger (0.3, 0.5, 1.0 cc) dose used for a
  severe low.
• Use if BG is low (e.g. lt60 mg/dl lt3.3 mmolL)
  and food cannot be kept down.
• Dose 1 unit/year of age up to 15 units.
• Can repeat every 20 minutes if needed.
• Has done more to save ER visits than anything
  else in my career.

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INSULIN DOSAGE WITH ILLNESS
(page 176 Understanding Diabetes)

• Some insulin MUST ALWAYS be taken (to keep
  ketones turned off).
• If BGs are low may only need basal insulin
  (Lantus, Levemir) or basal insulin in pump.
• If trace/small ketones with low or normal BG, may
  just need to eat (to provide calories and stop
  fat breakdown).
• If high BG or ketones, extra rapid-acting insulin
  every 2 hours (as above).

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EXERCISE WITH ILLNESS
1) Dont exercise with moderate or large urine
ketones or with blood ketones above 0.6 mmol/L.
Exercise results in increased adrenalin
(epinephrine) output which can further increase
ketones. 2) It is an old wives tale that one
cant exercise with high BG when ketones are
negative (the increased utilization of glucose
overrides any adrenalin effect). 3) Use common
sense.
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SUMMARY SICK DAY

• Sick days require a bit more work for
  people/families with diabetes but can be
  managed.
• Illness related factors (e.g. sore throat)
  should be handled by the primary care MD and
  diabetes related factors (ketones, insulin
  dose, etc.) by the diabetes team.
• Good education, as with all of diabetes
  management, is the key to handling sick-day
  management.
• QUESTIONS?