Sick day management in DM1can safe life

AMER ALALIPEDIA ENDCORINE CONSULTANT KFCH ,JIZAN

Why sick day management is critical for all Diabetic pateints

Death

sickness HypoglycemiaHypergylcemiaDKA

Introduction :During simple common illness e.g URTi , fever , GI ,

Diabetic patient may had Hyperglycemia (Stress) or Hypoglycemia (vomiting and diarrhea

,decrease intake) and failure of the ideal intervention may lead to catastrophic sequences

like DKA ,Cerebral Edema , Brain Damage and even death .so educating Parents about Sick Day management

is a top mandatory to safe life.

What is Our goal from educating Patients a bout sick day management ?

avoiding DKA or hypoglycemia that can complicate any simple common infection .

4 common scenario : 1) Dm1 patient with URTi and Ketone but borderline Blood gas ?

2) DM1 with Ketosis and inability to drink juice ?

3)DM1 with sickness and frequent hypoglycemia?

4) DM1 with Fever and frequent Hyperglycemia ?

5 yrs old child with dm1 since 2 yrs back on lantus 6 unit bed timeand novarapid 2 , 3 , 3 units ((1.4 unit kg day ))had URTi , fever , decreased oral intak and vomiting at ER was mild dehaydrated , arm hypertrophy , RBS 250 , Blood Ketone (Beta hydroxyButarate) was 2 but PH was 7.33 , Bicarbonate was 17

Scenario 1)

Q) what is the diagnosis ?

Is it Fullfill DKA criteria ?

Sick day management

What are the criteria to Diagnose DKA ?

1)• Hyperglycemia [blood glucose (BG) >200 mg

2)• Venous pH<7.3 or bicarbonate <15

3)• Ketonemia and ketonuria.Q) What will you do Next ??

Continue Scenario 1 )

Patient was admitted to PICU ????And plane of same management like home , patient is unwilling to eat so fluid started and since no dinner so no novarapid given and Lantus given as usual ,So what happen next ?

Patient next day morning found to have higher RBS reach around 400 and Ketone plus 3 and PH 7.1 3 and bicarbonate drop to 11So Diagnosis changed to DKA because of Poor Management !!!!

4)If Ketone decreased and oral intak improve discharge from ER

So in such scenario what to do to Prevent DKA during sickness (5 Steps ) :

1) No need to adamite, unless sick , so can be managed at ER and home most of the time

1) If can not take orally keep on IVF with Dextrose (maintenance plus deficit)

1) Short acting Insulin 0.05 - 0.1 U Kg dose and recheck RBS , Blood Ketone after 2 hrs and repeat it if still elevated

5) Teach parents about sick Day management before discharge

Approach for sick day management :

Starvation ketosis underinsulinization

Mixed

based on RBS

So for good sick day management for patient with positive Ketone (above 0.6 betahydroxybutarate)we have to look for RBS and categorized it into either.

V

Detailed sick day management approach

RBS> 180 mg

Underinsulinization Ketosis

Extra short acting insulin 0.05 -0.1 U Kg dose Repeat doseafter 2 h if ketones do not decrease and drink more fluids Sugar-free

<180

Starvation Ketosis

Extra fluid , Juice with carbohydrate (sugar)

RBS >100 mg but moderate Ketone > 1.5

Combined starvation and Underinsulinzation

Ketosis

Any time Ketone is Above 3 mean There is an immediate risk of ketoacidosis and Insulin treatment is needed urgently! Consider evaluation of patient at emergency department

Ketone blood above 0.6

Q )Why during Illness Ketones may increase ? Ketones are produced by the liver from free fatty acids breakdownthat are mobilized as an alternative energy source when the main source of energy (glucose) is inadequate or can not be utilized by the body cells due to insulinopenia So Ketones accumulate secondary to low insulin through 2 mechanism

2) increased ketogenesis to provide 2nd source of energy

1) increased lipolysis ( because normally insulin prevent breakdown of fat )

Q) How Ketone trigger more Ketone ?? # Elevated levels of ketones, whether associated with low BG (starvation)

or high BG (insulin deficiency), contribute to nausea and vomiting and may lead to

decreased food and fluid intake, this further cause elevated ketones and worse dehydration

-

Nausea , vomiting

Eat , drink less More Ketone Dehydration

Checking ketone at home during illness can reduce emergency room visits and unnecessarily hospitalizations but , Why Blood Is better ??

Because we are measuring the actual Ketone (betahydroxybutarate) not its late product aceto acetate which is measured by urine dipstick , so blood ketone give earlier alrming and also during insulin therapy it will be convetd to Aceto acetateSo urine ketone can persisit even if blood ketone is neligcable

Why Blood ketones are preferred over urine ketone ?

One of the study comparing blood to urine Ketone found that :

blood ketones were moderate to large in 15 patients but the urine ketones were negative

Measuring ketones in blood vs. urine - conclusions

00;18

- 2) The advantages of monitoring blood ketones include:

- Real-time direct measurement of the predominant ketone body - Patient acceptance and improved compliance

- 3) Careful monitoring of BG and blood ketones, plus supplemental insulin and hydration, may enhance sick-day guidelines and help to prevent ketoacidosis in children.

-1) Use of urine ketones may lead to inappropriate decisions regarding the severity of illness in insulin-treated children.

4 yrs old know Dm1 , on lantus and novarpaid had vomiting diarrhea , fever , decrease oral intake at ER appear mild hydrated and spit up any fluid per oral

RBS was 40 mg and Ketone blood was 1.2

PH = 7.35 bicarbonate = 19 , so patient was given fluid at ER till RBS increase

and parents told to hold insulin at home if had hypoglycemia .

Scenario 2)

so insulin was holded , after 3 days come back again with DKA ??

Q) Do you agree to hold Insulin to avoid hypoglycemia ?

Q) What should be done in such case ?

So what is the ideal management for such case , SICKNESS ASSOCITED HYPOGLYCEMIA ?

MCQ ) what to do in such scenario , sickness associated hypoglycemia ?A- admission for iv fluid with dextrose and hold both insulin to avoid hypoglycemiaB-give fluid at ER till glucose increase then discharge on same dose of insulin c- hold insulin and give IM Glucagone .D- non of the above

Ideal plane should include

1- Give iv fluid with dextrose at ER till RBS incesase and Blood Ketone decreased 2- if RBS increase above 180 mg with persistent Ketone give short acting insulin

but

WHAT TO DO IN CASE OF HYPOGLYCMIEA AT HOME???

SICKNESS ASSOCITED HYPOGLYCEMIA

Make sure consciousness level is good to avoid aspiration ThenPut simple sugar in the buccal cavity or honey or Molasses ( قصب عنب و رمان حبات ( سكرand

Replace meals with easily digestible food and fluid containing sugar To provides energy and to prevent further ketosis or hypoglcymeia .

Management of hypoglycmiea at home

Q) What to do if patient is hypoglycemia and can not drink or had vomiting ?

Dose :I unit per yr

If 3 years = 3 unit sc

Then reacheck after 30 minutes if still low give again but douple the dose

And If still Positive Ketone to give insulin short acting 0.05 U Kg dose when RBS above 180 mg .

WHAT TO DO IF MINI GLUCAGONE NA

ER FOR IV FLUID WITH DEXTROSE

What about stopping insulin during period of Hypoglycemia ?

Contraindicated since that could cause Iatrogenic DKA but

The insulin dose often needs to be decreased when there is gastroenteritis, but should not be lowered tothe extent that ketones are produced

One method is to use insulin sensitivity factor to adjust insulin dose pre meals

Insulin sensitivity factor = 1800 / total insulin dose e.g = total insulin dose (long plus short acting is 36) so insulin sensitivity is 60 mg ( I unit will decrease RBS by 60 )SoIf premeals RBS = 50 mg then ((( 150 mg - 50 mg / 50 = 2 unit which mean premeals dose should be 2 unit less than needed to cover Carbohydrate )

Q) During sickness do we need IV fluid for all patients ? No , not for all but in young children with diabetes, IVF may be required if nausea,

vomiting or diarrhea are persistent and associated with ongoing weight loss in order to prevent cardiovascular collapse, hypotension, coma,

and death if not well treated

Scenario 4) 6 yrs old with DM1 , on insulin had fever ,teeth pain , his RBS is high all the reading but no ketone , mother call you for advise , she ask you why RBS all are High ?

During sickness the counter regulatory hormones are fairly activated that increase gluconeogenesis and insulin resistant leading to persistent

Hyperglycemia so those patient should receive a higher doses of insulin up to 1 U Kg day as extra doses till illness subside or reading going down.

Generally if Tem = 38- 38.8 - often 25% increase of doses

above 38.8 - up to 50% increase of doses

Effects of insulin treatment :

- Blocked production of ketones in the liver

- Blocked production of glucose in the liver

- Increased uptake of glucose in tissue

DeFronzo RA et al. Diabetes Reviews 1994;2:209-38.

How is the blood glucose decreased when treating ketoacidosis?

How insulin work to decrease Blood Glucose and Ketone ?

q) Diabetes patient , are they immunocompromised and more prone for infections ?

well control should not experience more illnessor infections than children without diabetes.

poor controlledmay have a higher risk of urinary tract, bacterial skin, ormucous-membrane infections There is some evidence of impairedleukocyte function in poorly controlled diabetes andaltered immune function, increasing susceptibility toand delayed recovery from infection

One pediatric study found low IgG concentrations and reduction incomplement protein 4, variant B (C4B) levels

1)• More frequent BG and ketone (blood) monitoring

2)• DO NOT STOP INSULIN3)•Dose of insulin should be adjusted according to the reading

Continuee to give insulin and administer extra doses for as long as blood glucose and/or ketones are high

During hypoglycemia , increasing sugar intak is adviasable AND safer than decreasing insulin dose .

4) good hydration

• 5)Treat the underlying precipitating illness ( infection with Antibiotic if indicated)

• 6) sick day management education is mandatory for all patient with Dm1 to minimize

complication

General Sick Day Diabetes Management Rules :

7) When a child with diabetes vomits it should always be considered a sign of insulin deficiency until prove otherwise (check ketone and RBS) .

# Vomiting from gastroenteritis should be considered only when a lack of insulin has been excluded

# can use Antiemetics if severe vomiting prevents adequate fluid intake

When to visit ER ? 1-parents are unable to keep BG above (60 mg/dL)

◦ 2-BG continues to rise despite extra insulin

3- fruity breath odor (acetone) persists or worsens

4- blood ketones are persisitent > 1 mmol/L , despit good management at home .

◦ 5-patient becoming exhausted, confused, hyperventilating (? Kussmaul breathing) or has severe abdominal pain

6-◦ change in neurologic status, mental confusion, loss of consciousness, seizures, progression ofconfusion may indicate impending or present cerebral edema

7- vomiting persists beyond 2 h (particularly in young children)

8- weight loss continues suggesting worsening dehydration and potential circulatory compromise

9- family members are uncomfortable providing home care for any reason 10- patients/relatives are exhausted or do not know sick day management .

• 1-parents are unable to keep BG above (60 mg/dL)•

◦ 2-BG continues to rise despite extra insulin

• 3- fruity breath odor (acetone) persists or worsens

• 4- blood ketones are persisitent > 1 mmol/L , despit good management at home .•

◦ 5-patient becoming exhausted, confused, hyperventilating (? Kussmaul breathing) or has severe abdominal pain

•6-◦ change in neurologic status, mental confusion, loss of consciousness, seizures, progression ofconfusion may indicate impending or present cerebral edema

• 7- vomiting persists beyond 2 h (particularly in young children)

• 8- weight loss continues suggesting worsening dehydration and potential circulatory compromise

• 9- family members are uncomfortable providing home care for any reason• 10- patients/relatives are exhausted or do not know sick day management .

Hospital

Causes of DKA ?

1- dose omission 2-infection and poor education about sick day management 3-Hypertrophy of injection site decreasing insulin absorption 4- insulin Antibody decresing its efficacy -5 increase insulin requirement during Puberty 6= inadequate insulin dose or wrong admnstration .

1- Cerebal edema

2-Hypovolemia

3-Electrolyte disturbance

4-Infection inadequately treated (especially in poorly controlled diabetes )

5-Pulmonaru edema and heart failure from volume overload

6-Deep vein thrombosis secondary to dehydration , hyperglycemia , hyperviscosity ( so central line is dangerous in those patients)

Q) Causes of death in DKA ?

Q) Risk of cerebral edema ? 1) volume overload 2) newly diagnosed 3)Prolonged symptoms before seeking medical advise 4- Severe acidosis 5- Use of bicarbonate 6-use of insulin in the first hour (weak evidence) 7- Young age group 8-high urea and low co2 9-persisitent Hyponatremia even after decreasing glucose level.

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