2011 magdomar under diabetes

8/2/2019 2011 Magdomar Under Diabetes

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Diabetes Mellitus: Commonest chronic endocrinal

metabolic disease in children.

Due to insulin deficiency (type 1)

and or insulin resistance (type 2).

Disturbed Carboh drate Fat &

Protein metabolism.

HYPERGLYCEMIA.


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100 < 126 mg%

a e es 126 mg%

2h plasma glucose during OGTT

Less than 140 mg%

140 - 199 mg % 200 mg%

> 140 < 200 mg%

ADA. Position statement. Diagnosis and classification of diabetes Diabetes Care 2006,

29:S43-S48


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SYMPTOMS & BLOOD GLUCOSE LEVELS DO NOTDIFFERENTIATE TYPE 1 FROM TYPE 2

Diagnosis of type 2

.

Family history of type 2diabetes.

Signs of insulin resistance

Normal or high fasting.

Absent auto antibodies.


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Screening for Type 2 Diabetes

1

puberty

Over weight Plus any two of the

following risk factors: Family history of type 2 diabetes. Maternal history of diabetes or

gestational diabetes mellitus (GDM)

Signs of insulin resistance orconditions associated with insulinresistance

es : pre erre

Frequency: every 2 years


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a e es om p ca on s

Acute:

Insulin reaction ( hypoglycemia)

Microvascular

.


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ypog ycem a

Most common complication of diabeteso 100% of Type 1 patients affected

o 10% year develop severe attack (requiring

assistance)o

Multiple causes:

o Increased insulin dose

o reduced food intake

o delayed or omitted meal


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ymp oms o ypog ycem a

A renergic Neurog ycopenic

Palpitations Dizziness

Tachycardia

Pallor

Confusion

Agitation wea ng

Tremors

oma

Seizure


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50% after 15 yearsLong-term

10%diabetes

Prevention of long termi 20-40 % after 20 ears

complications.,

A new focus forpediatric diabetes care


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Diabetes Control & Complication TrialDiabetes Control & Complication Trial

1441 pt

10yrsTDM1

Intensive Insulin Therapy

Tight glycemic control

7 6 % Retinopathy

Ne hro ath

6 9 % Neuropathy


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children & adolescents

Insulin/medication

Exercise

BGBG BGBG

Food intake

BGBG


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Ke oints in Diabetes carein Children

Soothe, Educate, Empower &Support patient & care-giver.

Provide choices & involve


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a

Insulin injection.

Testing for urine ketones.

ecogn t on an treatment ohypoglycemia

Healthy Diet and life style. Sick day management


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Practical steps in Insulintherapy

maturity level

Imitate nature as much as

Adjust dose according to

. Use additional doses for

unexpec e g va ues or ex ra

carb.


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NOPre-meal Bed-time Hb A1C

mg/dl

mg/dl

. - - .>7.5

6-12 r. 90-180 100-180 < 8

13-19 yr. 90-130 90-150 < 7.5#

Diabetes Care- ADA Suppl. 1 / 2010

# < 7 if achievable without hypoglycemia


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Physiologic INSULIN strategy

Think like a Pancreas !

ADJUST for

Meal size, content, exercise &

BG

BOLUSES

to control hepatic glucose outputduring fasting

to cover meals & snacks ingested


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Physiologic Insulin SecretionRapidly generated, Short-lived,

prandial insulin peaks

Breakfast Lunch DinnerPrandial Insulin

un mL50

Low stead basal

Inu

(Um

25

Basal Insulin Fasting

insulin profile

g5-10 (U/mL

Skyler JS. In: DeFronzo RA, ed. Current Therapy of Diabetes Mellitus. St. Louis: Mosby- Year Book;

1998:108-116; Galloway JA, Chance RE. Horm Metab Res. 1994;26:591


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Total insulin dose : 0.5 to 1.2

Basal insulin: 40% to 50% of daily needs

Bolus insulin (prandial/mealtime) 10% to 20% of total dail insulinbefore meals.


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Key points for successfulinsulin therapy

Know the feeding and activity style of the.

Discuss insulin choices with the family. Explain time activity profile of chosen

Provide simple troubleshootingns ruc ons.


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Soluble or Regular insulin: Actrapid 100U/ml Humulin R 100U/ml

Insulins

In gyLong-acting insulin analogsGLARGINE (Lantus)DETEMIR Leve ir

Insulatard.Hmulin N

Rapid-acting insulin analogs:

INSULIN LISPRO (Humalog)

INSULIN GLULISINE (Apidra)


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Glargine/Detemir NPH

Basal insulin

Glargine / Detemir

Given once daily.

No need for snacks to revent h o l cemia.

Less nocturnal hypoglycemia.

No need for shaking.

No difference in the absorption rate from leg, arm

or abdomen.


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Regular

Human Insulin

Actrapid

onset: 30-60 mint.

Peak: 3 (2-4) hours

Duration: 6- 8 hours

Ra id InsulinAnalogs

onse : - m n . Peak: 1 hr.

Duration: 3- 4 hours


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Normal pattern of insulin

nLev

els 3 meal related insulin boluses

maInsuli

Plas

Basal Insulin

0 2 4 6 8 10 12 14 16 18 20 22 24

Hours

Adapted from Rosenstock J, Wyne K. In: Goldstein BJ, Muller-Wieland D, eds. Textbook of Type 2 Diabetes. London, England:Martin Dunitz; 2003:131-154.


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Two doses of pre-mixed Conv.

els

PrePre- -mixed Conv Insmixed Conv Ins PrePre--mixed Conv Insmixed Conv Ins

sulinLe

PlasmaI

0 2 4 6 8 10 12 14 16 18 20 22 24

Hours



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Two doses of pre-mixed insulin

els

PrePre--mixed analogmixed analog PrePre--mixed analogmixed analog

sulinLe

PlasmaI

0 2 4 6 8 10 12 14 16 18 20 22 24

Hours



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What are the shortcomings

?

lsPrePre--mixedmixed

PrePre--mixedmixed

B-B ins can not be adjusted separately.

No prandial coverage for lunch.R

ma

InsulinLev

overlaps & or mismatching

0 2 4 6 8 10 12 14 16 18 20 22 24

Plas

HoursIs there a compromise ?

Additional Reg or Rapid insulin analog for the

lunchNow it is 3 !

Fix time and content of meals & snacks.


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Pre-meal Rapid-acting Analogues & Bed

linLevels

m

aInsu

Pla

0 2 4 6 8 10 12 14 16 18 20 22 24

HoursIt is 4 !

INSULIN REGIMENS


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INSULIN REGIMENS


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Insulin correction & Supplement doses

prevent hyperglycemia

--

This insulin can only be regular,This insulin can only be regular, lisprolispro,,

aspartaspart oror g u s neg u s ne umu numu n ,, ActrapActrap ,,HumalogHumalog,, NovorapidNovorapid, or, or ApidraApidra))


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Age Insulin units added / Insulin units

mg a ove

target.

a e

carbohydrate atmeal.

10 years of ageIf Family history is negative

Fasting lipid profile

YEARS with Positive Family history of highcholesterol premature cardiovascular event

3 Bp in 3 sep days Target > 90th centile for

age, sex & Ht

M t f T 2 Di b t


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Management of Type 2 Diabetes

< 250mg/dl OR DKA

Metformin 500 mg qdincrease gradually Insulin

ntinuei

gradua

Dis

c

Target not reached


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1.

Hyperglycemia: Blood glucose > 200 mg /dl.

2. Ketonemia: Total serum ketone >3

nitroprusside test on undiluted urine.A

3. Acidosis: Blood pH < 7.3 & reducedserum bicarbonate to < 15 mEq/L.


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Diabetic KetoacidosisCommon Precipitating Causes

Infection

Psychic stress

Trauma


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Insulin deficienc + Counter re ulator

hormones

Increased Glycogenolysis.

Increased Gluconeogenesis.

Decreased entry of glucose tothe cells.

H l i > 200 /dl


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Hyperglycemia > 200 mg/dl

Hyperglycemia

plasma osmolality

Osmotic diuresisIntracellular dehydration

Dehydration ECF volume Electrolyte loss

(Na+, K+, PO4, MG++)

Shock GFR

glucose acidosis azotemia ( BUN)


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Major Ketoacids

Beta-hydroxybutyric acid

Acetoacetic acid Acetone


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1.Accumulation of Ketoacids

Diminished ketone body utilization

2. Lactic Acidosis.

. .


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Diabetic KetoacidosisSymptoms & Signs

Polyuria, polydipsia . Deh dration

Low blood pressure, rapid pulse

Kussmaul respirations Deep, rapid respiratory pattern

Anorexia, nausea, vomiting

Abdominal pain Altered mental status

Correlates with the degree of hyperosmolality

Di b ti K t id i


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Diabetic KetoacidosisLaboratory abnormalities due to hyperglycemia

Elevated blood glucose

Hyponatremia

ucosur a

Di b i K id i


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Diabetic KetoacidosisLaboratory abnormalities due to metabolic acidosis

Decreased pH ecrease p

Low serum bicarbonate

Increased anion gap

(= Na - [(Cl + HCO3)

Ketonemia Ketonuria


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Treatment of DiabeticKetoacidosis

1. Replace fluid and electrolyte losses

2. Insulin to Correct acidosis and

.

3. Look for and treat precipitating causes

an comp ca ons


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1. ap correc on o

shock andypovo em a s

hour):

Normal saline or Ringers,

the 1st hour.

Repeat if necessary.


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2. Slow correction of Deficit +

a ntenance over -

hours): ow muc e c

according to degree of dehydration

50 100 ml/Kg How muchmaintenance

Calculation of maintenance fluidsCalculation of maintenance fluids::

100 ml/kg for the first 10 kilograms of100 ml/kg for the first 10 kilograms ofbody weight +body weight +50 ml/kg for the next 10 kilograms of50 ml/kg for the next 10 kilograms of

20 ml/kg for the remaining body weight20 ml/kg for the remaining body weight

above 20 kilogramsabove 20 kilograms

Slow correction of Deficit +


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a ntenance over 4- ours :

normal saline.

Shift to Glucose 5% in half strengthsaline when blood glucose drops to

Potassium (30-40 mEq/liter of IVfluid).



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a ntenance over 4- ours :

ar n a y w a s reng normal saline.

Shift to Glucose 5% in halfstren th saline when blood

glucose drops to


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Saline or Ringer's Lactate for shock &hypovolaemia

Later on strength saline

2011 magdomar under diabetes

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