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What’s New in Paediatric T1DM TCH Paediatric Multidisciplinary Diabetes Team 10 July 2013

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Page 1: At GP surgery: BGL 25mmol/L – referred to ED In ED: Capillary blood gas: pH 7.18, bicarbonate (HCO3) 12 mmol/L, BGL 25 mmol/L, Na 136 mmol/L (corrected

What’s New in Paediatric T1DM

TCH Paediatric Multidisciplinary Diabetes Team10 July 2013

Page 2: At GP surgery: BGL 25mmol/L – referred to ED In ED: Capillary blood gas: pH 7.18, bicarbonate (HCO3) 12 mmol/L, BGL 25 mmol/L, Na 136 mmol/L (corrected

Learning objectives

• Recognise clinical signs and symptoms to allow for the earliest possible diagnosis and referral of children with new-onset T1DM.

• Describe current insulins and regimen options available in 2013.

• Develop an understanding of the various technologies available for the management of T1DM at home.

• Understand strategies for and review sick-day management plans for children with T1DM in your practice.

Page 3: At GP surgery: BGL 25mmol/L – referred to ED In ED: Capillary blood gas: pH 7.18, bicarbonate (HCO3) 12 mmol/L, BGL 25 mmol/L, Na 136 mmol/L (corrected

Case study1• 4 yr old boy• GP presentation: 3 week history of

weight loss, polyuria and polydipsia. • 2 day history of sore throat• Woke up in the morning with ‘heavy

breathing’• Past medical and family history were

unremarkable.

Page 4: At GP surgery: BGL 25mmol/L – referred to ED In ED: Capillary blood gas: pH 7.18, bicarbonate (HCO3) 12 mmol/L, BGL 25 mmol/L, Na 136 mmol/L (corrected

Case study2Physical examination• Alert• GCS score 15/15• Kussmaul breathing present• PR 136 bpm, RR 44, BP 92/58• >5% dehydration• Dry cracked lips• Weight 16kg (~3kg weight loss in 4 weeks)• Pharyngitis

Page 5: At GP surgery: BGL 25mmol/L – referred to ED In ED: Capillary blood gas: pH 7.18, bicarbonate (HCO3) 12 mmol/L, BGL 25 mmol/L, Na 136 mmol/L (corrected

Case study3

• At GP surgery: BGL 25mmol/L – referred to ED

In ED:• Capillary blood gas: pH 7.18, bicarbonate

(HCO3) 12 mmol/L, BGL 25 mmol/L, Na 136 mmol/L (corrected = 142) , K 4.9 mmol/L

Corrected Na = measured Na + 0.3 (glucose – 5.5)

Page 6: At GP surgery: BGL 25mmol/L – referred to ED In ED: Capillary blood gas: pH 7.18, bicarbonate (HCO3) 12 mmol/L, BGL 25 mmol/L, Na 136 mmol/L (corrected

Case study4

Management:• 10ml/kg bolus Normal saline• Re-assessed: PR 118, RR 36, BP 96/58• IV insulin infusion: 0.1U/kg/hr• Fluids: N/S + 40mmol/L KCL at

maintenance + 5% replacement over 48 hrs• Transferred to HDU – further management

as per DKA protocol

Page 7: At GP surgery: BGL 25mmol/L – referred to ED In ED: Capillary blood gas: pH 7.18, bicarbonate (HCO3) 12 mmol/L, BGL 25 mmol/L, Na 136 mmol/L (corrected

Case study5

At resolution of ketoacidosis:• Initiated on MDI: Levemir at bedtime;

Novorapid with meals using an insulin dosing card.

• DNE / Dietician / Social work involvement

• Discharged home on day 5 with nightly contact with on-call Paediatric Endocrinologist for dose adjustments

Page 8: At GP surgery: BGL 25mmol/L – referred to ED In ED: Capillary blood gas: pH 7.18, bicarbonate (HCO3) 12 mmol/L, BGL 25 mmol/L, Na 136 mmol/L (corrected

• Type 1 diabetes

– β-cell destruction• Type 2 diabetes

– Progressive insulin secretory defect• Other specific types of diabetes

– Genetic defects in β-cell function, insulin action

– Diseases of the exocrine pancreas

– Drug- or chemical-induced• Gestational diabetes mellitus (GDM)

Diabetes Care 2013;36(suppl 1):S11.

Classification of Diabetes

Page 9: At GP surgery: BGL 25mmol/L – referred to ED In ED: Capillary blood gas: pH 7.18, bicarbonate (HCO3) 12 mmol/L, BGL 25 mmol/L, Na 136 mmol/L (corrected

A1C ≥6.5%OR

Fasting plasma glucose≥7.0 mmol/L

OR

2-h plasma glucose ≥11.1 mmol/L during an OGTT

OR

A random plasma glucose ≥11.1 mmol/L

Diabetes Care 2013;36(suppl 1):S13; Table 2.

Criteria for diagnosis of Diabetes

Page 10: At GP surgery: BGL 25mmol/L – referred to ED In ED: Capillary blood gas: pH 7.18, bicarbonate (HCO3) 12 mmol/L, BGL 25 mmol/L, Na 136 mmol/L (corrected

Categories of increased risk for diabetes (prediabetes)

IFG: 5.6–6.9 mmol/LOR

IGT: 2-h plasma glucose in the 75-g OGTT7.8–11.0 mmol/L

OR

A1C 5.7–6.4%

*For all three tests, risk is continuous, extending below the lower limit of a range and becoming disproportionately greater at higher ends of the range.

Diabetes Care 2013;36(suppl 1):S13; Table 3.

Criteria for Prediabetes

Page 11: At GP surgery: BGL 25mmol/L – referred to ED In ED: Capillary blood gas: pH 7.18, bicarbonate (HCO3) 12 mmol/L, BGL 25 mmol/L, Na 136 mmol/L (corrected

• Autoimmune destruction of the pancreatic islet cell

• Hallmark = lymphocytic infiltration of islets

• Progresses over years• Leads to insulin deficiency• Glucagon production is

preserved but impaired action

Pathogenesis of T1DM

Page 12: At GP surgery: BGL 25mmol/L – referred to ED In ED: Capillary blood gas: pH 7.18, bicarbonate (HCO3) 12 mmol/L, BGL 25 mmol/L, Na 136 mmol/L (corrected

Diabetic Medicine 2009; 26(6): 596-601

Australian incidence (NDR) in children 0-14 years between 2000-2006

Incidence of T1DM in Australia

Page 13: At GP surgery: BGL 25mmol/L – referred to ED In ED: Capillary blood gas: pH 7.18, bicarbonate (HCO3) 12 mmol/L, BGL 25 mmol/L, Na 136 mmol/L (corrected

Genetics of T1DM 1

• Susceptibility to T1DM is an inheritable trait BUT >85% cases occur in the absence of first-degree relative

• Lifetime risk: first-degree relative (5%) vs general population (0.3%)

Page 14: At GP surgery: BGL 25mmol/L – referred to ED In ED: Capillary blood gas: pH 7.18, bicarbonate (HCO3) 12 mmol/L, BGL 25 mmol/L, Na 136 mmol/L (corrected

Genetics of T1DM 2

• Twin concordance: monozygotic (30-50%) vs dizygotic (6-10%)

• Risk increases with early age at diagnosis: 3-5 fold increase risk if first degree relative diagnosed <5 years age

Page 15: At GP surgery: BGL 25mmol/L – referred to ED In ED: Capillary blood gas: pH 7.18, bicarbonate (HCO3) 12 mmol/L, BGL 25 mmol/L, Na 136 mmol/L (corrected

Genetics of T1DM 3Susceptibility loci: HLA-DR3 and HLA-DR4• At least one locus: 95% T1DM vs 3%

general population

Protective loci: HLA-DR2, HLA-DR5, and HLA-DQB1*0602• 1 in 15,000 people with HLA-DQB1*0602

develop T1DM

Page 16: At GP surgery: BGL 25mmol/L – referred to ED In ED: Capillary blood gas: pH 7.18, bicarbonate (HCO3) 12 mmol/L, BGL 25 mmol/L, Na 136 mmol/L (corrected

Environmental factors in T1DM

• Cow’s milk protein exposure (bovine serum albumin and β-lactoglobulin)

• Vitamin D deficiency• Viruses: coxsackie A or B, enterovirus, rubella,

cytomegalovirus, ECHO virus, EBV, mumps, retrovirus• Drugs & toxins: eg alloxan-like or streptozotocin- like

agents that induce oxidant beta-cell damage• Stress

The Environmental Determinants of Diabetes in the Young (TEDDY) study

Page 17: At GP surgery: BGL 25mmol/L – referred to ED In ED: Capillary blood gas: pH 7.18, bicarbonate (HCO3) 12 mmol/L, BGL 25 mmol/L, Na 136 mmol/L (corrected

Islet-specific autoantibodies1

• Islet cell autoantibodies (ICA)• Glutamic acid decarboxylase autoantibodies

(GADA)• Insulinoma-associated 2 autoantibodies (IA-2A)• Insulin autoantibodies (IAA)• Zinc transporter autoantibodies (ZnT8A).

Multiple and specific combinations of autoantibodies more predictive

Diabetes Care 2009;32:2269-74

Page 18: At GP surgery: BGL 25mmol/L – referred to ED In ED: Capillary blood gas: pH 7.18, bicarbonate (HCO3) 12 mmol/L, BGL 25 mmol/L, Na 136 mmol/L (corrected

Islet-specific autoantibodies2

• Not causative • Present months to years before onset of

symptoms• Persist for varying duration after onset• 90-95% T1DM have at least one at

diagnosis

Cell Mol Life Sci 2007;64:865-72Ann Intern Med 2004;140:882-6J Clin Endocrinol Metab 2004;89:3896-902.Diabetes 1999;48:460-8

Page 19: At GP surgery: BGL 25mmol/L – referred to ED In ED: Capillary blood gas: pH 7.18, bicarbonate (HCO3) 12 mmol/L, BGL 25 mmol/L, Na 136 mmol/L (corrected

Atkinson MA & Eisenbarth GS. Lancet 2001; 358; 221-229

The Pathogenesis of T1DM

Page 20: At GP surgery: BGL 25mmol/L – referred to ED In ED: Capillary blood gas: pH 7.18, bicarbonate (HCO3) 12 mmol/L, BGL 25 mmol/L, Na 136 mmol/L (corrected

Meal

Normal glucose homeostasis

Page 21: At GP surgery: BGL 25mmol/L – referred to ED In ED: Capillary blood gas: pH 7.18, bicarbonate (HCO3) 12 mmol/L, BGL 25 mmol/L, Na 136 mmol/L (corrected

Insulin secretion

Page 22: At GP surgery: BGL 25mmol/L – referred to ED In ED: Capillary blood gas: pH 7.18, bicarbonate (HCO3) 12 mmol/L, BGL 25 mmol/L, Na 136 mmol/L (corrected

Fasting blood glucose is not an appropriate screen test for T1DM

Page 23: At GP surgery: BGL 25mmol/L – referred to ED In ED: Capillary blood gas: pH 7.18, bicarbonate (HCO3) 12 mmol/L, BGL 25 mmol/L, Na 136 mmol/L (corrected

Clinical Presentation

• Polyuria – 95%• Weight loss – 61%• Fatigue – 52%

Polyuria is often missed on history

The EURODIAB studyDiabetologia 2001;44(Suppl 3):B75-80.

Page 24: At GP surgery: BGL 25mmol/L – referred to ED In ED: Capillary blood gas: pH 7.18, bicarbonate (HCO3) 12 mmol/L, BGL 25 mmol/L, Na 136 mmol/L (corrected

• Utilize intensive therapy aimed at near-normal BG and A1C levels

• Prevent diabetic ketoacidosis and severe hypoglycemia

• Achieve the highest quality of life compatible with the daily demands of diabetes management

• In children, achieve normal growth and physical development and psychological maturation

• Establish realistic goals adapted to each individual’s circumstances

Goals of T1DM Management

Page 25: At GP surgery: BGL 25mmol/L – referred to ED In ED: Capillary blood gas: pH 7.18, bicarbonate (HCO3) 12 mmol/L, BGL 25 mmol/L, Na 136 mmol/L (corrected

DCCT and EDIC Findings• Intensive treatment reduced the risks of retinopathy,

nephropathy, and neuropathy by 35% to 90% compared with conventional treatment

• Absolute risks of retinopathy and nephropathy were proportional to the A1C

• Intensive treatment was most effective when begun early, before complications were detectable

• Risk reductions achieved at a median A1C 7.3% for intensive treatment (vs 9.1% for conventional)

• Benefits of 6.5 years of intensive treatment extended well beyond the period of most intensive implementation(“metabolic memory”)

DCCT/EDIC Research Group. JAMA. 2002;15;287:2563-2569.

Intensive treatment should be started as soon as is safely possible after the onset of T1DM and maintained thereafter

Page 26: At GP surgery: BGL 25mmol/L – referred to ED In ED: Capillary blood gas: pH 7.18, bicarbonate (HCO3) 12 mmol/L, BGL 25 mmol/L, Na 136 mmol/L (corrected

Principles for Good Glycaemic Control

Page 27: At GP surgery: BGL 25mmol/L – referred to ED In ED: Capillary blood gas: pH 7.18, bicarbonate (HCO3) 12 mmol/L, BGL 25 mmol/L, Na 136 mmol/L (corrected

• Paedaitric Endocrinologist• Diabetes Nurse Educator / Nurse Practitioner• Dietician• Social Worker• Psychologist

• Age-appropriate clinics

ISPAD Clinical Practice Consensus Guidelines 2006–2007

The Multidisciplinary Team Approach

Page 28: At GP surgery: BGL 25mmol/L – referred to ED In ED: Capillary blood gas: pH 7.18, bicarbonate (HCO3) 12 mmol/L, BGL 25 mmol/L, Na 136 mmol/L (corrected

ISPAD Clinical Practice Consensus Guidelines 2006–2007

• Education for parents / child (age appropriate)

• Correct insulin regimen• Contact in between clinics for

adjustments• Good relationship with GP

Contributors to good glycaemic control

Page 29: At GP surgery: BGL 25mmol/L – referred to ED In ED: Capillary blood gas: pH 7.18, bicarbonate (HCO3) 12 mmol/L, BGL 25 mmol/L, Na 136 mmol/L (corrected

Rapid (Humalog, Novorapid, Apidra)

Hours

Long (glargine)

Short (Humalin R, Actrapid)

Intermediate (NPH, Protaphane)

Long (detemir)

InsulinLevel

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

N Engl J Med. 2005;352:174-183.

Pharmacokinetics of insulin Products

Page 30: At GP surgery: BGL 25mmol/L – referred to ED In ED: Capillary blood gas: pH 7.18, bicarbonate (HCO3) 12 mmol/L, BGL 25 mmol/L, Na 136 mmol/L (corrected

Pre-mix

Twice-daily

MDI

IncreasedComplexity

Better control

Less Hypoglycaemia

CSII

Page 31: At GP surgery: BGL 25mmol/L – referred to ED In ED: Capillary blood gas: pH 7.18, bicarbonate (HCO3) 12 mmol/L, BGL 25 mmol/L, Na 136 mmol/L (corrected

INSULIN DOSING CARDEzy-BICC

SMART-METERAccu-Chek Aviva Expert

INSULIN DOSING APPInsulin Pro

Insulin dosing advice

Page 32: At GP surgery: BGL 25mmol/L – referred to ED In ED: Capillary blood gas: pH 7.18, bicarbonate (HCO3) 12 mmol/L, BGL 25 mmol/L, Na 136 mmol/L (corrected

DKA

Page 33: At GP surgery: BGL 25mmol/L – referred to ED In ED: Capillary blood gas: pH 7.18, bicarbonate (HCO3) 12 mmol/L, BGL 25 mmol/L, Na 136 mmol/L (corrected

Risk factors for DKA at diagnosis of T1DM

• Younger age• Ethnic minority• No first degree relative• Low SES/poor medical access/uninsured• Lack of community health screening• Lower weight SDS at diagnosis

Rates of DKA inversely related to prevalence of T1DM

Diabet Med 2013. doi: 10.1111/dme.12252Pediatr Clin N Am 2011; 58 : 1301–1315

Page 34: At GP surgery: BGL 25mmol/L – referred to ED In ED: Capillary blood gas: pH 7.18, bicarbonate (HCO3) 12 mmol/L, BGL 25 mmol/L, Na 136 mmol/L (corrected

• Hyperglycemia BG > 11 mmol/l (young or partially treated children, pregnant adolescents may

present with “euglycemic ketoacidosis”)

• Venous pH <7.3 and/or bicarbonate <15 mmol/L– mild DKA pH <7.3 bicarbonate <15 – moderate pH <7.2 bicarbonate <10– severe pH <7.1 bicarbonate < 5

• Glucosuria and ketonuria/ketonemia (β-HOB)

ISPAD Clinical Practice Consensus Guidelines 2006–2007

DKA criteria

Page 35: At GP surgery: BGL 25mmol/L – referred to ED In ED: Capillary blood gas: pH 7.18, bicarbonate (HCO3) 12 mmol/L, BGL 25 mmol/L, Na 136 mmol/L (corrected

ISPAD Clinical Practice Consensus Guidelines 2006–2007

Pathophysiology of DKA

Page 36: At GP surgery: BGL 25mmol/L – referred to ED In ED: Capillary blood gas: pH 7.18, bicarbonate (HCO3) 12 mmol/L, BGL 25 mmol/L, Na 136 mmol/L (corrected

• Feeling unwell for a short period, often less than 24 hours

• Polyuria, polydipsia and increased thirst, nocturia• Polyphagia • Weight loss • Nausea and vomiting, vomitus can have coffee-

ground colour due to haemorrhagic gastritis• Abdominal pain, due to dehydration and acidosis• Weakness

ISPAD Clinical Practice Consensus Guidelines 2006–2007

DKA Clinical Manifestations 1

Page 37: At GP surgery: BGL 25mmol/L – referred to ED In ED: Capillary blood gas: pH 7.18, bicarbonate (HCO3) 12 mmol/L, BGL 25 mmol/L, Na 136 mmol/L (corrected

• Neurologic signs: restlessness, agitation,lethargy and drowsiness, coma. Increased

• Osmolality is the main factor that contributes to altered mental status

• Visual disturbances due to hyperglycaemia • Deep and rapid breathing, known as Kussmaul

breathing, may have acetone odour on breath.

ISPAD Clinical Practice Consensus Guidelines 2006–2007

DKA Clinical Manifestations 2

Page 38: At GP surgery: BGL 25mmol/L – referred to ED In ED: Capillary blood gas: pH 7.18, bicarbonate (HCO3) 12 mmol/L, BGL 25 mmol/L, Na 136 mmol/L (corrected

• Signs of dehydration due to fluid loss through polyuria, vomiting and breathing: reduced skin turgor, dry mucous membranes

• Signs of hypovolaemia: tachycardia, hypotension, postural hypotension

ISPAD Clinical Practice Consensus Guidelines 2006–2007

DKA Clinical Manifestations 3

Page 39: At GP surgery: BGL 25mmol/L – referred to ED In ED: Capillary blood gas: pH 7.18, bicarbonate (HCO3) 12 mmol/L, BGL 25 mmol/L, Na 136 mmol/L (corrected

• Mild hypothermia due to acidosis-induced peripheral vasodilation, warm dry skin.

• Fevers are rare despite infection. Severe hypothermia is a poor prognostic sign

ISPAD Clinical Practice Consensus Guidelines 2006–2007

DKA Clinical Manifestations 4

Page 40: At GP surgery: BGL 25mmol/L – referred to ED In ED: Capillary blood gas: pH 7.18, bicarbonate (HCO3) 12 mmol/L, BGL 25 mmol/L, Na 136 mmol/L (corrected

Measurement of Ketone bodies

Page 41: At GP surgery: BGL 25mmol/L – referred to ED In ED: Capillary blood gas: pH 7.18, bicarbonate (HCO3) 12 mmol/L, BGL 25 mmol/L, Na 136 mmol/L (corrected

Hypoglycaemia

Page 42: At GP surgery: BGL 25mmol/L – referred to ED In ED: Capillary blood gas: pH 7.18, bicarbonate (HCO3) 12 mmol/L, BGL 25 mmol/L, Na 136 mmol/L (corrected

Hypoglycaemia 1

• Diaphoresis• Tachycardia/

Palpitations• Shakiness• Tingling• Pallor

Adrenergic

• Confusion• Irritability• Behavoural changes• Difficulties concentrating• Headache• Visual disturbance• Slurred speech• Altered consciousness• Seizures

Neuroglycopenic

Page 43: At GP surgery: BGL 25mmol/L – referred to ED In ED: Capillary blood gas: pH 7.18, bicarbonate (HCO3) 12 mmol/L, BGL 25 mmol/L, Na 136 mmol/L (corrected

Hypoglycaemia 2• Check BGL if symptoms: <4.0mmol/L• To increase BGL by 3-4mmol/L:

<30kg child use 10g

≥30kg child use 15g• Re-check BGL every 10-15 mins and

repeat treatment if necessary

ISPAD GuidelinesPediatric Diabetes 2009: 10(Suppl. 12): 134–145

Page 44: At GP surgery: BGL 25mmol/L – referred to ED In ED: Capillary blood gas: pH 7.18, bicarbonate (HCO3) 12 mmol/L, BGL 25 mmol/L, Na 136 mmol/L (corrected

Hypoglycaemia 3• Check 20-30 mins after resolution to

ensure BGL maintained• Solid food should be avoided until BGL ≥

4mmol/L (impairs absorption of fast-acting CHO)

• Severe hypoglycaemia: IM Glucagon – 0.5mg in <12 years; 1.0mg in ≥ 12 years

ISPAD GuidelinesPediatric Diabetes 2009: 10(Suppl. 12): 134–145

Page 45: At GP surgery: BGL 25mmol/L – referred to ED In ED: Capillary blood gas: pH 7.18, bicarbonate (HCO3) 12 mmol/L, BGL 25 mmol/L, Na 136 mmol/L (corrected

Cognitive Effects of Hypoglycemia in Children

• Repeated and early exposure to severe hypoglycemia has been reported to reduce long-term spatial memory in children with type 1 diabetes

• Early exposure to hypoglycemia may be more damaging to cognitive function than later exposure

Diabetes Care. 2005;28:2372-2377.

Page 46: At GP surgery: BGL 25mmol/L – referred to ED In ED: Capillary blood gas: pH 7.18, bicarbonate (HCO3) 12 mmol/L, BGL 25 mmol/L, Na 136 mmol/L (corrected

Incidence of Severe Hypoglycemia: T1DM Exchange

Garg S, et al. Presented at 5th International Conference on Advanced Technologies & Treatment for Diabetes, Barcelona, 2012.

Page 47: At GP surgery: BGL 25mmol/L – referred to ED In ED: Capillary blood gas: pH 7.18, bicarbonate (HCO3) 12 mmol/L, BGL 25 mmol/L, Na 136 mmol/L (corrected

J Pediatr. 2002;141:490-495.

Causes of Hypoglycemia in Toddlers and Preschoolers

• Unpredictable food intake and physical activity

• Imprecise administration of low doses of insulin

• Frequent viral infections• Inability to convey the symptoms of low

blood sugar

Page 48: At GP surgery: BGL 25mmol/L – referred to ED In ED: Capillary blood gas: pH 7.18, bicarbonate (HCO3) 12 mmol/L, BGL 25 mmol/L, Na 136 mmol/L (corrected

Glucose Variability and Health Outcomes: Direct and Indirect

Pathways

Health Psychol. 1992;11:135-138Diabetes Care. 1996;19:876-879;

Diabetes Technol Ther. 2008;10:69-80.

Glucose variabilityGlucose

variabilityReluctance to intensify

therapyReluctance to intensify

therapy

High A1CHigh A1C

ComplicationsMorbidity Mortality

ComplicationsMorbidity Mortality

Quality of lifeQuality of life

Fear of hypoglycemia

Fear of hypoglycemia

Severe hypoglycemiaSevere hypoglycemia

ControversialControversial

Page 49: At GP surgery: BGL 25mmol/L – referred to ED In ED: Capillary blood gas: pH 7.18, bicarbonate (HCO3) 12 mmol/L, BGL 25 mmol/L, Na 136 mmol/L (corrected

DEXCOM MEDTRONIC

HYPOMON

Page 50: At GP surgery: BGL 25mmol/L – referred to ED In ED: Capillary blood gas: pH 7.18, bicarbonate (HCO3) 12 mmol/L, BGL 25 mmol/L, Na 136 mmol/L (corrected

Sick Day Management

Page 51: At GP surgery: BGL 25mmol/L – referred to ED In ED: Capillary blood gas: pH 7.18, bicarbonate (HCO3) 12 mmol/L, BGL 25 mmol/L, Na 136 mmol/L (corrected

STRESS

COUNTER-REGULATORY

HORMONE

INSULINRESISTANCE KETOSISHYPERGLYCAEMIA

Also hypoglycaemia with ketosis eg gastroenteritis

Sick Day Management 1

Page 52: At GP surgery: BGL 25mmol/L – referred to ED In ED: Capillary blood gas: pH 7.18, bicarbonate (HCO3) 12 mmol/L, BGL 25 mmol/L, Na 136 mmol/L (corrected

Sick day management 2

• Regular BGL and ketone monitoring• Additional insulin: 10-20% of total daily

insulin as regular corrections• Encourage oral fluids

IV fluids necessary if unable to maintain BGL to sustain additional required insulin

Paediatric Diabetes 2009; 10 (Suppl. 12): 134-145

Page 53: At GP surgery: BGL 25mmol/L – referred to ED In ED: Capillary blood gas: pH 7.18, bicarbonate (HCO3) 12 mmol/L, BGL 25 mmol/L, Na 136 mmol/L (corrected

Sick day management 3

Insulin pump:• Check pump / line / site• Subcutaneous injection may be

appropriate• Increase basal rate: 150-200% • Regular correction boluses

Paediatric Diabetes 2009; 10 (Suppl. 12): 134-145

Page 54: At GP surgery: BGL 25mmol/L – referred to ED In ED: Capillary blood gas: pH 7.18, bicarbonate (HCO3) 12 mmol/L, BGL 25 mmol/L, Na 136 mmol/L (corrected

Who and when to call

• Concerns regarding early presentation of T1DM

• New diagnosis• Existing patients – issues while reviewing

at GP surgery

0466 655 068


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Lactate Scout 4 - ekfdiagnostics.de · Hämatokrit-Bereich 35 - 50 %: bei Laktatkonzentrationen von 0,5 - 6,7 mmol/L ist die Standard-abweichung ≤0,2 mmol/L, bei 6,8 - 25,0 mmol/l

USER GUIDE · 2019. 1. 15. · 1.1 mmol/L to 33.3 mmol/L. For results under 1.1 mmol/L or over 33.3 mmol/L; o If your blood sugar reading is under 1.1 mmol/L, the “Follow Medical

Heat Shock Protein 70 Gene Transfection Protects Rat ...taining 20 mmol/L Tris-HCl, pH 7.5, 150 mmol/L NaCl, 1% Nonidet P-40, 0.1% SDS, 1% sodium deoxycholate, 2 mmol/L EDTA, 1 mmol/L

 · 2020. 12. 24. · pC02 pC02 p02 p02 Na Cl- iCa iCa Glu Glu Lac Lac Product Description CONTROL 3 min -x- max nmol/L mmHg kPa mmHg kPa mmol/L mmol/L mmol/L mmol/L mg/dL mg/dL mmol/L

Management of diabetes - National Guidelines · Impaired glucose handling • Impaired Fasting Glucose 6.1- 6.9 mmol/l • Impaired Glucose Tolerance 7.8-11.0 mmol/l

CDK4/6 Inhibitors Sensitize Rb-positive Sarcoma ... · 0.5 mmol/L phenylmethylsulfonyl fluoride, 50 mmol/L sodium fluoride, and 0.5 mmol/L sodium orthovanadate). The primary antibodies

Diabetes and schools/media/Files... · Treatment of Hypoglycaemia Check BGL, if it is less than 4 mmol/L : Step 1: Sit down and rest under supervision Step 2: Immediately give fast-acting

ii...• The Contour next LINK 2.4 wireless blood glucose monitoring system has a measuring range of 1.1 mmol/L to 33.3 mmol/L. For results under 1.1 mmol/L or over 33.3 mmol/L: о

SUPPLEMENTARY INFORMATION Exercise and associated … · HDL (mmol/L) 1.44±0.04 1.2±0.4† 1.39±0.05 LDL (mmol/L) 3.07±0.1 2.94±0.1 2.73±0.2 Triglycerides (mmol/L) 0.86±0.05

添付バッファー Restriction Enzymes - NIPPON GENE...Restriction Enzymes 添付バッファー 10 × L Buffer 100 mmol/l Tris-HCl （pH 7.9） 100 mmol/l MgCl2 10 mmol/l DTT 10

Riesgo cardiovascular y marcadores electrocardiográficos ... · Dislipidemia: Presencia de colesterol sérico > 6,2 mmol/L y/o triglicéridos > 1,7 mmol/L. Riesgo cardiovascular

LE DISLIPIDEMIE. RISULTATI DELLO STUDIO BOTNIA Pazienti HbA 1C, % HOMA IR Trigliceridi, mmol/l Colesterolo, mmol/l LDL-col, mmol/l HDL-col, mmol/l 1988

The Na+/Glucose Cotransporter Inhibitor Canagliflozin ... · (10 mmol/L), HEPES (20 mmol/L), sucrose (110 mmol/L), and fatty acid–free BSA (1 g/L). Primary hepatocytes from WT mice

 · Blodprøver Viste Hb g/l, Na 134 mmol/l, K mmol/l, kreatinin 537 umol/l, e-GFR 7 ml/min/I,73 pH 6,71, PC02 kPa, kPa, BE -30 mmol/l, 24,3 kPa og laktat 22 mmol/l. CT caput og røntgen

Acidobazická rovnováha pro pokročilé · excesivní zvracení. První Astrup na ambulanci. Sodium 133 mmol/L Arterial Blood Gas. Potassium 3.4 mmol/L pH 7.316 Chloride 109 mmol/L

pH : 7,46 (air ambiant) PaCO 2 : 36 mm Hg CO 2 T : 23 mmol/l PaO 2 : 56 mm Hg Sat : 88 % Na + : 144 mmol/l K + : 4,2 mmol/l Cl - : 103 mmol/l CO 2 T :

IndicadBE. 2010.LA. ConsorcioLecheroPDF · Días del parto Glucosa 5 Períodos de riesgo: ... – Puntos de corte • 1,0 mmol/L • 1,2 mmol/L • 1,4 mmol/L • Ventajas – Costo

Poruchy metabolismu - is.muni.cz · • zvýšení hladiny glukózy v krvi nad 7,77 mmol/l - hyperglykemie • snížení pod 2,5 mmol/l - hypoglykemie •enzymopatie nebo regulační

Gut microbiota determine insulin sensitivity · Fasting Insulin (mmol/L) MMT 80 (15-178) 85 (19-180) Cholesterol (mmol/L) 5.2 (3.5-8.8) 4.5 (3.5-7.2) TG (mmol/L) 2.0 (0.7-4.5) 1.1