Tag Archives: Diabetes

Insulin pumps

Clinical, Endocrinology, General paediatrics

Pumps particularly good for recurrent hypoglycaemia, suboptimal control, under 5s, better QOL.

Good for sport.

Parents report loss of control!

Continuous blood glucose monitoring – 6 days, twice daily calibration bloods. Not Prescribable. Some link to pumps, others diagnostic only. Newest pumps can auto-adjust rate but only downwards. Esp normal pre-prandial bloods but Suspected hyperglycaemic between meals.

Ketones cause insulin resistance so higher doses acceptable. Blood ketone over 3 must come to hospital, but no fixed need for IV therapy.

Tight glucose from diagnosis seems to give best results in long term – “metabolic memory”? Prolonged honeymoon phase? Better education?

ADAPT study starting, prevention.

Only 15g snack allowed if on pen eg half apple! Else low carb eg cheese, pepperoni. Pumps allowed snacks of any size, tend to calm down after first couple of weeks!

Digestion v variable. High fat, high carb? Glycemic index ie fibre. Chewing!

Pump can bolus with individual courses! Slow bolus for cinema or buffet meal eg over 30 mins.

Non-waterproof pumps disconnected for bath etc, shower cap applies to cannula site, leave pump running to avoid air space.

 

 

Diabetic Ketoacidosis

Emergency medicine, Endocrinology, General paediatrics

DKA – BSPED guidance 2021.

The potentially serious acute complication of diabetes.  In the absence of adequate insulin, glucose levels start to rise in the blood, spilling over the threshold for kidney resorption and causing a diuresis.  Metabolism switches to ketone bodies, causing acidosis.

Presents with weight loss, tiredness, vomiting, heavy breathing (Kussmaul), reduced consciousness.  Diabetes symptoms of course, if first presentation, which might just be new wetting, or unusually heavy nappies.  Can be confused with pneumonia, or appendicitis! Often missed diagnosis.  In 2020 Lanarkshire audit, half had seen GPs at least once before diagnosis, with many having had bloods done rather than BM, or being asked to hand in urine the next day… 40% had BM done by family member!

Traditionally 15-17% of new presentations of diabetes are DKA, but with pandemic went up to 66%

ISPAD def DKA = Bicarbonate pH under 7.3 (H+50) PLUS ketones 3+ (blood or urine).

Beware can develop with normal glucose levels IN THOSE TAKING INSULIN.  Suspect if blood ketones above 3 in known diabetic, refer to hospital.  Between 0.5 and 3, follow sick day rules.

Mild (over 7.2 or 63) vs moderate (7.1-7.2 or 79) vs severe (79+) categories.  Treat as 5 vs 7 vs 10% dehydrated respectively.

All get 10ml/kg over 30 mins (assuming you start IV fluids) unless shocked (10/kg over 15 mins, repeat up to 40 then inotropes).

Maintenance fluids (0.9% NaCl with 20mmol KCl per 500ml bag) as per traditional formula (Holliday-Segar method) – 100ml/kg/d for under 10kg; 50ml/kg/d additionally for each kilo between 10-20kg; 20ml/kg/d for each kilo above that.

  • Calculate deficit as above. Subtract initial 10/kg bolus (but not shock boluses) and correct over 48hrs
  • ONLINE CALCULATOR (dka-calculator.co.uk) comes with disclaimer, gives fluid calculations but then prints out 16 pages which you don’t need! [KB]
  • Note SCOTSTAR has separate DKASupportDocument for those likely to need transfer

See graphic in BMJ 2016.

Complications

If acidosis not correcting, check cannula, check fluid calculations, consider sepsis.  Replace insulin syringe! Acidosis can also be caused by hyperchloraemia (hence Plasmalyte preferred at RHC – less chloride).

Risk of thromboembolism due to dehydration and immobility during recovery.

Cerebral oedema

25% mortality from cerebral oedema, 34% long term neurodisability.  Headache, irritability, agitation.  Posturing, focal neurology eg eye movements, pupil asymmetry.  Cushings triad – bradycardia, hypertension, breathing irregularity.

Hypertonic saline (2.7 or 3%, 2.5-5ml/kg over 10-15 mins) or mannitol (20%, 0.5-1g/kg over 15 mins), no preference.  

Switching

Stay on DKA pathway (and not transfer to subcutaneous insulin) until:

  • The patient has been reviewed by a Consultant, or paediatric diabetes team medical staff and
  • The patient has no evidence of dehydration has no nausea or vomiting for 6 hours, and
  • Has blood glucose less than 10mmol/l, and
  • The blood ketones have fallen below 0.9mmol/l

Anti-emetics

Common, General paediatrics,

Oral Ondansetron use for gastroenteritis has become v popular in many emergency departments.  In 1 study of 18 EDs, where it was a standard in nearly half all cases, there was no overall improvement in rates of either intravenous rehydration (remained around 18%) or hospital admission. There was a small decrease in re-attendance rates.

There was also a wide variation between institutions: perhaps the problem is not using Ondansetron it correctly eg not giving it soon enough, or rushing into IV fluids before allowing the drug time to work

Same group looked at Ondansetron in diabetic children with vomiting, again, usage increased from 0 to 67%. Admission rates dropped from 62% to 49% between these eras, as did use of IV fluids, but Ondansetron had no independent benefit.

From Archimedes Blog.  (Freedman S et al. JAMA Pediatr 2014;168:321–29, see also Editorial)( (Leung J et al. J Pediatr 2014. doi.org/10.1016/j.jpeds.2014.10.020). )