Diabetes Mellitus

Maura Lindenfeld, RN, MSN, CPNP

Cook Children’s Medical Center

Diabetes Mellitus:

A group of disorders characterized by hyperglycemia

with disturbed carbohydrate, protein, and fat metabolism associated with a relative or

absolute deficiency of insulin.

Type 1 Diabetes

–Insulin Dependent Diabetes Mellitus (IDDM)• autoimmune mediated• insulin deficient

Type 2 Diabetes

–Type 2 Diabetes–Non-Insulin Dependent Diabetes

Mellitus• insulin resistance• typically family history related• obesity

Normal Glucose Tolerance

• Fasting BG <100mg/dl • 2-hour post glucose <140

mg/dl

Impaired Glucose

Impaired Fasting GlucoseImpaired Glucose Tolerance

…a metabolic state intermediate between normal blood glucose and diabetes

Impaired Fasting Glucose (IFG)

• FBS 100mg/dl but 126 mg/dl

Impaired Glucose Tolerance (IGT)

• 2 hour post glucose 140mg/dl and 200mg/dl

Goals of Therapy

• Good blood sugar control• Improved quality of life • Routine• Minimize risk for hypoglycemia• Minimize risk for long-term

complications

Goals of Therapy

Age Blood Glucose<7yrs 80-200 mg/dl7-11yrs 80 -180 mg/dl>12yrs 80-150 mg/dl

HbA1C

Not a diagnostic tool• Provides a means to

monitor diabetes therapy• 3 month average blood

glucose • Under 8 is great! (within

1 ½ SD of non-diabetic range)

• At puberty, encourage control in the 7’s.

Type 2

• Hyperinsulinemia

• Insulin resistance

• Acanthosis Nigricans

• Insulin levels may be low or normal

Type 2

• Not always insulin-dependent

• Not prone to ketosis-prone under normal circumstances

• Onset may occur at any age, children are being diagnosed earlier and earlier.

Obesity• 15 – 20% of children and adolescents are

obese

• 62% of total population are obese,childhood obesity has increased by 25% since 2000

• On average, we consume 150 – 250 calories per day more than we did 10 years ago

Obesity• Decreased physical activity has

contributed to increase in obesity• Increases risks of Type 2 Diabetes,

hypercholesterolemia, hypertriglyceridemia, hypertension, vascular disease

• Prevalence of acanthosis nigricans and insulin resistance increases with the degree of obesity

Acanthosis Nigricans

“…is a skin lesion characterized by brown, velvety, hyperkeratotic plaques most often found in the axillae, the back of the neck, and other flexural areas.”

Mild

Moderate-to-Severe

Severe

Type 2 Treatment

• Diet– 45 grams of carbohydrates per meal– Small snacks (if any)– Reduced calorie intake 1500cals/day

• Exercise– 30 minutes of UNINTERRUPTED

exercise daily

Type 2 -Treatment• Medications

– Actos and Avandia• Taken with meals• Can cause hypoglycemia• Not approved for the use in children

– Glucophage• twice a day with food• Does NOT cause hypoglycemia

Insulin Regimens

• Conventional - 2 shots/day of short and intermediate insulin

• Intensive - 3 or more shots/day– Lantus or Levamir and Humalog, Novolog or Apidra– NPH and Humalog, Novolog or Apidra– Insulin Pumps

Insulin Curves

Insulin Curves

Insulin Types

Insulin Type Onset (hrs) Peak (hrs) Duration

Humalog 0.25 0.5 – 1.5 3 – 5

Novolog 0.25 0.5 – 1.5 3 - 5

Apidra 0.1 0.25- 1.0 2 - 4

Regular 0.5 – 1 2 – 3 6 – 8

NPH 1 – 1.5 6 – 8 12 – 18

Lantus 0.5 – 1 4-6 24

Levemir 0.5 – 1 4-6 12- 24

Injection Sites

Hyperglycemia

• Causes– Incorrect dose or missed dose– Eating more than allowed by meal plan

(incorrect carbohydrate counting)– Not enough exercise– Illness or infection

Hyperglycemia

• Onset– Symptoms present more slowly than

hypoglycemia– May progress to ketoacidosis and coma

if undetected

Symptoms of Hyperglycemia

• Polyuria, polydipsia, polyphagia• Hunger• Blurred vision• Headache• Emotional lability• Flushing• Yeast infections

Treatment of Hyperglycemia

• Insulin– Extra short acting insulin to correct

for highs– Adjust long acting insulin dose

Treatment of Hyperglycemia

• Hydration– Depending on the duration of

hyperglycemia May have mild to moderate volume loss• replace fluids orally if tolerated

• Exercise (as long as ketones are negative)

Correction Factor

• Typical format – For blood glucoses >150 mg/dl give:

150 – 199 1 unit Humalog200 – 249 2 unit Humalog250 – 299 3 units Humalog300 – 349 4 units Humalog350 – 399 5 units Humalog400 – 449 6 units Humalog>450 call endocrinologist on-call

Hypoglycemia

• Causes– Incorrect dose (too much insulin)– Missed meal or snack– Incomplete meal or snack– Unplanned or excess exercise– Illness– Alcohol consumption

Hypoglycemia

• Onset– Sudden– May progress to loss of consciousness or

seizure if untreated

Symptoms of Hypoglycemia

• Autonomic or adrenergic• Shakiness, trembling• Anxiety, nervousness• Weakness• Hunger• Sweating• Nausea, vomiting

Symptoms of Hypoglycemia

• CNS – Headache– Visual changes– Lethargy– Irritability, restlessness– Confusion– Somnolence, protracted sleep, stupor

Symptoms of Hypoglycemia

– Hypothermia– Seizures– Bizarre neurologic signs

• Motor• Sensory• Loss of intellectual ability• Personality changes

Treatment of Hypoglycemia

• Blood Glucose <70 mg/dl• Give 15g carbohydrates: 4 oz of juice,

6 oz of regular soda, 8 oz of milk,3–4 glucose tablets,6 life savers

• Recheck blood glucose in 15 minutes and retreat if blood glucose remains <70 mg/dl, if>70mg/dl give a 15g snack of complex carbohydrates

Treatment of Hypoglycemia

• If unable to take oral treatment– Glucagon

• <20 kg give 0.5 mg IM or SQ• >20 kg give 1 mg IM or SQ

Disposable Needles

Why to use a needle once, only once

Why shot site rotation matters

KetonesPathophysiology

• Relative or absolute insulin deficiency (diabetes) causes glucose (starvation) and results in the metabolism of fat for energy

• Ketones are a result of fat metabolism– Acetoacetate and -hydroxybutyrate

Causes of Ketosis

• New diagnosis• Not enough insulin• Illness or infection• Stress

–Emotional or physical• Starvation ketosis

Symptoms of Ketosis

• Fruity odor of breath or urine (acetone/nail polish odor)

• Abdominal pain• Nausea/vomiting• Kussmaul respirations• Drowsiness• Coma

Treatment of Ketosis

• Assess blood sugars and urine ketones every 2-4h until ketones cleared

• Extra rapid acting insulin (Humalog/Novolog) every 2-4h

• Extra fluids–Oral fluids initially glucose free

• NO EXCERCISE

Ketone Monitoring

• Urine–ketostix, multistick, ketodiastick–ketones are pink to purple–negative ketones on the ketone pad

are tan.

Ketone Monitoring

• Blood–lab - our current method gives ratio

expressed as 1:16, 1:32• the higher the number the more ketones

–bedside serum monitoring• available for home use

Monitoring

• Four times daily is recommended, always at bedtime (>100)

• Occasional nocturnal readings are required

• Pre-driving blood sugars (>100)

Monitoring• Honeymoon phase affects insulin regimen

– Partial remission of insulin deficiency after diagnosis

– Meals may trigger insulin release and a dose reduction may be indicated

Pump Therapy

Insulin Pump

• Site preparation

Transfusion Tubing

Pump Insulin Therapy

• Basal – Takes the place

of the long actinginsulin

Insulin Pump Therapy

•Bolus•“On Demand” insulin for food and corrections•Types: Normal•Square•Dual•Radio Frequency

Insulin Pump

• Troubleshooting– Always have a

back up plan– Check pump,

tubing and site

Questions

• Any Questions?