Paediatric Diabetes NursesOctober 2013

Diabetes Update

Diabetes

Aims and Objectives

• What is diabetes.• To understand the types of diabetes that we deal with.• What is hypoglycaemia.• How to manage hypoglycaemia in the hospital setting.• Hypo scenarios• What is hyperglycaemia.• Understanding sick day rules.• Understanding Diabetic Keto-acidosis (DKA)• How to understand the sick day correction dose.• Understand how the insulin chart should be completed.• Sick day scenarios.

What Diabetes isDiabetes is a condition where the amount of glucose in your blood is too high because the body cannot use it properly. This happens because your pancreas does not produce any insulin, or not enough, to help glucose enter your body’s cells.

Type 1 Diabetes

Type 1 diabetes develops when the insulin-producing cells in the body have been destroyed and the body is unable to produce any insulin.

Type 2 Diabetes

Type 2 diabetes develops when the body can still make some insulin, but not enough, or when the insulin that is produced does not work properly (known as insulin resistance).

Hypo’s• Low blood sugar, any reading less than 4 mmol/L

(Normal range 4 – 8mmol/L)• Needs to be acted on straight away• Refined sugar followed by complex carbohydrate.• Pump patients only require refined sugar

Reasons• Too much insulin, not enough food• Exercise

Signs and Symptoms

• Shaky• Sweating• Garbled speech• Vacant• Each persons symptoms may vary but are the same with

each hypo.• Always act if the person says they are hypoglycaemic.

Hypo’s continued

• Mild hypo: recognised, treated and a quick recovery• Moderate hypo: Person needing assistance to manage the hypo,

use Glucogel. This may need to be repeated.• Severe hypo: Unconscious, not to put anything in the mouth,

call for help Glucagen IM or Dextrose IV.

Treatment of Hypo’s

60 – 75mls of Lucozade3 x glucotabsTube of glucogelGlucagon IMIV DextroseComplex carbohydrate

Hypo Management

Gordon is 13yr oldFractured femurBlood Glucose 2.2Feeling hungry.Lunch is imminentWhat should we do?

Hypo Management

Donald 2 yearsAdmitted with Diarrhoea and vomitingBlood glucose 2.6 mmol/LUncooperative.What next?

Hypo Management

Tequila 6 year oldOn an Insulin pumpBlood glucose 3.6 mmol/LFeeling sweaty and has a

headache.What should we do.

Hypo Management

Kiki 3 year oldOn an insulin pumpAdmitted following a fit at

home.Uncooperative and drowsyBGM 1.2 mmol/L on

admissionWhat should we do?

Hyperglycaemia and Sick Day Rules

Hyperglycaemia

This happens when blood glucose levels go too high.

Common reasons for hyperglycaemia are:Illness

Not enough insulin, or a missed dose

Eating too much sugary or starchy food

Injecting into lumpy sites

Sudden excitement or stress

IllnessIllness usually causes high blood glucose levels because of the production of

‘stress’ hormones and because the body becomes resistant to insulin.

During illness never stop taking insulin (Particularly the levemir / Lantus) and regular adjustment of normal novorapid doses will be needed.

Blood sugars and ketone levels will need to be checked more frequently.

If it is possible for child to eat, replace solid food with liquids with carbohydrates in them.

If high sugars are not corrected with extra Insulin this will lead to the production of ketones.

Ketones

DO NOT USE URINE KETONE STIX. ONLY USE BLOOD KETONES

Ketones are produced when your body gets energy by breaking down fat instead of sugar

This will happen for one of 2 reasonsIf you do not have enough insulin in

your bloodIf there simply isn’t enough sugar

available

Diabetic Ketoacidosis

Diabetic Ketoacidosis (DKA) is a dangerous and potentially life-threatening condition. And is the result of ketone development

DKA most commonly happens in people with type 1 diabetes

DKA happens when there is persisitantly high glucose in the blood and a lack of insulin.

Correction DosesTotal of all insulin doses on a normal day (Units) eg add up Levemir and Novorapid doses

Sick Day Dose (Units)

1-4 0.5

5-9 1

10-14 2

15-19 3

20-24 4

25-29 5

30-34 6

35-39 7

40-44 8

45-49 9

50-54 10

55-59 11

60-64 12

65-69 13

70-74 14

75-79 15

80-84 16

85-89 17

90-94 18

95-99 19

100 or more 20

Sick day rule Correction doses are generally a 20% of Total daily dose of insulin if ketones are present this will be an extra dose of Novorapid on top of normal dose

Normal correction without ketones or less than 1 mmol/Lwould be approx 10 % of total daily dose, on top of normal dose.

Treatment

If a blood sugar is above 14mmol and the child is unwell Check bloods must be checked for ketones. If Ketones are present it is likely that the child does not have enough insulin in their body, so you may need to increase the dose or give an extra dose. This is known as a correction dose Correction doses can be given to reduce a blood sugar even if ketones are negative but at a reduced level. Make sure the child drinks plenty of sugar-free fluids.

Diabetes Scenarios

Betty is 13yr old Blood ketones 0.8 mmol Blood Glucose 19.2Total daily dose of insulin (TDD)

68 units

Diabetes Scenarios

Fred aged 8 ketones 4.1 mmol Blood glucose 22.6 mmol Kussmaul breathingDrowsyvomited x 6 timesTolerating oral fluids not eating.Total daily dose of insulin (TDD) 28

Diabetes Scenarios

Tallulah is 4yr old Blood ketones 1.0 mmol Blood Glucose 7.6 mmolTotal daily dose of insulin (TDD)

13.5 units

Diabetes Scenarios

Olivia is 11yr old Blood ketones 1.9 mmol Blood glucose 16.8 mmolEating and drinking cold like symptoms. Has had 2

sick day doses. Total daily dose of insulin (TDD)

37 units

Pump Animas Vibe

RCHT Protocols

• Guidelines of sick day rules for children on insulin injections• Management of hypoglycaemia for children with diabetes on

insulin injections and pumps• Management of high blood glucose levels and sick day rules

for children on insulin pumps• Guideline for Hospital Admission of Patients on Insulin Pumps

Conclusion

• To be confident to follow the hypo guidelines.• To be confident on how to use sick day rules.• To be able to recognise that an insulin

prescription sheet is completed correctly.