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Keeping your child with diabetes out of the hospital or emergency roomPre-Webinar Resource Material
Stephen W. Ponder MD, FAAP, CDEEndocrinologist
Baylor Scott & White Healthcare
General considerations
Let’s define type 1 diabetes first
• Type 1 diabetes: aka: insulin-dependent or juvenile diabetes
• Affects children and adults
• “Cured” only by a pancreas transplant
• Not caused by the patient in any way
• Increasing in frequency
7 principles of good diabetes control
1. Get organized, review your data, practice
2. Don’t let “good” be the enemy of “perfect”
3. Set reasonable age appropriate goals
4. Be consistent in what you do5. Resist the urge to over-react6. It’s all about CHOICES7. It should be a TEAM effort!
Are diabetic kids more sickly?
• I don’t see much difference with non-diabetic children in regards to frequency of illness
• Due to more attention to health care needs, I believe diabetic children have less risk of illness
• Why? More frequent contact with health care system, more attention to nutrition and activity
Person with type 1
Vaccines• I do recommend them
for my patients (e.g., flu shots)
• But if you choose not to use vaccines, make sure you know your diabetes sick day rules!
• We won’t debate the pros and cons of vaccination here
In general, when a person with diabetes is ill, they’ll need less insulin
YESNOX
What are “sick days”?
“Sick Day” really includes several situations
• High BG with ketones• Infections (viral/bacterial)
• Medical emergencies• Elective and Emergency
Surgeries/Accidents • Medication side-effects• Any interruption of
insulin therapy
How illness can affect diabetes
• You can’t always steer around it!
• It changes your “norm” or routine
• It’s best to be prepared!
Uh oh!
You’ve got to know when to hold ‘em, know when to fold ‘emKnow when to walk away and know when to run – Kenny Rogers
• Managing diabetes and illness is a series of important decisions
• The person who makes the best decisions usually stays out of the ER or hospital
“Life is not a matter of holding good cards, but of playing a poor hand well.”
R.L. Stevenson (1850-1894)
Managing diabetes and illness is about making and managing CHOICES
“Chance favors the prepared mind” Louis Pasteur
Louis Pasteur
SICK DAYS CAN HAPPEN QUICKLY
Disconnected pump
What are ketones?
What are ketones and why should I care?
• Under non-diabetic conditions…• Carbs (glucose) fuel the human
machine• When glucose energy is scarce,
insulin is also low• Low insulin allows us to convert
more fat into an energy source (ketones)
• Excess ketones come from using fat for energy too rapidly (ketosis)
Ketones are biological….
It takes just 1/10 the amount of insulin to prevent ketones as it does to control BG levels
Question: Eating too many carbs and sugars cause ketones in the blood
Yes
No
X
Common reasons for high BG with/without ketones
• Withholding insulin• “bad” insulin pump site• Insulin pump malfunction • Use of old/damaged
insulin• Some medications• Severe stress• Overeating
High sugars!
What is the most common cause of high ketones in kids?
Skipped/bad insulin!
Unexplained high, explained…
Culprit: unremoved cap
First discovered…
Corrected all by injection
New site
carb
How “rapid” insulin works
• 20 minutes to start lowering BG (from level)– Humalog (lispro)– Novolog (aspart)– Apidra (glulisine)
• BG can drop NO FASTER than 4 mg/dl/min!
• Insulin action peaks in 60-90 minutes
• Ketosis and high BG both slow down insulin effect
High BG
Ketones
insulin
A low insulin level in blood occurs in several ways
“Absolute”• Skipped insulin shot
– Forgotten– Intentional
• Insulin pump malfunction– Programming error– Problem with infusion site
• Use of bad insulin– Heat– Age
“Relative”• Assumes that good “working” insulin is
being taken properly• Illness
– Stress hormones– Dehydration (a stress)
• Medications– Glucocorticoids– Atypical antipsychotics
Absolute RelativeBoth
A low insulin level in blood occurs in several ways
If ketones are made in excess, what happens?
• Ketones (weak acids) uncontrollably build up in the blood/lower pH
• The body desperately tries to get rid of them
• Dehydration speeds up the process
• Uncontrolled vomiting is a serious sign
How does the body get rid of ketones?
1. In the urine2. Breathe them out3. Turns them into
something else
1
2
3
Dehydration
High blood sugar
Acid buildup
DKA
Diabetic Ketoacidosis
• A potentially lethal metabolic disturbance
• 1-2% of cases die • Sometimes misdiagnosed
in new onset cases• DKA is preventable • Expen$ive! (~$13,000)
DKA
Held insulin
Dose error
Old or heat
damaged
insulin?
Pum
p m
alfu
nctio
n
infectionPregnancy?
Stress
med
icatio
ns
“DKA” Roulette
Common DKA culprits
When (and why) should I look for ketones?
• Whenever blood sugar levels are high– 300 mg/dl or higher– 240 or higher? (some)
• During any illness– Surgery– Major infections– Trauma
• Taking steroids?
Do only type 1 diabetics get ketones?
• Any human being (mammal) can develop ketones
• Type 1’s have the greatest risk since they make the least insulin
• But any diabetic can develop ketones under the right conditions
How do I check for ketones?
Urine dipstick Fingerstick methodMeter: $68.08 on Amazon
10 ketone strips: $51.84 on Amazon
50 strips: $10.86 on Amazon
When should I be concerned?
concerned very concerned
When should I be concerned?
Get organized, know the “rules”
Diabetes “Sick day” rules…
1. Monitor blood sugar2. Measure ketones3. Drink plenty of fluids4. Treat nausea5. Take scheduled insulin6. Take extra insulin as needed7. Know when to call for help
What’s in your sick day toolkit?
• First…a good knowledge of the sick day rules!• BG meter/lancets/strips (your choice)
• Ketone measuring equipment (blood or urine)
• Flowsheet/notebook (to track progress)
• Rapid acting insulin/syringes/wipes• Anti-nausea medicine• Fluids and “safe” foods• Glucagon for injection
What’s in your diabetes think-kit?
• Why and how illness affects diabetes
• How insulin works• An appreciation that
improvement takes time and patience
• Judgment , experience and a touch of wisdom
The process of “Sick day care” is an exercise in abstract thinking. Kids can’t do this well without grown up help.
Why?
Because kids are concrete thinkers
Concrete thinkers* can’t…
1. Consider a hypothesis2. Consider multiple
possibilities in a scenario
3. Systematically solve a problem
4. Use combinatorial logic
*Lasts until 15-17 years of age*25% of adults are concrete thinkers.
Check BG often/keep good records
Time BG Ketones Insulin Fluids Other
7:30 AM 598 Large 12 u Humalog 2 oz nausea
8:32 AM 583 Large 12 u Humalog 4 oz nausea
9:45 AM 432 Mod-Large 12 u Humalog 6 oz Less nausea
10:34 AM 367 Moderate 12 u Humalog 6 oz No nausea
12:01 PM 231 Moderate 15 u Humalog Lunch No nausea
2:04 PM 167 Small 0 4 oz No nausea
4:14 PM 134 Trace 0 3 oz No nausea
6:23 PM 145 Negative 15 u Humalog Dinner No nausea
Prevent dehydration
• This is JOB one!• Small amounts are best.
Water is best• Sugar free popsicles or
Jello provide water too• If use diet soda pop,
shake out fizz• Low carb sport drinks
How to dose liquidsBody weight
• Under 40 pounds• 40 to 80 pounds• Over 80 pounds
Amount to drink every 20 minutes• ½ to ¾ cup = 4 to 6 ounces• 1 cup = 8 ounces• 1 to 1 ¼ cup = 8 to 10 ounces
Small sips: YES Big gulps: NO!
You need energy to fight back
• Ketones and/or illness itself will reduce appetite
• Liquid carbohydrates can be traded for solid carbs
• Focus on energy foods (carbs) over a balanced diet in the short term
Liquid versus Solid carbohydrates
• Basic concept: “a carb is a carb is a carb”
• Liquid carbs can be substituted for solid carbs
• Advantages– Provides water – Can be sipped to minimize vomiting
risk
Powdered drink mixes◦ Gatorade◦ Tang◦ Double strength for extra carbs
Regular popsicles Regular Jello Old fashioned peppermint
sticks◦ Source of carbs◦ Less risk of choking
KNOW HOW TO COUNT CARBS!
Other ideas to provide hydration and/or carbs
Manage nausea!
• Why? To maintain oral intake, especially liquids
• Over the counter treatments are a good start (Emetrol has some carbs too)
• Prescription meds may be needed– Suppositories– Oral Rx anti-emetics– Side effects?
Stop the vomiting!• Stomach rest: nothing by
mouth for 30 minutes• Emetrol (or Equate) 1
tablespoon every 15 minutes until vomiting stops
• Works best on empty stomach.• NO fluids for 10 minutes after
EMETROL is given• Consider adding Pepto-Bismol,
1 tablespoon every 10 to 15 minutes WITH the Emetrol. It may help with tummy pain.
If over the counter doesn’t work
• Your doctor may provide prescription anti-nausea medications– Zofran (Ondansetron)
– Phenergan (Promethazine)
– Compazine (Prochlorperazine)
• All have potential side-effects. Discuss with your doctor
• Some are $$$
After some stomach “rest”
• Give small sips by mouth • ½ ounce every 15 minutes
to start• Use liquid exchange lists
to provide carbs and fluids together
• Gradually increase the fluid amount as tolerated
Know how/when to use insulin
• Extra insulin given as rapid-acting– Humalog, Novolog, Apidra
• Calculate dose based on weight in kilograms
• Check BG results hourly– Ketones with every voiding– Blood ketones every hour
• Repeat as needed based on BG and ketones
But if a usual or scheduled dose of rapid acting insulin is supposed to be
given at the time you discover high BG and ketones, then give that dose and recheck BG in 1 hour. Or….give your
usual correction dose per the pump*.
* If the pump is the problem, this will cost you time.
Can I treat high sugars/ketones with pump?
• You can try…but• If pump is the problem
you lose valuable time• It’s always safest to take
insulin by a shot
Calculating an insulin dose for high BG and ketones
• Start with 0.1 units per kilogram weight– Range 0.075 to 0.2 U/kg/dose– Only correct with rapid insulin (Humalog, Novolog). – NEVER hold a scheduled insulin dose (e.g., long acting)
• To get kilograms from pounds– divide weight in pounds by 2.2– Example 1: 30 pounds/ 2.2 = 13.6 kilograms– Example 2: 120 pounds/2.2 = 54.5 kilograms
• Example 1: 0.1 x 13.6 = 1.3 units = 1 unit• Example 2: 0.1 x 54.5 = 5.5 = 5 to 6 units
When to call for back up/go to ER• If vomiting can’t be
controlled • Unusual sleepiness• Fast breathing• Poor concentration• If the child/person
just isn’t “looking right”
Help, Doc!
Summary: Diabetes “Sick day” rules…
1. Check blood sugar often2. Measure ketones until gone3. Drink plenty of fluids4. Treat nausea5. Take scheduled insulin6. Take extra insulin as needed7. Know when to call for help
Watch this video: https://www.youtube.com/watch?v=4urN3RBFQQs