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Sick Day Management

Sick Day Management. Ragnar Hanas, MD, PhD, Department of Pediatrics, Uddevalla, Sweden. Pediatric and adolescent diabetes in Sweden. - Sparsely populated with large geographical distances - High diabetes incidence (3 rd in the world after Finland and Sardinia)

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Sick Day Management

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  1. Sick Day Management Ragnar Hanas, MD, PhD, Department of Pediatrics, Uddevalla, Sweden

  2. Pediatric and adolescent diabetes in Sweden - Sparsely populated with large geographical distances - High diabetes incidence (3rd in the world after Finland and Sardinia) - ~7000 children and adolescents up to the age of 20~700 new cases/year (0 -18 years)

  3. How do we care for our patients? - Almost everyone is cared for at pediatric departments, the majority by a pediatric diabetologist - None are seen by GP:s - 40 centers, the largest with ~ 500 patients,but most have 75 -150 - Some travel 150 - 200 km to see their diabetologist - 50 -100 patients / diabetologist - 75 - 150 patients / diabetes nurse - Teams with dietician, psychologist, counselor (social worker)

  4. ”To dare is to lose foothold for a short while - not to dare is to lose yourself” Sören KierkegaardDanish philosopher 1813-55 Modern treatment of childhood diabetes Traditional approach -Insulin, diet, and exercise Diabetes treatment today -Insulin, love and care - Prof. Johnny Ludvigsson -Knowledge- There is nothing that is forbidden,you can always try something and find out what works for you

  5. Must know more than the average doctor to manage your diabetes What goals do we have? • The family is encouraged to take active part in diabetes and adjusting doses • -”It is no fun having diabetes - but you must be able to have fun even if you have diabetes” • - Prof. Johnny Ludvigsson

  6. ”Give a man a fish and he will not go hungry that day. Teach him how to fish and he will not be hungry for the rest of his life.” Chinese saying Important to learn for life... -After one year you will have experienced most things - “Then we want to learn from you!” -The clinic will function as an “intelligence center” with input from all families

  7. -It is important to come back to your ordinary parent-child rules in the family Try to keep on living as usual in the family... -It is our job to adjust the insulin doses to the child, not the other way around -Yourjob is to continue with important things you used to do, like mountain-biking, going for skiing vacation or a trip on the sea

  8. Healthy or sick? Healthy -Start with the need of food in your body -Take insulin to the food -Adjust the dose according to the carbohydrate content Sick -Start with the need of insulin in your body -Take food and drink to the insulin -Eat and drink to give the insulin sugar “to work with”, for example sweet drinks in small but frequent sips.

  9. Sick with fever -The child usually eats less but the fever requires more insulin -Begin by taking the sameinsulin doses as usual -100° F- often 25% increase of doses102° F- up to 50% increase of doses • Monitor BG before and after each mealUrine ketones at every voiding & in blood if positive • Check blood/urine ketones if vomiting or nauseous

  10. Insulin during sick days • Illness that raises BG • Increase doses if needed:High BG prior to a meal- premeal dose by 1 - 2 U or according to correction factor Multiple inj. -next day basal insulin by 1-2 UPump - basal rate by 10-20% (if needed up to 40-50%) High BG 1 - 2 h. after a meal- next day premeal dose by 1 - 2 U -Adjust doses according to body weight - Persons in remission phase may need to increase up to 1 unit/kg/day very quickly!

  11. Beware of vomiting when having diabetes! -Vomiting or nausea?- Caused by lack ofinsulin?!? -High blood glucose? Ketonesin blood or urine ? -When a child with diabetes vomits it should always be considered a sign of insulin deficiency until the opposite is proven! -Vomiting from gastroenteritisshould be considered only when a lack of insulin has been excluded!

  12. Gastroenteritis • -Vomiting with diarrheaor only diarrhea • -Low blood glucose levels • Always check for ketonesin blood or urine! • Vicious circle with ketones -nausea -eats less -more ketones • Decrease doses if needed: Low BG prior to the meal- premeal dose by 1 - 2 U oraccording to correction dose Multiple inj. -next day basal insulin by 2-4 U Pump - basal rate by 20-40% Low BG 1-2 h. after a meal- next premeal dose by 1 - 2 U

  13. Gastroenteritis • Give drinks containing sugar (not Light) in small and frequent portions (several sips every 10-15 min.) • Sweet ice cream or yoghurt may work well • Never miss a chance to give something containing sugar! -Keep records of how much the child has had to drink -Begin with solid foods as soon as the vomiting stops or decreases -Mini-doses of glucagon work well when everything else fails< 2 years: 2 “units” in a U-100 syringe> 2 years: 1 “unit”/year up to 15 “units” (0.15 mg)Repeat after 1 hour or more if neededHaymond MW. Diabetes Care 2001;24:643-45.

  14. Increased risk of ketoacidosis when ill -Relative insulin deficiency if doses are not increased -Nausea/vomiting makes it difficult to eat -Therefore it may be difficult to increase insulin doses • Small insulin depot with a pump- insulin deficiency develops quickly if there is a pump failure when you are ill • Drink more to prevent dehydration!Sugar-free fluids if BG is > ~220 mg/dlFluids containing carbohydratesif BG < ~220 mg/dl (~12 mmol/l)

  15. High blood glucose and ketones • Repeated BG > 270 mg/dl (15 mmol/l) and ketones • -Risk of developing ketoacidosis!! • 0.1 U/kg with pen or syringe (preferably Humalog/NovoLog) • Risk of over-correction -hypoglycemia • Check BG and ketones every hour If BG is not decreasing: Repeat dose every 1-2 hours (/2-3 hours with regular insulin) • The blood ketone level may increase after 1 hour but should be much lower after 2 hours • Urine ketones stay elevated for many hours

  16. Stored sugar in the liver (glycogen) Insulin from the pancreas - - - - - Carbohydrates from food Fat/muscle cell Vad happens to the carbohydrates from the food?

  17. A healthy cell Cell Insulin Blood vessel Urine test shows O2 CO2 Water Energy Glucose Ketones 0 0

  18. Starvation Cell (Insulin) Blood vessel Urine test shows in liver Fattyacids Ketones Glucose Ketones 0 +

  19. Diabetes - lack of insulin Cell Blood vessel Urine test shows in liver Fattyacids Ketones Glucose Ketones +++ +++

  20. Acetone Beta-hydroxybutyrate Beta-hydroxybutyrate Acetone Ketone bodies are used by the heart, kidneys, muscles, and brain as fuel Ketones + Ketone bodies in a healthy person Blood vessel Liver cell Fattyacids Mitochondrion StarvationLow insulinHigh fat diet Fatty acyl CoA Acetoacetate Acetoacetate

  21. Starvation ketones in people without diabetes -15 prepubertal children10 adult men10 adult women -Children fasted for 30 h.(part of clinical evaluation for hypoglycemia symptoms)Adults fasted for 86 h. -Children had much higher ketone levels than adults mmol/l men Blood ketones (Beta-hydroxybutyrate) children women 0 12 24 36 48 60 72 84 Time, hours

  22. Acetone Beta-hydroxybutyrate Beta-hydroxybutyrate Acetone Ketones +++ Fruity breath (Kussmaul breathing) Ketone bodies increase when there is a lack of insulin Blood vessel Liver cell Fattyacids Mitochondrion Low insulin Fatty acyl CoA Acetoacetate Acetoacetate

  23. Beta-hydroxybutyrate Beta-hydroxybutyrate Ketones 0 Urine ketones can be false neagative! Blood vessel Liver cell Fattyacids Mitochondrion Low insulin Fatty acyl CoA Acetoacetate Acetoacetate Ketones can only be detected by blood testing

  24. Acetoacetate Acetone Ketones +++ Acetone is deposited in fat tissue Urine ketones decrease slowly after insulin treatment Blood vessel Liver cell Fattyacids Mitochondrion High insulin Fatty acyl CoA Acetoacetate Acetone Beta-hydroxybutyrate Beta-hydroxybutyrate

  25. How is the blood glucose decreased when treating ketoacidosis? DeFronzo RA et al. Diabetes Reviews 1994;2:209-38. Effects of insulin treatment • -Blocked production of ketones in the liver • Blocked production of glucose in the liver • Increased uptake of glucose in tissue Increased dose needed

  26. Blood ketones > 1.5 mmol/l - 85% had ketoacidosis but only 2 pat. with blood ketones < 2.9 mmol/l had ketoacidosis. Blood ketones and ketoacidosis • 55 children, age 10.4 ± 3.9 y. with BG > 11.1 mmol/l (200 mg/dl) and ketones in urine. 37 had ketoacidosis (pH < 7.30) • Good correlation between patient method and lab. method Lab b-hydroxybutyrate Ham MR et. al. Ped Diab 2004;5:39-43.

  27. Measuring ketones in blood vs. urine • >100,000 episodes of DKA annually in the U.S. • 86 children, ages 2-18 (>0.5 units insulin/kg/day)unless <5 years old, with >0.3 units/kg/day. • 73 children on intensified insulin regimes and 18 used pumps. • 3900 concurrent pairs of blood and urine ketone tests were obtained. • 7783 concurrent pairs of BG and blood ketone tests were obtained. Laffel LMB. Diabetes 2002;51(suppl 1):A105. Slide from S Brink

  28. Measuring ketones in blood Precision Xtra meter • Accuracy has been well demonstrated Cembrowski GS,Diabetes 1999;48.Suppl:Abstract 265. Byrne HA, Diabetes Care 2000;23:500-503. • Linear response 0.0-6.0 mmol/L beta-hydroxybutyrate (b-OHB) • 5 µL blood sample • Results in 30 seconds • No interference by acetoacetate, acetone, lipids, etc. • No interference by common therapeutic agents (Captopril, L-DOPA, vitamin C, etc.)

  29. Measuring ketones in urine • KetoStix • It detects acetoacetate. • Results read from a color chart are Negative, trace (5 mg/dL), small (15 mg/dL), moderate (40 mg/dL),and large (80-160 mg/dL). • User timing is required. Read color at exactly 15 seconds after removing reagent strip from urine. • Proper read time is critical for optimal results. Must ignore color changes that occur after 15 seconds. • False-negative results when sticks have been exposed to air och after eating much vitamin C (acidic urine)

  30. On 15 occasions blood ketones were moderate to large but the urine ketones were negative! Measuring ketones in blood vs. urine Relationship between blood and urine ketones Slide from S Brink

  31. Measuring ketones in blood vs. urine • Relationship between blood and urine ketones Slide from S Brink

  32. Measuring ketones in blood vs. urine Slide from S Brink

  33. Measuring ketones in blood vs. urine Slide from S Brink

  34. Measuring ketones in blood vs. urine - conclusions • Use of urine ketones may lead to inappropriate decisions regarding the severity of illness in insulin-treated children. • The advantages of monitoring blood ketones include: - Real-time direct measurement of the predominant ketone body - Patient acceptance and improved compliance • Careful monitoring of BG and blood ketones, plus supplemental insulin and hydration, may enhance sick-day guidelines and help to prevent ketoacidosis in children.

  35. 60% fewer hospitalizations40% fewew emergency assessments Frequency of ketone measurements Measuring ketones in blood vs. urine - conclusions 123 children aged 3-22 years • Check ketones:When blood glucose was consistently > 13.9 mmol/l (250 mg/dl)During acute illness or stress • 6 months follow-up:21548 days578 sick days Laffel LMB. Diab Med 2005;23:278-84.

  36. How should blood ketones be interpreted? KetonesBG180-270 270-400 mg/dl >400 mg/dl < 0.5 mmol/l No problems Test again after 1-2 hours 0.5-0.9 mmol/l Test again 0.05 U/kg 0.1 U/kg 1.0 - 1.4 mmol/l Eat and take 0.1 U/kg 0.1 U/kg, x 1-2 0.05 U/kg 1.5 - 3 mmol/l Eat and take 0.1 U/kg. x 1-2 0.1 U/kg. x 1-2 0.1 U/kg > 3 mmol/l Eat and take 0.1 U/kg, x 1-2 0.1 U/kg, x 1-2 0.1 U/kg Contact your diabetes team or emergency ward!! Samuelsson, Diabetes Tech. 2002Laffel, poster 426, ADA 2002 -Every pump user should be able to test blood ketones -Also very helpful for younger children

  37. How should blood ketones be interpreted? Ketones BG< 250mg/dl 250-400 mg/dl >400 mg/dl < 0.6 mmol/l No change 5% 10% 0.6-0.9 mmol/l No change 5% 10% 1.0 - 1.4 mmol/l 0-5% 10% 15% ≥ 1.5 mmol/l 0-10% 15-20% 20% -Extra insulin to be given in percentage of total daily insulin dose -Don´t use % of daily dose when in remission phase! Laffel LMB. Diab Med 2005;23:278-84.

  38. Sick day rules -Monitorglucose (with adult supervision even in adolescents) every 3-4 h. and occasionally every 1-2 h. with results recorded in a log book -Test for ketones every 2-4 h.Check blood ketones if positive in urine -Continue monitoring in the middle of the night (no matter how tired the child or parent is) • Increased salty fluid intake to combat dehydration. Always drink something containing sugar • Check weight every 8-12 h. to monitor for clinical dehydration • Necessary medical treatment for underlying condition (antibiotics for tonsillitis, otitis, urinary tract infection) Stu Brink. Diab. Nutr. Metab. 1999;12:122-35

  39. Sick day rules • -Antipyretics (acetaminophen) to treat fever • -Antiemetics if severe vomiting prevents adequate fluid intake • -Continue to give insulinand administer extra doses for as long as blood glucose and/or ketones are high • Recognize of when insulin dose (rarely) needs to be temporarily decreased due to hypoglycemia (needs more sugar intake) • Contact your health team or hospitalif symtoms persist, worsen or do not get better. • All too frequently a physician or nurse advises omission of insulin because the child is ill and not eating!!! Stu Brink. Diab. Nutr. Metab. 1999;12:122-35

  40. When do you need to go to the hospital? • -Large or repeated vomiting • -Increasing levels of ketones or laboured breathing • Continued high BG level > 270 mg/dl (15 mmol/l) despite extra insulin • Unable to keep BG > 70 mg/dl (3.5 mmol/l) • The underlying condition is unclear • Severe or unusual abdominal pain • The child is confused or his/her general well-being is affected Adapted from Silink M. (Ed.) APEG handbook 1996

  41. When do you need to go to the hospital? • The child is young (< 2 - 3 years) or has another disease besides diabetes • Exhausted patients/relatives, for example due to repeated nighttime waking • Always call if you are in the least unsure about how to manage the situation Adapted from Silink M. (Ed.) APEG handbook 1996

  42. Diabetes and surgery • Schedule surgery first thing in the morning • I.v. insulin best for major surgery with general anesthesia • For minor surgery with local anesthesia,take only basal insulin (Lantus or pump) • Emergency surgery:I.v. insulin to bring down BG before surgery • Ketoacidosis can give abdominal pain of the same magnitude as appendicitis • Parents are the “diabetes experts” when their child is at a pediatric surgery ward!

  43. Increased doses- lower BG a Back to normal insulin resistance again a After a couple of days BG will be lower- doses need to be lowered a Insulin resistance in changed by the BG level High level due to infection- Õinsulin resistance a Blood glucose level 1-2 weeks a

  44. Infection cureda Continued insulin resistance a Insulin requirements increase with fever Cold with fever a Insulin requirements Increased insulin resistance due to fevera

  45. Infection cureda Continued low insulin resistance due to low BGa Insulin requirements decrease when having gastroenteritis Gastroenteritis withvomiting, diarrhea a Insulin requirements Decreased insulin resistance due to low BG levelsa

  46. Beware of vomiting when using a pump! -Vomiting or nausea?- Caused by lack ofinsulin?!?Especially true when using an insulin pump!! -Vomiting caused by pump problems may easily be mistaken for illness!! -When a child with a pump vomits it should always be considered as a pump problem until the opposite is proven!

  47. 2.24U/h 1.12U/h 1.12U/h Insulin kinetics increseases ketoacidosis risk 20 adults with type 1 diabetes Short-acting 125I-insulinCSII with infusion in the abdomen Hildebrandt P, Diabetic Medicine 1988;5:434-40

  48. How quickly will the ketones rise? -10 adults with pump, crossover with Velosulin and Humalog-Pump stopped between 7AM and 12 AM. -Blood glucose was ~ 5 mmol/l higher with Humalog after 5 hours 1.41.21.00.80.60.40.20 Humalog Velosulin Betahydroxy-buturate, mmol/l -All patients with pumps have blood ketone meters Guerci B et al. J Clin Endo Met 1999;84:2673-78.

  49. Increased risk of ketoacidosis with pump -Blood glucose will rise quickly when insulin supply is interrupted -Always check ketones in the urine when you are not feeling well Ketones!! mg/dl x x x 20 18 16 14 12 10 8 6 4 2 360 324 288 252 216 180 144 108 72 36 x x x Blood glucose mmol/L x x x x x x Example of pump problems: Time 10 AM 12 2 PM pH 7.28 7.31 7.36Ketones 3.6 3.0 0.2BG high 450 305 mg/dl 8 10 12 2 4 6 8 10 12 2 4 6 8 AM PM AM Time New needle inserted Needle came loose

  50. Diabetes equipment to bring on the trip • Extra insulin pen and/or syringes (pre-filled pens are handy for this) • Store in separate hand luggage • Thermometer to check the temperature of the refrigerator • Test strips + meter • Extra meter1 mmol/l = 18 mg/dl • Finger-pricking device + lancets • Test strips for ketones (blood and/or urine)

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