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

Sick Day ManagementSick Day Management

Ragnar Hanas, MD, PhD, Department of Pediatrics, Uddevalla, SwedenRagnar Hanas, MD, PhD, Department of Pediatrics, Uddevalla, Sweden

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Pediatric and adolescent diabetes in SwedenPediatric and adolescent diabetes in Sweden

-- Sparsely populated with large geographical distancesSparsely populated with large geographical distances

-- High diabetes incidence High diabetes incidence (3(3rdrd in the world after Finland and Sardinia) in the world after Finland and Sardinia)

-- ~~707000 children and adolescents up to the age of 2000 children and adolescents up to the age of 20~~700700 new cases/year (0 -18 years) new cases/year (0 -18 years)

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How do we care for our patients?How do we care for our patients?

-- Almost everyone is cared for at pediatric departments, Almost everyone is cared for at pediatric departments, the majority by a pediatric diabetologistthe majority by a pediatric diabetologist

-- None are seen by GP:s None are seen by GP:s

-- 40 centers, the largest with ~ 500 patients,40 centers, the largest with ~ 500 patients,but most have 75 -150but most have 75 -150

-- Some travel 150 - 200 km to see their diabetologistSome travel 150 - 200 km to see their diabetologist

-- 50 -50 -100100 patients / diabetologist patients / diabetologist

-- 75 - 150 patients / diabetes nurse75 - 150 patients / diabetes nurse

-- Teams with dietician, psychologist, Teams with dietician, psychologist, counselor (social worker)counselor (social worker)

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Modern treatment of childhood diabetesModern treatment of childhood diabetes

Traditional approachTraditional approach

-- Insulin, diet, and exerciseInsulin, diet, and exercise

””To dare is to lose foothold for To dare is to lose foothold for a short while - not to dare is to a short while - not to dare is to lose yourself”lose yourself”

Sören KierkegaardSören KierkegaardDanish philosopher 1813-55Danish philosopher 1813-55

Diabetes treatment todayDiabetes treatment today

-- Insulin, love and careInsulin, love and care

- - Prof. Prof. Johnny LudvigssonJohnny Ludvigsson

-- KnowledgeKnowledge --

There is nothing that is There is nothing that is forbidden,forbidden,you can always you can always try somethingtry something and and find out what works for you find out what works for you

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What goals do we have?What goals do we have?

- The family is eThe family is encouraged to ncouraged to take active part in diabetes take active part in diabetes and adjusting dosesand adjusting doses

--”It is no fun having diabetes - ”It is no fun having diabetes - but you must be able to but you must be able to have fun even if you have have fun even if you have diabetes”diabetes”

- Prof. Johnny - Prof. Johnny LudvigssonLudvigsson

- Must know more than Must know more than the average doctor to the average doctor to manage your diabetesmanage your diabetes

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Important to learn for life...Important to learn for life...

-- After one year you will have After one year you will have experienced most thingsexperienced most things

-- ““Then we want to learn from you!”Then we want to learn from you!”

-- The clinic will function as an The clinic will function as an “intelligence center” with input from “intelligence center” with input from all familiesall families

””Give a man a fish and he will not Give a man a fish and he will not go hungry that day. Teach him how go hungry that day. Teach him how to fish and he will not be hungry for to fish and he will not be hungry for the rest of his life.”the rest of his life.”

Chinese sayingChinese saying

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Try to keep on living as usual in the family...Try to keep on living as usual in the family...

-- It is our job to adjust the insulin doses to the It is our job to adjust the insulin doses to the child, not the other way aroundchild, not the other way around

-- YouYourr job isjob is to continue with important things to continue with important things you used to do, like mountain-biking, going you used to do, like mountain-biking, going for skiing vacation or a trip on the sea for skiing vacation or a trip on the sea

-- It is important to come It is important to come back to your ordinary back to your ordinary parent-child rules in parent-child rules in the familythe family

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HealthyHealthy

-- Start with the need of food in your bodyStart with the need of food in your body

-- Take insulin to the foodTake insulin to the food

-- Adjust the dose according to the carbohydrate contentAdjust the dose according to the carbohydrate content

Healthy or sick?Healthy or sick?

SickSick

-- Start with the need of insulin in your bodyStart with the need of insulin in your body

-- Take food and drink to the insulinTake food and drink to the insulin

-- Eat and drink to give the insulin sugar “to work with”, Eat and drink to give the insulin sugar “to work with”, for example sweet drinks in small but frequent sips.for example sweet drinks in small but frequent sips.

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-- The child usually eats less but The child usually eats less but the fever requires more insulinthe fever requires more insulin

-- Begin by taking the sameBegin by taking the sameinsulin doses as usualinsulin doses as usual

-- 100100° ° FF - - often 25% increase of dosesoften 25% increase of doses102102° ° FF - - up to 50% increase of dosesup to 50% increase of doses

Sick with feverSick with fever

- Monitor BG before and after each mealMonitor BG before and after each mealUrine kUrine ketones at every voidingetones at every voiding & & in blood if positivein blood if positive

- Check blood/urine ketones if vomiting or nauseousCheck blood/urine ketones if vomiting or nauseous

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Illness that raises BGIllness that raises BG

- Increase doses if neededIncrease doses if needed:: High BG prior to a mealHigh BG prior to a meal -- premeal dose by 1 - 2 U or premeal dose by 1 - 2 U or according to correction factoraccording to correction factor

Multiple inj. Multiple inj. -- next day next day basal insulin by 1-2 Ubasal insulin by 1-2 UPump Pump -- basal rate by 10-20% basal rate by 10-20%

(if needed up to 40-50%)(if needed up to 40-50%)

High BG 1 - 2 h. after a mealHigh BG 1 - 2 h. after a meal -- next next day day premeal dose premeal dose by 1 - 2 Uby 1 - 2 U

Insulin during sick daysInsulin during sick days

-- Adjust doses according to body weightAdjust doses according to body weight

-- Persons in remission phase may need to Persons in remission phase may need to increase up to 1 unit/kg/day very quickly! increase up to 1 unit/kg/day very quickly!

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-- Vomiting or nausea?Vomiting or nausea?

-- Caused by Caused by lack oflack of insulin?!?insulin?!?

-- High blood glucose? High blood glucose?

KetonesKetones in blood orin blood or urine ? urine ?

Beware of vomiting when having Beware of vomiting when having diabetes!diabetes!

-- When a child with diabetes vomits it When a child with diabetes vomits it

should should alwaysalways be considered a sign of be considered a sign of insulin deficiency until the opposite is proven!insulin deficiency until the opposite is proven!

-- Vomiting fromVomiting from g gastroenteritisastroenteritis should should

be considered only when a lack of be considered only when a lack of insulin has been excluded!insulin has been excluded!

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-- Vomiting with diarrheaVomiting with diarrheaor only diarrheaor only diarrhea

-- Low blood glucose levelsLow blood glucose levels

- Always check for ketonesAlways check for ketonesin blood or urine!in blood or urine!

- Vicious circle with ketones Vicious circle with ketones --

nausea nausea -- eats less eats less -- more ketonesmore ketones

GastroenteritisGastroenteritis

- Decrease doses if needed: Decrease doses if needed: Low BG prior to the mealLow BG prior to the meal -- premeal dose by 1 - 2 U premeal dose by 1 - 2 U oror according to correction doseaccording to correction dose

Multiple inj. Multiple inj. -- next day next day basal insulin by 2-4 U basal insulin by 2-4 U Pump Pump -- basal rate by 20-40% basal rate by 20-40%

Low BG 1-2 h. after a mealLow BG 1-2 h. after a meal -- next premeal dose by 1 - 2 U next premeal dose by 1 - 2 U

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- Give drinks containing sugar (Give drinks containing sugar (notnot Light Light) in small and frequent ) in small and frequent portions (several sips every 10-15 min.)portions (several sips every 10-15 min.)

- Sweet ice cream or yoghurt may work wellSweet ice cream or yoghurt may work well

- Never miss a chance to give something Never miss a chance to give something containing sugar!containing sugar!

GastroenteritisGastroenteritis

-- Keep records of how much the child has had to drinkKeep records of how much the child has had to drink

-- Begin with solid foods as soon as the vomiting stops or Begin with solid foods as soon as the vomiting stops or decreasesdecreases

-- Mini-doses of glucagonMini-doses of glucagon work well when everything else fails work well when everything else fails< 2 years:< 2 years: 2 “units” in a U-100 syringe2 “units” in a U-100 syringe> 2 years:> 2 years: 1 “unit”/year up to 15 “units” (0.15 mg)1 “unit”/year up to 15 “units” (0.15 mg)Repeat after 1 hour or more if neededRepeat after 1 hour or more if neededHaymond MW. Diabetes Care 2001;24:643-45.Haymond MW. Diabetes Care 2001;24:643-45.

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-- Relative insulin deficiencyRelative insulin deficiency if doses are not increased if doses are not increased

-- Nausea/vomiting makes it difficult to eatNausea/vomiting makes it difficult to eat

-- Therefore it may be difficult to increase insulin dosesTherefore it may be difficult to increase insulin doses

Increased risk of ketoacidosis when illIncreased risk of ketoacidosis when ill

- Small insulin depot with a pumpSmall insulin depot with a pump- - insulin deficiency develops quickly if theinsulin deficiency develops quickly if there is a re is a pump pump failure when you are illfailure when you are ill

- Drink more to prevent dehydration!Drink more to prevent dehydration!Sugar-free fluids if BG is > ~220 mg/dlSugar-free fluids if BG is > ~220 mg/dlFluids containing carbohydratesFluids containing carbohydratesif BG < ~220 mg/dlif BG < ~220 mg/dl (~12 mmol/l) (~12 mmol/l)

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High blood glucose and ketonesHigh blood glucose and ketones

Repeated BG > 270 mg/dl (15 mmol/l) and ketonesRepeated BG > 270 mg/dl (15 mmol/l) and ketones

-- Risk of developing ketoacidosis!! Risk of developing ketoacidosis!!

- 0.1 U/kg with pen or syringe 0.1 U/kg with pen or syringe (preferably Humalog/NovoLog)(preferably Humalog/NovoLog)

- Risk of over-correction Risk of over-correction -- hypoglycemiahypoglycemia

- Check BG and ketones every hourCheck BG and ketones every hour If BG is not decreasing:If BG is not decreasing:Repeat dose every 1-2 hours Repeat dose every 1-2 hours (/2-3 hours with regular insulin)(/2-3 hours with regular insulin)

- The blood ketone level may increase after 1 hour but should be The blood ketone level may increase after 1 hour but should be much lower after 2 hoursmuch lower after 2 hours

- Urine ketones stay elevated for many hoursUrine ketones stay elevated for many hours

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Insulin from the Insulin from the pancreaspancreas

Vad happens to the carbohydrates from the Vad happens to the carbohydrates from the food? food?

- -- -

- -- -- -

Fat/muscle cellFat/muscle cell

Stored sugar in the Stored sugar in the liver (glycogen)liver (glycogen)

Carbohydrates Carbohydrates from foodfrom food

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A healthy cellA healthy cell

InsulinInsulin

OO22 COCO22

WaterWater

EnergyEnergy

Urine test showsUrine test shows

Glucose Ketones Glucose Ketones

0 00 0

BloodBloodvesselvessel

CellCell

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StarvationStarvation

(Insulin)(Insulin)

in liverin liver FattyFattyacidsacids

KetonesKetones



0 +0 +


CellCell

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Diabetes - lack of insulinDiabetes - lack of insulin

CellCell

in liverin liver FattyFattyacidsacids

KetonesKetones



+++ ++++++ +++


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Ketone bodies in a Ketone bodies in a healthy personhealthy person

Liver cellLiver cell

FattyFattyacidsacids

Blood vesselBlood vessel

MitochondrionMitochondrion

Fatty acyl CoA

Acetoacetate

AcetoacetateAcetoacetate

Ketones Ketones

++

Beta-hydroxybutyrateBeta-hydroxybutyrate Beta-hydroxybutyrate

StarvationLow insulinHigh fat diet

Ketone bodies are used by the heart, Ketone bodies are used by the heart, kidneys, muscles, and brain as fuelkidneys, muscles, and brain as fuel

Acetone

AcetoneAcetone

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Starvation ketones in people without diabetesStarvation ketones in people without diabetes

-- 15 prepubertal children15 prepubertal children10 adult men10 adult men10 adult women10 adult women

-- Children fasted for 30 h.Children fasted for 30 h.(part of clinical evaluation (part of clinical evaluation for hypoglycemia for hypoglycemia symptoms)symptoms)Adults fasted for 86 h. Adults fasted for 86 h.

-- Children had much higher Children had much higher ketone levels than adultsketone levels than adults

0 12 24 36 48 60 72 84 Time, hours B

lood

ket

ones

(B

eta-

hydr

oxyb

utyr

ate)

mmol/l

children

men

women

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Ketone bodies increase when there is a Ketone bodies increase when there is a lack of lack of insulininsulin





Fatty acyl CoA

Acetoacetate


Ketones Ketones

++++++Fruity breath (Kussmaul breathing)Fruity breath (Kussmaul breathing)


Low insulin

Acetone

AcetoneAcetone

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Urine ketones can be Urine ketones can be false neagative!false neagative!





Fatty acyl CoA

Acetoacetate


Ketones Ketones

00


Low insulin

Ketones can only be detected by Ketones can only be detected by blood testingblood testing

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Urine ketones decrease slowly Urine ketones decrease slowly after insulin after insulin treatmenttreatment





Fatty acyl CoA

Acetoacetate


Ketones Ketones

++++++


Highinsulin

Acetone

Acetone is deposited in fat tissueAcetone is deposited in fat tissue

AcetoneAcetone

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Effects of insulin treatmentEffects of insulin treatment

-- Blocked production of Blocked production of ketones in the liverketones in the liver

- Blocked production of Blocked production of glucose in the liverglucose in the liver

- Increased uptake of Increased uptake of glucose in tissueglucose in tissue

Increased dose

needed

DeFronzo RA et al. Diabetes Reviews 1994;2:209-38.

How is the blood glucose How is the blood glucose decreased when treating decreased when treating ketoacidosis?ketoacidosis?

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Blood ketones and ketoacidosisBlood ketones and ketoacidosis

55 children, age 10.4 ± 3.9 y. with BG > 11.1 mmol/l (200 mg/dl) 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)and ketones in urine. 37 had ketoacidosis (pH < 7.30)

- Good correlation between patient method and lab. methodGood correlation between patient method and lab. method

Ham MR et. al. Ped Diab 2004;5:39-43.Ham MR et. al. Ped Diab 2004;5:39-43.

Lab -hydroxybutyrate

- Blood ketones > 1.5 mmol/l Blood ketones > 1.5 mmol/l -- 85% had ketoacidosis but only 85% had ketoacidosis but only 2 pat. with blood ketones < 2.9 mmol/l had ketoacidosis.2 pat. with blood ketones < 2.9 mmol/l had ketoacidosis.

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Measuring ketones in blood vs. urineMeasuring ketones in blood vs. urine

>100,000 episodes of DKA annually in the U.S.>100,000 episodes of DKA annually in the U.S.

- 86 children, ages 2-18 (>0.5 units insulin/kg/day)86 children, ages 2-18 (>0.5 units insulin/kg/day)unless <5 years old, with >0.3 units/kg/day.unless <5 years old, with >0.3 units/kg/day.

Slide from S BrinkSlide from S Brink

- 73 children on intensified insulin regimes and 18 used pumps.73 children on intensified insulin regimes and 18 used pumps.

- 3900 concurrent pairs of blood and urine ketone tests were 3900 concurrent pairs of blood and urine ketone tests were obtained.obtained.

- 7783 concurrent pairs of BG and blood ketone tests were 7783 concurrent pairs of BG and blood ketone tests were obtained.obtained.

Laffel LMB. Diabetes 2002;51(suppl 1):A105.Laffel LMB. Diabetes 2002;51(suppl 1):A105.

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Measuring ketones in bloodMeasuring ketones in blood

Precision Xtra meterPrecision Xtra meter

- Accuracy has been well demonstrated Accuracy has been well demonstrated Cembrowski GS,Diabetes 1999;48.Suppl:Abstract 265. Cembrowski GS,Diabetes 1999;48.Suppl:Abstract 265. Byrne HA, Diabetes Care 2000;23:500-503.Byrne HA, Diabetes Care 2000;23:500-503.

- Linear response 0.0-6.0 mmol/L beta-hydroxLinear response 0.0-6.0 mmol/L beta-hydroxyybutyrate butyrate ((-OHB)-OHB)

- 5 µL blood sample5 µL blood sample

- Results in 30 secondsResults in 30 seconds

- No interference by acetoacetate, acetone, lipids, etc.No interference by acetoacetate, acetone, lipids, etc.

- No interference by common therapeutic No interference by common therapeutic agents (Captopril, L-DOPA, vitamin C, etc.)agents (Captopril, L-DOPA, vitamin C, etc.)

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Measuring ketones in urineMeasuring ketones in urine

KetoStixKetoStix

- It detects acetoacetate. It detects acetoacetate.

- Results read from a color chart are Results read from a color chart are Negative, Negative, ttrace (5 mg/dL), race (5 mg/dL), ssmall (15 mg/dL), mall (15 mg/dL), mmoderate (40 mg/dL)oderate (40 mg/dL),,and large (80-160 mg/dL).and large (80-160 mg/dL).

- User timing is required. Read color at exactly 15 seconds after User timing is required. Read color at exactly 15 seconds after removing reagent strip from urine. removing reagent strip from urine.

- Proper read time is critical for optimal results. Must ignore color Proper read time is critical for optimal results. Must ignore color changes that occur after 15 seconds.changes that occur after 15 seconds.

- False-negative results when sticks have been exposed to air och False-negative results when sticks have been exposed to air och after eating much vitamin C (acidic urine) after eating much vitamin C (acidic urine)

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Relationship between blood and urine ketonesRelationship between blood and urine ketones


-OHB, mmol/L UKET>1.0 Moderate to Large

0.6-1.0 Small0-0.5 Negative to Trace

-OHB 0-0.5 0.6-1.0 1.1-1.5 1.6-3.0 >3.1

N 3420 65 10 4 1 Tr 282 29 2 9 1 S 47 26 3 1 1 M 17 20 4 4 2

U

KE

T

L 7 7 6 9 13

- On 15 occasions blood ketones were moderate to large but the On 15 occasions blood ketones were moderate to large but the urine ketones were negative!urine ketones were negative!

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- Relationship between blood and urine ketonesRelationship between blood and urine ketones


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Measuring ketones in blood vs. urine - conclusionsMeasuring ketones in blood vs. urine - conclusions

- Use of urine ketones may lead to inappropriate decisions Use of urine ketones may lead to inappropriate decisions regarding the severity of illness in insulin-treated children.regarding the severity of illness in insulin-treated children.

- The The advantages of monitoring blood ketonesadvantages of monitoring blood ketones include: include:

- - Real-time direct measurement of the predominant ketone Real-time direct measurement of the predominant ketone bodybody - - Patient acceptance and improved compliancePatient acceptance and improved compliance

- Careful Careful monitoring of BG and blood ketonesmonitoring of BG and blood ketones, plus supplemental , plus supplemental insulin and hydrationinsulin and hydration, may enhance sick-day guidelines and help , may enhance sick-day guidelines and help to to prevent ketoacidosisprevent ketoacidosis in children. in children.

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Measuring ketones in blood vs. urine - conclusionsMeasuring ketones in blood vs. urine - conclusions

123 children aged 3-22 years123 children aged 3-22 years

- Check ketones:Check ketones:When blood glucose was consistently > 13.9 mmol/l (250 mg/dl)When blood glucose was consistently > 13.9 mmol/l (250 mg/dl)During acute illness or stressDuring acute illness or stress

- 6 months follow-up:6 months follow-up:21548 days21548 days578 sick days578 sick days

Laffel LMB. Diab Med 2005;23:278-84.

60% fewer hospitalizations

40% fewew emergency assessments

Frequency of ketone measurements

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How should How should bloodblood ketone ketones bes be interpreted? interpreted?

KetonesKetones BGBG 180-270 180-270 270-400 mg/dl270-400 mg/dl >400 mg/dl>400 mg/dl

< 0.5 mmol/l< 0.5 mmol/l No problems No problems Test again after 1-2 hours Test again after 1-2 hours

0.50.5 -- 0.9 mmol/l 0.9 mmol/l Test again Test again 0.05 U/kg0.05 U/kg 0.1 U/kg 0.1 U/kg

1.0 - 1.4 mmol/l1.0 - 1.4 mmol/l Eat and take Eat and take 0.1 U/kg0.1 U/kg 0.1 U/kg, x 1-20.1 U/kg, x 1-20.05 U/kg 0.05 U/kg

Samuelsson, Diabetes Tech. 2002Samuelsson, Diabetes Tech. 2002Laffel, poster 426, ADA 2002Laffel, poster 426, ADA 2002

-- Every pump user should be able to test blood ketonesEvery pump user should be able to test blood ketones

-- Also very helpful for younger childrenAlso very helpful for younger children

1.5 - 3 mmol/l1.5 - 3 mmol/l Eat and take Eat and take 0.1 U/kg. x 1-2 0.1 U/kg. x 1-2 0.1 U/kg. x 1-20.1 U/kg. x 1-20.1 U/kg 0.1 U/kg

> 3 mmol/l> 3 mmol/l Eat and take Eat and take 0.1 U/kg, x 1-2 0.1 U/kg, x 1-2 0.1 U/kg, x 1-2 0.1 U/kg, x 1-2 00..1 U/kg 1 U/kg Contact your diabetes team or emergency ward!!Contact your diabetes team or emergency ward!!

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How should How should bloodblood ketone ketones bes be interpreted? interpreted?

Ketones Ketones BGBG < 250mg/dl < 250mg/dl 250-400 mg/dl250-400 mg/dl >400 mg/dl>400 mg/dl

< 0.6 mmol/l< 0.6 mmol/l No change No change 5%5% 10% 10%

0.60.6 -- 0.9 mmol/l 0.9 mmol/l No change No change 5%5% 10% 10%

1.0 - 1.4 mmol/l1.0 - 1.4 mmol/l 0-5%0-5% 10%10% 15% 15%

≥ ≥ 1.5 mmol/l1.5 mmol/l 0-10%0-10% 15-20%15-20% 20% 20%

Laffel LMB. Diab Med 2005;23:278-84.

-- Extra insulin to be given in percentage of total daily insulin doseExtra insulin to be given in percentage of total daily insulin dose

-- Don´t use % of daily dose when in remission phase!Don´t use % of daily dose when in remission phase!

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Sick day rulesSick day rules

-- MonitorMonitor glucose glucose (with adult supervision even in adolescents) (with adult supervision even in adolescents) every 3-4 h. and occasionally every 1-2 h. with results recorded in every 3-4 h. and occasionally every 1-2 h. with results recorded in a log booka log book

-- Test for ketonesTest for ketones every 2-4 h. every 2-4 h.Check blood ketones if positive in urineCheck blood ketones if positive in urine

-- Continue monitoring in the middle of the night (no matter how Continue monitoring in the middle of the night (no matter how tired the child or parent is) tired the child or parent is)

Stu Brink. Diab. Nutr. Metab.

1999;12:122-35

- Increased salty fluid intakeIncreased salty fluid intake to combat dehydration. to combat dehydration. Always drink something containing sugarAlways drink something containing sugar

- Check weight every 8-12 h. to monitor for clinical dehydrationCheck weight every 8-12 h. to monitor for clinical dehydration

- Necessary medical treatment for underlying condition (antibiotics Necessary medical treatment for underlying condition (antibiotics for tonsillitis, otitis, urinary tract infectionfor tonsillitis, otitis, urinary tract infection))

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Sick day rulesSick day rules

-- Antipyretics (acetaminophen) to treat feverAntipyretics (acetaminophen) to treat fever

-- Antiemetics if severe vomiting prevents adequate fluid intake Antiemetics if severe vomiting prevents adequate fluid intake

Stu Brink. Diab. Nutr. Metab. 1999;12:122-35

-- ContinuContinue to givee to give insulin insulin and and administer extra doses for as long as administer extra doses for as long as blood glucose and/or ketones blood glucose and/or ketones are are high high

- Recognize of when insulin dose (rarely) needs to be temporarily Recognize of when insulin dose (rarely) needs to be temporarily decreased due to hypoglycemia (decreased due to hypoglycemia (needs more sugar intakeneeds more sugar intake))

- Contact Contact youryour health team health team or hospitalor hospital if symtoms persist, worsen if symtoms persist, worsen or do not get better. or do not get better.

- All too frequently a physician or nurse advises omission of insulin All too frequently a physician or nurse advises omission of insulin because the child is ill and not eating!!!because the child is ill and not eating!!!

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When do you need to go to the hospital?When do you need to go to the hospital?

-- LargeLarge or repeated vomiting or repeated vomiting

-- Increasing levels of ketones or Increasing levels of ketones or laboured breathing laboured breathing

- Continued high BG level > 270 mg/dl Continued high BG level > 270 mg/dl (15 mmol/l) (15 mmol/l) despite extra insulindespite extra insulin

- Unable to keep BG Unable to keep BG >> 70 mg/dl 70 mg/dl (3.5 mmol/l) (3.5 mmol/l)

Adapted from Silink M. (Ed.) APEG handbook 1996

- The underlying condition is unclearThe underlying condition is unclear

- Severe or unusual abdominal pain Severe or unusual abdominal pain

- The child is confused or his/her general well-being is affectedThe child is confused or his/her general well-being is affected

Hospita l

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When do you need to go to the hospital?When do you need to go to the hospital?

Adapted from Silink M. (Ed.) APEG handbook 1996

- The child is young (< 2 - 3 years) The child is young (< 2 - 3 years) or has another disease besides diabetesor has another disease besides diabetes

- Exhausted patients/relatives, for example Exhausted patients/relatives, for example due to repeated nighttime wakingdue to repeated nighttime waking

- Always call if you are in the least unsure Always call if you are in the least unsure about how to manage the situationabout how to manage the situation

Hospita l

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Diabetes and surgeryDiabetes and surgery

- Schedule surgery first thing in the morningSchedule surgery first thing in the morning

- I.v. insulin best for major surgery with I.v. insulin best for major surgery with general anesthesiageneral anesthesia

- FFor minor surgery with local anesthesiaor minor surgery with local anesthesia,, ttake only basal insulin (ake only basal insulin (LantusLantus or pump) or pump)-

- Emergency surgery:Emergency surgery:I.v. insulin to bring down BG before surgeryI.v. insulin to bring down BG before surgery

- Ketoacidosis can give abdominal pain of the Ketoacidosis can give abdominal pain of the same magnitude as appendicitissame magnitude as appendicitis-

- Parents are the “diabetes experts” when Parents are the “diabetes experts” when their child is at a pediatric surgery ward!their child is at a pediatric surgery ward!

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Insulin resistance in changed by the BG Insulin resistance in changed by the BG levellevel

High level due to infectionHigh level due to infection- - insulin resistance insulin resistance aa

Blo

od g

luco

se le

vel

B

lood

glu

cose

leve

l

Increased dosesIncreased doses- - lower BG lower BG aa

After a couple of days BG will be lowerAfter a couple of days BG will be lower- - doses need to be lowered doses need to be lowered aa

Back to normal insulin Back to normal insulin resistance again resistance again aa

1-2 weeks 1-2 weeks aa

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Insulin requirements increase with feverInsulin requirements increase with fever

Cold with fever Cold with fever aa

Insu

lin r

equi

rem

ents

Insu

lin r

equi

rem

ents

Increased insulin Increased insulin resistance due to feverresistance due to feveraa

Infection curedInfection curedaa

Continued insulin Continued insulin resistance resistance aa

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Insulin requirements decrease when having Insulin requirements decrease when having gastroenteritisgastroenteritis

Gastroenteritis withGastroenteritis withvomiting, diarrhea vomiting, diarrhea aa

Insu

lin r

equi

rem

ents

Insu

lin r

equi

rem

ents

Decreased insulin Decreased insulin resistance due to resistance due to low BG levelslow BG levelsaa

Infection curedInfection curedaa

Continued low Continued low insulin resistance insulin resistance due to low BGdue to low BGaa

00;1800;18 R Hanas, CWD 2006

-- Vomiting or nausea?Vomiting or nausea?

-- Caused by Caused by lack oflack of insulin?!?insulin?!?

Especially true when using an insulin pump!!Especially true when using an insulin pump!!

-- Vomiting caused by pump problems may easily be Vomiting caused by pump problems may easily be

mistaken for illness!!mistaken for illness!!

Beware of vomiting when using a Beware of vomiting when using a pump!pump!

-- When a child with a pump vomits it When a child with a pump vomits it

should should alwaysalways be considered as a pump be considered as a pump problem until the opposite is proven!problem until the opposite is proven!

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Insulin kinetics increseases ketoacidosis riskInsulin kinetics increseases ketoacidosis risk

20 adults with type 1 diabetes 20 adults with type 1 diabetes Short-acting Short-acting 125125I-insulinI-insulinCSII with infusion in the abdomen CSII with infusion in the abdomen

Hildebrandt P, Diabetic Medicine 1988;5:434-40

2.24U/h

1.12U/h 1.12U/h

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How quickly will the ketones riseHow quickly will the ketones rise??

-- 10 adults with pump, crossover with Velosulin and 10 adults with pump, crossover with Velosulin and HumalogHumalog

-- Pump stopped between 7AM and 12 AM. Pump stopped between 7AM and 12 AM.

-- Blood glucose was ~ 5 mmol/l higher with Humalog after 5 hoursBlood glucose was ~ 5 mmol/l higher with Humalog after 5 hours

Guerci B et al. J Clin Endo Met 1999;84:2673-78.

1.4

1.2

1.0

0.8

0.6

0.4

0.2

0

Bet

ahyd

roxy

-bu

tura

te,

mm

ol/l

Humalog

Velosulin

-- All patients with All patients with pumps have blood pumps have blood ketone metersketone meters

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-- Blood glucose will rise Blood glucose will rise quickly when insulin quickly when insulin supply is interrupted supply is interrupted

-- Always check ketones Always check ketones in the urine when you in the urine when you are not feeling well are not feeling well

Increased risk of ketoacidosis with pumpIncreased risk of ketoacidosis with pump

Needle Needle came loose came loose

New needle New needle inserted inserted

Ketones!! Ketones!!

202018181616141412121010

88664422

8 10 12 2 4 6 8 10 12 2 4 6 8 8 10 12 2 4 6 8 10 12 2 4 6 8 AM PM AMAM PM AM Time Time

Blo

od g

luco

se m

mol

/LB

lood

glu

cose

mm

ol/L

x

x

x

x

x

x

x

x

x

xx

x

Example of pump Example of pump problemsproblems::

Time Time 10 AM 1210 AM 12 2 PM2 PM

pHpH 77..2828 77..3131 77..3636KetonesKetones 33..66 33..00 00..22BGBG highhigh 450450 305 mg/dl305 mg/dl

360360324324288288252252216216180180144144108108

72723636

mg/dlmg/dl

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Diabetes equipment to bring on the tripDiabetes equipment to bring on the trip

- Extra insulin pen and/or syringes Extra insulin pen and/or syringes (pre-filled pens are handy for this)(pre-filled pens are handy for this)

- Store in separate Store in separate hand luggagehand luggage

- Thermometer to check the Thermometer to check the temperature of the refrigeratortemperature of the refrigerator

- Test strips + meterTest strips + meter

- Extra meterExtra meter1 mmol/l = 18 mg/dl1 mmol/l = 18 mg/dl

- Finger-pricking device + lancetsFinger-pricking device + lancets

- Test strips for ketones (blood and/or urine)Test strips for ketones (blood and/or urine)

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Diabetes equipment to bring on the tripDiabetes equipment to bring on the trip

- Dextrose/glucose tablets and gelDextrose/glucose tablets and gel

- GlucagonGlucagon

- Clinical thermometerClinical thermometer

- Fever suppressing drugs:Fever suppressing drugs:Paracetamol/acetaminophen Paracetamol/acetaminophen and/or aspirin /salicylic acid (adults only)and/or aspirin /salicylic acid (adults only)

- Oral rehydration solutionOral rehydration solution

- ID indicating that you have diabetes and a necklace/braceletID indicating that you have diabetes and a necklace/bracelet

- Telephone and fax. numbers for your diabetes clinic at homeTelephone and fax. numbers for your diabetes clinic at home

- Insurance documentsInsurance documents

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Always call your home teamAlways call your home team

-- You are never longer away from home You are never longer away from home than a telephone callthan a telephone call

-- Ask for a doctor’s contact before leaving homeAsk for a doctor’s contact before leaving homeCheck Check www.ispad.org for names of doctors for names of doctors

-- Staying at a hospital where you Staying at a hospital where you don’t understand the language is a don’t understand the language is a difficult experiencedifficult experience

-- Try to find a children’s hospital in Try to find a children’s hospital in an emergency situationan emergency situation

-- With glucagon and frequent With glucagon and frequent monitoring you can prevent most monitoring you can prevent most emergencies!emergencies!

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Preventing “The revenge of MontezumaPreventing “The revenge of Montezuma””

- Antibiotics for diarrheaAntibiotics for diarrhea when travelling to Asia, Africa, when travelling to Asia, Africa, Latin/South America or Southern Europe:Latin/South America or Southern Europe:

- LexinorLexinor®® (norfloxacine) (norfloxacine) Not for children younger than 12 years old Not for children younger than 12 years old or pregnant women.or pregnant women.

- Dose:Dose:200 mg twice daily for prophylactic use or 200 mg twice daily for prophylactic use or 400 mg twice daily for 3 days if you are 400 mg twice daily for 3 days if you are having acute diarrhea.having acute diarrhea.

- Co-trimoxazoleCo-trimoxazole®®, Colizole, Colizole®®

(trimethoprim + sulphamethoxazole) (trimethoprim + sulphamethoxazole) or similar for children younger than 12 years old.or similar for children younger than 12 years old.

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

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