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MANAGEMENT OF DIABETIC CHILDREN IN RACH
March 2006
Version 1.3
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THE NEWLY DIAGNOSED PATIENT ................................................................... 4
DIAGNOSIS OF DIABETES..................................................................................................4HANDLING A NEW REFERRAL.........................................................................................4INITIAL MEDICAL MANAGEMENT.................................................................................4INITIAL NURSING MANAGEMENT..................................................................................5INSULIN....................................................................................................................................6
The First Injection........................................................................................................................6Injection Sites................................................................................................................................6Initial Insulin.................................................................................................................................6Insulin Regimes.............................................................................................................................7
DIET...........................................................................................................................................8EDUCATION............................................................................................................................9PREPARING FOR DISCHARGE..........................................................................................9OTHER......................................................................................................................................9NEW DIABETIC FLOW CHART.......................................................................................10
MANAGEMENT OF KNOWN DIABETIC CHILDREN ..................................... 11
INSULIN REGIMES..............................................................................................................11Twice daily injections.................................................................................................................11Three daily injections.................................................................................................................12Basal-Bolus regime.....................................................................................................................12
FOOD.......................................................................................................................................13HYPOGLYCAEMIA.............................................................................................................13EXERCISE..............................................................................................................................15BLOOD SUGAR MONITORING........................................................................................15KETONE TESTING..............................................................................................................16
Blood............................................................................................................................................16Urine............................................................................................................................................17
MANAGEMENT OF INTERCURRENT ILLNESS/ HYPERGLYCAEMIA.................18MANAGEMENT OF DIABETIC KETOACIDOSIS.........................................................19SURGERY...............................................................................................................................21
Minor elective procedures.........................................................................................................21Medium/Major Elective procedures.........................................................................................21Elective procedures- afternoon list...........................................................................................22Emergency surgery.....................................................................................................................22
OUTPATIENT SERVICES...................................................................................................22Medical clinics.............................................................................................................................22Nurse led clinics..........................................................................................................................22Podiatry.......................................................................................................................................23Psychology...................................................................................................................................23
ROUTINE FOLLOW UP......................................................................................................23SCI-DC.....................................................................................................................................23CGMS......................................................................................................................................24INSULIN PUMPS...................................................................................................................24TYPE 2 DIABETES...............................................................................................................24COMPLICATIONS................................................................................................................24
OTHER ....................................................................................................................... 25
OUT OF HOURS ADVICE AND WEEKEND ARRANGEMENTS................................25
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Newly Diagnosed Diabetics........................................................................................................25Out Of Hours..............................................................................................................................25
DIABETES TEAM CONTACT NUMBERS.......................................................................25
REFERENCES ........................................................................................................... 26
GLOSSARY ................................................................................................................ 27
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THE NEWLY DIAGNOSED PATIENT
DIAGNOSIS OF DIABETES
In the majority of children and young people the diagnosis of type 1 diabetes can be made without difficulty. The assessment of a child with possible diabetes is an emergency. The child should be assessed by an experienced middle grade doctor immediately upon arrival.
Presenting symptoms are:
thirst excessive drinking (polydipsia) excessive urination (polyuria) or nocturnal enuresis weight loss lethargy and tiredness abdominal pain
The child should be tested for:
glycosuria ketonuria hyperglycemia
HANDLING A NEW REFERRAL
Admit to Medical Ward directly. Unless arranged by the diabetes team, all newly diagnosed patients are managed as in-patients. The duration of the stay is in most cases 2 to 3 days.
Inform the diabetes team as soon as the referral is taken- do not wait until the child arrives to the hospital- as this allows better planning of the input offered to the family. (DIABETES TEAM CONTACT NUMBERS p.25)
When dealing with newly diagnosed diabetics remember that families, and often children, remember the day of diagnosis (what happened, what was said) forever.
INITIAL MEDICAL MANAGEMENT
Exclude DKA!! This may require blood tests (U&E, Bicarbonate, pH) but there are clinical pointers to the diagnosis:
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WHO definition of diabetes:
Fasting plasma glucose >7.0 mmol/l Random or 2- hours plasma glucose > 11.1 mmol/l
acidotic respiration, dehydration drowsiness abdominal pain/vomiting
Assess hydration and need for IVI If mild dehydration (5% or less) with high blood glucose and ketones consider a correction
dose of rapid acting insulin (MANAGEMENT OF INTERCURRENT ILLNESS/ HYPERGLYCAEMIA) and encourage oral fluids
If the child is well start insulin when next dose would be due Routine bloods: thyroid function, coeliac antibodies, islet cell antibodies (these are non-
urgent investigations and the child/family should have an explanation about the purpose of this tests prior to any blood being taken)
Initial Insulin dose 0.7 U/kg/day (0.5 U/kg/day in small children) Insulin regime depends on the age of the child
Communicating the diagnosis to child and parents: this should be done by a senior doctor or member of diabetes team; there is no need to give a full explanation but it is important to confirm the certainty of the diagnosis
INITIAL NURSING MANAGEMENT
On admission :
Notify Diabetes Team Consultant Paediatrician: Dr Amalia Mayo (Tel. 53822 – Bleep 3308) or Dr Wheldon
Houlsby (Tel. 51727 – Bleep 3807) according to diabetes rota Diabetes Nurses: Isla Fairley / Edna Stewart (Tel. 52743 – Bleep 3731) Dietician: Elsie Carnegie (Tel. 52630 – Bleep 2464)Please leave a message if you cannot speak to a member of the team directly or if out of hours.
Settle patient into ward Record: height, weight and routine observations Test urine and/or blood for ketones (KETONE TESTING p.17) and record on diabetic chart Test blood glucose (BLOOD SUGAR MONITORING p.16) – explain to the child what you
are going to do and why you are doing it Medical staff should tell parents/carers and child that they have diabetes and give an outline
of treatment. Parents often experience a feeling of shock and may not retain information given. It is therefore helpful if a member of the nursing staff can be present to help support the family later when they will ask more questions.
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Definition of DKA:
hyperglycaemia (BG >11 mmol/l) and pH <7.3 or Bicarbonate < 15 mmol/l
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You should not give any information unless you are sure that you are giving the correct information (if in doubt it is better to give less than to cause confusion by giving wrong information).
INSULIN
The prescription of Insulin is the responsibility of the medical staff. Nursing staff should be aware of the different regimes and reasons for administering insulin.As far as possible, parents/carers should be present when insulin is administered, as learning to give injections is one of the main objectives of the new diabetic admission.
The First Injection
As the child and their family might be upset at diagnosis it is best if nursing staff do the first injection. Giving a clear explanation of why it is required and demonstration of how to give the injection.
This should include: Showing the syringe, explaining the markings on it and how to draw up the insulin to avoid
air bubbles, or Use of pen injection devices Injection technique – how to pinch skin
Injection Sites
Initially it is best to use the legs as the child has often lost weight and may not have much subcutaneous tissue elsewhere. However in toddlers it may be appropriate to use buttocks, as it is often easier for a parent/carer to hold the child.
Initial Insulin
Newly diagnosed patients will often have blood glucose readings above 10mmol/l. The body needs time to adjust to the insulin regime therefore blood glucose may run at higher levels initially.
Starting insulin depends on the time of day the child is admitted and whether there are ketones present.
If BG is >12 but ketones are negative or only trace-small, the first dose of insulin given can be at the time dictated by the next due dose on their regime, i.e. admitted 2 pm, BG 14 mmol/l, Ketones trace, then give teatime dose of insulin as first dose.
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If BG >12 and ketones moderate or large, then it is necessary to give a correction dose to bring sugar down and clear ketones. This would be given as 0.1 U/kg of fast acting insulin (Novorapid). The usual regime is then commenced when the next injection would be due.
Note: The duration of action for Novorapid is 2-4 hours. If routine dose of insulin is due in less than 2 hours the combined effect could cause hypoglycaemia.
Insulin Regimes
Initial Insulin Dose Calculation – 0.5-0.7 U/Kg/Day
Children under 5 years should be started on 0.5 U/kg/day
A. Children in primary school (usually aged 11 or under)
Twice daily insulin regime
Novomix® 30 (biphasic insulin aspart)- 2/3 of total daily dose before breakfast Novomix® 30 (biphasic insulin aspart)- 1/3 of total daily dose before evening meal
B. Children in secondary school
The choice of regime depends on the child preference and other factors such as needle phobia but most children will be commenced on a basal-bolus regime. More dietetic input is required for this regime and they should be seen by a dietician on the ward prior to discharge.
Basal–bolus regime
Levemir® (insulin Detemir) or Lantus® (insulin Glargine) - 50% of total daily dose before evening meal
Novorapid® (insulin Aspart) - 50% of total daily dose divided between 3 main meals as below: 30% before breakfast 30% before lunch 40% before evening meal
Three times daily insulin regime
Novomix® 30- 2/3 of total daily dose before breakfast Remaining insulin is further divided into 1/3 and 2/3, i.e.: Novorapid®- 1/9 of total daily dose before evening meal Insulatard®– 2/9 of total daily dose before bed
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DIET
Children and young people with diabetes are often hungry after diagnosis. Encourage a good fluid intake (water or sugar free juice). Don’t restrict food and snacks – the team will adjust insulin according to the child’s intake.
Food in newly diagnosed diabetes-What’s important?
1. Regular mealsThree meals and 3 snacks fairly evenly spread throughout the day. Meals and snacks should always contain a reasonable amount (dependant on age) of starchy carbohydrate. Starchy carbohydrate foods include – bread, plain breakfast cereals, potatoes, pasta, rice, pulses (eg baked beans, lentil soup or broth), milk or fruit.
2. Sugar free drinks (including water)Allow these freely. All diet coke, lemonade, Irn Bru etc are suitable. Ensure all diluting juices are sugar free. Volvic Touch of Fruit and Ribena Light are not suitable.Limit pure fruit juice to one small glass daily with a meal. Milk to drink should not be more than 1 pint daily spread throughout the day (for over 2’s the milk of choice is semi skimmed)
3. Snacks away from the wardParents may wish to take their children to the picnic box or out of the hospital for a short while. Remind them to have sugar free drinks (or milk). Suitable snacks would include a scone, pancake, toast, milk, fruit or crisps. We recommend limiting crisps to once daily.
4. Food when blood sugar is highWhen children are newly diagnosed with diabetes they are often very hungry. Even if their blood sugar is high food should not be restricted, remembering the above advice.
5. PuddingsFamilies are encouraged to use less foods that are high in sugar i.e. sweets, puddings, cakes etc. However, a small amount of sugar included as part of a meal is fine, so children can have an average portion of pudding following their main course or soup and sandwich.
6. Bedtime
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Example: Twelve year old boy weighing 32 kgTotal daily dose of insulin 0.7x32=22.4 U, divided as: Basal-bolus regime
Novorapid 3 U before breakfast and lunch (10x0.30=3), 4 U before evening meal
Glargine 12 U before evening meal (22.4x0.50=11.2)
Three daily insulin Novomix 30- 15 U before breakfast
(22.4x2/3=14.9) Novorapid- 2.5 U before evening meal
(22.4x1/9=2.48) Insulatard- 5 U before bed (22.4x2/9=4.97)
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It is important that the children manage to maintain their blood sugar throughout the night. Depending on the insulin regime it is important for most children that they have a bedtime snack containing a reasonable amount of carbohydrate. This is often a smaller version of their breakfast but could be a sandwich, milk and toast or a scone.
EDUCATION
The Newly Diagnosed Checklists (available from the PDSNs) should be placed with the child kardex/ recordings and completed by the appropriate staff as education progresses. After discharge the checklists should be passed on to the PDSN so that the education process can be completed at home or on follow on visits.The play specialists are available in the Medical Ward to see patients as requested. Their help is particularly useful in children who are worried about staying in hospital or about injections or blood testing. Children can also be referred to the play team for education through play.
PREPARING FOR DISCHARGE
This is an example ‘discharge checklist’. The content will vary according to the patient insulin regime, injection method and blood testing equipment. The PDSN will provide an individual list for every new patient.
From Pharmacy From Diabetes Nurses/Ward Insulin Novomix® 30– vial Insulin Novorapid® – vial Insulin Insulatard® – vial (insulin prescription will vary according to regime)
GlucoGel® (formerly Hypostop) GlucaGen Hypokit® 1mg
Blood Glucose monitor Syringes 0.3ml with 8 mm needle
or Insulin Pen and needles Safe Clip Sharps Bin Ketostix®
Glucose testing strips Control solution Information pack
Following discharge all of the items above will be prescribed by the GP
OTHER
See OUT OF HOURS ADVICE AND WEEKEND ARRANGEMENTS p.25
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NEW DIABETIC FLOW CHART
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Junior Dr notified of new patientInform:
Medical Ward Admissions Diabetes Team
Patient arrives to Medical Ward: Rapid assessment by SpR Clerking by SHO Notify Diabetes Team Initial observations obtained (incl. Blood
glucose, ketones)
DKA Dehydrated with Large Ketones
Well with up to moderate ketones
DKA protocol Correction dose of insulinNovorapid 0.1U/kgEncourage oral fluids
Start routine insulin when next injection would be dueTotal daily dose (tdd):
0.7 U/kg/day 0.5 U/kg/day (under fives)
Age < 11 years (primary school)
Twice daily insulin
Novomix® 30- 2/3 of tdd before breakfast
Novomix® 30- 1/3 of tdd before evening meal
Age >11 years (secondary school)
Basal–bolus regime
Levemir® or Lantus® - 50% of tdd before evening meal
Novorapid® - 50% of tdd divided as:
30% before breakfast 30% before lunch 40% before evening meal
DKA correctedEating and drinking
Deterioration/ DKA
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MANAGEMENT OF KNOWN DIABETIC CHILDREN
INSULIN REGIMES
The insulin regimen should be tailored to the individual child and family lifestyle. The discussions take place between the family and the diabetes team.The most widely used insulin regimens are:
Two daily injections - a mixture of short- and intermediate-acting insulin before both breakfast and the evening meal
Three daily injections - a mixture of short- and intermediate-acting insulin before breakfast, short-acting insulin before the evening meal and intermediate-acting insulin at bedtime
Basal-bolus injections (also termed multiple injection therapy) - short-acting insulin before the main meals and long-acting insulin analogue once or twice daily
Some considerations when changing to an intensive insulin regime are: well-motivated with good diabetes education (or willing to accept input) willing to inject insulin several times a day, including at school willing to measure blood glucose several times a day capable of adjusting the insulin doses for food and physical exercise good family support no needle-phobia.
Poor metabolic control is not per se an indication for intensified insulin treatment regimens and may even lead to poorer HbA1c values in patients who are not motivated to meet the above requirements.
Twice daily injections
Insulin: This regime uses a biphasic insulin such as Novomix® 30 insulin, which is a mixture of 30% fast acting and 70% intermediate acting insulin and is given before breakfast and before evening meal.
Dose adjustment: Insulin adjustments are done by reverse testing looking at trends in blood sugars and NOT on a dose to dose basis nor on the immediate blood sugar result. So if there are persistent HIGH results before the EVENING MEAL then the MORNING insulin is increased. If persistent HIGH results are found before BREAKFAST then it is the BEDTIME insulin that has to be increased. After a change in insulin dose the dose should remain the same for 3 or 4 days before making further adjustments.
An Insulin dose change of 10% is usually required to have an effect on blood sugars. Blood glucose testing: Minimum testing is twice daily before insulin injections. Very young children should be tested before bed (or when the parents go to bed) to ensure blood sugar is at least 8 mmol/l.
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Meals: Children on twice daily pre-mixed insulin should have regular meals and snacks throughout the day and a bed time snack. The meals/snacks and insulin injections should be given at approximately the same time every day.
Three daily injections
Insulin: With this regime 3 different insulins are used: Novomix® 30- biphasic insulin (30% fast acting, 70% intermediate acting) before breakfast. Novorapid® (fast acting) with evening meal. Insulatard® (intermediate acting) before bed.
Dose adjustment: Insulin is adjusted by reverse testing as per twice daily regime, apart from the rapid acting insulin given with the evening meal which can be altered according to food intake and current blood sugar result. Adjustment to insulin at evening meal can also be made to take into account evening activities.
Blood glucose testing: Blood sugar should be tested before every insulin injection.
Meals: As per twice daily regime with some flexibility at the evening meal.
Basal-Bolus regime
Insulin: In this regime children take an injection of long acting insulin analogue Glargine (Lantus®) or Detemir (Levemir®) once a day (in some cases twice daily). This injection is usually given in the evening at the same time as their evening meal insulin but in a different site. The long acting insulin should be given at the same time every day to ensure a steady background insulin supply. Fast acting insulin (Novorapid® or Humalog®) is given with meals (and snacks containing more than 10 g of CHO) based on how much carbohydrate they eat and the current blood sugar result. There is no need to wait before eating once the injection has been given.
Dose adjustment: Before breakfast blood sugar will guide adjustment of the long acting background insulin. It is important to get the background insulin dose right before starting to adjust the bolus doses. Adjusting bolus insulin will depend on the calculated insulin/CHO ratio for the patient. If the correct dose has been given the 2 hour post meal blood sugar will be in the normal range. If the pre meal blood sugar is above 12 mmol/l an increased dose of insulin to include a correction dose can be given.
Blood glucose testing: First thing in the morning and before meals.
Meals: There is no need to stick to a strict meal routine with this insulin regime. Insulin should be given immediately prior to eating. Snacks are not compulsory and should be taken according to natural hunger and predicted activity. Bed time snacks are recommended if blood sugar is less than 8 mmol/l before bed.
CHO/ insulin ratios: Most children with established diabetes will be injecting 1 U of insulin per 10g of CHO eaten. This can vary between children and they should let you know which ratio they are currently using. An insulin injection is required for meals as well as snacks including more than 10 g CHO.
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Dose adjustment for blood sugar result: If the BG is high before a meal extra insulin can be given to correct this. Aim to correct down to 10 mmol/l. Several formulas can be used such as the Insulin Sensitivity Factor where 100 divided by total daily dose equals number of mmol/l of glucose that will be reduced by 1 U of insulin.
FOOD
General principles:
Food should always be available for children with diabetes in the ward Insulin injections are often timed around meals Depending on type of insulin, the injection needs to be given either 20-30 minutes before
food (i.e. Mixtard 30 or Actrapid) or immediately before food (Novomix 30 or Novorapid) Depending on insulin regime (p.7), some children must have regular snacks through the day Food can be used to treat hypoglycaemia
HYPOGLYCAEMIA
There is not an exact ‘number’ definition of hypoglycaemia (low blood glucose or ‘hypo’) but often is considered as a blood glucose levels below 2.5-3 mmol/l. Generally, if blood glucose is less than 4 mmol/L there should be some action instigated, i.e. treat as per ‘hypo’, offer a snack or eat meal without delay.
The symptoms and signs of hypoglycaemia vary between individuals and change with age. They can be classified into:
Autonomic: sweating/clammy, hunger, tremor, pallor, restlessness Neuroglycopenic: weakness, headache, glazed expression, mood changes/lack of
concentration, tiredness/lethargy, visual and speech disturbances, vertigo, confusion, fits and unconsciousness
A child may display some or all of the above symptoms. Some children with hypoglycaemia unawareness might not have any symptoms. If you suspect that a child is ‘hypo’ it is essential that treatment is given as quickly as possible.
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Example: 13 years old girl on Lantus 30 U and Novorapid 1U/ 10g CHO (total daily insulin aprox. 52U). She is going to have for breakfast 60 g CHO (typical for her) and BG is 16 mmol/l.
Insulin required to cover CHO= 60/10= 6 U Insulin required to bring down BG from 16 to 10 mmol/l (i.e. by 6 mmol/l) = 100/52= 1.9mmol
reduction per 1 U insulin, so 6/1.9= 3.1U In total she should have 6+3= 9U insulin before breakfast
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First check blood glucose level if it is over 4mmol/l they are not ‘hypo’ and do not need sugary drinks or food. They maybe hungry, so offer an appropriate snack or meal if meal is due. Giving sugar when they are not hypo causes an unnecessary rise in blood glucose.
Symptomatic hypoglycaemia can be:
Mild (grade 1) - the patient is able to observe and treat the episode him/herself Moderate (grade 2) - the patient can be treated orally, but with help from someone else Severe (grade 3) - the patient is unconscious or having fits and can not be treated orally
The treatment of hypoglycaemia varies with the degree of severity:
Mild: If child is co-operative and aware of episode give 10-20 g of fast acting oral carbohydrate in the form of 3- 6 glucose tablets, 50ml fresh juice or lucozade, two teaspoons jam or honey. The fast acting sugar should raise the blood glucose level within 5 to 10 minutes. Only if there is no improvement after 10 minutes give more sugar. You must then follow it up with slow-acting carbohydrate to make sure the blood glucose level does not fall again. For example: Digestive biscuit and glass of milk, toast or sandwich, cereal, crisps, piece of fruit. Additional complex long-acting carbohydrate is not required for children and young people using continuous subcutaneous insulin infusion (insulin pump).
Moderate: If the child is unco-operative use GlucoGel® (formerly Hypostop gel). This is a fast acting sugary gel, which comes in a tube with easy twist top. The tube content is squirted into the side of the mouth and massaged into cheek. This is also followed with a snack.
Severe: Do not attempt to give anything orally. In hospital and when IV access is available give an intravenous glucose bolus (5ml/kg of 10% glucose solution over 3 minutes), followed by intravenous infusion of 5% glucose solution at 12ml/kg/h. If IV access is not immediately available give glucagon (GlucaGen Hypokit®) by injection (i.m.):
- Children < 8 years or body weight less than 25 kg: 0.5 mg (half of the emergency kit) - Children > 8 years or body weight more than 25 kg: 1 mg (the whole emergency kit)
NB: Glucagon can cause vomiting afterwards.
After severe hypoglycaemia, blood glucose should be measured after 4-5 minutes and frequently during the next hours. The blood glucose values should stay in the range of 10-15 mmol/l and after waking, the child should be offered simple carbohydrates in the form of white bread or similar. If the child is still unconscious half an hour after normalising the blood glucose level, cerebral oedema should be considered and treated accordingly.
After a severe hypoglycaemic episode the cause of the event should be sought and corrected. Hypoglycemia is the result of a mismatch between insulin, food and exercise. Points to be
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considered are:
Altered routine (missed or erratic meals, changes in physical activity, alterations or errors in insulin dosage or absorption)
Younger age (<6 years) Lower HbA1c Total deficiency of endogenous insulin Antecedent hypoglycemic episodes Hypoglycemic unawareness Defective glucagon and catecholamine counter-regulation (longer duration of diabetes) Alcohol ingestion
All patients admitted with hypoglycaemic seizures should be seen by the PDSN prior to discharge (at the weekend leave a message in their maibox ext. 52734). Patients should be discussed with the consultant for consideration of CGMS (CGMS).
EXERCISE
Exercise has a number of effects on blood glucose levels: Increased absorption of insulin from injection site Increased consumption of glucose without the need for extra insulin The glycogen stores in the liver are used up and have to be replenished sometimes hours after
exerciseThese can cause hypoglycaemia immediately and many hours after exercise
Cells can not take up glucose if there is lack of insulin During competitive strenuous sport counteregulatory hormones are released These can cause the blood glucose to go up
Children should not be allowed to exercise if the blood glucose is high (>15 mmol/L) AND there are ketones present as this can precipitate DKA
Prevention of hypoglycaemia during exercise:
For light or brief exercise (up to 30 min) a small intake (10 g) of rapidly absorbed carbohydrate is usually recommended prior to exercise if blood glucose is < 6 mmol/L
For intensive, strenuous or prolonged exercise Careful monitoring of BG levels Reduction of insulin should be considered For every 30 min of heavy exercise 10- 15g of carbohydrate are required (a mixture of
slow and quick acting), for example 100 ml of fruit juice. Extra slowly absorbed complex carbohydrate will be necessary at bedtime. A bedtime
snack containing fat and protein may help to prevent nocturnal hypoglycemia Exercise should take place in the presence of a companion familiar with the recognition
and treatment of hypoglycemia
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BLOOD SUGAR MONITORING
Self-monitoring of blood glucose (SMBG) is an essential tool in the management of childhood and adolescent diabetes:
Helps to monitor immediate and daily levels of control Detects hypoglycemia Assists in the safe management of hyperglycemia Has educational value in assessing BG responses to insulin, food and exercise
Equipment
The following equipment is required: Blood glucose meter Test strips Finger pricking equipment
Equipment maintenance: The meter should be calibrated for every new pack of test strips and also monthly with the control solutions.
Technique
Wash hands Prepare device by loading strip, ensuring that meter has been calibrated Prick finger – using the side, by the nail. Try not to use the pad of the finger as there are more
nerve endings there and it is more painful Place drop of blood on strip Wait for meter to count down and record blood glucose reading on chart.
Timing of SMBG
The number and regularity of SMBG should be individualised depending on acceptance by the young person and the type of insulin regimen. Frequent, accurate SMBG is the only method by which optimal glycaemic control can be achieved by intensified management regimens.
Suggested timing of SMBG would be:
Before insulin injections At different times in the day to assess BG response to insulin, food intake and exercise. In this
way, changes may be made in management to improve BG profiles To confirm hypoglycaemia and to monitor recovery During intercurrent illness to prevent hyperglycaemic crises In association with vigorous sport or exercise
KETONE TESTING
Ketones should be checked whenever the blood sugar is high (>15 mmol/L) or if there is concern regarding the development of ketoacidosis. They can be checked either in blood or urine.
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Blood
Blood ketones are measured by monitoring blood ß-hydroxybutyrate (ß-OHB). Near-patient blood ketone testing is available with the Medisense Optium or Optium Xceed meters.
This is the preferred method of monitoring ketones during an episode of DKA.
Technique: Wash your hands put a B-ketone strip into the meter and put a drop of blood on the end of the strip.
Interpretation of results:
Between 0.1 and 1.0: These are acceptable blood ketone levels. Continue to test blood glucose as usual
Between 1.1 and 3.0: This is too high. A correction dose of insulin should be administered (MANAGEMENT OF INTERCURRENT ILLNESS/ HYPERGLYCAEMIA). Blood glucose and ketones should be rechecked in 1 to 2 hours.
Over 3.0: This is too high and might indicate ketoacidosis. If blood sugar is also high a correction dose of insulin should be given or the DKA protocol initiated as appropriate.
Urine
Ketone Reagent Strips are used to check for the presence of acetoacetate in the urine.
Technique:
Check the strips are not out of date or have been open for more than 6 months Remove the strip from the box and put the lid back on the box Dip the strip into fresh urine, remove strip, shake to remove excess urine At exactly 15 seconds (use a watch with seconds hand) check the strip against the colour key
on the side of the container
Interpretation:
Small to moderate – This level is acceptable. Continue routine monitoring or as indicated.
Moderate to large – This is too high. A correction dose of fast acting insulin should be given and blood sugar and urine ketones rechecked in 1 to 2 hours.
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MANAGEMENT OF INTERCURRENT ILLNESS/ HYPERGLYCAEMIA
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Calculate the insulin correction dose =‘total daily dose’ /6
and give NOW as an extra injection of fast acting insulin (eg Novorapid)
Continue usual insulin doses at usual times. Check blood glucose 2-3 hrly
Blood Glucose <15 mmol/l Ketones: Urine: negative/ trace/ small Blood: <1.0
Blood Glucose >15 mmol/lVomiting or unwell
Check ketones: Blood (B-ketone strip),
or Urine (Ketostix)
Ketones: Urine: negative/ trace/ small Blood: <1.0
Ketones: Urine: moderate/ large Blood: > 1.0
Check BG and ketones after 1 or 2 hours
Blood Glucose >15 mmol/l Ketones: Urine: moderate/ large Blood: > 1.0
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MANAGEMENT OF DIABETIC KETOACIDOSIS
The management of Diabetic Ketoacidosis (DKA) includes not only the acute management but also understanding the reasons why DKA developed in the first instance. The acute management of DKA is everybody’s responsibility and the DKA protocol below should be followed. The underlying cause for the development of DKA is often straight forward and should be elucidated by good history taking. The diabetes team will usually deal with the further management such as psychology referral and increased educational input.The full and most up to date DKA guideline is available at the following link:
www.bsped.org.uk/professional/guidelines/docs/BSPEDDKAApr04.pdf
or
www.nice.org.uk/pdf/Type1diabetes(child)FULLguideline.pdf (see appendix D)
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Algorithm for the Management of Diabetic Ketoacidosis
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Clinical History- polyuria- polydipsia- weight loss- abdominal pain- weakness- vomiting- confusion
Clinical Signs- assess dehydration- deep sighing respiration (Kussmaul)- smell of ketones- lethargy, drowsiness
Biochemical Signs- ketones in urine or blood- elevated blood glucose (>11mmol/l)- acidaemia (pH<7.3)- take blood also for electrolytes, urea- perform other investigations if indicated
Confirm DiagnosisDiabetic Ketoacidosis
Call Senior Staff
ShockReduced peripheral pulse volumeReduced conscious levelComa
Dehydration > 5%Clinically acidoticVomiting
Dehydration < 5%Clinically wellTolerating fluid orally
Resuscitation- Airway + N/G tube- Breathing (100% 02)- Circulation (10ml/kg of 0.9% saline repeated until circulation restored, max 3 doses)
Intravenous therapy- calculate fluid requirements- correct over 48 hours- 0.9% saline- add KCL 20 mmol every 500 ml- insulin (Novorapid) 0.1U/kg/hour by infusion
Therapy- start with s.c insulin- give oral fluids
Observations- hourly blood glucose- neurological status at least hourly- hourly fluid input:output- electrolytes 2 hours after start of IV-therapy,
then 4-hourly
No improvement
No improvement
blood glucose < 15 mmol\L
Neurological deterioration Warning signs :headache, irritability, slowing heart rate, reduced conscious level, specific signs raised intra-cranial pressure
Intravenous therapy- change to 0.45% saline + glucose 5%- continue monitoring as above- consider reducing insulin 0.05/kg/hour, but
only when pH>7.3
exclude hypoglycaemia
is it cerebral oedema ?
Re-evaluate- fluid balance + IV-therapy- if continued acidosis, may require further resuscitation fluid - check insulin dose correct- consider sepsis
Improvement- clinically well, drinking well, tolerating food- urine ketones may still be positive
Insulinstart subcutaneous insulin thenstop intravenous insulin 1 hour later
Management - give mannitol 1.0 g/kg- call senior staff- restrict I.V. fluids by 2/3- move to ITU- CT Scan when stabilised
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SURGERY
The ISPAD consensus guideline makes recommendations regarding children and young people with type 1 diabetes who require surgery or fasting. Children and young people with type 1 diabetes who require surgery:• should be admitted to hospital for general anaesthesia• require insulin, even if they are fasting, to avoid ketoacidosis• should receive glucose infusion when fasting before an anaesthetic to prevent hypoglycaemia (unless having a minor procedure).
The Medical Team is responsible and available for advising on the management of diabetic children.
As a general rule, for children on basal-bolus regimes (Basal-Bolus regime), the basal insulin is given as usual and the bolus insulin is omitted until they start eating again. Children should have IV access to manage possible hypoglycaemia.
Minor elective procedures
The child should always be placed first on the morning list. For grommets or other very short, relatively painless procedures, at the discretion of the Consultant Anaesthetist the child can be fasted, not given morning Insulin and then given normal Insulin plus breakfast on return to the Ward at 9 to 9.30 am. A cannula is not required prior to going to theatre.
Medium/Major Elective procedures
Admit to hospital the afternoon prior to surgery. The usual evening or bedtime insulin(s) and a bedtime snack should be given.
Earlier admission might be necessary if glycaemic control is poor. The child must be first on the morning list and have intravenous access in situ. For procedures where a child may not be eating or drinking later in the day an Insulin
infusion and intravenous fluids should be started. It is often most convenient to arrange this by putting in a heparinised cannula the evening before and writing up an Insulin infusion and maintenance fluids according to the instructions on the paediatric Insulin infusion sheet for the Nurses to start at 7 am.
No solid food from midnight. Clear fluids may be allowed up to 4 hours pre-operatively (this should be checked with the
anaesthetist). Omit usual morning insulin dose. Start intravenous fluid and insulin infusion at 6.00–7.00 a.m. Hourly blood glucose monitoring pre-operatively, then half-hourly during operation and until
woken from anaesthetic. Hourly blood glucose monitoring 4 hours post-operatively Aim to maintain blood glucose between 5 and 12 mmol/l. Continue intravenous infusion until the child or young person tolerates oral fluids and snacks
(this may not be until 24–48 hours after major surgery). The infusion can then be stopped whenever the child is ready to drink and eat.
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Change to usual subcutaneous insulin regimen or short-acting insulin/rapid-acting insulin analogue before the first meal is taken.
This could be at lunchtime on the day of the operation giving half the morning dose of Insulin as Novorapid or at teatime giving the normal teatime dose of Insulin or breakfast time the next morning giving the normal morning dose of Insulin.
Stop insulin infusion 60 minutes after subcutaneous insulin is given.
Elective procedures- afternoon list
Whenever possible the afternoon list should be avoided unless the clinical need is such that the procedure should go ahead. For children on twice or three time a day insulin regimes:
Give one-third of the usual morning insulin dose as short-acting insulin if the operation is after midday.
Allow a light breakfast. Clear fluids may be allowed up to 4 hours preoperatively. Start intravenous fluids at midday at the latest. There is no need for IV insulin infusion for
minor procedures such as a jejunal biopsy. Then as for morning operations (see above). The child should have his usual tea time insulin and meal.
Emergency surgery
• Diabetic ketoacidosis may present as ‘acute abdomen’.• Acute illness may precipitate diabetic ketoacidosis (with severe abdominal pain).• Nil by mouth.• Secure intravenous access.• Check weight, electrolytes, glucose, blood gases and ketones pre-operatively.• If ketoacidosis is present, follow protocol for diabetic ketoacidosis and delay surgery untilcirculating volume and electrolyte deficits are corrected.• If there is no ketoacidosis, start intravenous fluid and insulin infusion as for elective surgery.
OUTPATIENT SERVICES
Medical clinics
RACH Clinic: Friday morning weekly from 9 am Fraserburgh Clinic: all day clinic alternate months Orkney Clinic: twice a year June and December one day only Shetland Clinic: twice a year April and October two days clinic Woolmanhill Young Persons Clinic: Tuesday morning, last of month
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Nurse led clinics
Routine review clinic: Second Thursday of the month 2-4pm – Patients whose diabetes is well controlled and do not require to see a doctor every visit can come to this clinic and have HbA1C, height, weight checks and discuss their progress with the specialist nurse (medical advice will be available should it be required).
Diabetes education clinic: Fourth Thursday of the month 2-4pm - Education clinic for newly diagnosed patients, adolescents pre-transfer to adult service and any other educational issues. Patients/families have a 20minute slot with specialist nurse.
Podiatry
A podiatrist is in attendance at the clinic on the 2nd Friday of the month but occasionally dates may changes so please check before asking a patient to attend a specific clinic.
Psychology
Dr Andrew Keen is available on the last Friday of each month at the Diabetic outpatient clinic. Referral should be made through the PDSNs Isla Fairley and Edna Stewart.
ROUTINE FOLLOW UP
The following checks and discussions should take place at every routine clinic visit:
Height and weight- plot in chart HbA1c Check current insulin therapy Review of blood sugar home monitoring Review of hypoglycaemia Injection sites School issues Family issues (holidays, special dates, new situation) Other problems Has the child had an annual review in the last year?
In addition, at the time of the annual review, the following take place:
BP Urine for microalbumin (over 10 years old) Blood test for thyroid function and coeliac antibodies Check retinal screening in place Check Podiatrist screening done DSN review Dietetic review
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SCI-DC
Details of all children are available in the SCI-DC database which is accessed from the main computers in all wards. A password is required to access the system.
CGMS
Some patients might benefit from a period of Continuous Glucose Monitoring. This is available as an outpatient procedure. CGMS should only be organised after full discussion with the Consultant. A separate protocol is available for this procedure.All patients admitted with hypoglycaemic seizures should be discussed with the consultant for consideration of CGMS.
INSULIN PUMPS
Children using insulin pumps are highly competent in their use and they will guide you on their use and their insulin requirements.Never disconnect a pump for more than 30 min (for showering, etc) as there is no reserve of insulin in the body and the child might become unwell very quickly.Contact a member of the diabetes team if you are unsure about anything.
TYPE 2 DIABETES
Children with type 2 diabetes may be asymptomatic, or may have symptoms of thirst and polyuriaplus ketonuria. There is usually a family history of type 2 diabetes, and there may be evidence ofinsulin resistance (acanthosis nigricans). These children are usually overweight (=85th centile according to the new BMI charts of Cole) or obese (=95th centile on the BMI charts). The differential diagnosis is usually between type 1 diabetes (children may have more weight loss and symptoms) or Maturity Onset Diabetes of the Young (MODY) (white UK children who are usually thin, asymptomatic, and family history of diabetes in 3 generations), or diabetes secondary to another condition (such as Prader Willi , cystic fibrosis). It cannot be stressed enough that a child should be treated as type 1 diabetes and commenced on insulin if there is any doubt about the diagnosis, or the child presents with significant symptoms, or with ketonuria. The diagnosis can always be revised at a later stage, and the child taken off insulin, if appropriate.A separate protocol on the management of children with Type 2 Diabetes is available from the diabetes team.
COMPLICATIONS
For advise on the diagnosis and management of diabetes complications please see the Grampian Guidelines for Management of Diabetes Mellitus, Feb 2004, available in the intranet (http://193.195.78.72/nhsgrampian/files/Guidelines2004).
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OTHER
OUT OF HOURS ADVICE AND WEEKEND ARRANGEMENTS
Newly Diagnosed Diabetics
If a child is admitted on Friday evening/Saturday please contact a member of the diabetic team and if available we might be able to come and see them. Contact numbers are available through the Medical Ward at RACH.Contact: Isla Fairley /Edna Stewart and Elsie Carnegie.
Out Of Hours
Patients are referred to the Medical Ward RACH ext. 50380 for out of hours urgent advise- please record details of the call and advice given and pass on to Diabetes Team. If the staff member answering the call is unable to give suitable advice then the call should be passed on to middle-grade doctor on call for Medical Unit on bleep 2678.For non-urgent enquiries patients and staff are advised to leave a message on voicemail ext. 52734
DIABETES TEAM CONTACT NUMBERS
Name Role bleep phone e-mail addressDr Amalia Mayo
Consultant (RACH)
3308 Xt 53822 Xt 50125 (Sec)
Dr Wheldon Houlsby
Consultant (RACH)
3807 Xt 51727 [email protected]
Dr Willem van Ijperen
Consultant (Elgin)
Lisa Wallis Secretary Xt 50125Fax: 01224 550704
Isla Fairley PDSN 3731 Xt 52734 [email protected] Stewart PDSN 3731 Xt 52734 [email protected] Hill DSN
(Woolmanhill)Xt 55527 [email protected]
Sheena Duffus DSN (Fraserburgh)
01346 585244 [email protected]
Caroline Page DSN (Orkney) 01856 888218mobile 07884114517 page 07623978203
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Kirsty Anderson
Community Paediatric Nurse (Shetland)
01595 743362 [email protected]
Elsie Carnegie Paediatric Dietitian
2464 Xt 52630 [email protected]
Shona Milne Dietitian (Fraserburgh)
Xt 56305 [email protected]
Shelly Watt/ Lynda Sime
Podiatrist Xt 55273 [email protected]
Dr Andrew Keen
Health Psychologist
Xt 52234 [email protected]
Postal address:
Diabetes ServiceDepartment of Medical PaediatricsRoyal Aberdeen Children’s HospitalWestburn Road AberdeenAB25 2ZG
REFERENCES
1. ISPAD and International Diabetes Federation (European Region). Laron Z (ed). Consensus guidelines for the management of insulin-dependent (Type 1) diabetes mellitus (IDDM) in childhood and adolescence. Tel Aviv: Freund Publishing House Ltd, 1995.
2. The Diabetes and Complications Trial Research Group. The effect of intensive treatment of diabetes on the development and progression of long-term complications in insulin-dependent diabetes mellitus. The Diabetes Control and Complications Trial Research Group. New England Journal of Medicine, 1993, 329:977-986.
3. SIGN 55 “Children and Young People” Management of Diabetes. November 2001: ISBN 1899893 82 2
4. NICE. Type 1 Diabetes (Childhood) - Full Guideline,September 2004 www.nice.org.uk/pdf/Type1diabetes(child)FULLguideline.pdf
5. Grampian Guidelines for Management of Diabetes Mellitus, Feb 2004 http://193.195.78.72/nhsgrampian/files/Guidelines2004
6. BSPED Recommended DKA Guidelines, Feb 2004 http://www.bsped.org.uk/professional/guidelines/docs/BSPEDDKAApr04.pdf
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GLOSSARY
BG Blood GlucoseBMI Body Mass Index. Weight (kg) divided by square height (m2)CGMS Continuous Glucose Monitoring SystemCHO CarbohydrateDKA Diabetic KetoacidosisHbA1c A fraction of the total Haemoglobin content of the blood with glucose stuck
to it. This measurement is used to monitor diabetes controlISPAD International Society for Pediatric and Adolescent Diabetes. See
‘References’ for their consensus documentIVI Intravenous InfusionPDSN Paediatric Diabetes Specialist NurseRACH Royal Aberdeen Children’s HospitalSCI-DC Scottish Care Information- Diabetes Collaboration. This diabetes database
is used for clinical management at the children’s servicesSMBG Self Monitoring of Blood Glucose (with a near-patient blood glucose meter)tdd Total daily dose (of insulin)WHO World Health Organisation
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