Diabetes GP TALK June 2011 - Dr Nick Mann.pdf - Oxfordlearning ...

Prompt diagnosis of
diabetes

Common presenting symptoms
• Thirst
• Polyuria
• Nocturia
• Bed wetting – new
• Weight loss
• Vulvovaginitis – thrush

Less common presenting
features
• Abdominal pain
• Excess appetite
• TATT
• Nausea/vomiting
• Breathlessness – esp. below 3 years
• Ketones on breath
• Drowsiness
• Coma or ketoacidosis

Diagnosis
• Blood sugar over 11.1mmol/l (will need
confirming on venous sample)
• Strongly positive urine ketones
• Blood ketones >3mmol/l

What to do

Is child in ketoacidosis
• Drowsy/confused
• Dehydrated
• Poorly
• Vomiting
• Blood sugar very high
• Urine ketones +++
• Blood ketones >3mmol/l

Plan for DKA
• Urgent hospital transfer by ambulance to
A&E
• Speak to Paediatric Registrar
Don’t
• Give insulin
• Give fluid bolus unless moribund
• Delay

Well child with new diabetes
• Discuss with on call paed Registrar
• Send up to Paediatric Assessment unit
within a few hours
Don’t
• Refer on Choose & Book or refer urgently
to clinic!
• Wait till next day
• Say it might get better

Well child- models of care
• Admit for 48hr
• Start treatment at home
• Teach practical techniques on day ward

Type 2 diabetes
1. Incidence of type 2 diabetes, which is closely
linked to obesity, is rising worldwide.
2. Genetic predisposition in ethnic groups such as
Asians, Afro-Caribbean's, Hispanics and Pima
Indians.
3. Obese individuals predisposed to diabetes
around puberty when there is insulin
resistance.
4. Families more likely to live in a deprived area,
and be cigarette smokers.

Acanthosis Nigricans

Type 2 Diabetes
• Obese ++ usually BMI > 99.6 th
centile
• Insulin resistance
• Few symptoms
• No ketosis
• Respond to oral medication
• 32% β-cell antibody +ve

Outcome of young Type 2 diabetes
• High incidence of microalbuminuria
• High incidence of renal failure
• Retinopathy common
• In young people outlook just as bad as
type 1 in terms of morbidity and mortality
• Refer to Children’s Diabetes clinic

Ketoacidosis

Risk Factors
• Poor compliance
• High HbA1c
• Teenagers
• Alcohol
• Infection
• Missed insulin on MDI or pump

Symptoms of Ketoacidosis
• Vomiting
• Abdominal pain
• Drowsiness/coma
• Kussmaul breathing
• Confusion/exhaustion
• High blood sugar
• Ketones

Definition of ketoacidosis
• Glucose >11mmol/l
• pH

Deaths in DKA
• Failure of diagnosis
• Hypokalaemia- inadequate or no
K+ replacement
• Cerebral oedema- see below
• Aspiration

Confirm the Diagnosis :
History :
polydipsia, polyuria
Clinical :
acidotic respiration
dehydration
drowsiness
abdominal
pain/vomiting
Biochemical :
high blood glucose on
finger-prick test
glucose and ketones in
urine/blood

Does the child need to be on ICU
• YES if :
∀ • severe acidosis
pH

DKA How Common
• 12 new children
per year at RBH
• 30 known
• Total 42 per
year

Treatment of DKA
• Similar to adults
except-
• Avoid fluid boluses
• No insulin boluses
• Avoid rapid falls in
blood sugar
• Correct dehydration
over 24hr
• Monitor Glasgow
coma score hrly
• Avoid anticoagulation
unless in ITU
• No antibiotics
• Avoid NaHCo3
• Halve insulin in
HONK

Management
•Fluid management
•INSULIN :
Once rehydration fluids and
potassium are running,
blood glucose will already
be falling. However, insulin
is essential to switch off
ketogenesis and reverse the
acidosis.
Continuous low-dose
intravenous infusion is the
preferred method
There is no need for an
initial bolus. Make up a
solution of 1 unit per ml. of
human soluble insulin (e.g.
Actrapid or Novorapid)
using a syringe pump.
The solution should then run
at 0.1 unit/kg/hour

Persistent Ketones
• Check IV infusion lines
• Consider giving more insulin
• Consider infection such as
appendicitis or an abscess
• Give 10% rather than 5% glucose
to clear ketones

Fingerprick ketone testing

Final messages
1. Prevention of DKA
better than cure
2. Mortality can be
minimised by careful
treatment
3. Child under 5 years who
is breathless with clear
chest might have
diabetes
4. Teenagers take risks
5. Type 2 diabetes not
benign
4. Parents have a role