T1DM and DKA

Glucose not entering → cells starve for energy insulin ↓ Sr Glucose glucagon ↑ Sr Glucose binds to insulin-R on cell membranes of insulin responsme cells eg. muscle cells & adipore hisques islets of langerhans & cells contrally located & cells periphere-lly located →vesicles in cells with G-R fuse with cell membrane 4 can be dravoported in cello geb live b gererate new gluore modecules from other molecules break glycogen into glucose dumbed into the blood TIOM tyne III hypusensitiuty ↓ Chr 6 ( MHC not enough insulin cell mediated immune reoponie herenhas abnormalichs ↓GHLA ORZE T cells → in self tolerance HLADRY early in life attack loss of self tolerance in T cells againt f-cells clue as not everyone with there develop diubets pancrealic but somelimes 40% of & cells loss of self-blevance are dedrayed belive d the symptoms marilet T cells recurit leer immune cells J Symptoms attads on f cello polyvia de palydipsia * polyphagia * guičasvia featers of uncontroller diabeles ↓ beta celb insulin due to being in a catabolic stule Though can't make roulin but cas reopend to insulin OKA lipolysis FA ketone bodies ↓ used by cells for energy cas happer in people who have already been diagnosed ½ have some surt of isulin therapy ↓ eg. in smess body relee ses epinephrine + glucagon ↓ affect the delicate bulance between glucagon+ keto acids iauli large difference in umeasued ions J ↓ high anion ↑a loss in urine gup ↑ 120 loss bussmal boreutling ↑ Jiroulin ↓Nutllet ATPass ↓ ↑blood acidity Jkt inb Jelis ↓ 14t lot out thit in cell ict out cells deep laboras breathing os body mes do coz Prom the blood to blood acidity hypercalcemia excreted Ovehme ever though it in blood remain high laut kt storesd rollen 7 sweet huites breath OKA need for allesnahue Ketones if seve ↓ nausea, vonut, mental status alteration, akado pain + cerebral edena MANAGEMENT Random BSL 7,11.1 mmol/2 fusting BSL > 7.0 mmol/2 hyperglycemia symptoms YES Blood Icetones 70.6 06 tue urine ketones ↓ YES NO VB4 ↓ venous pH <7.3 HCO3- <18 mmol/L μο Manage with subcutaneous insulin insulin given under skin to subcutaneous hissue YES Marages as OKA Fixed dosing MOI-mullide daily? injections S Total daily dose caculation based on weight 1-2× a day 40% ↓ long acting insulin ↓ once daily usually @wight 60% rapid aching J split into 3 doses before each meal How to calculate Top *1-Syrs O.S units/kg/day 5-10 yrs 0.7 units legy Units//cy/day * 10 yrs →07-09 niby nib/kg/day eg. 6 year old weighing 200g 0.7 x 20 = 14 unible unib/day 2 ways to give insulin Flexible Doses customising insulin before each meat 10-15 minutes before meals Insulin Carb rahio C (CR) has many grams of callos need I unit of insulin Monitoriner * check BGL before meals, @2am. whenever Wild feels unwell or coul *check ketone if BUL),15 of sick child Correchion Factor ↓ how much unit of insulin d BGL Frequency * long acting (besal) insulin → IX daily usually everings * rapid insulin = →pre-meals breakfest, lunch, dinne with snacks containing isg of callbs if BGL) 8 mmd/½ ½ talker 2 his affe last insulin during day dose or BGL >15 overnight overnight Management of OKA Timeline of monitoring and management Chservation/Investigation ABC Management Wrigh chill Start ehydration ftude Fudbalance Vital sigu Neurological observ Startinguin nhan Adjusted on Fudbalance Vital signa VIIG and be UECm hour of starting 3 hours Fhid balanc V Shors Neurological obse BCL and betade katones Fluid balanom UEC Fluid banc Vital signe Neuroligical ohn Vital nue the following houty BGL and bettade katones Cons following 1-2 heurly: BGL the following 2-4 heurly Serum raicium, magnesium, phosphate Goals of Treatment: Sections below include 1. Correct dehydration 2. Reverse ketosis, correct acidosis and glucose 3. Monitor for complications of DKA and its treatment. Cerebral oedema, hypo/hyperkalsema, hypoglycaena iderdify and treat any precipitating cause 2 hours electrolytes Adjust flods required bosed on o Adjust flus frequried blond on glucose and electrolytes Child with DKA diagnosis (BGL>11 mmol/L,pH<7.3+/-HCO3 <18 mmol/L & moderate or large ketonuria/ketonaemia) Neonate or on insulin pump? Assessment Seek urgent specialist advice. For child with pump, stop pump. Including signs of dehydration (see Box A) and circulatory or neurological compromise. Additional investigations: U&E, HbA1C. If a new diagnosis - TFT, coeliac screen Moderate to severe pH<7.2+/-HCO3 10 mmol/L 7-10% dehydration Mild pH7.2-7.3 or HCO3-18 mmol/L -5% dehydration Oral fluids Insulin: SC insulin on Paediatric/Endocrine advice Monitor: -Hourly: HR, RR strict fluid balance, and neuro obs -4-hourly: temperature & BP -standard BGL & ketones Clinical & biochemical Improvement? Seek paediatric endocrine/critical care advice if: age 5 years electrolyte abnormalities IV Rehydration Consider fluid bolus Sodium Chloride 0.9% Calculate IV fluid requirements Aim to correct over 48 hours Use 1 L Sodium Chloride 0.9% + 40 mmol Potassium Chloride- unless anuric Ice to suck otherwise nil by mouth Consider NG tube (if gastric paresis) Insulin After 1 hour of IV fluids commence low-dose continuous Insulin infusion at 0.1 units/kg/hr Monitor Continuous: ECG (assess T waves) Hourly: vital signs, BGL, blood ketones, strict fluid balance and neuro obs Life-threatening (including suspected cerebral oedema) Resuscitate using ABCD Oxygen via NRBM Support ventilation (BVM) +/-ETT IV or 10 access IV fluid bolus 10 mL/kg Sodium Chloride 0.9%, repeat to maximum of 20 mL/kg Monitor for signs of cerebral oedema Consider sepsis Management if suspect cerebral oedema (Box B) Raise head of bed to 30° Restrict fluids by one third Consider hyperosmolar agents (Hypertonic saline/Mannitol) Active airway management to avoid hypercarbia (aim for pCO2 35-40 mmHg) Consider CT/MRI once stabilised IV fluid and insulin therapy as per moderate to severe DKA 2-4-hourly: temperature, VBG, FBC formal glucose and USE Responding to treatment? Refer to appropriate inpatient service Refer to Ongoing Management DKA Flowchart Refer to Paediatric Critical Care (onsite or via RSQ) 4: Calculate insulin doses carefully as very serious errors can occur. Never give bolus IV or IM insulin. Miscalculations of added potassium to fluids can be fatal. Outside of critical care, pre-mixed fluid bags are recommended. Box A: Hydration assessment in DKA Volume deficit can be overestimated in DKA which can result in over resuscitation with IV fluids. Specific considerations in DKA include: tachypnoea secondary to acidosis can exacerbate dryness of oral mucosa vasoconstriction from acidosis may contribute to the appearance of cool extremities catabolism due to insulin deficiency may result in weight loss Pedal pulses will be affected once shock is present Seek senior Paediatric/Endocrine advice as per local practice. Box B: Signs and symptoms of cerebral oedema worsening headache inappropriate slowing of heart rate recurrence of vomiting change in neurological status (restlessness, irritability, confusion, increased drowsiness, incontinence) rising BP specific neurological signs- esp CN III, IV & VI palsy decreased oxygen saturation thermal instability Seek urgent Paediatric Endocrine/Critical Care advice (onsite or via Retrieval Services Queensland (RSQ) on 1300 799 127)