endocrine and metabolic disorders part 2

diabetes mellitus

chronic disorder of metabolism characterized by a partial or complete deficiency of insulin hormone

• most common metabolic disease in childhood

normal carbohydrate metabolism

insulin builds bridge for sugar in bloodstream from external and internal sources to enter cells so they can create energy

carbohydrate metabolism in type 1 diabetes

no insulin to shut off internal sugar production or manage external sugar sources or build bridge for cells to use sugar for energy

classification of type 1 diabetes

• diagnosed in children and young adults

• previously known as juvenile diabetes

• insulin dependent

• body does not produce insulin (autoimmune destruction of pancreatic beta cells)

• rarely overweight

• rarely has family history

classification of type 2 diabetes

• typically diagnosed in adulthood

• non-insulin dependent

• body fails to produce and properly use insulin

• commonly overwight

• common familial tendency

• treatment is weight maintenance/loss, exercise, insulin, and oral agents

clinical manifestations of type 1 DM

hyperglycemia and acidosis

• weight loss

• polyphagia

• polydipsia

• polyuria

• enuresis

• irritability

• unusual fatigue

• abdominal pain

risk factors of type 2 DM

• overweight

• family history

• inactivity

• low HDL and high triglycerides

• certain ethnic races

  • hispanics

  • african americans

clinical manifestations of type 2 DM

• 3 P’s (polyphagia, polydipsia, polyuria)

• fatigue

• extreme hunger but loss of weight

• blurred vision

• frequent infections

• acanthosis nigrocans

  • leathery skin appearance that feels rough

diabetes medical management

• medical nutrition therapy

• medication administration

  • insulin

  • oral agents

• developmental issues

• glucose/urine monitoring

• hypoglycemia management

• hyperglycemia management

• sick-day management

medical nutrition therapy

• carbs main food sources that increases blood sugar

• fat can increase blood sugar later

• develop CHO goals

  • conventional - consistent CHO intake

  • intensive - insulin to CHO ration (most frequent)

objectives of nutritional management

• appropriate meal and snack planning

  • dietary balance of carbs, fats, and proteins

  • extra food during increased exercise

  • consistent meal times

  • avoid high sugar

• develop appropriate insulin regimen and physical activity program

  • increase insulin with extra food

  • decrease insulin need with strenuous exercise (can be difficult to know, typically just increase food intake)

carbohydrate sources

• breads, grains, cereals, pastries, rice, pasta

• milk, dairy

• fruits

• vegetables

carb-free foods

• meat

• cheese

• sugar-free jello

goal of insulin therapy

provide for physiologic needs

rapid acting insulin

aspart (novolog)/lispro (humalog)

short-acting insulin

regular insulin

intermediate acting insulin

NPH/Lente

long-acting insulin

glargine (Lantus)/detemir (Levemir)

rapid acting onset, peak, and duration

onset - 15 minutes

peak - 1 hours

duration - 3-4 hours

short acting onset, peak, and duration

onset - 30 minutes

peak - 3 hours

duration - 6-8 hours

intermediate acting onset, peak, and duration

onset - 1-2 hours

peak - 6-8 hours

duration - 12-18 hours

long acting onset, peak, and duration

onset - 4-6 hours

peak - 8-20 hours

duration - 24 hours

conventional insulin therapy

BID or TID dosing

intensive insulin therapy

basal/bolus insulin dosing

management tools for intensive therapy

• insulin pens

• blood glucose meters

• sub-q ports (changed every 7-10 days)

• insulin pumps

  • only gives short acting insulin; delivers steady amount and can program boluses but can stop working and are very expensive

blood glucose monitoring

• monitored at least 4 times a day - before meals and at bedtimes

• also should be checked anytime child feels/displays symptoms of hypoglycemia

• check before recess/PE class

urine ketone monitoring

• any time BG >240 mg/dl on two separate occasions

• during illness

• pump therapy - blood glucose levels >240 mg/dl on any occasion

management tools for intensive insulin therapy

• rapid acting insulin

• basal rate

• bolus - match insulin dose to actual CHO intake

• correction factor - correct for blood sugars above desired level

• pump emergency kit

know insulin dosing calculations

examples on canvas

toddler developmental issues with diabetes management

• parents must differentiate misbehavior from hypoglycemia

• encourage child to report funny feelings

• expect food jags

• give choices regarding self blood glucose monitoring, injection site, and food choices

preschool developmental issues with diabetes management

• reassure child who views diabetes tasks as punishment for behavior 

• encourage child to participate in simple diabetes tasks

• teach child to report lows to an adult

• teach child what to eat when low

school age developmental issues with diabetes management

• educate school personnel about diabetes

• encourage age-appropriate independence

• all activities must be supervised

• encourage extracurricular activities and participation in social groups

• 11-12 year olds able to perform an occasional injection

adolescence developmental issues with diabetes management

• more capable of performing self care activities

• know which foods fit into meal plan and how to adjust

• more willing to perform multiple injections

• risk takers - may not be checking

• needs continues parental involvement and support

• glucose will drop when drinking alcohol, make sure they keep snack with them if planning on drinking

sick day management

• give insulin as scheduled

• check blood sugar more frequently

• monitor urine for ketones

complications of blood glucose alterations

• hypoglycemia

• hyperglycemia

• ketosis

• acidosis

• DKA (hyperglycemia + ketosis + acidosis)

hypoglycemia

low blood glucose; treated when less than 60 mg/dl

• develops because body doesn’t have enough glucose to burn energy

• can happen suddenly

causes of hypoglycemia

• too little food

• too much insulin

• vomiting

• exercise

• change in schedule

signs and symptoms of hypoglycemia

• low blood glucose

• hunger

• headache

• confusion

• shakiness

• dizziness

• sweating

treatment of hypolgycemia

• check blood sugar - if less than 60-65 mg/dl, treat

• treat with 15 g of fast acting cho

  • ½ cup of juice or regular soft drink

  • 1 cup of milk (not chocolate)

  • glucose tablets

  • cake icing 

• follow rule of 15’s - 15 grams of cho and recheck blood sugar every 15 minutes until normal

• follow with meal or snack

• once above 60, give protein to keep above 60

severe hypoglycemia

• if unable to swallow, use glucagon emergency kit - dose 1mg

• inject into subq or muscle - once given place patient in recovery position to prevent aspiration

• after awake, must feed

• check glucagon expiration date

hyperglycemia

develops when body has too much glucose in blood

• serious problem if not treated

• major cause of complications in children with diabetes

causes of hyperglycemia

• too much food (carbs)

• too little activity

• too little insulin

• illness/infection

signs and symptoms of hyperglycemia

• high blood glucose

• high levels of glucose in urine

• frequent urination

treatment of hyperglycemia

• check urine ketones

• if ketones are moderate to large, call HCP ASAP

• increase fluids (caffeine free)

• do not increase activity

ketones

acidic substance that are made when body breaks down fat for energy

ketosis

presence of excess ketones in body

• blood ketone concentration between 0.3-7.0 mmol/L

ketoacidosis

• when ketones build up in the blood, they make it more acidic

• severe form of ketosis

• levels of 7.0 mmol/L or higher

• lowers pH to 7.3 or lower

pathophysiology of ketosis

1. cells don’t get glucose for energy bc of lack of insulin

2. body begins to burn fat for energy

3. ketones are produced when fat breaks down

4. ketones accumulate in body

acidosis

when ketones build up in blood, making it more acidic

• acidemia is a pH below 7.35

signs and symptoms of acidosis

• deep, rapid breathing (kussmaul’s respirations)

• confusion or lethargy

• abdominal pain

blood tests to diagnose acidosis

• arterial or venous blood gas

• electrolytes - sodium, potassium, chloride, and bicarb

• anion gap (Na+K) - (Cl+HCO3); high anion gap indicates metabolic acidosis

diabetic ketoacidosis (DKA)

complex metabolic state of hyperglycemia, ketosis, and acidosis

• hyperglycemia (>300 mg/dl)

• evidence of significant ketosis

• acidosis

life threatening and needs immediate treatment

signs and symptoms of DKA

• deep, rapid breathing

• very dry mouth

• lethargy/drowsiness

• fruity breath odor

• nausea and vomiting

• respiratory distress

causes of mortality with DKA

• failure to make diagnosis

• cerebral edema

• hypokalemia/hyperkalemia

• hypoglycemia

• hypovolemia

electrolyte disturbances during DKA

• potassium loss caused by shift of potassium from intracellular to extracellular space in exchange with hydrogen ions that accumulate extracellularly during acidosis

  • potassium then lost in urine because of osmotic diuresis

• high serum osmality also drives water from intracellular to extracellular space causing hyponatremia

DKA therapy

• fluid replacement (PRIORITY)

• electrolyte replacement

• insulin therapy

• careful monitoring

goals for DKA

• correct dehydration

• correct acidosis and reverse ketosis

• restore normal blood glucose levels

• avoid complications of therapy

goal of first hour of treatment of DKA (IVF)

• fluid resuscitation

• confirmation of DKA by lab studies

goals of second and succeeding hours of treatment of DKA (IVF)

• slow correction of hyperglycemia, metabolic acidosis, and ketosis

• start correcting electrolyte imbalances

• continued volume replacement

fluids for mild to moderate dehydration in DKA

0.9% NS 10 ml/kg/hr over initial hour

fluids for hypovolemic shock in DKA

0.9% NS 20 ml/kg/hr bolus infused as fast as possible

after first hour of IVF

replace fluid deficit evenly over 48hr with 0.45-0.9% NS

insulin administration in DKA

begun after initial fluid resuscitation; at beginning of 2nd hour

insulin therapy

• turns off production of ketones

• decreases blood glucose

• check glucose hourly

low dose insulin infusion

• decreases risk of hypoglycemia or hypokalemia

• goal is to decrease blood glucose by 100 mg/dL/hr

things to know for insulin administration in DKA

• do not reduce or discontinue insulin infusion based solely on blood glucose

• insulin infusion should be continues until ph >7.3 and/or HCO3 >15 meq/L and serum ketones have cleared

first step of insulin administration during DKA

IV insulin infusion regular insulin 0.1 units/kg/hr

second step of insulin administration during DKA

continue until acidosis clears (pH >7.30, HCO3 >15 meq/L)

third step to insulin administration during DKA

decrease to 0.05 units/kg/hr until SQ insulin initiated

key points for insulin

• prior to administration, reassess vital signs, BG levels, and neuro status

• insulin is administers as a continuous IV infusion of regular insulin of 0.1 units/kg/hr 

• insulin is high alert med, two nurses should verify insulin order, doe, and volume prior to administration

• IV tubing should be primed with insulin before administration

• do not give insulin as bolus

• dose of 0.1 units/kg/her continues until acidosis resolves

• do not decrease rate or stop insulin administration based solely on glucose values

• once blood glucose reaches 250-300 mg/dl, maintain insulin and begin dextrose infusion to keep BG from dropping too fast

• at time of insulin infusion, make sure any indwelling insulin pump has been disconnected and/or stopped

guidelines for potassium administration

• consult with pharmacist before administering

• make sure they have urinated first

• start replacing potassium after initial fluid resuscitation and concurrent with starting insulin therapy

• monitor closely

• in general, with DKA< there is a significant potassium deficit to replace

• potassium replacement should continue throughout IVF therapy

• max recommended rate of IV K+ replacement is institution specific

dextrose administration

• check glucose hourly until stable

• check electrolytes every 2-4 hours until stable

first step to dextrose administration in DKA

add to IVF when blood glucose reaches 250-300 mg/dl

second step to dextrose administration in DKA

change to 5% dextrose with 0.45 NaCl at rate to complete rehydration in 48 hours

third step to dextrose administration in DKA

check glucose hourly and electrolytes every 2-4 hours until stable

fourth step to dextrose administration in DKA

after resolution of DKA, initiate SQ insulin 0.5-1.0 units/kg/day (or stated otherwise)

bicarbonate therapy

bicarbonate therapy is generally contraindicated in pediatric DKA due to increased risk of cerebral edema

• consult pediatric endocrinologist before initiating bicarbonate

• should only be considered with

  • severe acidemia

  • life threatening hyperkalemia

monitoring DKA

• hourly assessments

  • VS

  • neuro status

  • accurate fluid intake/output

  • point of care testing BG level

  • potassium level

• every 2 hours

  • urine ketones

  • serum bicarbonate

  • labs

    • serum glucose

    • electrolytes

    • BUN

    • calcium

    • magnesium

    • phosphorus

    • hematocrit

    • blood gases

• continuous cardiac monitoring

• amount of administered insulin

• administer oxygen

• insert additional peripheral IV catheter

  • repetitive blood sampling

  • if insulin drip is initiated

high risk patients that have DKA

• ICU admission for closer monitoring if:

  • severe DKA (<7.1 or <7.2 in young child)

  • altered level of consciousness

  • under age of 5 years

  • increased risk for cerebral edema

• be prepared for intubation

• caution with meds that may alter mental status

when DKA has resolved

• discontinue IVF after patient tolerates oral fluids

• give SQ insulin; discontinue IV insulin

  • at the time of SQ rapid acting insulin or after 30 mins after SQ regular insulin

transition off of IV insulin

• pH >7.30 and HCO3 > 15-18

• anion gap typically less than 12

• patient able to eat

• SQ insulin

  • give SQ injection, D/C IV insulin and IV dextrose, feed child

• known diabetes

• previous dosing

• may need additional rapid actnig insulin to overcome insulin resistance after DKA

• new patient 0.7-1 units/kg/day is general guideline