1. Paediatric Diabetes Nurses October 2013 Diabetes Update

2. Diabetes

3. Aims and Objectives What is diabetes. To understand the types of diabetes that we deal with. What is hypoglycaemia. How to manage hypoglycaemia in the hospital setting. Hypo scenarios What is hyperglycaemia. Understanding sick day rules. Understanding Diabetic Keto-acidosis (DKA) How to understand the sick day correction dose. Understand how the insulin chart should be completed. Sick day scenarios.

4. What Diabetes is Diabetes is a condition where the amount of glucose in your blood is too high because the body cannot use it properly. This happens because your pancreas does not produce any insulin, or not enough, to help glucose enter your body’s cells.

5. Type 1 Diabetes Type 1 diabetes develops when the insulin- producing cells in the body have been destroyed and the body is unable to produce any insulin.

6. Type 2 Diabetes Type 2 diabetes develops when the body can still make some insulin, but not enough, or when the insulin that is produced does not work properly (known as insulin resistance).

7. Hypo’s Low blood sugar, any reading less than 4 mmol/L (Normal range 4 – 8mmol/L) Needs to be acted on straight away Refined sugar followed by complex carbohydrate. Pump patients only require refined sugar Reasons Too much insulin, not enough food Exercise

9. Signs and Symptoms Shaky Sweating Garbled speech Vacant Each persons symptoms may vary but are the same with each hypo. Always act if the person says they are hypoglycaemic.

10. Hypo’s continued Mild hypo: recognised, treated and a quick recovery Moderate hypo: Person needing assistance to manage the hypo, use Glucogel. This may need to be repeated. Severe hypo: Unconscious, not to put anything in the mouth, call for help Glucagen IM or Dextrose IV.

11. Treatment of Hypo’s 60 – 75mls of Lucozade 3 x glucotabs Tube of glucogel Glucagon IM IV Dextrose Complex carbohydrate

12. Hypo Management Gordon is 13yr old Fractured femur Blood Glucose 2.2 Feeling hungry. Lunch is imminent What should we do?

13. Hypo Management Donald 2 years Admitted with Diarrhoea and vomiting Blood glucose 2.6 mmol/L Uncooperative. What next?

14. Hypo Management Tequila 6 year old On an Insulin pump Blood glucose 3.6 mmol/L Feeling sweaty and has a headache. What should we do.

15. Hypo Management Kiki 3 year old On an insulin pump Admitted following a fit at home. Uncooperative and drowsy BGM 1.2 mmol/L on admission What should we do?

16. Hyperglycaemia and Sick Day Rules

17. Hyperglycaemia This happens when blood glucose levels go too high. Common reasons for hyperglycaemia are: Illness Not enough insulin, or a missed dose Eating too much sugary or starchy food Injecting into lumpy sites Sudden excitement or stress

18. Illness Illness usually causes high blood glucose levels because of the production of ‘stress’ hormones and because the body becomes resistant to insulin. During illness never stop taking insulin (Particularly the levemir / Lantus) and regular adjustment of normal novorapid doses will be needed. Blood sugars and ketone levels will need to be checked more frequently. If it is possible for child to eat, replace solid food with liquids with carbohydrates in them. If high sugars are not corrected with extra Insulin this will lead to the production of ketones.

19. Ketones DO NOT USE URINE KETONE STIX. ONLY USE BLOOD KETONES Ketones are produced when your body gets energy by breaking down fat instead of sugar This will happen for one of 2 reasons If you do not have enough insulin in your blood If there simply isn’t enough sugar available

20. Diabetic Ketoacidosis Diabetic Ketoacidosis (DKA) is a dangerous and potentially life-threatening condition. And is the result of ketone development DKA most commonly happens in people with type 1 diabetes DKA happens when there is persisitantly high glucose in the blood and a lack of insulin.

21. Correction Doses Total of all insulin doses on a normal day (Units) eg add up Levemir and Novorapid doses Sick Day Dose (Units) 1-40.5 5-91 10-142 15-193 20-244 25-295 30-346 35-397 40-448 45-499 50-5410 55-5911 60-6412 65-6913 70-7414 75-7915 80-8416 85-8917 90-9418 95-9919 100 or more20 Sick day rule Correction doses are generally a 20% of Total daily dose of insulin if ketones are present this will be an extra dose of Novorapid on top of normal dose Normal correction without ketones or less than 1 mmol/Lwould be approx 10 % of total daily dose, on top of normal dose.

22. Treatment If a blood sugar is above 14mmol and the child is unwell Check bloods must be checked for ketones. If Ketones are present it is likely that the child does not have enough insulin in their body, so you may need to increase the dose or give an extra dose. This is known as a correction dose Correction doses can be given to reduce a blood sugar even if ketones are negative but at a reduced level. Make sure the child drinks plenty of sugar-free fluids.

27. Diabetes Scenarios Betty is 13yr old Blood ketones 0.8 mmol Blood Glucose 19.2 Total daily dose of insulin (TDD) 68 units

28. Diabetes Scenarios Fred aged 8 ketones 4.1 mmol Blood glucose 22.6 mmol Kussmaul breathing Drowsy vomited x 6 times Tolerating oral fluids not eating. Total daily dose of insulin (TDD) 28

29. Diabetes Scenarios Tallulah is 4yr old Blood ketones 1.0 mmol Blood Glucose 7.6 mmol Total daily dose of insulin (TDD) 13.5 units

30. Diabetes Scenarios Olivia is 11yr old Blood ketones 1.9 mmol Blood glucose 16.8 mmol Eating and drinking cold like symptoms. Has had 2 sick day doses. Total daily dose of insulin (TDD) 37 units

31. Pump Animas Vibe

33. RCHT Protocols Guidelines of sick day rules for children on insulin injections Management of hypoglycaemia for children with diabetes on insulin injections and pumps Management of high blood glucose levels and sick day rules for children on insulin pumps Guideline for Hospital Admission of Patients on Insulin Pumps

34. Conclusion To be confident to follow the hypo guidelines. To be confident on how to use sick day rules. To be able to recognise that an insulin prescription sheet is completed correctly.