Keeping your child (or you) with diabetes out of the hospital

Webinar August 19, 2014Stephen W. Ponder MD, FAAP, CDE

Baylor Scott & White Healthcare7:30-9:00PM Central Standard Time

Housekeeping notes… This Webinar IS being recorded for future playback. I hope you reviewed the Prewebinar background materials I

posted to Slideshare and You Tube. This slide deck will be posted to Slideshare too Links to all resources will be put on my Facebook page:

“The Power Within by Stephen Ponder MD, FAAP CDE” Submit your questions during the webinar and the moderator

will collect them for our Q&A at the end. This Webinar will end promptly at 9PM CST The next Webinar is scheduled for Tuesday October 28th 2014

from 6:30-7:30PM CST: Topic “Travelling with Diabetes” by Dr. Matthew Stephen.

This area of the patient/parent brain needs some help

DEALING WITH ANNOYING THINGS OTHERS SAY CENTRE

INSULIN AND CARB

CALCULATOR

6 things you should remember…

1) How type 1 diabetes works2) Importance of water3) Dual role of insulin (on/off role)4) Most carbs become sugar5) Exercise is a form of stress6) Our brains run on sugar

Your “toolkit”…A method to check BGA method to check ketones (urine or blood)Access to liquids (carb and non-carb)Carbs (fast and slow acting)Glucagon for injectionInsulin and a way to deliver it reliably Anti-nausea medicine?Your wits (and maybe a phone)

“The process”

1) Get the necessary facts 2) Identify immediate needs3) Prioritize your actions4) Do your actions5) Repeat the cycle as needed6) Don’t stop until job is done

Common problems in type 1 diabetes

Missed insulin dose(s) Insulin dose reversalsSurreptitious insulin dosesOutdated/damaged insulinChanges in routine/preparedness Insulin pump/site/tubing problemsMedication side effects Stress and infections

Communication/observation is everything

Low blood sugar– Sweatiness– Shakiness/tremor– Loss of energy/interest– Sleepiness– Confusion– Irritability/Moodiness– Headache– Upset stomach

High blood sugar• Thirsty• Peeing more often• Headache• Itchy skin• Cramping muscles• Stomach ache• Nausea/vomiting• Irritable/moodiness• Deep breathing • StuporH

igh

keto

nes H

igh ketones

FAQ/Comment: I get told to go to the emergency room whenever my diabetic child is sick. But they often don’t seem to know as much as I do!

Prepare for the ER/hospital

Role of the ER Many health professionals

are uncomfortable/unaware of the practical side of most diabetes technologies.

This causes tension/stress Still, most parents are

directed to go to the local ER for all urgent problems, no matter how minor.

Prepare yourself for the ER/Hosp

Many ER docs will want to remove an insulin pump (this can solve as well as cause problems)

IV’s in the ER are almost standard these days Just a little IV sugar water can drive up BG Most ER docs will not know what a CGM is Bring additional supplies with you to hospital Be understanding, they are only trying to help But in ER, protocols often overtake thinking! Withheld insulin doses in ER can happen!

Expect your calls for emergent problems to be returned in a timely fashion…not 5 hours!

If the problem is advanced (e.g., severe dehydration, uncontrolled

vomiting), you MUST go to ER, or call EMS.

But…the best management is PREVENTION by knowing the sick day rules.

However…

Take your diabetes supplies with you to ER when possible

Ask and expect clear explanations

Try to be calm and collected. HCP’s ultimately want to help.

You know your child/yourself best. Work with the HCP as a team. You are the team leader!

How to approach an ER visit

Problems to solve…

Sound vaguely familiar?My 14 year old teen with type 1 diabetes is feeling ill. The teen says the blood sugars are “alright”. My teen

has now thrown up twice. What should I do next?

a. Measure her ketonesb. Change the infusion sitec. Check for air bubbles in the tubingd. Give her some Emetrole. Check her blood sugar

After awakening, your child with diabetes on an insulin pump says she is sick to her stomach, but hasn’t thrown up. You just changed the infusion site last evening. What do you do NEXT?

a. Measure her ketonesb. Change the infusion sitec. Check for air bubbles in the tubingd. Give her some Emetrole. Re-check her blood sugar

Blood sugar is 453 mg/dl (25.1 mmol). What do you do next?

a. Give insulin correction dose through pumpb. Change the pump infusion sitec. Check for air bubbles in the tubingd. Give a shot of rapid-acting insuline. Give her anti-nausea medication

Ketones are large by urine dipstick. What do you do NEXT?

One method is to give the “correction” dose assigned to you by your doc/team

Another method is to dose rapid-insulin based on body weight. (e.g., lispro, aspart, glulisine)

0.1 Units/rapid insulin per kilogram weight◦ Weight in lbs divided by 2.2 = weight in kilograms◦ Give one tenth of that amount as rapid insulin◦ Example: 60 pound child: 60/2.2 = 27 kg

27 x 0.1 = 2.7 units or…3 units

Dosing rapid-acting insulin

a. Give her an anti-nausea suppositoryb. Offer a trial of a bland solid food (e.g., toast)

c. Take her to the emergency room nowd. Recheck blood sugar and ketonese. Give her another shot of rapid insulin

You give a correction dose of rapid-acting insulin by injection and decide to change out the infusion site and load fresh insulin. She is sipping water ok. One hour after the shot she hasn’t vomited but still feels queasy. What do you do NOW?

a. Repeat shot with same amount of rapid acting insulin as the previous dose

b. Give anti-nausea medicine/suppositoryc. Offer a trial of a bland solid food (e.g., toast)

d. Take her to the emergency room nowe. Use smart pump to calculate/deliver a

correction dose for 320 mg/dl (17.7 mmol)

Blood sugar is 320 mg/dl (17.7 mmol) and ketones are large. What do you do NEXT?

a. Administer another rapid insulin shotb. Deliver a correction insulin dose with pumpc. Offer a trial of a bland solid food (e.g., toast)

d. Stop sips of watere. Go to emergency room since ketones are

still large

You repeat another dose of rapid-acting insulin by injection with the same amount. She continues to sip water while resting at home. She says she feels like eating. In another hour, her BG is 210 mg/dl (11.7 mmol) and ketones are still large. What do you do NEXT?

a. Deliver a correction insulin dose with pumpb. Continue bland foods, sips of water and

give bolus insulin for carbsc. Go to emergency room since ketones are

still presentd. Keep checking BG but stop checking

ketones

She eats a slice of toast and continues to sip water every 15-20 minutes . In another hour, her BG is 163 mg/dl (9 mmol) and ketones are moderate to large. Her tummy feels better. What do you do NEXT?

a. It’s alright to go back to normal diabetes care routine now and stop checking ketones

b. Encourage fluids and check BG and ketones every 2-4 hours until ketones are all gone

c. Increase the pump basal rate by 25% for 12 hours to eliminate ketones

Bland foods and sips of water are continued. Bolus insulin is given for carbs eaten. You decide to check BG and ketones every couple of hours. At the next check, BG is 131 mg/dl (7.3 mmol) and ketones are moderate. Her appetite is now normal. What do you do NEXT?

a. 3 year old boy has vomited 6 times this morning and won’t eat or drink, BG 412 (23 mmol) ketones, blood ketones high

b. 12 year old girl has sharp lower belly pain and vomiting x 3, BG 220 mg/dl (12.2 mmol) , ketones trace

c. 10 year old boy with nausea and one episode of vomiting , BG 557 mg/dl (31 mmol), large urine ketones

d. 14 year old girl who is hard to arouse. BG is not readable on meter. Can’t get urine sample for ketones

Which of the following high BG and ketone situations might be managed at home? All cases have type 1 diabetes

High blood sugars may/may not be associated with ketones

The presence of high sugar and high ketones MEANS INSULIN IS NEEDED IMMEDIATELY

Frequent sugar and ketone re-checks are key to successful treatment

Staying well hydrated and managing nausea is ongoing

If vomiting can’t be stopped, you must go straight to the hospital/ER/EMS

Blood sugars improve well before ketones disappear

What have we learned so far

Working on “why this happened” usually occurs as you are treating the situation

Never treat high sugars and ketones with an insulin pump at first.

High sugar and ketones on a pump is a pump problem until proven otherwise

What else we have learned

Ketones are not bad

• A normal part of human biochemistry• Always present in low amounts• Used as a source of brain energy• Non-d people would be frequently

hypoglycemic without ketones. Normal life would be quite difficult.

Unlike those scary movies...just finish off the bad guy!

Ketone man

PWD or parent

If I or my child forget to take a meal time insulin dose through a pump or shot, this will cause ketones to occur in the blood.

FALSE: At most, high blood sugar will happen. If the basal insulin through the pump (or shot) is working, this is enough insulin to prevent ketone production, not enough to control the sugar rise.

True or False

SituationA toddler with diabetes normally gets 5 units NPH in the morning and 1 unit NPH in the afternoon plus a dose of 2 U Lantus in the evening. Father accidently gives a 5 unit dose of NPH at 3PM. What should be done? ANSWER: 1. Check sugars more often until AM

2. Give a larger meal for dinner 3. Give usual Lantus dose at bedtime

SituationI got a call from my ex-husband in California. Our 14 year old daughter with type 1 diabetes spends two weeks with him every summer. This morning he called to tell me she was up all night vomiting. He said she told him her blood sugars were ok. Is she coming down with the flu?ANSWER: 1. Check BG and ketones directly

2. Get ready to go to ER ASAP

SituationI just got a call from EMS about my daughter with type 1 diabetes. Bystanders at the mall said she was acting strange and screaming obscenities at other people. She kicked a clerk and someone called 911. What’s the reason?ANSWER: 1. Low BG

2. Substances3. Both?

SituationEMS treated her with IV sugar twice. Her sugar quickly came up to 275 mg/dl (15.3 mmol) in two minutes, but she was still acting irrational. Why?ANSWER: 1. Lag before sugar gets into brain

2. Substances?3. Both?

SituationYour child with diabetes also has moderate to severe asthma. Her doctor just prescribed prednisone pills by mouth to help with a flare up, in addition to his other medicines. What do you need to be prepared for?ANSWER: 1. higher sugars 2. maybe ketones

SituationAt midnight my d-daughter had a severe low blood sugar. We heard her moaning in her room. Her sugar was 32mg/dl (1.8 mmol) and she was incoherent. We injected her with 1 mg glucagon and called EMS. By the time they arrived she was awake but nauseous. She went to bed early after dinner she and her dad got into an argument over a new boyfriend. She wears an insulin pump. What can I do next?ANSWER: 1. check the insulin pump history

2. review BG’s to see if changes are needed

Oh no. Not Mystery Boluses!

But what about low BG and nausea?

Situation

Your 3 year old with diabetes is very fussy and has a blood sugar of 58 mg/dl (3.2 mmol). He refuses to eat or drink anything you offer him. Should you take him to the ER or call EMS? What else can you do?ANSWER: 1. Mini-dose glucagon

Mini-dose glucagon • For treating non-severe low blood sugar with

nausea, usually in younger children.• Requires careful attention by parent/caregiver

Recipe – Mini-dose glucagon

• Prepare Glucagon as you normally would for a severe low BG– 100 units diluent into 1 mg powder

• Give by subq injection:– 1 unit for every year of age between 3 and 15– No less than 3 units– No more than 15 units

• Check BG in 30 minutes– Repeat if still under 100 mg/dl

Situation

It’s 3:00AM and you go to check your d-child’s blood sugar. She wears an insulin pump. The sugar is 427 mg/dl (23.7 mmol). What do you do next? ANSWER: check ketones

• Dislodged site• Improperly inserted site• Infected site• Air (bubbles) in tubing• Heat damaged insulin• Programming error(s)• A skipped food bolus is

NOT a reason but certainly enables the situation

Insulin pump debacles

Straight versus angled infusion sets

Air in infusion tubing

Air in luer lock hub

120 U of air

Defective tubing connections

Subcutaneous layerMuscle tissue

Dermal layer

“Tunneling” A problem with Teflon infusion sets

Back-leakage occurs due to a slightly dislodged catheter

High BG is the only sign Tennis players, golfers and

other vigorous activities Solution: Make a tape

“sandwich”, use metal sets

Tunneling

What have we learned

Insulin pumps are complex devices and can malfunction or be misused in different ways

Never trust a pump to treat high sugars and ketones. Go with shots and/or new insulin

When in doubt…change it outUncontrolled vomiting = go to hospital ASAP

Situation

My 12 year old son with diabetes just threw up unexpectedly after lunch and says his stomach hurts. What should I do next? He is very responsible and takes his own shots.ANSWER: have a grown up re-check his BG and ketones anyway

Situation

It’s an hour after lunch on the weekend. Your teen son ate three large slices of pepperoni pizza and took 15 units of Novolog (the most the pump would allow). He was next door playing basketball for 30 minutes with his friends. Now, he’s feeling sleepy and has laid down on the sofa. Why?

Sleepy after pizza? Why?

a. Pizza makes us drowsyb. Spiking sugar levelsc. Ketones from the fatd. Insulin-food mismatche. Pump malfunction

Situation

Your daughter with type 1 diabetes plays 3rd base on her high school softball team. Her team has played games all day long and advanced to the state finals. Her blood sugar at the end of the last game today was 210 mg/dl (11.7 mmol). What considerations should you have? She takes Lantus and Novolog shots.ANSWER: Post exercise hypoglycemia

Post-Exercise Hypoglycemia

• Lows that happen well after exercise

• Happens in up to one third of PWD’s

• Lowering sugar independent of insulin

• Treatment– Increase snacks– Reduce basal overnight– Check BG at 3AM

Liver

Situation

Your 10 year old son is scheduled to have a plantar wart removed by the podiatrist. He wears an insulin pump. How should his diabetes be managed during the procedure?ANSWER: No differently than anyone else

SituationMy 16 year old daughter with type 1 diabetes (diagnosed 3 years ago) developed a skin infection on her foot from an insect bite and is now on several antibiotic pills prescribed by her doctor. Does she need to do anything different for her diabetes? Could this cause her to lose her leg? ANSWER: 1. Check BG more often

2. Her leg should be fine in time

FAQ: Why can BG go so high sometimes? For example: 1,600 mg/dl (88.9 mmol) or higher?

First, it’s not a category in the Guinness Book of World Records!

Blood sugar is measured relative to the amount of water in the blood (the “dl”)

Higher the BG, the more dehydrated you are.

It’s why hydration (water) is an important first step in care

Hourly at first. You want to know what direction BG is headed. If using sensor: every 20-30 minutes check trend line

Check ketones hourly if you can (urine or blood)

Check things less often as you get comfortable that trends are improving

BUT never let up until normalcy reestablished

FAQ: How often should I check BG during acute illness?

FAQ: Can I treat high sugars and ketones with my insulin pump?

• Maybe after improvement on shots. But if the problem is the pump, insulin, tubing or site, treating with the pump would only slow down recovery or worsen the situation

• The safest approach is use insulin by injection until normal. If there is any question about whether the insulin is bad, open a new bottle.

Unexplained high, explained…

Culprit: unremoved cap

First discovered…

Corrected all by injection

New site

carb

FAQ: Can I rely on my CGM sensor during DKA?

YES, MOSTLY

Potpourri

Why is insulin usually LESS effective when sugars are high and ketones present

1) Temporary insulin resistance

2) “Glucose toxicity”3) Higher levels of anti-

insulin substances in body

4) Dehydration makes insulin harder to absorb

Tip: Ketones clear slower than the BG can come down

Ketones• Are lost in urine• Are lost through lungs• Are converted to other things in the

liver

Sugar• Is lost in urine for a while• Is driven back into muscle, fat and liver• Is burned up for energy• Is produced less internally when insulin

is around

Tip: It takes less insulin to arrest ketone production than it takes to control BG

About one-tenth as much!

Tip: Totally normalize sugars and eliminate ketones before resting

Stop and remove ketones with EXTREME PREJUDICE

Tip: As you treat an extreme high or low sugar, at some point try to figure out what

might have caused the situation

But don’t take valuable time away from treating the

immediate problem!

Tips: The little things overlooked

• Not discarding opened insulin after 1 mo of use

• Avoiding prolonged exposure of insulin to hi heat or freezing temps

• Dosing insulin then forgetting to eat on time

Troubleshooting tips

• Making too many changes on a pump at once

• Not double checking a high BG before correcting (false high)

• Not cleaning hands before checking BG

Troubleshooting tips• Blaming everything on

diabetes• Ignoring pump and sensor

alarms• Over-treating low blood

sugars• Not filling a pump cannula

after insertion• Priming insulin pump

tubing while wearing it

Troubleshooting tips

• Not having an off insulin pump regimen or back up plan

• Not using insulin pump temporary infusion rates for illnesses

• Not having a source of fast carbs within reach

Troubleshooting tips

• Not checking ketones for high BG levels

• Not finishing the bolus cycle of some pumps

• Not checking pumps for air bubbles

• Not checking BG after a site change to make sure it’s working The “forgetting curve”

Common diabetes errors

• Skipped/omitted shot(s)• Inconsistent BG checks without

attention to what the number is saying (over 300 mg/dl or 16.7 mmol)

• Assuming immunity to ketosis • Intentional insulin skips for weight

loss/body image• Lacking emotional maturity for self

care: too young

How often can I take extra rapid-acting insulin?

• If by a protocol, by what the doctor recommends

• At a minimum, check BG/K every 2 hours and act

• Some docs (me) will advise hourly injections with hourly BG/ketone checks and call backs

(0.1 Units/kg body weight*)

* Weight in pounds divided by 2.2 = weight in kilograms

Deciding to treat at home

• No major symptoms and alert/awake: STAY

• Perhaps only nausea: STAY• Vomited once or twice and

able to keep trying: DEPENDS• Appearing ill and vomited 3

times or more times: GO!!• Not sure what to do: GO or

CALL MD

When to call for back up/go to ER• If vomiting can’t be

controlled • Can’t stay awake• Fast deep breathing• Twitching/seizing• If the child/person

just isn’t “looking right” to you

Help, Doc!

Summary: Diabetes “Sick day” rules…

1. Check blood sugar often2. Measure ketones until gone3. Drink plenty of fluids4. Treat nausea5. Take scheduled insulin6. Take extra insulin as needed7. Know when to call for help

Finally…Give yourself credit for what you do WELL!!

I hope you learned something!

Thank you!

Questions and Answers