Keeping your child with diabetes out of the hospital or emergency roomPre-Webinar Resource Material

Stephen W. Ponder MD, FAAP, CDEEndocrinologist

Baylor Scott & White Healthcare

General considerations

Let’s define type 1 diabetes first

• Type 1 diabetes: aka: insulin-dependent or juvenile diabetes

• Affects children and adults

• “Cured” only by a pancreas transplant

• Not caused by the patient in any way

• Increasing in frequency

7 principles of good diabetes control

1. Get organized, review your data, practice

2. Don’t let “good” be the enemy of “perfect”

3. Set reasonable age appropriate goals

4. Be consistent in what you do5. Resist the urge to over-react6. It’s all about CHOICES7. It should be a TEAM effort!

Are diabetic kids more sickly?

• I don’t see much difference with non-diabetic children in regards to frequency of illness

• Due to more attention to health care needs, I believe diabetic children have less risk of illness

• Why? More frequent contact with health care system, more attention to nutrition and activity

Person with type 1

Vaccines• I do recommend them

for my patients (e.g., flu shots)

• But if you choose not to use vaccines, make sure you know your diabetes sick day rules!

• We won’t debate the pros and cons of vaccination here

In general, when a person with diabetes is ill, they’ll need less insulin

YESNOX

What are “sick days”?

“Sick Day” really includes several situations

• High BG with ketones• Infections (viral/bacterial)

• Medical emergencies• Elective and Emergency

Surgeries/Accidents • Medication side-effects• Any interruption of

insulin therapy

How illness can affect diabetes

• You can’t always steer around it!

• It changes your “norm” or routine

• It’s best to be prepared!

Uh oh!

You’ve got to know when to hold ‘em, know when to fold ‘emKnow when to walk away and know when to run – Kenny Rogers

• Managing diabetes and illness is a series of important decisions

• The person who makes the best decisions usually stays out of the ER or hospital

“Life is not a matter of holding good cards, but of playing a poor hand well.”

R.L. Stevenson (1850-1894)

Managing diabetes and illness is about making and managing CHOICES

“Chance favors the prepared mind” Louis Pasteur

Louis Pasteur

SICK DAYS CAN HAPPEN QUICKLY

Disconnected pump

What are ketones?

What are ketones and why should I care?

• Under non-diabetic conditions…• Carbs (glucose) fuel the human

machine• When glucose energy is scarce,

insulin is also low• Low insulin allows us to convert

more fat into an energy source (ketones)

• Excess ketones come from using fat for energy too rapidly (ketosis)

Ketones are biological….

It takes just 1/10 the amount of insulin to prevent ketones as it does to control BG levels

Question: Eating too many carbs and sugars cause ketones in the blood

Yes

No

X

Common reasons for high BG with/without ketones

• Withholding insulin• “bad” insulin pump site• Insulin pump malfunction • Use of old/damaged

insulin• Some medications• Severe stress• Overeating

High sugars!

What is the most common cause of high ketones in kids?

Skipped/bad insulin!

Unexplained high, explained…

Culprit: unremoved cap

First discovered…

Corrected all by injection

New site

carb

How “rapid” insulin works

• 20 minutes to start lowering BG (from level)– Humalog (lispro)– Novolog (aspart)– Apidra (glulisine)

• BG can drop NO FASTER than 4 mg/dl/min!

• Insulin action peaks in 60-90 minutes

• Ketosis and high BG both slow down insulin effect

High BG

Ketones

insulin

A low insulin level in blood occurs in several ways

“Absolute”• Skipped insulin shot

– Forgotten– Intentional

• Insulin pump malfunction– Programming error– Problem with infusion site

• Use of bad insulin– Heat– Age

“Relative”• Assumes that good “working” insulin is

being taken properly• Illness

– Stress hormones– Dehydration (a stress)

• Medications– Glucocorticoids– Atypical antipsychotics

Absolute RelativeBoth

A low insulin level in blood occurs in several ways

If ketones are made in excess, what happens?

• Ketones (weak acids) uncontrollably build up in the blood/lower pH

• The body desperately tries to get rid of them

• Dehydration speeds up the process

• Uncontrolled vomiting is a serious sign

How does the body get rid of ketones?

1. In the urine2. Breathe them out3. Turns them into

something else

1

2

3

Dehydration

High blood sugar

Acid buildup

DKA

Diabetic Ketoacidosis

• A potentially lethal metabolic disturbance

• 1-2% of cases die • Sometimes misdiagnosed

in new onset cases• DKA is preventable • Expen$ive! (~$13,000)

DKA

Held insulin

Dose error

Old or heat

damaged

insulin?

Pum

p m

alfu

nctio

n

infectionPregnancy?

Stress

med

icatio

ns

“DKA” Roulette

Common DKA culprits

When (and why) should I look for ketones?

• Whenever blood sugar levels are high– 300 mg/dl or higher– 240 or higher? (some)

• During any illness– Surgery– Major infections– Trauma

• Taking steroids?

Do only type 1 diabetics get ketones?

• Any human being (mammal) can develop ketones

• Type 1’s have the greatest risk since they make the least insulin

• But any diabetic can develop ketones under the right conditions

How do I check for ketones?

Urine dipstick Fingerstick methodMeter: $68.08 on Amazon

10 ketone strips: $51.84 on Amazon

50 strips: $10.86 on Amazon

When should I be concerned?

concerned very concerned

When should I be concerned?

Get organized, know the “rules”

Diabetes “Sick day” rules…

1. Monitor blood sugar2. Measure ketones3. Drink plenty of fluids4. Treat nausea5. Take scheduled insulin6. Take extra insulin as needed7. Know when to call for help

What’s in your sick day toolkit?

• First…a good knowledge of the sick day rules!• BG meter/lancets/strips (your choice)

• Ketone measuring equipment (blood or urine)

• Flowsheet/notebook (to track progress)

• Rapid acting insulin/syringes/wipes• Anti-nausea medicine• Fluids and “safe” foods• Glucagon for injection

What’s in your diabetes think-kit?

• Why and how illness affects diabetes

• How insulin works• An appreciation that

improvement takes time and patience

• Judgment , experience and a touch of wisdom

The process of “Sick day care” is an exercise in abstract thinking. Kids can’t do this well without grown up help.

Why?

Because kids are concrete thinkers

Concrete thinkers* can’t…

1. Consider a hypothesis2. Consider multiple

possibilities in a scenario

3. Systematically solve a problem

4. Use combinatorial logic

*Lasts until 15-17 years of age*25% of adults are concrete thinkers.

Check BG often/keep good records

Time BG Ketones Insulin Fluids Other

7:30 AM 598 Large 12 u Humalog 2 oz nausea

8:32 AM 583 Large 12 u Humalog 4 oz nausea

9:45 AM 432 Mod-Large 12 u Humalog 6 oz Less nausea

10:34 AM 367 Moderate 12 u Humalog 6 oz No nausea

12:01 PM 231 Moderate 15 u Humalog Lunch No nausea

2:04 PM 167 Small 0 4 oz No nausea

4:14 PM 134 Trace 0 3 oz No nausea

6:23 PM 145 Negative 15 u Humalog Dinner No nausea

Prevent dehydration

• This is JOB one!• Small amounts are best.

Water is best• Sugar free popsicles or

Jello provide water too• If use diet soda pop,

shake out fizz• Low carb sport drinks

How to dose liquidsBody weight

• Under 40 pounds• 40 to 80 pounds• Over 80 pounds

Amount to drink every 20 minutes• ½ to ¾ cup = 4 to 6 ounces• 1 cup = 8 ounces• 1 to 1 ¼ cup = 8 to 10 ounces

Small sips: YES Big gulps: NO!

You need energy to fight back

• Ketones and/or illness itself will reduce appetite

• Liquid carbohydrates can be traded for solid carbs

• Focus on energy foods (carbs) over a balanced diet in the short term

Liquid versus Solid carbohydrates

• Basic concept: “a carb is a carb is a carb”

• Liquid carbs can be substituted for solid carbs

• Advantages– Provides water – Can be sipped to minimize vomiting

risk

Powdered drink mixes◦ Gatorade◦ Tang◦ Double strength for extra carbs

Regular popsicles Regular Jello Old fashioned peppermint

sticks◦ Source of carbs◦ Less risk of choking

KNOW HOW TO COUNT CARBS!

Other ideas to provide hydration and/or carbs

Manage nausea!

• Why? To maintain oral intake, especially liquids

• Over the counter treatments are a good start (Emetrol has some carbs too)

• Prescription meds may be needed– Suppositories– Oral Rx anti-emetics– Side effects?

Stop the vomiting!• Stomach rest: nothing by

mouth for 30 minutes• Emetrol (or Equate) 1

tablespoon every 15 minutes until vomiting stops

• Works best on empty stomach.• NO fluids for 10 minutes after

EMETROL is given• Consider adding Pepto-Bismol,

1 tablespoon every 10 to 15 minutes WITH the Emetrol. It may help with tummy pain.

If over the counter doesn’t work

• Your doctor may provide prescription anti-nausea medications– Zofran (Ondansetron)

– Phenergan (Promethazine)

– Compazine (Prochlorperazine)

• All have potential side-effects. Discuss with your doctor

• Some are $$$

After some stomach “rest”

• Give small sips by mouth • ½ ounce every 15 minutes

to start• Use liquid exchange lists

to provide carbs and fluids together

• Gradually increase the fluid amount as tolerated

Know how/when to use insulin

• Extra insulin given as rapid-acting– Humalog, Novolog, Apidra

• Calculate dose based on weight in kilograms

• Check BG results hourly– Ketones with every voiding– Blood ketones every hour

• Repeat as needed based on BG and ketones

But if a usual or scheduled dose of rapid acting insulin is supposed to be

given at the time you discover high BG and ketones, then give that dose and recheck BG in 1 hour. Or….give your

usual correction dose per the pump*.

* If the pump is the problem, this will cost you time.

Can I treat high sugars/ketones with pump?

• You can try…but• If pump is the problem

you lose valuable time• It’s always safest to take

insulin by a shot

Calculating an insulin dose for high BG and ketones

• Start with 0.1 units per kilogram weight– Range 0.075 to 0.2 U/kg/dose– Only correct with rapid insulin (Humalog, Novolog). – NEVER hold a scheduled insulin dose (e.g., long acting)

• To get kilograms from pounds– divide weight in pounds by 2.2– Example 1: 30 pounds/ 2.2 = 13.6 kilograms– Example 2: 120 pounds/2.2 = 54.5 kilograms

• Example 1: 0.1 x 13.6 = 1.3 units = 1 unit• Example 2: 0.1 x 54.5 = 5.5 = 5 to 6 units

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

controlled • Unusual sleepiness• Fast breathing• Poor concentration• If the child/person

just isn’t “looking right”

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

Watch this video: https://www.youtube.com/watch?v=4urN3RBFQQs