DKA
A 14 year old patient with PMHx T1DM rolls in Acute after being found lethargic at home. On your initial examination, she is doing deep labored breathing called this.
What is Kussumaul breathing?
Name the four categories of insulin commonly used?
Bonus points if you can name the types!
What are rapid acting, regular acting, intermediate acting and long acting?
Rapid acting: Lispro (*), Aspart, Glulisine
Regular acting: Insulin
Intermediate: NPH
Long acting: Glargine (*), Determir
These are three antibodies you screen for when working up a patient presenting with concern for new onset T1DM?
What are anti-GAD 65, anti-IA-2, anti-insulin?
Other initial work up labs include:
A1C, Anti-TTG IgA, IgA Insulin, C-peptide,
TSH, free T4, anti-TPO
These are the two types of T1DM.
What are autoimmune (Type 1A) and idiopathic (Type 1B)?
Type 1B: strong hereditary component, no autoimmunity.
Your patient in clinic states that she wants to get her HA1C under better control, but she is unsure of the goal value in pediatric patients. You share that this number is the goal.
What is <7.5%?
You can be more liberal or more strict depending on the circumstance. For example, more liberal if patient has struggled with hypoglycemia.
In the Pedi ED, your patient's labs reveal BG 560, pH of 7.2, gap of 22. You decide to start them on this and titrate it to blood glucose ranges?
What is the two bag system?
Bag 1: LR + KAcetate +KPhosphate
Bag 2: D10 LR + KAcetate + KPhosphate
True or False: patients can use their insulin pump while admitted to the hospital?
True but only if older than 16 and parents have signed a waiver.
The HA1C, which is an indicator of glycemic control, gives you an estimate of glucose control over what period of time?
What is three months?
As you are signing out to the upstairs team, they ask about your patient's hypokalemia to 2.9. Hypokalemia occurs in DKA due which interventions?
What is insulin pushing potassium into the cells, fluids resuscitation, as well as depleted stores?
What additional speciality should patients with T1DM see on a yearly basis?
What is ophthalmology for yearly eye examination?
Screening for retinopathy, usually starts either after 3-5 years of T1DM or onset of puberty (whichever starts first)
You are in the Pedi ED evaluating someone in DKA. She has been vomiting at home and has decreased urine output. You want to give her a bolus but are worried about this complication.
Bonus: how big of a bolus do you give this patient?
What is cerebral edema?
10 cc/kg or 500 cc bolus depending on the size of the patient.
Mechanism of cerebral edema is controversial, though thought to hinge on hypoperfusion injury as opposed to osmotic shifts.
You are helping your patient learn how to navigate insulin around her meals. Her pre-meal POCT blood sugar is 225 with a goal of 120, her carb ratio is 1:15 and correction factor of 1:40. Her burger for dinner has 30 g of carbs.
You recommend giving her this amount of insulin.
What is 4.5 units?
2U to cover her hamburger (30/15)
(225-120)/40 = 2.625 --> round down to the nearest 0.5 to give you 2.5 U
2+2.5 = 4.5
This "Sucker" singer was diagnosed with T1DM in 2007.
Who is Nick Jonas?
Other famous celebrities with T1DM include Mary Tyler Moore, Jay Cutler, Bret Michaels and Justice Sonia Sotomayor!
T1DM manifests due to destruction of which cells in the pancreas?
What the insulin-producing beta cells?
Name three annual screening labs for patients with T1DM in addition to blood glucose monitoring at HA1C?
What are lipid panel, TFTs, celiac screening, urine albumin:creatinine ratio?
- Lipid panel after age 10, even if diagnosed earlier.
- TFTs and Celiac screening in particular due to increased risk of autoimmune conditions.
- Screening for nephropathy
You are on overnight when you get a page that your patient's BG at 2 am is 33. Your patient is shaking and feeling dizzy. She is feeling nauseous and does not want to take any PO. You decide to give her a bolus of D10 at this amount (units are important!)
What is 5 cc/kg? ("Rule of 50")
D10 x 5 cc/kg = 50
D25 x 2 cc/kg = 50
Always aim to try and give PO first if patient is able to tolerate.
You have a patient overnight who becomes sweaty and dizzy, her nurse checks her POCT BG which is 44. You start by giving her this and rechecking her BG in this time frame?
What is 15 g of carbs, recheck in 15 minutes? ("Rule of 15"
The guidelines instruct that if a low blood glucose value is obtained, treat with 15 g of quick-acting carbohydrate, that is 4 oz. (1/2 cup) of fruit juice, regular soda or 3 to 4 glucose tablets. Recheck the blood glucose in 15 minutes and repeat treatment if the blood glucose is below target.
True or false: DKA and HHS are distinct from each other.
False!
HHS is characterized by hyperosmolarity with extreme serum glucose elevation. Thought to initially be distinct from DKA in the absence of ketosis but we now know that both can certainly co-exist.
We are also starting to see more and more HHS in kids.
Your patient in the ED who came in with elevated POCT BG in the office today has a BMP drawn which shows a sodium of 129. This phenomenon is how you explain the low serum sodium value.
What is pseudohyponatremia?
Hyperglycemia causes osmotic shifts of water from the intracellular to the extracellular space, causing a relative dilutional hyponatremia
What vaccine in addition to the yearly influenza shot should be considered for pediatric patients with T1DM?
What is the pneumococcal 23 valent (PPV23) vaccine?
For patients older than 2 years old
Patients with diabetes at three-times increased risk of pneumococcal related pneumonia.
These are the specific criteria you use to transition from an insulin drip to subcutaneous insulin.
What are:
1) pH>7.3
2) CO2>15
3) Anion gap closure
You are in the PICU when you patient who was admitted with DKA seems to have closed their anion gap. You are working on transitioning them to subcutaneous insulin but only discontinue the drip this much time after giving them their first dose of SQ insulin?
What is at least two hours after basal insulin OR >15-30 minutes after short acting insulin bolus +food?
If patient is asleep, continue the insulin infusion until the patient is able to eat.
These are the interventions you may use when worried about cerebral edema.
What are:
1) Raise the head of the bed to 30 degrees
2) Hypertonic (3%) saline
3) Mannitol
Name two environmental factors thought to contribute to T1DM.
What are viruses and diet?
Viruses include enteroviruses (Coxsacke B, in particular) and Rubella
The influence of diet (cow's milk, cereals, low Vitamin D, low omega-3 fatty acids) remains controversial.
This is the exercise goal recommended for pediatric patients with T1DM.
What is goal of 60 min of moderate-to-vigorous intensity aerobic activity daily, with vigorous muscle-strengthening and bone-strengthening activities at least 3 days per week?