Transcript Hypoglycemia

Diabetes Mellitus
Maura Lindenfeld, RN, MSN, CPNP
Cook Children’s Medical Center
Diabetes Mellitus:
A group of disorders
characterized by hyperglycemia
with disturbed carbohydrate,
protein, and fat metabolism
associated with a relative or
absolute deficiency of insulin.
Type 1 Diabetes
–Insulin Dependent Diabetes
Mellitus (IDDM)
• autoimmune mediated
• insulin deficient
Type 2 Diabetes
–Type 2 Diabetes
–Non-Insulin Dependent Diabetes
Mellitus
• insulin resistance
• typically family history related
• obesity
Normal Glucose Tolerance
• Fasting BG <100mg/dl
• 2-hour post glucose <140 mg/dl
Impaired Glucose
Impaired Fasting Glucose
Impaired Glucose Tolerance
…a metabolic state intermediate between
normal blood glucose and diabetes
Impaired Fasting Glucose
(IFG)
• FBS 100mg/dl but 126 mg/dl
Impaired Glucose Tolerance
(IGT)
• 2 hour post glucose 140mg/dl and
200mg/dl
Goals of Therapy
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Good blood sugar control
Improved quality of life
Routine
Minimize risk for hypoglycemia
Minimize risk for long-term complications
Goals of Therapy
Age
Blood Glucose
<7yrs
80-200 mg/dl
7-11yrs
80 -180 mg/dl
>12yrs
80-150 mg/dl
HbA1C
Not a diagnostic tool
• Provides a means to
monitor diabetes therapy
• 3 month average blood
glucose
• Under 8 is great! (within
1 ½ SD of non-diabetic
range)
• At puberty, encourage
control in the 7’s.
Type 2
• Hyperinsulinemia
• Insulin resistance
• Acanthosis Nigricans
• Insulin levels may be low or normal
Type 2
• Not always insulin-dependent
• Not prone to ketosis-prone under
normal circumstances
• Onset may occur at any age, children
are being diagnosed earlier and
earlier.
Obesity
• 15 – 20% of children and adolescents are
obese
• 62% of total population are obese,
childhood obesity has increased by 25%
since 2000
• On average, we consume 150 – 250
calories per day more than we did 10 years
ago
Obesity
• Decreased physical activity has
contributed to increase in obesity
• Increases risks of Type 2 Diabetes,
hypercholesterolemia,
hypertriglyceridemia, hypertension,
vascular disease
• Prevalence of acanthosis nigricans and
insulin resistance increases with the
degree of obesity
Acanthosis Nigricans
“…is a skin lesion characterized by
brown, velvety, hyperkeratotic
plaques most often found in the
axillae, the back of the neck, and
other flexural areas.”
Mild
Moderate-to-Severe
Severe
Type 2 Treatment
• Diet
– 45 grams of carbohydrates per meal
– Small snacks (if any)
– Reduced calorie intake 1500cals/day
• Exercise
– 30 minutes of UNINTERRUPTED
exercise daily
Type 2 -Treatment
• Medications
– Actos and Avandia
• Taken with meals
• Can cause hypoglycemia
• Not approved for the use in children
– Glucophage
• twice a day with food
• Does NOT cause hypoglycemia
Insulin Regimens
• Conventional - 2 shots/day of short
and intermediate insulin
• Intensive - 3 or more shots/day
– Lantus or Levamir and Humalog,
Novolog or Apidra
– NPH and Humalog, Novolog or
Apidra
– Insulin Pumps
Insulin Curves
Insulin Curves
Insulin Types
Insulin Type
Onset (hrs)
Peak (hrs)
Duration
Humalog
0.25
0.5 – 1.5
3–5
Novolog
0.25
0.5 – 1.5
3-5
Apidra
0.1
0.25- 1.0
2-4
Regular
0.5 – 1
2–3
6–8
NPH
1 – 1.5
6–8
12 – 18
Lantus
0.5 – 1
4-6
24
Levemir
0.5 – 1
4-6
12- 24
Injection Sites
Hyperglycemia
• Causes
– Incorrect dose or missed dose
– Eating more than allowed by meal plan
(incorrect carbohydrate counting)
– Not enough exercise
– Illness or infection
Hyperglycemia
• Onset
– Symptoms present more slowly than
hypoglycemia
– May progress to ketoacidosis and coma
if undetected
Symptoms of Hyperglycemia
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Polyuria, polydipsia, polyphagia
Hunger
Blurred vision
Headache
Emotional lability
Flushing
Yeast infections
Treatment of Hyperglycemia
• Insulin
– Extra short acting insulin to correct
for highs
– Adjust long acting insulin dose
Treatment of Hyperglycemia
• Hydration
– Depending on the duration of
hyperglycemia May have mild to
moderate volume loss
• replace fluids orally if tolerated
• Exercise (as long as ketones are negative)
Correction Factor
• Typical format
– For blood glucoses >150 mg/dl give:
150 – 199 1 unit Humalog
200 – 249 2 unit Humalog
250 – 299 3 units Humalog
300 – 349 4 units Humalog
350 – 399 5 units Humalog
400 – 449 6 units Humalog
>450 call endocrinologist on-call
Hypoglycemia
• Causes
– Incorrect dose (too much insulin)
– Missed meal or snack
– Incomplete meal or snack
– Unplanned or excess exercise
– Illness
– Alcohol consumption
Hypoglycemia
• Onset
– Sudden
– May progress to loss of consciousness or
seizure if untreated
Symptoms of Hypoglycemia
• Autonomic or adrenergic
• Shakiness, trembling
• Anxiety, nervousness
• Weakness
• Hunger
• Sweating
• Nausea, vomiting
Symptoms of Hypoglycemia
• CNS
– Headache
– Visual changes
– Lethargy
– Irritability, restlessness
– Confusion
– Somnolence, protracted sleep, stupor
Symptoms of Hypoglycemia
– Hypothermia
– Seizures
– Bizarre neurologic signs
• Motor
• Sensory
• Loss of intellectual ability
• Personality changes
Treatment of Hypoglycemia
• Blood Glucose <70 mg/dl
• Give 15g carbohydrates: 4 oz of juice,
6 oz of regular soda, 8 oz of milk,3–4
glucose tablets,6 life savers
• Recheck blood glucose in 15 minutes
and retreat if blood glucose remains
<70 mg/dl, if>70mg/dl give a 15g
snack of complex carbohydrates
Treatment of Hypoglycemia
• If unable to take oral treatment
– Glucagon
• <20 kg give 0.5 mg IM or SQ
• >20 kg give 1 mg IM or SQ
Disposable Needles
Why to use a needle once, only once
Why shot site rotation
matters
Ketones
Pathophysiology
• Relative or absolute insulin deficiency
(diabetes) causes glucose (starvation) and
results in the metabolism of fat for energy
• Ketones are a result of fat metabolism
– Acetoacetate and -hydroxybutyrate
Causes of Ketosis
• New diagnosis
• Not enough insulin
• Illness or infection
• Stress
–Emotional or physical
• Starvation ketosis
Symptoms of Ketosis
• Fruity odor of breath or urine
(acetone/nail polish odor)
• Abdominal pain
• Nausea/vomiting
• Kussmaul respirations
• Drowsiness
• Coma
Treatment of Ketosis
• Assess blood sugars and urine
ketones every 2-4h until ketones
cleared
• Extra rapid acting insulin
(Humalog/Novolog) every 2-4h
• Extra fluids
–Oral fluids initially glucose free
• NO EXCERCISE
Ketone Monitoring
• Urine
–ketostix, multistick, ketodiastick
–ketones are pink to purple
–negative ketones on the ketone pad
are tan.
Ketone Monitoring
• Blood
–lab - our current method gives ratio
expressed as 1:16, 1:32
• the higher the number the more
ketones
–bedside serum monitoring
• available for home use
Monitoring
• Four times daily is recommended,
always at bedtime (>100)
• Occasional nocturnal readings are
required
• Pre-driving blood sugars (>100)
Monitoring
• Honeymoon phase affects insulin regimen
– Partial remission of insulin deficiency
after diagnosis
– Meals may trigger insulin release and a
dose reduction may be indicated
Pump Therapy
Insulin Pump
• Site preparation
Transfusion Tubing
Pump Insulin Therapy
• Basal
– Takes the place
of the long
acting
insulin
Insulin Pump Therapy
•Bolus
•“On Demand”
insulin for food
and corrections
•Types: Normal
•Square
•Dual
•Radio Frequency
Insulin Pump
• Troubleshooting
– Always have a
back up plan
– Check pump,
tubing and site
Questions
• Any Questions?