Diabetes Mellitus Maura Lindenfeld, RN, MSN, CPNP Cook Children’s Medical Center

1. Diabetes Mellitus Maura Lindenfeld, RN, MSN, CPNP Cook Children’s Medical Center

2. 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.

3. Type 1 Diabetes • Insulin Dependent Diabetes Mellitus (IDDM) • autoimmune mediated • insulin deficient

4. Type 2 Diabetes • Type 2 Diabetes • Non-Insulin Dependent Diabetes Mellitus • insulin resistance • typically family history related • obesity

5. Normal Glucose Tolerance • Fasting BG <100mg/dl • 2-hour post glucose <140 mg/dl

6. Impaired Glucose Impaired Fasting Glucose Impaired Glucose Tolerance …a metabolic state intermediate between normal blood glucose and diabetes

7. Impaired Fasting Glucose (IFG) • FBS 100mg/dl but 126 mg/dl

8. Impaired Glucose Tolerance (IGT) • 2 hour post glucose 140mg/dl and 200mg/dl

9. Goals of Therapy • Good blood sugar control • Improved quality of life • Routine • Minimize risk for hypoglycemia • Minimize risk for long-term complications

10. Goals of Therapy Age Blood Glucose <7yrs 80-200 mg/dl 7-11yrs 80 -180 mg/dl >12yrs 80-150 mg/dl

11. 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.

12. Type 2 • Hyperinsulinemia • Insulin resistance • Acanthosis Nigricans • Insulin levels may be low or normal

13. 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.

14. 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

15. 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

16. 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.”

17. Mild

18. Moderate-to-Severe

19. Severe

20. 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

21. 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

22. 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

23. Insulin Curves

24. Insulin Curves

25. 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

26. Injection Sites

27. Hyperglycemia • Causes • Incorrect dose or missed dose • Eating more than allowed by meal plan (incorrect carbohydrate counting) • Not enough exercise • Illness or infection

28. Hyperglycemia • Onset • Symptoms present more slowly than hypoglycemia • May progress to ketoacidosis and coma if undetected

29. Symptoms of Hyperglycemia • Polyuria, polydipsia, polyphagia • Hunger • Blurred vision • Headache • Emotional lability • Flushing • Yeast infections

30. Treatment of Hyperglycemia • Insulin • Extra short acting insulin to correct for highs • Adjust long acting insulin dose

31. 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)

32. 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

33. Hypoglycemia • Causes • Incorrect dose (too much insulin) • Missed meal or snack • Incomplete meal or snack • Unplanned or excess exercise • Illness • Alcohol consumption

34. Hypoglycemia • Onset • Sudden • May progress to loss of consciousness or seizure if untreated

35. Symptoms of Hypoglycemia • Autonomic or adrenergic • Shakiness, trembling • Anxiety, nervousness • Weakness • Hunger • Sweating • Nausea, vomiting

36. Symptoms of Hypoglycemia • CNS • Headache • Visual changes • Lethargy • Irritability, restlessness • Confusion • Somnolence, protracted sleep, stupor

37. Symptoms of Hypoglycemia • Hypothermia • Seizures • Bizarre neurologic signs • Motor • Sensory • Loss of intellectual ability • Personality changes

38. 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

39. 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

40. Disposable Needles Why to use a needle once, only once

41. Why shot site rotation matters

42. KetonesPathophysiology • 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

43. Causes of Ketosis • New diagnosis • Not enough insulin • Illness or infection • Stress • Emotional or physical • Starvation ketosis

44. Symptoms of Ketosis • Fruity odor of breath or urine (acetone/nail polish odor) • Abdominal pain • Nausea/vomiting • Kussmaul respirations • Drowsiness • Coma

45. 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

46. Ketone Monitoring • Urine • ketostix, multistick, ketodiastick • ketones are pink to purple • negative ketones on the ketone pad are tan.

47. 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

48. Monitoring • Four times daily is recommended, always at bedtime (>100) • Occasional nocturnal readings are required • Pre-driving blood sugars (>100)

49. 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

50. Pump Therapy