PAEDIATRIC DIABETES AND ILLNESS MANAGEMENT Effects of illness on Type 1 Diabetes
Patient Information Leaflet
February 2015
TAMESIDE AND GLOSSOP INTEGRATED CARE NHS FOUNDATION TRUST
Infections associated with high blood glucose (Hyperglycaemia:BG ≥15 mmol), with or without ketones Many illnesses, particularly those with a high temperature cause blood glucose levels to rise. This is because high levels of stress hormones cause the insulin to work less effectively. It also promotes the production of glucose (gluconeogenesis) and insulin resistance. Illness increases ketone production because of inadequate insulin levels: • Starvation ketones are produced from free fatty acids as an alternative energy source when you are not eating carbohydrate • Ketones are also produced when there is not enough insulin on board to initiate the transport of glucose into the cells from the blood stream. This triggers further breakdown of fatty acids (lipolysis) and production of ketones (ketogenesis) Sometimes there are increased insulin requirements a few days before the onset of illness. The increased need for insulin may persist for a few days after the illness has passed, due to insulin resistance. Extra doses of fast acting insulin (Novorapid/Humalog/Apidra) are often required to: • Reduce blood glucose levels • Prevent ketoacidosis • Reduce hospital admissions (we call them sugar or ketone correction doses) The dose and frequency of these correction doses depends on the level of blood ketones and the blood glucose. If the high blood glucose levels and blood ketones are not improving significantly by 1-2 hours after the second correction dose (see table), You should make contact with the diabetes team for further advice. Your child may need to be admitted to the Children’s Unit for further assessment and treatment. Infections associated with Hypoglycaemia Illness associated with diarrhoea and vomiting may lead to lower blood glucose and hypoglycaemia rather than hyperglycaemia. This is because of reduced food intake, poor absorption and slower emptying of the stomach during gastroenteritis.
replace meals with frequent small volumes of sugary drinks Maintain careful blood glucose monitoring every 1-2 hours plus whenever the child has symptoms of possible hypoglycaemia Do not give non- sugar fluids in this situation Give sufficient fluids to maintain hydration Keep a note how much the child has had to drink Ensure your child is passing urine or having plenty of wet nappies Check blood ketones every 2-4 hours
Insulin You may need to reduce the total daily insulin dose by 20-50%. However, if the doses are lowered too much, there is a risk of then not having enough insulin on board leading to ketone production and ketoacidosis.
PAEDIATRIC DIABETES AND ILLNESS MANAGEMENT
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TAMESIDE AND GLOSSOP INTEGRATED CARE NHS FOUNDATION TRUST
Glucagon should be administered if the child is having a severe hypo (blood glucose below 4 mmol/l with reduced conscious level or seizure) at home. You should ring 999 if you cannot give the glucagon, or if your child does not recover within a few minutes of the glucagon injection. Advice should be taken from the diabetes team if not done so already
KETONES Ketones associated with gastrointestinal illnesses (Diarrhoea and Vomiting) and hypoglycaemia is usually because inadequate energy supply rather than insulin deficiency (ie starvation ketones). Blood ketone levels should be checked when blood glucose levels are above 15mmols and your child is unwell, particularly if they have a high temperature. At what level are ketones said to be raised? Blood ketones more than 1mmol/l are considered raised. Below is a guide for ketone levels:
Blood ketone reading
Suggested action
Less than 0.6mmol/L
This is in the normal range. Seek advice before making changes to your insulin doses
0.6 – 1.5mmol/L
When accompanied by blood glucose higher than 15.0mmol/L, extra insulin may be required. Contact your Diabetes Nurse Specialist for advice
Over 1.5mmol/L
When accompanied by blood glucose higher than 15.0mmol/L, there may be a risk of DKA. Contact your Diabetes Nurse Specialist immediately.
What can cause ketones?
Forgetting to give one or more insulin injections Giving spoiled insulin (over 30 days old, over 90 degrees or less than 32 degrees) Illness – the amount of insulin needed is usually more so the body will have the extra energy it needs to fight the illness Not enough insulin An insulin pump that is not working or has been disconnected from the body Traumatic stress on the body
Ketones + high glucose level = lack of insulin These ketones have been produced because the body does not have enough insulin. If your child’s blood sugars are high encourage your child to drink plenty of unsweetened fluids. Depending on the amount of ketones your child may require extra rapid acting insulin. Please call the diabetes team for help and advice.
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TAMESIDE AND GLOSSOP INTEGRATED CARE NHS FOUNDATION TRUST
Ketones + low glucose level = lack of food These ketones have been produced because the body is hungry. If your child’s blood sugars are very low and blood ketones are present then your child’s body is hungry for food. Respond by offering sweet drinks/food or whatever your child can eat Always have an in-date supply of blood ketone strips to use with your blood test meter. For blood ketone testing, check every 2-4 hours. The presence of ketones can occur even with a normal blood sugar when your child is unwell. It is important to act if the blood ketones measure more than 0.6 on the meter. The effects of illness on diabetes One of the body’s responses to stress and illness is to produce more glucagon (blood glucose raising hormone). This means your child will probably need more insulin. However it is also usual to eat less when you are feeling unwell, therefore these two factors must be considered whilst your child is unwell.
The body normally turns most of the carbohydrate food eaten into glucose (sugar). Glucose is the body’s main source of energy. If there is not enough insulin in the body, then the blood glucose level may be high. Therefore cells cannot get the glucose from the blood for energy. When this happens the body may break down its own fat to use as energy. When fat is broken down, ketones are made and will go into the bloodstream. Ketones are harmful to the body. Ketosis = increased level of ketones in the blood. Prompt action is essential to avoid hospital admission and treatment with intravenous insulin and fluids. Ketosis can cause abdominal pains and vomiting (and you may know what other symptoms they get when ketotic if they have had previous episodes). The build-up of ketones in the blood is called ketoacidosis. The body tries to get rid of these ketones by spilling them into the urine. Ketoacidosis describes how acidic the blood has become because there is NOT enough insulin in the body. Ketoacidosis can be dangerous and life threatening and can develop within a few hours, especially for insulin pump users
IMMEDIATE ACTION IS REQUIRED. Ketoacidosis Ketoacidosis is always caused by insufficient insulin please check blood ketones:If your child is ill or feeling unwell If the blood glucose has been higher than 15mmol/L for 2 hours or longer If your child feels sick or has vomited If your child is feeling under stress
Identifying rising ketone levels early can prevent an emergency situation or hospital admission. Delayed treatment for high blood ketone levels can be life threatening.
PAEDIATRIC DIABETES AND ILLNESS MANAGEMENT
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TAMESIDE AND GLOSSOP INTEGRATED CARE NHS FOUNDATION TRUST
Increasing ketone levels affect the function of the heart, lungs, digestive system and brain and in the worst situation can cause coma and death. If identified early and with appropriate advice and treatment from the diabetes team ketone levels usually reduce into the safe range. Managing this may take up to 24 hours and requires extra insulin doses and careful observation of fluid intake and regular telephone contact. In some cases admission to hospital may be unavoidable.
Please contact your diabetes team for advice on managing illness. You will have your “sick day” advice leaflet for multiple injections/pumps. However it can be very stressful and difficult to manage your child/young person’s diabetes during illness so please seek advice
Who to contact for advice Paediatric Diabetes Nurse Specialists during office hours 08.30- 16.30 • • •
Out of hours: 0161 922 6000 - hospital switchboard and ask for on-call paediatric registrar
Other Useful Contacts or Information NHS Direct Patient Information Centre Diabetes UK
PAEDIATRIC DIABETES AND ILLNESS MANAGEMENT
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TAMESIDE AND GLOSSOP INTEGRATED CARE NHS FOUNDATION TRUST
ISPAD Clinical Practise Consensus Guidelines 2009 Compendium for Sick Day Management in Children and Adolescents with Diabetes Paediatric Diabetes 2009 10 (Suppl 12) p146-153 Hanas, Ragnar (2004) Type 1 Diabetes in children, adolescents and young adults: How to become an expert on your own diabetes. Class Publishing, London. https://www.upbete.co.uk/media/20644/ketones_and_ketoacidosis_chart.pdf (Leeds Children’s Hospital) http://www.asph-childhealth.org.uk/docs/Leaflet%20Sick%20Days.pdf http://www.google.co.uk/url?url=http://www.esht.nhs.uk/EasysiteWeb/getresource.ax d%3FAssetID%3D505750%26type%3Dfull%26servicetype%3DAttachment&rct=j&fr m=1&q=&esrc=s&sa=U&ei=NDV2VJz6DuPX7AbpooCoBQ&ved=0CCUQFjAD&usg= AFQjCNHksQeoRamEGuaBgi2DBhu7nMe_hg (insulin pump advice) http://www.uhcw.nhs.uk/clientfiles/File/Ketone_testing___612__-_June_2013[1].pdf http://www.hertschs.nhs.uk/Library/Adult_Services/Diabetes/Diabetes%20Clini cal%20Guidelines-V21.0%2027.07.10.updated%20Jun2012pdf.pdf If you have any questions you want to ask, you can use this space below to remind you
If you have a visual impairment this leaflet can be made available in bigger print or on audiotape. If you require either of these options please contact the Patient Information Centre on 0161 922 5332
Author: Karen Wright and Jenny Butterworth Paediatric diabetes team Division/Department: February 2015 Date Created: Reference Number: 1.0 Version:
