EAST OF ENGLAND PAEDIATRIC DIABETES NETWORK
Management of Diabetes during Illness in Children and Adolescents Management at Home and in Hospital
Authors: Nadeem Abdullah, Consultant in Paediatric Diabetes, Cambridge University Hospitals Foundation Trust, Cambridge Vipan Datta, Consultant Paediatrician, Norfolk and Norwich University Hospitals NHS Trust, Norwich Ronald Misquith, Consultant Paediatrician, Luton and Dunstable Hospitals NHS Trust, Luton Sharon Lim, Consultant Paediatrician, Mid Essex Hospital NHS Trust, Chelmsford
Contributions: John Hyde, Retired Consultant Paediatrician, Lead for Shared Guidelines Group, EEPDN Anjum Rafiq, Specialist Registrar in Paediatrics, East of England Multi-Professional Deanery Mandy Stevenson, PDSN, Princes Alexandra Hospital, Harlow
Acknowledgements: Nisha Nathwani, Andy Raffles, Jackie Angelo-Gizzi Kate Wilson, East of England Paediatric Diabetes Network Co-ordinator, NHS Diabetes
Text © East of England Paediatric Diabetes Network
East of England Paediatric Diabetes Network, Shared Guidelines Group Management of Diabetes during Illness in Children and Adolescents
Management of Diabetes during Illness in Children and Adolescents Management at Home and in Hospital
Contents
Page
1
Scope
3
2
Purpose
3
3
Introduction
3
4
General Principles
3
5
Cutaneous Blood Glucose
3
6
Blood Ketones
3
Table 1: Interpretation of Ketone Levels and the Actions Required 7
Maintaining Hydration
4
8
Specific Medical Management
4
9
Management of Hyperglycaemia
5
9.1
Patients on Insulin Injections
5
9.2
Patients on Insulin Pump Therapy
5
10
Management of Hypoglycaemia
5
10.1
Patients on Insulin Injections
5
10.2
Patients on Insulin Pump Therapy
6
11
Children and Adolescents who may have Poor Oral Intake or Unable to Tolerate any Oral Fluids during Illness and are Not Ketoacidotic
6
11.1
Shock/Dehydration
6
11.2
Maintenance IV Fluids
6
11.3
Intravenous Insulin Infusion
6
11.4
Safe Preparation and Administration of VRIII
7
Table 2: Infusion Rates for VRIII
7
11.5
Transferring from VRIII to Subcutaneous Insulin
7
12
Appendix 1: Patients on insulin injections
8
Appendix 2: How to calculate the amount of extra insulin on sick days (if not familiar with rule of 100)
9
Appendix 3: Patients on insulin pump therapy
10
Appendix 4: Patients on insulin pump therapy and blood ketones >0.6mmol/L
11
Appendix 5: Management of hypoglycaemia
12
Appendix 6: Maintaining CBG during poor intake/vomiting
13
Appendix 7: Safer preparation and administration of variable rate insulin infusion (VRIII)
14
East of England Paediatric Diabetes Network, Shared Guidelines Group Management of Diabetes during Illness in Children and Adolescents: November 2013 Page 2 of 14
Management of Diabetes during Illness in Children and Adolescents 1
Scope This guideline is for the use of paediatricians, children’s nurses and dieticians in treating diabetes in children over 6 months of age. It may be used by adult clinicians dealing with older teenagers if this is agreed by local units.
2
Purpose To be available in all departments within the East of England Paediatric Diabetes Network to ensure that quality of care is standardised. To enable clinicians to provide safe advice to children and families on managing diabetes during illness. It is hoped that this guideline will not only prevent children becoming unwell with DKA and reduce the need for admission during illness.
3
Introduction Effect of illness on diabetes: Most illnesses especially those associated with fever raise blood glucose levels secondary to increased production of cortisol. Cortisol promotes gluconeogenesis and induces insulin resistance. Relative insulin deficiency in illness causes ketone body production. However, illness associated with vomiting and diarrhoea may cause hypoglycaemia as a result of decreased food intake and poor absorption. Occasionally insulin requirements may increase during the incubation period of an infection. This increased need for insulin may persist for a few days after the illness, due to sustained insulin resistance.
4
General Principles during Illness Never stop insulin- the dose may need adjustment depending on blood glucose levels. Test blood glucose frequently (every 1-2 hours). Test blood ketone if glucose is above 14mmol/L. If the blood ketones are above 0.6mmol/L, repeat the test 2 hourly. In units that do not have a blood ketone meter, check urine ketones (table 1). Drink water/sugar free fluids every hour Eat as normal. If unable to eat or have reduced appetite, replace solid food with sugary fluids or semi solids e.g., milk, ice cream, fruit juice etc.
5
Capillary Blood Glucose (CBG) Frequent (every 4 hours) monitoring of CBG facilitates optimal diabetes management during illness. It should be monitored more frequently (every 1-2 hours), if additional doses of insulin have been given and blood ketones are raised.
East of England Paediatric Diabetes Network, Shared Guidelines Group Management of Diabetes during Illness in Children and Adolescents: November 2013 Page 3 of 14
6
Blood Ketones Ketone bodies (beta hydroxyl butyric acid, aceto-acetic acid and acetone) are produced in the liver from metabolising fat as a source of energy. This can happen either due to starvation (starvation ketones) or due to lack of insulin (in diabetes). Insulin is required to transport glucose from blood into cells, where the glucose is metabolised to produce energy. Lack of intracellular glucose sends messages to liver to mobilize free fatty acids as an alternative source of energy. It is the metabolism of FFA which results in the production of ketone bodies as a by-product. Urine strips measure acetoacetate (AcAc) and acetone while blood strips measure beta-hydroxybutyrate (BOHB). In acute ketoacidosis the majority of blood ketones are BOHB (75-85%). During treatment with insulin the levels of BOHB falls rapidly thus helping monitor the response to treatment effectively. In contrast the level of urine ketones may falsely remain high for many hours after the blood levels of BOHB has decreased. Blood ketones testing therefore provide valuable information in the management of diabetes during illness. It is recommended that blood ketones be used to monitor the response to treatment during illness along with blood glucose testing. Table 1: Interpretation of ketone tests and the actions to be taken by the family and clinicians. Urine ketones are only required if blood ketones are not available. Blood or Urine Ketones Levels BLOOD URINE Comments
0.0 – 0.6 Negative Normal
0.7 – 1.5 1.6 – 3.0 3.1 – 6.0 (Hi) Trace Mild to moderate Large Follow ‘Sick Day Rules’ Follow ‘Sick Day Rules’ Follow ‘Sick Day Rules’
If treating hyperglycaemia
Insulin injections: follow appendix 1
Appendix 1 or 4
Appendix 1 or 4
Insulin injections: Insulin pump therapy: follow appendix 1 follow appendix 4
If not getting better, contact Hospital
Admission to hospital may be required-use clinical judgement
Insulin pump: follow appendix 3
If patient already in hospital, monitor closely for DKA
If patient already in hospital, rule out DKA
Adapted from EEPDN ‘Out of Hours’ telephone advice guidelines
7
Maintaining Hydration 1. Hyperglycaemia, fever, glycosuria and ketonuria increase fluid losses 2. Elevated levels of ketones contribute to nausea and vomiting, leading to decreased intake, further worsening dehydration. It is therefore crucial to maintain adequate hydration during illness. 3. Liquids containing salt and water (e.g. dioralyte, diet soft drink) are preferable to plain water in avoiding electrolyte abnormalities. If CBG is falling or below 10mmol/L, sugar containing fluids (e.g. sports drinks, diluted fruit drinks, usual soft drinks) should be advised. It is best to shake the bubbles out of the sugar containing soft drinks, to minimise indigestion and advise patients to take sips rather than a large amount at a time (i.e. little and often). East of England Paediatric Diabetes Network, Shared Guidelines Group Management of Diabetes during Illness in Children and Adolescents: November 2013 Page 4 of 14
4. In young children especially under the age of 6 years who are unable to tolerate fluids orally and/or have persistent nausea, vomiting or diarrhoea, consider admission and intravenous fluid.
8
Specific Medical Management 1. Treat underlying illness if known i.e. UTI, tonsillitis etc. 2. Consider sugar free antipyretics to manage fever, malaise and headaches. 3. Avoid unknown or uncertain alternative medicine
9
Management of Hyperglycaemia
9.1
Patients on Insulin Injections: Hyperglycaemia is any CBG level above 10mmol/L. However, in illness often the blood glucose is much higher and needs treatment with additional doses of rapid acting insulin to bring it down. 1. Additional doses of rapid acting insulin (Humalog® or NovoRapid® or Apidra®) are required with careful monitoring to prevent ketoacidosis. 2. Dose and frequency of the injection will depend on the level of CBG and blood ketones see appendix 1 and 2.
9.2
Patients on Insulin Pump Therapy: For management of hyperglycaemia in patients on insulin pump therapy follow appendix 3 or appendix 4 depending on the level of blood ketones.
10
Management of Hypoglycaemia
10.1
Patients on Insulin Injections: 1. Hypoglycaemia is defined as CBG of 14mmol/L, use 0.9% sodium chloride with 10mmol KCl in 500mL and increase insulin infusion rate. Change to 5% dextrose in 0.45% sodium chloride with 10mmol KCl when CBG has dropped below14mmol/L. To prepare 500ml 10% dextrose in 0.45% sodium chloride with 10mmol KClwithdraw 50ml fluid from a 500ml bag of 5% dextrose in 0.45% sodium chloride with 10mmol KCl and add 50ml of 50% glucose.
11.3
Intravenous Insulin Infusion The previously used term ‘Sliding Scale’ for intravenous insulin has been replaced by the term ‘Variable Rate Intravenous Insulin Infusion’ (VRIII). The insulin infusion used here is significantly less than the one used in BSPED DKA because these children are not ketoacidotic. If they are, the DKA guidelines should be followed.
East of England Paediatric Diabetes Network, Shared Guidelines Group Management of Diabetes during Illness in Children and Adolescents: November 2013 Page 6 of 14
11.4
Safe Preparation and Administration of VRIII For safe preparation and administration of insulin infusion see appendix 7. Start VRIII according to the CBG as below: Table 2: Variable rate intravenous insulin infusion (these rates are similar to those for management of children and adolescents with diabetes during surgery) CBG Insulin infusion rate 6-8mmol/L 0.025ml/kg/h (i.e. 0.025units/kg/h) For safe preparation and administration of insulin infusion see appendix 7. Start 8-12mmol/L 0.05ml/kg/h (i.e. 0.05units/kg/h) VRIII according to the CBG as below: 12-15mmol/L 0.075ml/kg/h (i.e. 0.075units/kg/h) >15mmol/L 0.1ml/kg/h (i.e.insulin 0.1units/kg/h) Table 2: Variable rate intravenous infusion (these rates are similar to those for management of children and adolescents with diabetes during surgery) Adapted from; ISPAD Clinical Practice Consensus Guidelines. Pediatric Diabetes, 2009; 10: 169--74
1. The aim of the VRIII is to maintain CBG between 5 and 12mmol/L 2. Monitor CBG hourly while on IV fluids and VRIII 3. If CBG 1.5mmol/L, offer sugary drink/glucogel/GlucoTabs. If CBG >10mmol/L, repeat rapid insulin. Max 2 more doses Target CBG 8 to 10mmol/L. Doses to be at least 2 hours apart. To reduce BK, continue insulin and keep CBG up as above.
IN THE CASE OF AN EMERGENCY attend hospital ASAP; if immediate concerns consider 999 To calculate the TDD, for patients on insulin injections add up all the insulin given on a usual day or for patients on insulin pump therapy TDD can be found in the pump memory. Adapted from EEPDN ‘Out of Hours’ telephone advice Page 8 of 14
Appendix 2: How to calculate the amount of extra insulin during illness Many patients and their parents calculate the doses of Rapid-Acting Insulin using the Insulin Sensitivity Factor (ISF)/Rule of 100. When they are unsure of the calculations or the child is under the care of general paediatric staff, the following doses should be used. Ketones Blood Urine Ketones Ketones mmol/L
Blood glucose 3mmol/L. Insulin treatment is needed urgently!
Adapted from global IDF/ISPAD guideline for ‘diabetes in childhood and adolescence’. 2011
Page 9 of 14
Repeat if needed
Appendix 3: Patients on insulin pump therapy
CBG >14mmol/L Identify reason for high CBG Too much food, not enough insulin, loss of insulin strength, disruption of insulin delivery from pump
Use the pump to give a correction bolus Test for ketones
Test CBG in 1 hour Are CBG levels coming down?
Yes
No Give a correction bolus of insulin by a syringe or pen Use the same insulin sensitivity factor as in the pump to correct CBG to 10mmol/L Change entire infusion set system (new reservoir, infusion set, and cannula), consider changing the - - believes is no longer stable insulin vial if parent Check insulin pump (self-test)
Test CBG in 1 hour Is a CBG level coming down?
Carry on as normal
Yes
No
Check blood ketones Consider using ‘Sick Day Rules’, appendix 4 Consider using increased temporary basal rates Adapted from EEPDN ‘Out of Hours’ telephone advice guidelines
East of England Paediatric Diabetes Network, Shared Guidelines Group Management of Diabetes during Illness in Children and Adolescents: September 2013 Page 10 of 14
Appendix 4: Patients on insulin pump therapy If blood ketones >0.6mmol/L CBG >14mmol/L and ketones >0.6mmol/L First correction bolus with pump and second correction bolus with pen failed to correct hyperglycaemia (see appendix 3)
Start a ‘temporary basal rate’ of 125% (Medtronic, Roche, Dana pumps) or +25% (Animas pump) for 2 hours Aim for CBG levels in the target range (4 – 10mmol/L)
Check CBG and blood ketones level after 2 hours
Levels within target range
Levels reducing or same
Levels rising
Consider reducing or stopping the temporary basal rate
Continue with temporary basal rate
Consider increasing basal rate to 150% or +50% depending on the type of the pump, see above
Check CBG levels every one 4 hour. Check blood ketones levels 2 hourly. Drink plenty of sugar free fluids. If not hungry, take small amounts of carbohydrate containing fluid often (e.g. fruit juice, ice cream, Lucozade etc.)
Levels within target range
Levels rising
Consider increasing basal rate to 175% or +75%. Maximum 200% or +100%, depending on the type of the pump, see above
Check CBG levels every one hour. Check blood ketones levels 2 hourly. Drink plenty of sugar free fluids. If not hungry, take small amounts of carbohydrate containing fluid often (e.g. fruit juice, ice cream, Lucozade etc.) Adapted from EEPDN ‘Out of Hours’ telephone advice guidelines
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Appendix 5: Management of hypoglycaemia Patients on insulin injections or on insulin pump therapy
Is the child vomiting?
No
Ask parents: Is the child/young person: Drowsy
Alert
Alert but altered behaviour or drowsy
Alert Recommend oral GlucoTabs or glucogel or sugary drinks Hypo treatment for age; see bottom of page*
Test CBG levels at 10-15 minute intervals. Are the CBG levels >4 mmol/L?
NO
YES
Follow with a carbohydrate snack: See bottom of page** or next meal if it is due (Do not omit insulin for meal; give this at the end of meal)
If associated with vomiting, also see appendix 6
Yes
Start at top of tree again and repeat treatment as necessary. After 3 cycles Consider A&E
*Rapid acting carbohydrates:
Use Glucogel/Dextrogel: Under 8 years – 1 tube Over 8 years – 1.5 tubes Advice to squeeze tube contents down side of mouth between gums and buccal mucosa
Test CBG at 10-15 minute intervals. Are the C BG levels>4 mmol/L and child alert?
YES
Follow with a carbohydrate snack: See bottom of page** or next meal if it is due (Do not omit insulin for meal; give this at the end of meal)
Weight > 30 kg or age > 8 yrs. Give 15 gram of glucose 1.5 tubes of Glucogel/Dextrogel (15 g) 3 - 4 GlucoTabs (12-16 g) 100ml Lucozade (17g)
Collapse
Unconscious, collapse with or without seizures First place the child in the recovery position and then Dial 999
Do not leave the child alone Do not give any fluid or tablets by mouth Place in the recovery position Give Glucagen (orange box) if parent/ carer is confident to do so
NO
Repeat glucogel once and retest CBG 10mins later
Dose: Under 8 years: 0.5ml (½ dose =0.5mg) 8 years and over: 1.0ml (give all = 1.0mg)
CBG >4mmol/L and child responsive No action
This may take up to 10 minutes to work
If CBG still less than 4 mmol/L or child not responsive
*Rapid acting carbohydrates:
Wait for the ambulance crew to arrive Weight < 30 kg or age < 8 yrs. Give 10 gram of glucose 1 tube of Glucogel/Dextrogel (10 g) 2.5 GlucoTabs (10 g) 60ml Lucozade (10 g)
If the weight of the child is known, the dose of rapid glucose could be 0.3grams /kg as per ISPAD guidelines on the management of hypoglycaemia Examples of rapid carbohydrate: I tube of glucogel = 10grams; GlucoTabs = 4 grams; Dextro Energy Tablets = 3grams; 100ml Cola = 10grams **Carbohydrate snack: approximately 15 gram of carbohydrate
**Carbohydrate snack: approximately 8 and over 10 gram of carbohydrate
**One plain digestive biscuit (10g), 2 rich tea biscuits (14g), 1 slice bread with cheese or butter spread (15g), 3 cream cracker (16g), 100 ml glass of milk (not soya) (10g), 2 Jaffa cakes (14g), 0ne small apple (10g) Children on insulin Pump therapy: Insulin boluses with meals may need to be reduced as patients may be eating less and gastrointestinal absorption may be poor during illness. Basal insulin rate may also need to be decreased as a temporary basal rate for a few hours if the CBG still tends to be low, provided the blood ketones continue to be 1.5mmol/L
Blood ketones:
