Diabetes in a mildly ill child

Assessment

Occasionally an astute clinician makes the diagnosis of diabetes mellitus in a mildly ill child, with <3% dehydration, no acidosis and no vomiting. Baseline investigations should be carried out, as in the child with ketoacidosis. The diagnosis of diabetes mellitus brings with it a lifetime of treatment. The education and care of child and family should be taken over by a team including a pediatrician, nurses and a dietician. However, management can be initiated without admission to hospital.

Management

Initial insulin treatment. Give 0.25 units/Kg weight of quick-acting insulin s.c. stat. If the child is within 2 hours of a meal, give the meal-time dose only. Halve the dose if he or she is under 4 years old. Before breakfast and lunch (7.30 a.m., 11.30 a.m.) give 0.25 units/Kg weight of quick-acting insulin. Before the evening meal (5.30 p.m.) give 0.25 units/Kg weight of quick-acting insulin and 0.25 units/Kg weight of intermediate-acting insulin. If this is the first insulin dose, give 0.25 units/Kg weight quick-acting insulin only, followed by a further 0.25 units/Kg weight quick-acting insulin at midnight followed by a snack.

Ongoing insulin treatment. Once normoglycemia is achieved and ketonuria disappears, you should change the insulin to a twice daily mixture of short and intermediate insulins usually at 1 unit/Kg weight but this may need modification. It should be given as 2/3 in morning and 1/3 at night; 2/3 of each dose should be intermediate-acting, and 1/3 short-acting. Occasionally older adolescents go onto a basal bolus regimen of 30– 40% intermediate acting insulin given at 10 p.m., with the rest given as short-acting insulin in 3 equal doses before meals.

You must inform your consultant about all admissions of children with diabetic ketoacidosis.

Mildly ill hyperglycemic diabetic patients who are already on insulin Children who have already been diagnosed as having diabetes mellitus and who are already on insulin can present to the Emergency Department with a mild illness and hyperglycemia. They are usually advised to take 10% of total daily dose of insulin as rapid-acting insulin every 2 hours until normoglycemic (in addition to usual insulin). You should notify your consultant if there are any management issues that you want to discuss.

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Diabetes Melitus in Pediatric Emergency

Thirty per cent of children with diabetes present with vomiting and secondary dehydration from the development of acidosis and ketosis. Diabetic ketoacidocis is a medical emergency. The clinical presentation may vary from polydipsia and polyuria or abdominal pain and vomiting to dehydration and weight loss with rapid acidotic breathing. It is important to check the blood glucose in any child who presents with any of these signs or symptoms.

Assessment

Assessment includes the clinical assessment, particularly of the level of dehydration and the laboratory investigations. The level of dehydration is often overestimated.

Degree of dehydration

• Mild-nil (<4%): no clinical signs

• Moderate (4–7%): easily detectable dehydration, e.g. reduced skin turgor, poor capillary return

• Severe (>7%): poor perfusion, rapid pulse, reduced blood pressure, i.e. shock.

Investigations

• Blood glucose, urea, electrolytes.

• Arterial or capillary acid/base

• Urine: ketones, culture

• Check for precipitating cause, e.g. infection (urine, FBC, blood cultures; consider CXR)

• Islet cell antibodies and insulin antibodies in newly diagnosed patients.

Management

Fluid requirements

If hypoperfusion is present, give normal saline at 20 ml/kg weight stat. This should be repeated until the patient is hemodynamically stable with warm, pink extremities and rapid capillary refill time. If more than 30 ml/kg weight is needed, call for senior advice. Rehydration should continue with normal saline.

The child should be kept nil by mouth (except ice to suck) until alert and stable. A nasogastric tube should be inserted if he or she is comatose or has recurrent vomiting. It should be left on free drainage. Rehydration can be completed orally after the first 24–36 hours if the patient is metabolically stable.

Maintenance fluids

If the blood sugar falls very quickly, i.e. within the first few hours, you should change to normal saline with 5% dextrose. When the blood sugar reaches 12–15 mmol/liter, use 0.45% NaCl with 5% dextrose. You should aim to keep the blood sugar at 10–12 mmol/liter. 

If the blood glucose falls below 10–12 mmol/liter and the patient is still sick and acidotic, increase the dextrose in the infusate to 7.5–10%. Do not turn down insulin infusion.

Bicarbonate

Bicarbonate is usually not necessary if shock has been adequately corrected and should not be required in most cases. You must remember that treatment of the dehydration will correct the acid-base disturbance. In extremely sick children (with pH <7.0±HCO3<5 mmol/liter), small amounts of sodium bicarbonate can be given after discussion with the consultant endocrinologist. It should be given over 30 minutes with cardiac monitoring.

The acid base status must then be reassessed.

Note:

• Remember the risk of hypokalemia.

• Continuing acidosis usually means insufficient resuscitation.

Insulin

The insulin should be prepared by adding 50 units of clear/rapid-acting insulin (Actrapid HM or Humulin R) to 49.5 ml 0.9% NaCl (1 unit per ml solution). The insulin infusion may be run as a sideline with the rehydrating fluid via a 3-way tap, provided a syringe

pump is used. Ensure that the insulin is clearly labelled.

You should start at 0.1 units/Kg weight per hour in newly diagnosed children, and in those already on insulin who have glucose levels >15 mmol/liter. Children who have had their usual insulin and whose blood sugars are <15 mmol/liter should receive 0.05 units/kg weight per hour. Adjust the concentration of dextrose to keep the blood glucose at 10–12 mmol/liter.

Adequate insulin must be continued to clear acidosis (ketonemia).

The insulin infusion can be discontinued when the child is alert and metabolically stable (blood glucose <10–12 mmol/liter, pH>7.30 and HCO3>15). The best time to change to subcutaneous insulin is just before meal time. The insulin infusion should only be stopped 30 minutes after the first subcutaneous injection of insulin.

Potassium

Potassium chloride should be added to each bag of i.v. fluid once the patient has urinated. Add this at a rate of 40 mmol/liter if the body weight <30 kg, or 60 mmol/liter if >30 kg. You should measure the levels 2 hours after starting therapy and 2–4 hourly thereafter.

Specimens should in general be arterial or venous. Give no potassium if the serum level is >5.5 mmol/liter or if the patient is anuric.

Admission to ICU

Consider admission to the ICU if the patient is under 2 years of age at onset or if in coma, cardiovascular compromise or is having seizures. Strict monitoring must continue while the child is transferred to ward or to the ICU .

Monitoring during transport to ICU

• Strict fluid balance; check all urine for ketones

• Hourly observations: pulse, BP, respiratory rate, level of consciousness and pupils

• Hourly glucose (Glucometer) during insulin infusion; other biochemistry as clinically indicated

• 4 hourly temperature measurements

Added hazards during the management of ketoacidosis include:

1. Hypernatremia. 

Measured serum sodium is depressed by the dilutional effect of the hyperglycemia. To ‘adjust’ sodium concentration, use the following formula:

i.e. 3 mmol/liter of sodium to be added to the measured result for every 10 mmol/liter of glucose above 5.5 mmol/liter. If Na is >160 mmol/liter, the case should be discussed with the consultant. The sodium should rise as the glucose falls during treatment. If this does not happen or if hyponatremia develops, it usually indicates overzealous volume correction and insufficient electrolyte replacement. This may place the patient at risk of cerebral edema.

2. Hypoglycemia.

 Hypoglycemia can occur during correction of the hyperglycemia. If the blood glucose is <2.2 mol/liter give i.v. 10% dextrose 5 ml/kg weight. Do not discontinue the insulin infusion. Continue with a 10% dextrose infusion until stable. Cerebral edema. Some degree of subclinical brain swelling is present during most episodes of diabetic ketoacidosis. Clinical cerebral edema occurs suddenly, usually between 6 and 12 hours after starting therapy (range 2–24 hours). Mortality or severe morbidity is very high without early treatment.

3. Cerebral edema

Occurrence of cerebral edema is reduced by slow correction of the fluid and biochemical abnormalities. Optimally, the rate of fall of blood glucose and serum osmolality should not exceed 5 mmol/liter per hour, but in children there is often a quicker initial fall in glucose. Patients should be nursed head up. The warning signs are :

Warning signs of cerebral edema

• First presentation, long history of poor control, young age (<5 years)

• No sodium rise as glucose falls, hyponatremia during therapy, initial adjusted hypernatremia

• Headache, irritability, lethargy, depressed consciousness, incontinence, thermal instability

• Very late—bradycardia, increased BP and respiratory impairment

Treatment consists of:

• Mannitol 20% 0.5 g/kg weight i.v. stat if hemodynamically stable. Give immediately when the clinical diagnosis is made—do not delay for confirmatory brain scan.

• Reduce fluid input to 2/3 and replace deficit over 72 hours rather than 24 hours.

• Nurse head up.

• Transfer immediately to ICU.

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Hypoglycemia in Pediatric Emergency

There should be a low threshold for performing a Dextrostix test in the acutely unwell child in the Emergency Department. Beyond the neonatal period, hypoglycemia is defined as a blood glucose less than 2.5 mmol/liter. In children who have had a seizure, hypoglycemia can be the cause of the seizure, or the result of a prolonged seizure.

Effects of hypoglycemia

The effects of the hypoglycemia itself, from whatever cause, are mainly effects on the central nervous system and those of adrenergic overdrive as Table below. Other clinical signs will depend on the cause of the hypoglycemia and a thorough clinical examination is required, including height and weight. 

Hypoglycemia Effects in pediatric

Investigation

Blood and urine must be taken off for metabolic investigation as soon as the child presents, before treatment is commenced. Investigations are listed in Box A.

Note that:

• Hyperinsulinism is the commonest cause of hypoglycemia in children under 2 years old, This diagnosis is excluded by ketonuria.

• ‘Accelerated starvation’ (idiopathic ketotic hypoglycemia) is the commonest cause of hypoglycemia after the age of 2 years, but may present earlier. The diagnosis can be established when fasting-induced hypoglycemia is accompanied by elevated urinary ketones, in the absence of other pathology. It is treated by frequent high protein and carbohydrate meals.

Management

Symptomatic hypoglycemia should be treated with an i.v. bolus of 5 ml/kg weight of 10% dextrose (0.25–0.5 mg/kg weight). The expected maintenance infusion rate is 3–5 ml/kg weight per hour of 10% dextrose (6–8 mg/kg weight per minut). A required infusion rate of 10–20 mg/kg weight per minute is consistent with hyper-insulinism.

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Adrenal Crisis in Pediatric Emergency

An adrenal crisis is a physiological event caused by an acute relative insufficiency of adrenal hormones. It may be precipitated by physiological stress, such as infection or surgery in a susceptible patient. It should be considered in patients with:

• congenital adrenal hyperplasia

• hypopituitarism with replacement therapy

• previous or current prolonged steroid therapy

• a history of central nervous system pathology or neurosurgical procedures.

Assessment

Signs of both glucocorticoid deficiency and mineralocorticoid deficiency should be looked for if adrenal insufficiency is suspected. In the history and examination, you should look for the following:

• glucocorticoid deficiency presenting with weakness, anorexia, nausea and/or vomiting, hypoglycemia, hypotension (particularly postural) and shock

• mineralocorticoid deficiency presenting with dehydration, hyperkalemia, hyponatremia, acidosis and prerenal renal failure.

Investigations

Prompt treatment is essential and should be based on the following investigations:

• immediate blood glucose using a Dextrostix

• serum glucose, urea, sodium and potassium

• arterial or capillary acid base

Where the underlying diagnosis of adrenal insufficiency is suspected, you should collect at least 2 ml of clotted blood for later analysis (cortisol and 17-hydroxyprogesterone). The results are unlikely to be available to help in the emergency management of the patient.

Management

Susceptible patients who present with vomiting

Susceptible patients who present with vomiting but who are not other-wise unwell should be considered to have incipient adrenal crisis. To prevent this from possibly developing further:

• Administer i.v. or i.m. hydrocortisone 2 mg /kg weight

• Give oral fluids and observe for 4–6 hours before considering discharge.

• Discuss with appropriate consultant.

For all other children

For all other children where adrenal insufficiency is suspected, the various abnormalities should be considered, namely, fluid requirements, hydrocortisone requirements, hypoglycemia, hyperkalemia and precipitating causes such as sepsis.

1. Give intravenous fluids

The level of dehydration should be assessed and intravenous fluids given accordingly. For management of various levels of dehydration,

Management of dehydration in adrenal insufficiency

a. For shock and severe dehydration

• Normal saline 20 ml/kg weight i.v. bolus. Repeat until circulation is restored.
• Administer remaining deficit plus maintenance fluid volume as normal saline in 5% dextrose evenly over 24 hours.
• Check electrolytes and glucose frequently.
• After the first few hours, if serum sodium is >130 mmol/liter, change to half normal saline.
• 10% dextrose may be needed to maintain normoglycemia.

b. For moderate dehydration in adrenal insufficiency

• Normal saline 10 ml/kg i.v. bolus. Repeat until circulation is restored.
• Administer remaining deficit plus maintenance fluid volume as normal saline in 5% dextrose evenly over 24 hours.

c. For mild dehydration in adrenal insufficiency

• No bolus.
• 1.5 times maintenance fluid volume administered evenly over 24 hours.

2. Give hydrocortisone

Hydrocortisone must be given intravenously. If intravenous access is difficult, hydrocortisone should be given intramuscularly while you are establishing the intravenous line, in the following doses:

Neonate: hydrocortisone 25 mg stat and then 50 mg/m² per 24 hours by continuous infusion

• 1 month–1 year: hydrocortisone 25 mg stat, then 50 mg/m² body surface per 24 hours by continuous infusion
• Toddlers (1–3 years): hydrocortisone 25–50 mg stat then 50 mg/m² per 24 hours by continuous infusion
• Children (4–12years): hydrocortisone 50–75 mg stat, then 50 mg/m² per 24 hours by continuous infusion
• Adolescents and adults: hydrocortisone 100–150 mg stat, then 50 mg/m² per 24 hours by continuous infusion

When the patient is stable, you should reduce the intravenous hydrocortisone dose, and then switch to triple dose oral hydrocortisone therapy, gradually reducing to maintenance levels (10–15 mg/m² per day).

In patients with mineralocorticoid deficiency, start fludrocortisone at maintenance doses (usually 0.1mg daily) as soon as the patient is able to tolerate oral fluids.

3. Treat hypoglycemia

Hypoglycemia is common in infants and small children. Treat with an intravenous bolus of 5 ml/kg weight 10% dextrose in a neonate or infant and 2 ml/kg weight of 25% dextrose in an older child or adolescent. Maintenance fluids should contain 5–10% dextrose.

4. Treat hyperkalemia

Hyperkalemia usually normalises with fluid and electrolyte replacement.

• If potassium is above 6 mmol/liter, perform an ECG and apply a cardiac monitor as arrhythmias and cardiac arrest can occur.
• If potassium is above 7 mmol/liter and hyperkalemic ECG changes are present (e.g. peaked T waves, wide QRS complex), give 10% calcium gluconate 0.5 ml/kg weight i.v. over 3–5 minutes. Commence an infusion of insulin 0.1 units/kg weight per hour i.v. together with an infusion of 50% dextrose 2 ml/kg weight per hour.
• If the potassium is above 7 mmol/liter with a normal ECG, give sodium bicarbonate 1–2 mmol/kg weight i.v. over 20 minutes, with an infusion of 10% dextrose at 5 ml/kg weight per hour.

5. Identify and treat potential precipitating causes such as sepsis.

6. Admit to appropriate inpatient facility.

Prevention

The prevention of a crisis is usually possible in susceptible individuals. Situations likely to precipitate a crisis should be anticipated and the patient given:

• triple normal oral maintenance steroid dose for 2–3 days during stress (e.g. fever, fracture, laceration requiring suture)

• intramuscular hydrocortisone when absorption of oral medication is doubtful (e.g. in vomiting or severe diarrhea)

• increased parenteral hydrocortisone (1–2 mg/kg weight) before anesthesia, with or without an increased dose postoperatively.

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