CASE PRESENTATION. CATALINA RUIZ MESA, MD PL 1 SBH. CASE. 17 yo, FEMALE 1 week history of polyuria, polydispsia, weight loss. PMH: negative FHX: type 1 and 2 DM in the maternal side, mom had gestational diabetes. COURSE. At home: CBG: 300. At clinic: PE and VS: WNL.
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CATALINA RUIZ MESA, MD
CBG:320, UA: glucosuria
UA: prot: Neg, glu: 1000, ketone: 10, LE: TR, RBC: 0, Sq cells: 3, bact: few.
CBC: WBC: 8.6, HB: 14.2, Hto:39.9, plat: 231. N: 72.2, L:21.7
4.4 23 0.5 9.1 6.9 23 112
Disorder of the metabolic homeostasis controlled by insulin, resulting in abnormalities of carbohydrate and lipid metabolism.
TYPE 1: absolute insulin deficiency
TYPE 2: Insulin resistance
Autoimmune destruction of beta cells (T cell mediated) induced by environmental triggers.
Major Histocompatibility Complex on chromosome 6.
Family history: 10-20% have a family member with DM
Congenital Rubella: up to 20% develop type 1 DM.
No other specific environmental factors are confirmed.
AUTOANTIBODIES AGAINST BETA CELL
AB against whole islets
AB against specific proteins such as insulin, glutamic acid decarboxylase, tyrosine phosphatase, insulinoma- associated prot. 2.
No specific role in Beta cell damage, not everyone with this AB develop DM, but they are at risk.
More than 80% of beta cell must be lost before glycemic control is impaired significantly. At that point insulin is insufficient to maintain glucose and lipid homeostasis.
Blood glucose >180mg/dl glucosuria osmotic diuresis polyuria Polydipsia to maintain euvolemia.
Decreased insulin lipolysis and protein breakdown
Glucosuria, lipolysis and protein breakdown (caloric loss) weight loss and hyperphagia.
Polyuria usually < 1 month
Symptoms and glucose 100-125mg/dl should have an oral glucose tolerance test
Sweating, trembling, hunger and palpitations, headache, light headness, dizziness, diplopia, confusion. Seizures.
Mild to moderate: 10-15gr glucose (4oz juice)
Severe: IM or SC glucagon (1mg, except infants <10kg in whom 0.5mg is given)
Vomiting, dehydration, abdominal pain, presence of an altered sensorium.
Acidosis: pH <7.3, HCO3 <15meq/L
Acidosis and ketosis cause an ileus that can lead to abdominal pain, can be severe.
Elevation of stress hormones, epinephrine and cortisol, can lead to an elevation in the WBC.
Fluid resuscitation 10ml/kg (0.9% NS)
AFTER 2 HOUR:
Total fluid no more than 1.5 or 2 times maintenance fluid rate.
When blood glucose < 300mg/dl 0.9%NS is changed to D5 0.45% saline + K.
If blood glucose < 150mg/dl the dextrose content may need to be increased to 10% or even 12.5%.
Until acidosis resolves (pH >7.3, HCO3 >15meq/L).
Increased dose to 0.15 or 0.2U/kg/h if acidosis is not resolving.
-Decrease glucose at a rate of 100mg/dl/h
- After the 1 hour pH should increase at least 0.03 units/hour.
Normal sensorium, normal VS, ability to tolerate PO, no acidosis (normal pH, HCO3 >18, normal anion Gap)
D/C IV insulin at time of SC rapid acting insulin or 30 minutes AFTER SC insulin.
Peak: 0.5- 1h
REGULAR INSULIN (is used IV in DKA)
DETEMIR (LEVEMIR) time of action depends on the dose
Peak: NO PEAK
DAILY REQUIREMENTS (Units/kg/day)
<3y - 0.3- 0.4
3-6y - 0.5
7-10y - 0.6- 0.8
11-14y - 0.8- 1
>14y - 1- 1.5
2. Basal bolus regimen:
If pump the basal insulin can be short acting insulin (#units/hour)
2. Amount of insulin needed to correct for a blood glucose concentration outside of the target range. (80- 120mg/dl day time, 100-150mg/dl at bed time)
<10y: 1000kcal + 100kcal/year
>10y: female: 45kcal/kg/day
50-55% carbohydrate calories, 20% protein, and approximately 30% fat
Regular exercise should be encouraged.
During exercise increase cals or decrease insulin
Before meals, bedtime, overnight (2am). If basal/bolus regimen more often, also in exercise, illnesses.
During illnesses: insulin requirement increases. Extrafluids to avoid dehydration, if no solids are tolerated, sugar containing foods can be given to maintain some caloric intake and prevent hypoglycemia. If no PO or vomiting ER
Every 3 months
Values depend on age:
7.5- 8.5% toddlers and preschoolers (<6y)
<8% school age children (6- 12y)
<7.5% adolescents and young adults (13-19y)
URINE OR BLOOD KETONES
should be monitored when blood glucose values are elevated (>250-300), when children have a fever, or when they are not feeling well.
At Dx of DM and then every 1-2y because of the association with other autoimmune disease.
Once the child is 10y and has had DM for 3-5years. Yearly F/U. Retinopathy not seen before 5-10 years.
After the child is 10y and has had DM for 5years.
Changes in nerve conduction may be seen after 4-5 years
If >10y treat with statins if LDL >160mg/dl
Consider treatment if LDL > 130mg/dl and other risk factors.
Life long process to the patient and families.
Plan: - CBG before meals, bedtime, 2am
Insulin Lantus 20Units SC daily
- Humalog SS: