Diabetes and Endocrine Flashcards
Classification of diabetes
Type 1: autoimmune beta cell destruction
Type 2: insulin resistance followed by beta cell failure
Maturity onset diabetes of the young
Medications .e.g. corticosteroids
Pancreatic insufficiency .e.g. cystic fibrosis, thalassaemia
Endocrine disorder .e.g. Cushing
Genetic/chromosomal syndromes .e.g. Downs, Turners
Neonatal: transient and permanent
Gestational diabetes
Presentation diabetes
Excessive drinking (polydipsia) Polyuria Weight loss Enuresis Skin sepsis Candida and other infections
Presentation DKA
Smell of acetone on breath Vomiting Dehydration Abdominal pain Hyperventilation (Kussmaul breathing) Hypovolaemic shock Drowsiness Coma and death
Aetiology T1DM
Molecular mimicary between environmental trigger and antigen on beta-cell surface of pancreas
Possible triggers: enteroviral infections, cow’s milk protein, overnutrition
Autoimmune destruction of the pnacreatic B cells causing insulin deficiency
T1DM associated diseases
Hypothyroidism
Addisons disease
Coeliac disease
Rheumatoid arthritis
Markers of beta-cell destruction
Antibodies to glutamic acid decaroxylase, islet cells, insulin
Diagnosis T1DM
Raised random blood glucose >11.1mmol/L Glycosuria Ketosis Fasting blood glucose >7mmol/L Raised HbA1c
Features T2DM
Severely obese children Family history PCOS in females Acanthosis nigrican: velvety dark skin in armpits or neck Skin tags
Patient education T1DM
Basic pathophysiology Insulin injection tech and sites blood glucose monitoring to allow insulin adjustment Blood ketones when unwell healthy diet: carb counting Regular exercise Insulin sick day and exercise adjustment Recognition of hypoglycaemia How to get advice 24/7 psychological impact of life long condition
Insulin
All insulin used in children is human
Concentration 100units/ml (U-100)
Types:
-rapid acting insulin analogues .e.g. insulin lispro
-long acting insulin analogues .e.g. levemir, lantus
-short acting soluble human regular insulin
-Intermediate acting
- predermined mixed preparations with 25-30% short acting component
Short acting insulin properties
Effect within 30-60m Peak effect 2-4h Duration 8h Given 15-30m before food E.g. Actrapid, Humulin S
Intermediate acting insulin properties
Onset 1-2h
Peak 4-12h
Isophane insulin: insulin and protamine .e.g. insulatard, Humulin I
Insulin injection technique
Subcutaneous injection
Anterior and lateral aspect of the thigh, buttocks and abdomen
Rotation of sites
Cx of repeated site use: lipohypertropy, lipoatrophy
Skin gentley pinched and insulin injected at 45’
Long needles/high angle causes painful bruised IM injection
Shallow dermal injections cause scarring
Factors increase blood glucose
Insufficient insulin Food especially carbohydrates Illness Menstruation (shortly before onset) Growth hormone Corticosteroids Sex hormones at puberty Stress
Factors decreasing blood glucose
Insulin Exercise Alcohol Some medications Marked anxiety/excitement Hot weather
Diet with T1DM
Match insulin dose to carbohydrate intake
High complex carbohydrate
Modest fat content <30% calories
High in fibre: sustained release of glucose
Monitoring blood glucose
Pre-meal 4-7mmol/L target
Diary of insulin doses and blood glucose
Typically BM taken before breakfast, lunch, dinner, bed
During illness, change in routine >5 tests per day
Blood ketone testing during illness or with poor control
HbA1c shows control over previous 6-12w
-misguiding in reduced rbc lifespan e.g. sickle cell, thalassaemia
Presentation hypoglycaemia
Hunger Tummy ache Pallor Irritability/ Unreasonable behaviour Sweatiness Feeling faint/dizzy/wobbly Seizure/coma
Mx Hypoglycaemia
Administration of easily absorbed gluycose .e.g. glucose tablets, sugary drink
Oral glucose gels on buccal mucosa
Glucagon injection kit for severe hypo with reduced GCS- IM glucagon
Ix DKA
Blood glucose <11.1mmol/L
Blood ketones >3mmol/L
Urea, electrolytes, creatinine (dehydration)
Blood gas analysis (severe metabolic acidosis)
Blood and urine cultures (indicated if infection underlying cause)
Cardiac monitoring: T wave changes in hypokalaemia
Weight (assessing dehydration)
DKA can cause a neutrophilia
Mx DKA
Fluids 0.9% saline 10ml/Kg in shock Gradual correction of dehydration over 24hrs Insulin infusion Potassium Identify underlying cause
Long term Cx T1DM
hypertension coronary heart disease cerebrovascular disease retinopathy nephropathy neuropathy
Problems with diabetes control
Eating too many sugary foods Infrequent or unreliable blood glucose testing Illness Exercise Eating disorders Family disruption Inadequate family motivation
Annual assessment diabetes
Normal growth and pubertal development Blood pressure check for hypertension Renal disease: screening for microalbuminuria Circulation: pulse and sensation Eyes: retinopathy and cataracts Feet: good foot care Screening for caeliac (only on presentation), thyroid Annual flu vaccination
Diabetic changes in puberty
Growth hormone, oestrogen and testosterone antagonise insulin action
Increase in insulin requirement during puberty to 2U/Kg/day
Increase marked during morning due to peak growth hormone secretion overnight
Ix Hypoglycaemia
Lab blood glucose
Growth hormone, IGF-1, cortisol, insulin, C-peptide, fatty acids, ketones, glycerol, branched-chain amino acids, acylcarnitine profile, lactate, pyruvate
Urine organic acids
