Endocrinological Conditions Flashcards
(18 cards)
Congenital adrenal hyperplasia management
Corrective surgery for external genitalia
Definitive surgery delayed until puberty
Acute (salt losing crisis) - IV saline, IV hydrocortisone, IV dextrose
Long term - lifelong hydrocortisone to suppress ACTH, fludrocortisone if salt loss, monitor growth, skeletal maturity, androgens and 17 alpha hydroxyprogesterone levels
Congenital hypothyroidism management
Thyroxine started within 2-3 weeks
Lifelong oral thyroxine
Delayed puberty management
Boys - observation, otherwise short course of oxandrolone or testosterone
Girls - observation, otherwise short course of oestrogen
Diabetic ketoacidosis diagnosis
Plasma glucose >11mmol/L
Ketosis (plasma ketone >3mmol/L or ketonuria >++)
Acidosis (pH <7.3 or HCOS <15mmol/L)
Diabetic ketoacidosis initial management
Cared for with one to one nursing either in HDU or general ward if
- <2 yrs
- Severe DKA
Diabetic ketoacidosis fluid therapy management
If clinically dehydrated
- fluid bolus of 10ml/kg over 30 minutes
Total fluid requirement = estimated fluid deficit + maintenance requirement
5% fluid deficit in mild DKA (pH 7.2-7.29)
7% fluid deficit in moderate DKA (pH 7.1-7.19)
10% fluid deficit in severe DKA (pH < 7.1)
Fluid bolus at 10 ml/kg.
* Shocked patients: fluid bolus volume does NOT need to be subtracted from estimated fluid deficit.
* Non-shocked: subtract from total fluid deficit.
0.9% saline without added glucose should be used for rehydration and maintenance until plasma glucose is < 14 mmol/L
Change to 0.9% saline + 5% glucose after plasma glucose drops below 14 mmol/L
Ensure all fluids (except boluses) administered to children with DKA contain 40 mmol/L potassium chloride (unless anuric or potassium >5.5mmol/L)
Only consider stopping IV fluids if ketosis is resolving, the child is alert, and can take oral fluids without nausea or vomiting
Diabetic ketoacidosis insulin therapy management
IV insulin infusion 1-2 hours after beginning IV fluid therapy in children with DKA
Soluble insulin infusion at a dose 0.05-0.1 units/kg/hour
Continue any long-acting insulin that a child is already on
If the blood ketone level is NOT falling after 6-8 hours, think about increasing the insulin dosage to 0.1 units/kg/hour or more AND seek senior help
Do NOT change from IV insulin to SC insulin until ketosis is resolving (<1 mmol/L), the child is alert, and can take oral fluids without nausea or vomiting
Start SC insulin in the child at least 30 mins BEFORE stopping IV insulin
If using an insulin pump, start the pump at least 60 mins BEFORE stopping the IV insulin
Consider the use of inotropes in a patient with DKA who is in hypovolaemic shock
Consider sepsis in a patient with DKA who has any of:
* Fever or hypothermia
* Hypotension
* Refractory acidosis
* Lactic acidosis
Diabetic ketoacidosis monitoring during therapy management
Monitor vitals every hour
Monitor consciousness and heart rate every 30 minutes in children <2 and severe DKA
Monitor using continuous ECG to detect hypokalaemia
Diabetic ketoacidosis complications
Cerebral oedema
- suspect if headache, agitation, fall in HR, increased BP
- treat with mannitol or hypertonic sodium chloride
Hypokalaemia (<3mmol/L)
- consider temporarily stopping infusion
VTE - increased risk in DKA
Diabetes mellitus types of insulin therapy
Multiple Daily Injection Basal-Bolus - short-acting insulin or
rapid-acting insulin analogue before meals, with 1 or more separate daily injections of intermediate acting insulin or long-acting insulin analogue
Continuous Subcutaneous Insulin Infusion (insulin pump therapy) - programmable pump and insulin storage device that gives regular or
continuous amounts of insulin by subcutaneous cannula
One, Two or Three Insulin Injections Per Day: injections of short-acting insulin or rapid-acting insulin analogue mixed with intermediate-acting insulin
Offer multiple daily injection basal-bolus insulin regimens from diagnosis, otherwise continuous subcutaneous insulin infusion (CSII or pump therapy)
Diabetes mellitus monitoring and target
Routinely perform at least 5 capillary glucose tests per day
Fasting plasma glucose and at other times in the day: 4-7 mmol/L
After meals: 5-9 mmol/L
If driving: > 5 mmol/L
Offer ongoing real-time continuous glucose monitoring with alarms for children with:
- Frequent severe hypoglycaemia
- Impairment awareness of hypoglycaemia with adverse consequences
- Inability to recognise or communicate symptoms of hypoglycaemia (e.g. cognitive disability)
HbA1c target < 48 mmol/L (6.5%)
Diabetes mellitus complications
Diabetic retinopathy, nephropathy, and hypertension – monitor annually from 12 years
Thyroid disease at diagnosis and annually until transfer to adult services
Hyperthyroidism management
Carbimazole or propylthiouracil - risk of neutropenia - educate on sore throat or fever whilst on treatment
Beta blockers for symptomatic relief
Hypocalcaemia management
Acute - IV calcium gluconate
Chronic - oral calcium, high dose vitamin D analogous, urinary excretion monitored
Hypoglycaemia mangement
Mild to moderate
- fast acting glucose
- small amounts if vomit
- recheck blood in 15 minutes
- oral complex long acting carbohydrate to maintain
Severe
- in hospital
- IV 10% glucose
- otherwise IM glucagon or concentrated oral glucose
Obesity management
In primary care
Treatment considered if BMI is above 98th decile
Lifestyle modification
Orlistat - >12 with extreme obesity
Precocious puberty management
Gonadotrophin-Dependent Precocious Puberty (raised FSH and LH)
- manage associated brain neoplasms
- GnRH agonist (leuprolide) can suppress puberty via negative feedback
- GH therapy
- Cryproterone (anti-androgen) is used by specialists
Gonadotrophin-Independent Precocious Puberty (low FSH and LH)
- McCune Albright or Testotoxicosis - ketoconazole or cyproterone, GnRH agonist, aromatase inhibitors
- Congenital Adrenal Hyperplasia - adjustment of hydrocortisone therapy, GnRH agonist
Severe hypercalcaemia management
Rehydration
Diuretics
Biphosphonates
