SICK-DAY MANAGEMENT
Children With Diabetes
Friends for Life Conference
Orlando, FL
July 23 – 27, 2008
H. Peter Chase, MD
Professor of Pediatrics
University of Colorado Denver
Barbara Davis Center for Childhood Diabetes
1
DIABETES EDUCATION:
The cornerstone for optimal care and outcome.
“Apple pie and Motherhood”
 New-onset (1-3 days)
 Daily phone contact, one week, one month –
every three months
 Understanding Diabetes: 15,000 copies/year
“ The Pink Panther Book”
 “The First Book” (Synopsis of “big book”)
53,000 copies last year
(available: 1-800-695-2873 or free on the internet at: www.barbaradaviscenter.org)
2
SICK-DAY MANAGEMENT
1) People with diabetes get sick just like
anyone else.
2) Average = 6 known infections per year in
children.
3) Four main concerns:
I. Dehydration
II. Hyperglycemia (high BG)
III. Ketones (DKA)
IV. Hypoglycemia
3
I. DEHYDRATION
(loss of body fluids)
1) Can occur in anyone if fluid intake is not adequate.
2) More likely with diabetes because the glucose pulls
water out of the body for excretion in the urine (can’t
excrete sugar cubes).
3) Diabetes is the only disease in which someone can be
dehydrated and still pass much urine.
4) The higher the BG, the more water that is “pulled” out
of the body.
5) Vomiting and not drinking adequate fluids add to the
problem.
6) A good physical sign to look at is often the dryness of
the tongue.
DEHYDRATION/VOMITING*
1) May need a medicine to stop vomiting:
Phenergan: children over age 2 years
Zofran: oral
2) Fluids – Start slowly: Pedialyte, juice, water
BG <100: Fluids with sugar; popsicles, jello, etc.
- Gradually increase to requirement of 1 oz/yr of
age/hour for up to age 16 yrs.
3) The fluids help to “wash-out” sugar and ketones, to restore
circulation, BP and other parameters.
4) Solid foods: When no further vomiting
(e.g. crackers, banana, soup, what child wants)
* Understanding Diabetes – page 178
5
II) HYPERGLYCEMIA
(High blood sugar)
1) Many infections cause release of cortisone
which raises BG (e.g. Mumps).
2) Make sure ketones are not present.
3) Give usual insulin plus extra injections or
boluses every 2 hours. Use usual
correction factor (most common is 1 unit/50
mg/dl over 150).
4) Frequent blood sugars is a key.
6
III. KETONES (DKA)
1) MUST CHECK KETONES WITH ANY ILLNESS (even
vomiting one time) OR IF HIGH BG (e.g. >300mg/dl).
2) Education about ketone testing is the most common
deficiency in families referred to our Center.
3) If ketones build up = DKA.*
4) DKA is the number one cause of death in children with
diabetes.
5) DKA is almost completely preventable in a properly
trained family.
*(Understanding Diabetes, Chapter 15, page 163)
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WHAT CAUSES KETONES?*
1) INFECTIONS – number 1. Due to fat breakdown
to supply extra energy and secondary to
increased cortisol.
2) MISSED INSULIN → fat breakdown.
3) PUMP INSERTION DISLODGING.
4) NOT ENOUGH INSULIN.
5) TRAUMATICE STRESS ON BODY.
*Understanding Diabetes – page 164
8
WHERE DO KETONES COME FROM?
Fatty Acids and Glycerol
Fat
Liver
Acetyl-CoA
+ Oxaloacetate
Hydroxybutyric acid (-OHB)
TCA Cycle for energy
Acetoacetic acid (AcAc)
Acetone
9
HOW TO CHECK FOR KETONES
1. MUST ALWAYS HAVE A METHOD IN THE HOME and
ALONG ON TRIPS.
2. Urine test: cheapest; not as accurate as urine may not
reflect current status. Ketostix – good for 6 months
once bottle opened (get foil-wrapped!).
3. Blood meter: PrecisionXtra
•
More expensive; most accurate – gives the exact level at
time of testing.
•
Many families do only if can’t get urine or if urine test
high.
•
More apt to do (93%) than urine (53%) when ill.
10
COMPARISON OF BLOOD and URINE
KETONES:*
Blood (mmol/L)
Urine
< 0.6
negative
0.6 to 1.5
small to moderate
1.6 to 3.0
usually large
≥ 3.0
go directly to the E.R.
Very large
*Understanding Diabetes – page 30
11
The Annual ADA Standards of Care
states:
“Blood Ketone testing methods that
quantify ß-HBA, the predominant ketone
body, are available and are preferred
over urine ketone testing for diagnosing
and monitoring ketoacidosis.”
ADA Clinical Practice Recommendations: Jan, 2003 Position Statement:
Diabetes Care, S107, 2003
12
-hydroxybutyrate is a better indicator of metabolic
status when detecting and treating DKA*
* Schade DS, Eaton RP Special Topics in Endo and Metab 1982;4:1-27
13
Old Paradigm: Check urine ketones
New Paradigm: Check blood -OHB
 Blood -OHB tells you how you are doing at
the time of the test
(Urine may have been in bladder for hrs)
 Urine ketone levels may not accurately reflect
the severity of the problem
 A person may not be able to void
 Some (teens) give false urine test results
14
New Paradigm: Check blood -OHB (cont.)
 Some people are too ill/exhausted to do the
urine test
 Urine ketone strips spoil after opened x >6
months
 Urine strips check for AcAc, whereas the more
important ketone is -OHB
 Use of blood -OHB test may save an ED visit
or a life!
15
If Money/Insurance Is a Problem:
1. Can test urine ketones
(If a sample can be obtained)
2. Skip the blood ketone test if the urine
test is negative, trace or small
3. Use the blood strips anytime the urine
test is moderate or large
16
Why are ketones dangerous?
 Acidosis ensues as ketones build up
  - Hydroxybutyric acid (-OHB) is the
main ketone
 Glucose is high: dehydration
 Potassium is lost 
 GI motility
 vomiting
 The “acid” state of the body interferes with
body metabolism
17
Diabetic KetoAcidosis (DKA)
 160,000 Admissions to private
hospitals/year

Cost = over 1 billion $ annually
 65% = <19 years old
 Main cause of death in children with
diabetes (approximately 85%)
 Cerebral edema in 69% of deaths
18
Signs of DKA:
i)
Increased urination
ii)
Stomachache, vomiting
iii)
Fruity odor to breath
iv)
Dry mouth and tongue
v)
Drowsiness
vi)
Deep breathing
vii) Coma
viii) Death (very rare if treated early)
19
Denver DKA Data (ED or Hospitalization)
(Rewers, Chase, et al: JAMA 287:2511,2002)
 Definition: an episode of DKA leading to an
ED and/or hospital admission
 1243 children living in metro Denver with
known type 1 diabetes (not new onsets)
 3994 person years of f/u (1/1/1996-12/31/2002)
 Infancy to age 19 yrs
 Incidence: 8 per 100 patient-years
20
TREATMENT:
(Directions from Understanding Diabetes* page 167)
-OHB level (mmol/L)
1) 0.6 – 1.5 = Take 10% of total daily
insulin dose every 2 hrs;  fluids;
Call HCP.
2) > 1.5 – 3.0 = Take 20% of total daily
insulin dose every 2 hrs;  fluids.
Must call HCP.
3) >3.0 = Go to ED.
*available: www.barbaradaviscenter.org or call: 1--800-695-2873
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TREATMENT:
“Mild” Ketones*
•A much more common problem than severe
DKA.
•Almost every child with diabetes has 1-4 times
annually after the “honeymoon” period is over.
•By definition: Able to be handled in the home
setting – usually with telephone help from the
HCP. Always take phone numbers on trips!
*Small - moderate urine ketones or blood ketone
level <3.0 mmol/L.
22
“Mild” Ketones: Denver Data on
Phone – Management:
Chase et al:
i)
Ped in Review 11:297, 1990
ii) Arch Pedriatr Adolesc Med 152:672, 1998
57 children, ages 1 – 18 yrs.
Small ketones = 4 pts
Moderate ketones = 22 pts
Large ketones = 31 pts.
Time to resolution: Mod = 4.1 Hrs
Lge = 4.5 Hrs
Four children = ED and/or Hospital (6%)
23
Sick Day Management Study*
Goal: To evaluate the impact on hospitalizations of a blood
ß-hydroxybutyrate (ßOHB) test vs. urine ketone tests
Design:
• 123 participants, ranging in age from 3–23 years
• 61 participants randomized to use blood ßOHB
measurements using the Precision Xtra™ Advanced Diabetes
Management System
• 62 participants randomized to use traditional urine
acetoacetate measurement using Ketostix®
• All participants were trained on their sick-day guidelines
• Data collected included episodes of illness, ER visits,
hospitalizations, blood glucose testing frequency, ketone
testing frequency and A1c (glycohemoglobin)
*From Laffel et al, Poster 426-P, presented at ADA Scientific Sessions, San Francisco June 2002
24
Testing for Ketones When ill
123 Adolescents randomized:
 62 to blood OHB
 61 to urine ketone testing
Sick Days
Checked for Ketones
OHB = 304
91%
Urine K = 279
56%
(Laffel L et al, Diabetes 51,426P,2002)
25
Summary: Study Findings
• Participants managed with blood ßOHB
ketone test during sick days were 46%
less likely to require an ER visit
• Participants managed with blood ßOHB
ketone tests during sick days were 64%
less likely to be admitted to the hospital
• 70% of those participants testing blood
ßOHB reported they would check blood
ketones more often than urine ketones
(Laffel L et al, Diabetes 51,426P,2002)
26
Directions in Understanding Diabetes
regarding blood -OHB (page 166)
-OHB level (mmol/L)
< 0.6 = Normal
0.6 to 1.0 = Take extra insulin + fluids
1.0 to 1.5 = Same; call HCP
1.5 to 3.0 = Call HCP STAT
> 3.0 = Go to ED
27
CASE EXAMPLES
11 yo ♀; Mom calls (10:00 am)
•Home from school with fever
•Rapid-strep test positive yesterday
•Treatment with penicillin
•BG 380 mg/dL; -OHB = 1.3 mmol/L
•Usual AM insulin: 4 H/12 NPH – 7:00pm: 4H/20 Lantus
(40 units total per day)
•Plan: 4 units H every 2 hrs until -OHB <0.6
Encourage fluids (juice if BG <150)
28
CASE EXAMPLES:
4 yo ♂; GI flu
7:00 am:
Mother phoned: emesis x 5 thru night
1st void since 9 pm
BG = 180 mg/dL; Urine ketones = Large
? Take extra insulin ?
Advice:
Do blood -OHB level
7:15 am:
Blood -OHB = 0.3 mmol/L (normal)
Advice:
No extra insulin; Usual dose + fluids
9:00 am:
Urine ketones neg; feeling fine
29
CASE EXAMPLE:
14 yo♂; Pump failure
Time
-OHB
Art. pH
BG (mg/dL)
11 am
> 6.0
7.02
1042
2:30 pm
5.7
7.2
409
5 pm
3.0
7.23
267
7:30 pm
1.7
7.34
162
8:30 pm
0.2
7.45
119
30
CASE EXAMPLES:
Diabetes Camp
7:00 am:
4 children with moderate urine ketones,
which one(s) need to go to the infirmary?
-OHB level (mmol/L)
#1:
10 yo ♂; BG = 276/mod
0.3
#2:
13 yo ♀; BG = 303/mod
0.5
started menses
#3:
9 yo ♀; BG = 240/mod
1.7
upset stomach
#4:
9 yo ♂; BG = 320/mod
URI, Homesick
0.4
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III) KETONES
SUMMARY
 DKA is a serious illness and complication
of diabetes.
 Checking serum -OHB early (and often
when elevated) and implementing proper
treatment can lead to early resolution and
MAY BE LIFE-SAVING!
 Use of blood -OHB testing likely saves
money in the prevention and treatment of
severe DKA.
32
SICK DAY MANAGEMENT:
IV. HYPOGLYCEMIA
1) When treating Dehydration (I above) or Ketones (III
above), must add fluids with sugar when the BG is
<150 mg/dl (<8.3 mmol/L) (Ketones may still be
present and need to continue giving insulin every 2
hours to turn ketone production off – so must keep
BG up in safe range).
2) Pedialyte, Gatorade, Jello, Popsicles are examples
of early liquids in Table 4, page 179.
3) Solids (when ready) might include: soup, crackers,
bananas, apple sauce (page 179).
4) Frequent checks of BG (and/or CGM) are essential.
33
IV: HYPOGLYCEMIA:
A Low Dose of Glucagon:
(page 178 – Understanding Diabetes)
1) NOT the larger (0.3, 0.5, 1.0 cc) dose used for a
severe low.
2) Use if BG is low (e.g. <60 mg/dl [<3.3 mmolL])
and food cannot be kept down.
3) Dose: 1 unit/year of age up to 15 units.
4) Can repeat every 20 minutes if needed.
5) Has done more to save ER visits than anything
else in my career.
34
INSULIN DOSAGE WITH ILLNESS:
(page 176 – Understanding Diabetes)
1) Some insulin MUST ALWAYS be taken (to
keep ketones turned off).
2) If BGs are low – may only need basal
insulin (Lantus, Levemir) or basal insulin in
pump.
3) If trace/small ketones with low or normal
BG, may just need to eat (to provide
calories and stop fat breakdown).
4) If high BG or ketones, extra rapid-acting
insulin every 2 hours (as above).
35
EXERCISE WITH ILLNESS
1) Don’t exercise with moderate or large urine
ketones or with blood ketones above 0.6 mmol/L.
Exercise results in increased adrenalin
(epinephrine) output which can further increase
ketones.
2) It is an “old wives tale” that one can’t exercise
with high BG when ketones are negative (the
increased utilization of glucose overrides any
adrenalin effect).
3) Use common sense.
36
SUMMARY: SICK DAY
1) Sick days require a bit more work for
people/families with diabetes – but can be
managed.
2) Illness – related factors (e.g. sore throat)
should be handled by the primary care MD
and diabetes – related factors (ketones,
insulin dose, etc.) by the diabetes team.
3) Good education, as with all of diabetes
management, is the key to handling sick-day
management.
4) QUESTIONS?
37