Sick Day Management
Ragnar Hanas, MD, PhD, Department of Pediatrics, Uddevalla, Sweden
Pediatric and adolescent diabetes in Sweden
-
Sparsely populated with large geographical distances
-
High diabetes incidence
(3rd in the world after Finland and Sardinia)
-
~7000 children and adolescents up to the age of 20
~700 new cases/year (0 -18 years)
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R Hanas, CWD 2006
How do we care for our patients?
-
Almost everyone is cared for at pediatric departments,
the majority by a pediatric diabetologist
-
None are seen by GP:s
-
40 centers, the largest with ~ 500 patients,
but most have 75 -150
-
Some travel 150 - 200 km to see their diabetologist
-
50 -100 patients / diabetologist
-
75 - 150 patients / diabetes nurse
-
Teams with dietician, psychologist,
counselor (social worker)
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R Hanas, CWD 2006
Modern treatment of childhood diabetes
Traditional approach
-
Insulin, diet, and exercise
Diabetes treatment today
-
Insulin, love and care
- Prof. Johnny Ludvigsson
-
Knowledge There is nothing that is forbidden,
you can always try something and
find out what works for you
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”To dare is to lose foothold for
a short while - not to dare is to
lose yourself”
Sören Kierkegaard
Danish philosopher 1813-55
R Hanas, CWD 2006
What goals do we have?
-
The family is encouraged to
take active part in diabetes
and adjusting doses
-
”It is no fun having diabetes
- but you must be able to
have fun even if you have
diabetes”
- Prof. Johnny Ludvigsson
-
Must know more than
the average doctor to
manage your diabetes
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R Hanas, CWD 2006
Important to learn for life...
- After one year you will have
experienced most things
-
“Then
we want to learn from you!”
- The clinic will function as an
“intelligence center” with input from
all families
”Give a man a fish and he will not go
hungry that day. Teach him how to
fish and he will not be hungry for the
rest of his life.”
Chinese saying
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R Hanas, CWD 2006
Try to keep on living as usual in the family...
- It is our job to adjust the insulin doses to the
child, not the other way around
- Your job is to continue with important things
you used to do, like mountain-biking, going
for skiing vacation or a trip on the sea
- It is important to come
back to your ordinary
parent-child rules in
the family
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R Hanas, CWD 2006
Healthy or sick?
Healthy
-
Start with the need of food in your body
- Take insulin to the food
- Adjust the dose according to the carbohydrate content
Sick
- Start with the need of insulin in your body
- Take food and drink to the insulin
- Eat and drink to give the insulin sugar “to work with”,
for example sweet drinks in small but frequent sips.
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R Hanas, CWD 2006
Sick with fever
- The child usually eats less but
the fever requires more insulin
- Begin by taking the same
insulin doses as usual
- 100° F - often 25% increase of doses
102° F - up to 50% increase of doses
- Monitor BG before and after each meal
Urine ketones at every voiding & in blood if positive
- Check blood/urine ketones if vomiting or nauseous
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R Hanas, CWD 2006
Insulin during sick days
Illness that raises BG
- Increase doses if needed:
High BG prior to a meal -  premeal dose by 1 - 2 U or
according to correction factor
Multiple inj. Pump
-
 next day basal insulin by 1-2 U
 basal rate by 10-20%
(if needed up to 40-50%)
High BG 1 - 2 h. after a meal -  next day premeal dose
by 1 - 2 U
- Adjust doses according to body weight
- Persons in remission phase may need to
increase up to 1 unit/kg/day very quickly!
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R Hanas, CWD 2006
Beware of vomiting when having diabetes!
-
Vomiting or nausea?
- Caused by lack of insulin?!?
-
-
High blood glucose?
Ketones in blood or urine ?
When a child with diabetes vomits it
should always be considered a sign of
insulin deficiency until the opposite is proven!
Vomiting from gastroenteritis should
be considered only when a lack of
insulin has been excluded!
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R Hanas, CWD 2006
Gastroenteritis
- Vomiting with diarrhea
or only diarrhea
- Low blood glucose levels
- Always check for ketones
in blood or urine!
- Vicious circle with ketones nausea - eats less - more ketones
- Decrease doses if needed:
Low BG prior to the meal -  premeal dose by 1 - 2 U
or according to correction dose
Multiple inj. -  next day basal insulin by 2-4 U
Pump
-  basal rate by 20-40%
Low BG 1-2 h. after a meal -  next premeal dose by 1 - 2 U
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R Hanas, CWD 2006
Gastroenteritis
- Give drinks containing sugar (not Light) in small and frequent
portions (several sips every 10-15 min.)
- Sweet ice cream or yoghurt may work well
- Never miss a chance to give something
containing sugar!
- Keep records of how much the child has had to drink
- Begin with solid foods as soon as the vomiting stops or
decreases
- Mini-doses of glucagon work well when everything else fails
< 2 years:
2 “units” in a U-100 syringe
> 2 years:
1 “unit”/year up to 15 “units” (0.15 mg)
Repeat after 1 hour or more if needed
Haymond MW. Diabetes Care 2001;24:643-45.
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R Hanas, CWD 2006
Increased risk of ketoacidosis when ill
- Relative insulin deficiency if doses are not increased
- Nausea/vomiting makes it difficult to eat
- Therefore it may be difficult to increase insulin doses
- Small insulin depot with a pump
- insulin deficiency develops quickly if there is a pump
failure when you are ill
- Drink more to prevent dehydration!
Sugar-free fluids if BG is > ~220 mg/dl
Fluids containing carbohydrates
if BG < ~220 mg/dl (~12 mmol/l)
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R Hanas, CWD 2006
High blood glucose and ketones
Repeated BG > 270 mg/dl (15 mmol/l) and ketones
-
Risk of developing ketoacidosis!!
- 0.1 U/kg with pen or syringe
(preferably Humalog/NovoLog)
- Risk of over-correction - hypoglycemia
- Check BG and ketones every hour
If BG is not decreasing:
Repeat dose every 1-2 hours
(/2-3 hours with regular insulin)
- The blood ketone level may increase after 1 hour but should be
much lower after 2 hours
- Urine ketones stay elevated for many hours
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R Hanas, CWD 2006
Vad happens to the carbohydrates from the food?
Stored sugar in the
liver (glycogen)
Insulin from the
pancreas
Carbohydrates
from food
Fat/muscle cell
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R Hanas, CWD 2006
A healthy cell
Cell
Insulin
Blood
vessel
Urine test shows
O2
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CO2
Water
Energy
Glucose Ketones
0
0
R Hanas, CWD 2006
Starvation
Cell
(Insulin)
Blood
vessel
Urine test shows
Fatty
acids
in liver
Ketones
Glucose Ketones
0
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+
R Hanas, CWD 2006
Diabetes - lack of insulin
Cell
Blood
vessel
Urine test shows
Fatty
acids
in liver
Ketones
Glucose Ketones
+++
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+++
R Hanas, CWD 2006
Ketone bodies in a healthy person
Blood vessel
Fatty
acids
Liver cell
Mitochondrion
Starvation
Low insulin
High fat diet
Fatty acyl CoA
Acetoacetate
Acetoacetate
Acetone
Beta-hydroxybutyrate
Beta-hydroxybutyrate
Acetone
Ketones
+
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Ketone bodies are used by the heart,
kidneys, muscles, and brain as fuel
R Hanas, CWD 2006
- 15 prepubertal children
10 adult men
10 adult women
- Children fasted for 30 h.
(part of clinical evaluation
for hypoglycemia
symptoms)
Adults fasted for 86 h.
- Children had much higher
ketone levels than adults
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Blood ketones (Beta-hydroxybutyrate)
Starvation ketones in people without diabetes
mmol/l
men
children
women
0
12
24
36
48
60 72 84
Time, hours
R Hanas, CWD 2006
Ketone bodies increase when there is a lack of insulin
Blood vessel
Fatty
acids
Liver cell
Mitochondrion
Low insulin
Fatty acyl CoA
Acetoacetate
Acetoacetate
Acetone
Beta-hydroxybutyrate
Beta-hydroxybutyrate
Acetone
Ketones
+++
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Fruity breath (Kussmaul breathing)
R Hanas, CWD 2006
Urine ketones can be false neagative!
Blood vessel
Fatty
acids
Liver cell
Mitochondrion
Fatty acyl CoA
Low insulin
Acetoacetate
Acetoacetate
Beta-hydroxybutyrate
Beta-hydroxybutyrate
Ketones
0
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Ketones can only be detected by
blood testing
R Hanas, CWD 2006
Urine ketones decrease slowly after insulin treatment
Blood vessel
Fatty
acids
Liver cell
Mitochondrion
High
insulin
Fatty acyl CoA
Acetoacetate
Acetoacetate
Acetone
Beta-hydroxybutyrate
Beta-hydroxybutyrate
Acetone
Ketones
+++
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Acetone is deposited in fat tissue
R Hanas, CWD 2006
Effects of insulin treatment
-
Blocked production of
ketones in the liver
-
Blocked production of
glucose in the liver
-
Increased uptake of
glucose in tissue
How is the blood glucose
decreased when treating
ketoacidosis?
Increased
dose
needed
DeFronzo RA et al. Diabetes
Reviews 1994;2:209-38.
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R Hanas, CWD 2006
Blood ketones and ketoacidosis
55 children, age 10.4 ± 3.9 y. with BG > 11.1 mmol/l (200 mg/dl)
and ketones in urine. 37 had ketoacidosis (pH < 7.30)
- Good correlation between patient method and lab. method
- Blood ketones > 1.5 mmol/l - 85% had ketoacidosis but only
2 pat. with blood ketones < 2.9 mmol/l had ketoacidosis.
Lab b-hydroxybutyrate
Ham MR et. al. Ped Diab 2004;5:39-43.
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R Hanas, CWD 2006
Measuring ketones in blood vs. urine
>100,000 episodes of DKA annually in the U.S.
- 86 children, ages 2-18 (>0.5 units insulin/kg/day)
unless <5 years old, with >0.3 units/kg/day.
- 73 children on intensified insulin regimes and 18 used pumps.
- 3900 concurrent pairs of blood and urine ketone tests were
obtained.
- 7783 concurrent pairs of BG and blood ketone tests were
obtained.
Laffel LMB. Diabetes 2002;51(suppl 1):A105.
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Slide from S Brink
R Hanas, CWD 2006
Measuring ketones in blood
Precision Xtra meter
- Accuracy has been well demonstrated
Cembrowski GS,Diabetes 1999;48.Suppl:Abstract 265.
Byrne HA, Diabetes Care 2000;23:500-503.
- Linear response 0.0-6.0 mmol/L beta-hydroxybutyrate (b-OHB)
- 5 µL blood sample
- Results in 30 seconds
- No interference by acetoacetate, acetone, lipids, etc.
- No interference by common therapeutic
agents (Captopril, L-DOPA, vitamin C, etc.)
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R Hanas, CWD 2006
Measuring ketones in urine
KetoStix
- It detects acetoacetate.
- Results read from a color chart are
Negative, trace (5 mg/dL),
small (15 mg/dL), moderate (40 mg/dL),
and large (80-160 mg/dL).
- User timing is required. Read color at exactly 15 seconds after
removing reagent strip from urine.
- Proper read time is critical for optimal results. Must ignore color
changes that occur after 15 seconds.
- False-negative results when sticks have been exposed to air och
after eating much vitamin C (acidic urine)
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R Hanas, CWD 2006
Measuring ketones in blood vs. urine
Relationship between blood and urine ketones
b-OHB, mmol/L
>1.0
0.6-1.0
0-0.5
UKET
b-OHB
N
Tr
S
M
L
0-0.5
3420
282
47
17
7
UKET
Moderate to Large
Small
Negative to Trace
0.6-1.0
65
29
26
20
7
1.1-1.5
10
2
3
4
6
1.6-3.0
4
9
1
4
9
>3.1
1
1
1
2
13
- On 15 occasions blood ketones were moderate to large but the
urine ketones were negative!
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Slide from S Brink
R Hanas, CWD 2006
Measuring ketones in blood vs. urine
- Relationship between blood and urine ketones
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Slide from S Brink
R Hanas, CWD 2006
Measuring ketones in blood vs. urine
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Slide from S Brink
R Hanas, CWD 2006
Measuring ketones in blood vs. urine
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Slide from S Brink
R Hanas, CWD 2006
Measuring ketones in blood vs. urine - conclusions
- Use of urine ketones may lead to inappropriate decisions
regarding the severity of illness in insulin-treated children.
- The advantages of monitoring blood ketones include:
- Real-time direct measurement of the predominant ketone body
- Patient acceptance and improved compliance
- Careful monitoring of BG and blood ketones, plus supplemental
insulin and hydration, may enhance sick-day guidelines and help
to prevent ketoacidosis in children.
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R Hanas, CWD 2006
Measuring ketones in blood vs. urine - conclusions
123 children aged 3-22 years
- Check ketones:
When blood glucose was consistently > 13.9 mmol/l (250 mg/dl)
During acute illness or stress
- 6 months follow-up:
21548 days
578 sick days
60% fewer hospitalizations
40% fewew emergency assessments
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Laffel LMB. Diab Med 2005;23:278-84.
Frequency of ketone measurements
R Hanas, CWD 2006
How should blood ketones be interpreted?
Ketones
BG 180-270
< 0.5 mmol/l
No problems
270-400 mg/dl
>400 mg/dl
Test again after 1-2 hours
0.5 - 0.9 mmol/l Test again
0.05 U/kg
0.1 U/kg
1.0 - 1.4 mmol/l Eat and take
0.05 U/kg
0.1 U/kg
0.1 U/kg, x 1-2
1.5 - 3 mmol/l
Eat and take
0.1 U/kg
0.1 U/kg. x 1-2
0.1 U/kg. x 1-2
> 3 mmol/l
Eat and take
0.1 U/kg, x 1-2 0.1 U/kg, x 1-2
Samuelsson, Diabetes Tech. 2002
0.1 U/kg
Laffel, poster 426, ADA 2002
Contact your diabetes team or emergency ward!!
-
Every pump user should be able to test blood ketones
-
Also very helpful for younger children
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R Hanas, CWD 2006
How should blood ketones be interpreted?
Ketones
BG
< 250mg/dl
250-400 mg/dl
>400 mg/dl
No change
5%
10%
0.6 - 0.9 mmol/l No change
5%
10%
1.0 - 1.4 mmol/l 0-5%
10%
15%
≥ 1.5 mmol/l
15-20%
20%
< 0.6 mmol/l
0-10%
-
Extra insulin to be given in percentage of total daily insulin dose
-
Don´t use % of daily dose when in remission phase!
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Laffel LMB. Diab Med 2005;23:278-84.
R Hanas, CWD 2006
Sick day rules
-
Monitor glucose (with adult supervision even in adolescents)
every 3-4 h. and occasionally every 1-2 h. with results recorded in
a log book
- Test for ketones every 2-4 h.
Check blood ketones if positive in urine
- Continue monitoring in the middle of the night (no matter how
tired the child or parent is)
- Increased salty fluid intake to combat dehydration.
Always drink something containing sugar
- Check weight every 8-12 h. to monitor for clinical dehydration
- Necessary medical treatment for underlying condition (antibiotics
Stu Brink. Diab. Nutr. Metab.
for tonsillitis, otitis, urinary tract infection)
1999;12:122-35
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R Hanas, CWD 2006
Sick day rules
- Antipyretics (acetaminophen) to treat fever
- Antiemetics if severe vomiting prevents adequate fluid intake
- Continue to give insulin and administer extra doses for as long as
blood glucose and/or ketones are high
- Recognize of when insulin dose (rarely) needs to be temporarily
decreased due to hypoglycemia (needs more sugar intake)
- Contact your health team or hospital if symtoms persist, worsen
or do not get better.
- All too frequently a physician or nurse advises omission of insulin
because the child is ill and not eating!!!
Stu Brink. Diab. Nutr. Metab. 1999;12:122-35
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R Hanas, CWD 2006
When do you need to go to the hospital?
- Large or repeated vomiting
- Increasing levels of ketones or
laboured breathing
al
Hospit
- Continued high BG level > 270 mg/dl
(15 mmol/l) despite extra insulin
- Unable to keep BG > 70 mg/dl (3.5 mmol/l)
- The underlying condition is unclear
- Severe or unusual abdominal pain
- The child is confused or his/her general well-being is affected
Adapted from Silink M. (Ed.) APEG handbook 1996
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R Hanas, CWD 2006
When do you need to go to the hospital?
- The child is young (< 2 - 3 years)
or has another disease besides diabetes
al
Hospit
- Exhausted patients/relatives, for example
due to repeated nighttime waking
- Always call if you are in the least unsure
about how to manage the situation
Adapted from Silink M. (Ed.) APEG handbook 1996
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R Hanas, CWD 2006
Diabetes and surgery
- Schedule surgery first thing in the morning
- I.v. insulin best for major surgery with
general anesthesia
- For minor surgery with local anesthesia,
- take only basal insulin (Lantus or pump)
- Emergency surgery:
I.v. insulin to bring down BG before surgery
- Ketoacidosis can give abdominal pain of the
- same magnitude as appendicitis
- Parents are the “diabetes experts” when
their child is at a pediatric surgery ward!
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R Hanas, CWD 2006
Insulin resistance in changed by the BG level
Blood glucose level
High level due to infection
-  insulin resistance a
Increased doses
- lower BG a
1-2 weeks a
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Back to normal insulin
resistance again a
After a couple of days BG will be lower
- doses need to be lowered a
R Hanas, CWD 2006
Insulin requirements increase with fever
Insulin requirements
Cold with fever a
Infection cureda
Increased insulin
resistance due to fevera
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Continued insulin
resistance a
R Hanas, CWD 2006
Insulin requirements
Insulin requirements decrease when having gastroenteritis
Gastroenteritis with
vomiting, diarrhea a
Infection cureda
Decreased insulin
resistance due to
low BG levelsa
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Continued low
insulin resistance
due to low BGa
R Hanas, CWD 2006
Beware of vomiting when using a pump!
-
Vomiting or nausea?
- Caused by lack of insulin?!?
Especially true when using an insulin pump!!
-
Vomiting caused by pump problems may easily be
mistaken for illness!!
When a child with a pump vomits it
should always be considered as a pump
problem until the opposite is proven!
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R Hanas, CWD 2006
Insulin kinetics increseases ketoacidosis risk
20 adults with type 1 diabetes
Short-acting 125I-insulin
CSII with infusion in the abdomen
2.24U/h
1.12U/h
1.12U/h
Hildebrandt P, Diabetic Medicine 1988;5:434-40
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R Hanas, CWD 2006
How quickly will the ketones rise?
Betahydroxy-buturate, mmol/l
- 10 adults with pump, crossover with Velosulin and Humalog
- Pump stopped between 7AM and 12 AM.
- Blood glucose was ~ 5 mmol/l higher with Humalog after 5 hours
1.4
1.2
1.0
0.8
0.6
Humalog
Velosulin
- All patients with
pumps have blood
ketone meters
0.4
0.2
0
Guerci B et al. J Clin Endo
Met 1999;84:2673-78.
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R Hanas, CWD 2006
Increased risk of ketoacidosis with pump
- Always check ketones
in the urine when you
are not feeling well
mg/dl
Blood glucose mmol/L
- Blood glucose will rise
quickly when insulin
supply is interrupted
Ketones!!
Example of pump problems:
Time
10 AM 12
20
18
16
14
12
10
8
6
4
2
x x
x
x
x
x
x
x
x
x
x
8 10 12 2 4
AM
PM
2 PM
pH
7.28 7.31 7.36
Ketones 3.6 3.0 0.2
BG
high 450 305 mg/dl
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x
6 8 10 12 2 4
AM
6
360
324
288
252
216
180
144
108
72
36
8
Time
New needle
Needle
came loose inserted
R Hanas, CWD 2006
Diabetes equipment to bring on the trip
- Extra insulin pen and/or syringes
(pre-filled pens are handy for this)
- Store in separate
hand luggage
- Thermometer to check the
temperature of the refrigerator
- Test strips + meter
- Extra meter
1 mmol/l = 18 mg/dl
- Finger-pricking device + lancets
- Test strips for ketones (blood and/or urine)
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R Hanas, CWD 2006
Diabetes equipment to bring on the trip
- Dextrose/glucose tablets and gel
- Glucagon
- Clinical thermometer
- Fever suppressing drugs:
Paracetamol/acetaminophen
and/or aspirin /salicylic acid (adults only)
- Oral rehydration solution
- ID indicating that you have diabetes and a necklace/bracelet
- Telephone and fax. numbers for your diabetes clinic at home
- Insurance documents
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R Hanas, CWD 2006
Always call your home team
- You are never longer away from home
than a telephone call
- Ask for a doctor’s contact before leaving home
Check www.ispad.org for names of doctors
- Staying at a hospital where you
don’t understand the language is a
difficult experience
- Try to find a children’s hospital in
an emergency situation
- With glucagon and frequent
monitoring you can prevent most
emergencies!
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R Hanas, CWD 2006
Preventing “The revenge of Montezuma”
- Antibiotics for diarrhea when travelling to Asia, Africa,
Latin/South America or Southern Europe:
- Lexinor® (norfloxacine)
Not for children younger than 12 years old
or pregnant women.
- Dose:
200 mg twice daily for prophylactic use or
400 mg twice daily for 3 days if you are
having acute diarrhea.
- Co-trimoxazole®, Colizole®
(trimethoprim + sulphamethoxazole)
or similar for children younger than 12 years old.
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R Hanas, CWD 2006