This slide deck is material for preparation for the August 19th 2014 Webinar by the same title to be presented at 7:30-9:00PM Central Standard Time in the USA. To register for the webinar go to https://baylorscottandwhiteevent.webex.com/mw0307l/mywebex/default.do?siteurl=baylorscottandwhiteevent

1. Keeping your child with diabetes out of
the hospital or emergency room
Pre-Webinar Resource Material
Stephen W. Ponder MD, FAAP, CDE
Endocrinologist
Baylor Scott & White Healthcare

3. Let’s define type 1 diabetes first
• Type 1 diabetes: aka:
insulin-dependent or
juvenile diabetes
• Affects children and
adults
• “Cured” only by a
pancreas transplant
• Not caused by the patient
in any way
• Increasing in frequency

4. 7 principles of good diabetes control
1. Get organized, review your
data, practice
2. Don’t let “good” be the
enemy of “perfect”
3. Set reasonable age
appropriate goals
4. Be consistent in what you do
5. Resist the urge to over-react
6. It’s all about CHOICES
7. It should be a TEAM effort!

5. Are diabetic kids more sickly?
• I don’t see much difference with
non-diabetic children in regards
to frequency of illness
• Due to more attention to health
care needs, I believe diabetic
children have less risk of illness
• Why? More frequent contact
with health care system, more
attention to nutrition and activity
Person
with type 1

6. Vaccines
• I do recommend them
for my patients (e.g., flu
shots)
• But if you choose not to
use vaccines, make sure
you know your diabetes
sick day rules!
• We won’t debate the
pros and cons of
vaccination here

7. In general, when a person with diabetes
is ill, they’ll need less insulin
YES
NO
X


9. “Sick Day” really includes several situations
• High BG with ketones
• Infections (viral/bacterial)
• Medical emergencies
• Elective and Emergency
Surgeries/Accidents
• Medication side-effects
• Any interruption of
insulin therapy

10. How illness can affect diabetes
• You can’t
always steer
around it!
• It changes
your “norm”
or routine
• It’s best to
be prepared!
Uh oh!

11. You’ve got to know when to hold ‘em, know when to fold ‘em
Know when to walk away and know when to run – Kenny Rogers
• Managing diabetes and
illness is a series of
important decisions
• The person who makes
the best decisions
usually stays out of the
ER or hospital

12. “Life is not a matter of holding good cards, but of
playing a poor hand well.”
R.L. Stevenson (1850-1894)
Managing diabetes and illness is about making and managing CHOICES

13. “Chance favors the prepared mind”
Louis Pasteur
Louis Pasteur

14. SICK DAYS CAN HAPPEN QUICKLY
Disconnected
pump

16. What are ketones and why should I care?
• Under non-diabetic conditions…
• Carbs (glucose) fuel the human
machine
• When glucose energy is scarce,
insulin is also low
• Low insulin allows us to convert
more fat into an energy source
(ketones)
• Excess ketones come from using fat
for energy too rapidly (ketosis)
Ketones are biological….

17. It takes just 1/10 the amount of insulin to prevent
ketones as it does to control BG levels
Question: Eating too many carbs and
sugars cause ketones in the blood
Yes
No
X


18. Common reasons for high BG with/without ketones
• Withholding insulin
• “bad” insulin pump site
• Insulin pump malfunction
• Use of old/damaged
insulin
• Some medications
• Severe stress
• Overeating
High
sugars!

19. What is the most common cause of
high ketones in kids?
Skipped/bad insulin!

20. Unexplained high,
explained…
Culprit: unremoved cap
First discovered…
Corrected all by injection
New site
carb

21. How “rapid” insulin works
• 20 minutes to start lowering BG
(from level)
– Humalog (lispro)
– Novolog (aspart)
– Apidra (glulisine)
• BG can drop NO FASTER than 4
mg/dl/min!
• Insulin action peaks in 60-90
minutes
• Ketosis and high BG both slow
down insulin effect
insulin

22. A low insulin level in blood occurs in several ways
“Absolute”
• Skipped insulin shot
– Forgotten
– Intentional
• Insulin pump malfunction
– Programming error
– Problem with infusion site
• Use of bad insulin
– Heat
– Age
“Relative”
• Assumes that good “working” insulin is
being taken properly
• Illness
– Stress hormones
– Dehydration (a stress)
• Medications
– Glucocorticoids
– Atypical antipsychotics

23. Absolute RelativeBoth
A low insulin level in blood occurs in several ways

24. If ketones are made in excess, what happens?
• Ketones (weak acids)
uncontrollably build up in the
blood/lower pH
• The body desperately tries to get
rid of them
• Dehydration speeds up the
process
• Uncontrolled vomiting is a
serious sign

25. How does the body get rid of ketones?
1. In the urine
2. Breathe them out
3. Turns them into
something else

26. Dehydration
High
blood
sugar
Acid
buildup
DKA

27. Diabetic Ketoacidosis
• A potentially lethal
metabolic disturbance
• 1-2% of cases die
• Sometimes misdiagnosed
in new onset cases
• DKA is preventable
• Expen$ive! (~$13,000)

28. Held insulin
Doseerror
Oldorheat
damaged
insulin?
Pump
malfunction
“DKA”
Roulette
Common DKA culprits

29. When (and why) should I look for ketones?
• Whenever blood sugar
levels are high
– 300 mg/dl or higher
– 240 or higher? (some)
• During any illness
– Surgery
– Major infections
– Trauma
• Taking steroids?

30. Do only type 1 diabetics get ketones?
• Any human being
(mammal) can develop
ketones
• Type 1’s have the
greatest risk since they
make the least insulin
• But any diabetic can
develop ketones under
the right conditions

31. How do I check for ketones?
Urine dipstick Fingerstick method
Meter: $68.08 on Amazon
10 ketone strips: $51.84 on Amazon
50 strips: $10.86 on Amazon

32. When should I be concerned?
concerned very concerned

33. When should I be concerned?

35. Diabetes “Sick day” rules…
1. Monitor blood sugar
2. Measure ketones
3. Drink plenty of fluids
4. Treat nausea
5. Take scheduled insulin
6. Take extra insulin as needed
7. Know when to call for help

36. What’s in your sick day toolkit?
• First…a good knowledge of the sick day rules!
• BG meter/lancets/strips (your choice)
• Ketone measuring equipment (blood or urine)
• Flowsheet/notebook (to track progress)
• Rapid acting insulin/syringes/wipes
• Anti-nausea medicine
• Fluids and “safe” foods
• Glucagon for injection

37. What’s in your diabetes think-kit?
• Why and how illness
affects diabetes
• How insulin works
• An appreciation that
improvement takes time
and patience
• Judgment , experience
and a touch of wisdom

39. Concrete thinkers*
can’t…
1. Consider a hypothesis
2. Consider multiple
possibilities in a
scenario
3. Systematically solve a
problem
4. Use combinatorial
logic
*Lasts until 15-17 years of age
*25% of adults are concrete thinkers.

40. Check BG often/keep good records
Time BG Ketones Insulin Fluids Other
7:30 AM 598 Large 12 u Humalog 2 oz nausea
8:32 AM 583 Large 12 u Humalog 4 oz nausea
9:45 AM 432 Mod-Large 12 u Humalog 6 oz Less nausea
10:34 AM 367 Moderate 12 u Humalog 6 oz No nausea
12:01 PM 231 Moderate 15 u Humalog Lunch No nausea
2:04 PM 167 Small 0 4 oz No nausea
4:14 PM 134 Trace 0 3 oz No nausea
6:23 PM 145 Negative 15 u Humalog Dinner No nausea

41. Prevent dehydration
• This is JOB one!
• Small amounts are best.
Water is best
• Sugar free popsicles or
Jello provide water too
• If use diet soda pop,
shake out fizz
• Low carb sport drinks

42. How to dose liquids
Body weight
• Under 40 pounds
• 40 to 80 pounds
• Over 80 pounds
Amount to drink every 20 minutes
• ½ to ¾ cup = 4 to 6 ounces
• 1 cup = 8 ounces
• 1 to 1 ¼ cup = 8 to 10 ounces
Small sips: YES Big gulps: NO!

43. You need energy to fight back
• Ketones and/or illness
itself will reduce appetite
• Liquid carbohydrates can
be traded for solid carbs
• Focus on energy foods
(carbs) over a balanced
diet in the short term

44. Liquid versus Solid carbohydrates
• Basic concept: “a carb is a carb is
a carb”
• Liquid carbs can be substituted
for solid carbs
• Advantages
– Provides water
– Can be sipped to minimize vomiting
risk

45. Powdered drink mixes
◦ Gatorade
◦ Tang
◦ Double strength for extra carbs
Regular popsicles
Regular Jello
Old fashioned peppermint
sticks
◦ Source of carbs
◦ Less risk of choking
KNOW HOW TO COUNT CARBS!

46. Manage nausea!
• Why? To maintain oral
intake, especially liquids
• Over the counter
treatments are a good
start (Emetrol has some carbs too)
• Prescription meds may be
needed
– Suppositories
– Oral Rx anti-emetics
– Side effects?

47. Stop the vomiting!
• Stomach rest: nothing by
mouth for 30 minutes
• Emetrol (or Equate) 1
tablespoon every 15 minutes
until vomiting stops
• Works best on empty stomach.
• NO fluids for 10 minutes after
EMETROL is given
• Consider adding Pepto-Bismol,
1 tablespoon every 10 to 15
minutes WITH the Emetrol. It
may help with tummy pain.

49. If over the counter doesn’t work
• Your doctor may provide
prescription anti-nausea
medications
– Zofran (Ondansetron)
– Phenergan (Promethazine)
– Compazine (Prochlorperazine)
• All have potential side-effects.
Discuss with your doctor
• Some are $$$

50. After some stomach “rest”
• Give small sips by mouth
• ½ ounce every 15 minutes
to start
• Use liquid exchange lists
to provide carbs and
fluids together
• Gradually increase the
fluid amount as tolerated

51. Know how/when to use insulin
• Extra insulin given as rapid-acting
– Humalog, Novolog, Apidra
• Calculate dose based on weight
in kilograms
• Check BG results hourly
– Ketones with every voiding
– Blood ketones every hour
• Repeat as needed based on BG
and ketones

52. But if a usual or scheduled dose of
rapid acting insulin is supposed to be
given at the time you discover high BG
and ketones, then give that dose and
recheck BG in 1 hour. Or….give your
usual correction dose per the pump*.
* If the pump is the problem, this will cost you time.

53. Can I treat high sugars/ketones with pump?
• You can try…but
• If pump is the problem
you lose valuable time
• It’s always safest to take
insulin by a shot

54. Calculating an insulin dose for high BG and ketones
• Start with 0.1 units per kilogram weight
– Range 0.075 to 0.2 U/kg/dose
– Only correct with rapid insulin (Humalog, Novolog).
– NEVER hold a scheduled insulin dose (e.g., long acting)
• To get kilograms from pounds
– divide weight in pounds by 2.2
– Example 1: 30 pounds/ 2.2 = 13.6 kilograms
– Example 2: 120 pounds/2.2 = 54.5 kilograms
• Example 1: 0.1 x 13.6 = 1.3 units = 1 unit
• Example 2: 0.1 x 54.5 = 5.5 = 5 to 6 units

55. When to call for back up/go to ER
• If vomiting can’t be
controlled
• Unusual sleepiness
• Fast breathing
• Poor concentration
• If the child/person
just isn’t “looking
right”
Help,
Doc!

56. Summary: Diabetes “Sick day” rules…
1. Check blood sugar often
2. Measure ketones until gone
3. Drink plenty of fluids
4. Treat nausea
5. Take scheduled insulin
6. Take extra insulin as needed
7. Know when to call for help
Watch this video: https://www.youtube.com/watch?v=4urN3RBFQQs