Gds137 Slide Diabetes Melitus Type 1

7/27/2019 Gds137 Slide Diabetes Melitus Type 1

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DIABETES MELITUSDIABETES MELITUS

TYPE ITYPE I

dr. H. Hakimi, Sp.AK

dr. H. Charles Darwin Siregar, Sp.A

dr. Melda Deliana, Sp.AK

dr. Siska Mayasari Lubis, Sp.A

PEDIATRIC ENDOCRINOLOGY

. am a

HOSPITALMedan


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Chronic disease

Major DM group in children.


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DM Classification based on

etiology (ADA,1998)

.

a. immune mediatedb. idiopathic

.

3. DM other type

a. genetic defect of B cell function

b. genetic defect ofinsulin function

c. pancreas exocrine disease

d. endocrinopathy

e. drug and chemical substance induction

f. Infectiong. uncommon immune mediated DM

h. Genetic syndrome related to DM

. ges as ona


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Systemic disorder because glucose

chronic hyperglicemy

Caused b autoimunne rocess whichdestroy pancreas B cell insulin production

decrease or stopped


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Patogenese

Addison disease Tirodiditis hashimoto Anemia pernisiosa Viral infection Chemical exposure

, , , ac va on

autoantibody process

langerhans islets destruction

Pancreas B cell function failure

Insulin secretion decrease or stop

DM type I


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Normal blood glucose : 200mg/dl

Asymptomatic : blood glucose ad random

> mg


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GTT is not nesecary if distinguished symptoms are found

n cat on : n ou t u case

glucose dose : 1,75 gr/W in 200-250 cc water in 5

minutes GTT result intepretation :

DM: fasting blood glucose > 140 mg/dl or at 2nd hour >200mg /dl

mpa re ucose o erance : as ng oo g ucosemg/dl or at 2nd hour : 140 199 mg/dl

Normal : fasting blood glucose < 110 mg/dl or at 2nd hour : 50% : >20 yrs old

,virus, toxin, etc


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Acute

, , ,

hyperglycemy

consequences


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DM type I management

Good metabolic control with normal blood glucose level

Unified team

Objective Spesific objective

. .

2. Enjoy social life 2. normal emosional development

3. Prevent complications 3. Good metabolic control without

4. Few school absence days and

active in school

.

6. Able to manage disease

independently


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Insulin

Earlier : pig/cow pancreatic gland purification

Usage based on age , social economic,

culture, and drug distribution Important to know :

somogyi effect

awn e ecMorning hyperglycemy


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Insulin Ultra short acting insulin ( lispro )

Give 15 min before meal

Useful in sick da mana ement and before meal in ection

Short acting insulin

For acute stage : ketoacidosis, new patient, injection beforemeal, and in surgery or combination with medium acting

insulin

For toddler : prevent hypoglycemy


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Insulin

Medium acting InsulinUsed twice daily for patient with same daily

routine pattern

Widely used in chi ldren

Mix InsulinStandard mixture ( short+medium acting insulin)

Good metabolic control

For young age child with low education parent


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Insulin pen Mixing insulin

Storage : temp 4 8 oC not in freezer

Type onset (hour) peak(hour) duration(hour)

Ultra short acting 0,25 1 4

short acting 0,5 1 2-4 5-8

Medium acting 1-2 4-12 8-24

Long acting 2 6-20 18-36


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Insulin usage principal

De end on Indonesia situation and condition

Use glucometer and routine daily home testing

Objective parameter : Serum HbA1c / 3 months Insulin dose adjustment :

For metabolic control

, , ,


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Injection technique : subcutaneous with

Self injection


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Objective : achieve good metabolic control

Total calory : 1000 + (age(year)x100) calory

er da

Carbohydrate 60 65% , protein 25%, lipid


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Management when diagnosed Insulin : start 0,5 U/kg/day, gradually adjust

education

ketoacidosis management

Insulin

Fluid

elektrolite balance

Acid base balance

Management while surgery

Management while Ramadhan fasting

omp ca on


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Complication Short term complication : hypoglicemy, ketoacidosis

Hypoglycemy : blood glucose < 50 mg/dL

neurogenic symptoms neuroglycopeny

Cholinergic weak, headache, visual disturbance

Sweating,hungry,numb dizziness, tired, sleepy, affective disorder l

Adrenergic (depression,angry), coma, convulsion

, , , ,

anxious


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Retinopathy

Growth & development disorder


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Hypoglycemy reven on

Regular insulin management Regular food intake

Parent supervision and education

Thera Mild/moderate hypoglycemy

Give 10 20 gr of carbohydrate followed by snack

Lemonade hone lucose tablet can be used

Severe hypoglycemy

Unconscious / convulsion

Parent education inject glucagon 0,5 mg or 1 mg for child

> 5 yrs old


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Education

ect ve Understand the disease Motivation

ype managemen s

Positive attitude

Good metabolic control

First education --> at hospital

Continous education :

amp School

Advice on : ong ourney

Alkoholic and smoker


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Growth and diabetes

Monitor:

o y e g mon s

Body weight


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Family education

Advice parent not to give excessive


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1.Body weight measurement (kg)2.Dehidration thera decision

3.Calculation of free water deficit

4.Administration of normal saline (0,9NS), bolus iforthostatic or shock occurs

5.Calculate excess of water deficit after the third bolus

. next 48 hours

7.Calculate total fluid iven within 48 hours


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Ketoacidosis Protocol

-Potassium-Urine (-) : dont give K+

-Urine (+) : add KCL20-40mmol/L

-Give K+

as half Chloride/half phophate at first 8 hour-Dextrose

- Patient with BG>15mmol/L: dont give dextrose

- - ,- Try to maintain BG 10-15mmol/l without adding isulin

dose.


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-Bicarbonate : NaHCO3 is not advised

12. Start fluid replacement therapy as mention on umber 11 withthe value in number 10

.exists. Severe headache, consciousness or blood pressurechanges, dilated pupil, bradicardy, postural signs and

,

hyperventilate, give mannitol 1 gr/kgBB/iv bolus)


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Ketoacidosis Protocol

14. Follow laboratorium value:-Follow BG/ 30-60 mnt, whether the child response ?

-Follow Na,K,Cl,HCO3, capillary pH value/ 2 4 hrs

-Follow Ca and P value if phosphate is given

- -

15. Re- evaluate every fluid change , antisipate the changeof K, dextrose, etc value


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Gds137 Slide Diabetes Melitus Type 1

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