Type: Clinical Guideline. Management of the newly diagnosed child with Diabetes Mellitus. Register No: Status: Public

Transcription

1 Management of the newly diagnosed child with Diabetes Mellitus. Type: Clinical Guideline Register No: Status: Public Developed in response to: Guideline Review Contributes to CQC Regulation 9,12 Consulted With Post/Committee/Group Date Alison Cuthbertson/ Miss Rao Mahesh Babu Manas Datta Aloke Agrawal Muhammed Ottayil Sharmila Nambiar Sharon Lim Ahmed Hassan Mel Chambers Mel Hodge Andrea Stanley Sarah Moon Clinical Director for Women s, Children s and Sexual Health Directorate Lead Nurse Senior Sister, Phoenix Ward Clinical Facilitator Children s Acute Care Specialist Midwife Guidelines and Audit Professionally Approved by Dr Datta Clinical Lead, February 2016 February 2016 Version Number 3.0 Issuing Directorate Children s and Young People Service Ratified by: DRAG Chairmans Action Ratified on: 28 April 2016 Executive Management Board Sign Off Date May 2016 Implementation Date 3 May 2016 Next Review Date March 2019 Author/Contact for Information Victoria Machell, Paediatric Nurse Policy to be followed by (target staff) All Clinicians Distribution Method Hard copies on ward Intranet & website Related Trust Policies (to be read in conjunction with) Hand Hygiene v Aseptic ANTT DKA Policy Diabetic Management of Children undergoing surgery. Document Review History Version Number Reviewed by Active Date 1.0 Sharon Lim 19 May Sharon Lim 8 October Victoria Machell, Paediatric Nurse 3 May

2 Index 1.0 Purpose 2.0 Equality and Diversity 3.0 Scope 4.0 Admission Policy 5.0 General Management 6.0 Insulin Profiles 7.0 Insulin for all ages 8.0 Discharge 9.0 Differential Diagnosis 10.0 Staff Training 11.0 Infection Prevention 12.0 Audit and Monitoring 13.0 Communication 14.0 References Appendix 1 Newly diagnosed diabetic flowchart 2

3 1.0 Purpose 1.1 This document provides guidance for the management of the newly diagnosed child/young person with proven or suspected diabetes mellitus who is not in diabetic ketoacidosis (DKA) or after management and treatment of DKA when insulin injections are being initiated. 2.0 Equality and Diversity 2.1 Mid Essex Hospital Services NHS Trust is committed to the provision of a service that is fair, accessible and meets the needs of all individual. 3.0 Scope. 3.1 These guidelines are for the use of all staff caring for children and young people within thetrust. 3.2 Many children with new onset diabetes are well and do not require management as per Diabetic Ketoacidosis (DKA ICP) Protocol. 3.3 These guidelines are for the newly diagnosed non DKA child/young person, or child who has recovered from DKA initiating subcutaneous insulin treatment. 4.0 Admission Policy 4.1 Any child referred with a new diagnosis of diabetes mellitus should be seen on the same day on Phoenix Ward. 5.0 General Management 5.1 Admit to ward, explain that the purpose of the admission is to confirm the diagnosis, initiate treatment and start to educate the child and family in how to manage a child with diabetes 5.2 It is very helpful to take a comprehensive family history including parents names and occupations and of course any history of endocrinopathies / autoimmune conditions. 5.3 Confirm the diagnosis. (If in any doubt, see appendix 1 and discuss with Consultant Paediatrician) 5.4 Perform the following investigations: Blood glucose essential to confirm high capillary blood readings minimum 0.5ml in a fluoride oxalate (grey) bottle. Diagnosis of Diabetes Mellitus is confirmed if random blood glucose >= 11mmol/l or fasting blood glucose >7.1 mmol/l HbA1c (EDTA bottle) FBC, full biochemical profile and TFTs with thyroid (TPO) antibodies 3

4 Coeliac screen (ttg antibodies), Islet Cell antibodies and Glutamic Acid Decarboxylase (GAD) antibodies Urine dipstick for ketones and glucose please record results in notes even if negative Blood Ketones MSU 5.5 Weigh and measure the height of the child and plot on a centile chart 5.6 Commence insulin regimen: Initial Insulin Dose Calculation for >= 5 years is Units/Kg/Day Children under 5 years should be started on 0.5 Units/kg/day unless presented in DKA (start 1 Units/kg/day). If newly diagnosed diabetic was not in DKA, insulin requirements are lower Discuss with Consultant/Senior Paediatric Doctor the insulin regimen to be commenced. Novorapid Cartidges may be preferred in toddlers because of the availability of half unit dosing (not available in Apidra Solostar / Humalog Lispro) 5.7 If the child is nauseous or unwell, check a venous gas in addition to investigations above if acidotic (ph <7.25 and bicarbonate <15) treat as DKA. If blood ketone > 3 mmol/l, treat as DKA. 5.8 It is important to give clear positive messages, support and advice to children/ families and young people 6.0 Insulin Profiles 7.0 Insulin regimen for all ages 7.1 Children should commence on a basal-bolus regimen with prescriptive doses while diabetes education on carbohydrate counting is being arranged after discharge home. This regimen mimics the normal physiology of insulin production. The Diabetes nurses will ensure that the school has a care plan as children will have to inject at lunchtime. 7.2 Basal bolus regimen is the recommendation from diagnosis. 4

5 7.3 Lantus Solostar (insulin Glargine) or Levemir - 50% of total daily dose before bedtime. 7.4 Apidra Solostar / Humalog Lispro or Novorapid (insulin Aspart) - 50% of total daily dose divided between 3 main meals as below:- 30% before breakfast 30% before lunch 40% before evening meal (assuming this is the biggest carbohydrate intake of the day) 7.5 Prescribe Levemir or Lantus Solostar (check with Children s Diabetes Nurse Specialist (CDNS), this is a prefilled pen device/cartridges, which are easy to use. Novorapid is given by flexpens (disposable) or cartridges. Lantus Solostar /Apidra Solostar as disposable pens. If child is < 5 yrs old, prescribe Levemir and Novorapid cartridges for Novopen Echo for half unit dosing. 7.6 When the children start on basal bolus regimen the short acting insulin i.e NovoRapid / Apidra Solostar / Humalog Lispro should be given with main meals. Long acting insulin i.e. Lantus/Levemir is usually given at bedtime. 7.7 Lantus/ Levemir insulin should be given at night within a 1 hour window (e.g. between 7-8pm, CDNS or medical staff will discuss with parents/child/young person) 7.8 Check blood sugar levels 5 times per day, pre-breakfast, pre-lunch, pre-tea, 2 hours post-tea and at 2 am while inpatient. 7.9 Use a soft click pen device for blood sugar testing from the start. These are in the blood testing kit supplied with the meter (in the new patient pack). Use as low a setting as possible to prevent painful fingers Initially 5 blood glucose level tests a day (see below) until a clear pattern has been established The blood glucose level can run high between mmol/l for the first 3-5 days. There is no need to keep correcting this with extra insulin in between regular doses. Please note that constantly giving small amounts of Novorapid /Humalog Lispro/ Apidra insulin in a newly diagnosed child, who is well, is counterproductive 7.12 Before bed the aim is to ensure blood glucose of at least 8 mmol/l to reduce the risk of night time hypoglycaemia. No new patient should be kept on the ward just to improve blood sugar control There is no need to routinely check blood sugars during the night unless they appear hypoglycaemic, or have had their first dose of insulin at bedtime. 5

6 7.14 Check blood ketones on admission to record a base line level and reassess the patient s need for more insulin or intravenous fluids After the first few days the blood sugar level target can be variable 4-15 mmol/l. The blood sugar level target range will be agreed individually at discharge There is flexibility at meal times with the basal/bolus insulin regimen. Insulin should be given immediately prior to eating. Snacks are not compulsory and should be taken according to natural hunger and predicted activity. Bed time snacks are recommended if blood sugar is less than 8 mmol/l before bed Start the education programme and checklist for parents/carers as early as possible Give out new diabetic backpack and start use of educational resource CD- ROM in the schoolroom, which is on a desktop. This educational resource is for both parents and child/young person. 8.0 Discharge 8.1 Write up medicines to take home(tta s) on admission to have them ready for discharge. Only discharge the patient once patient and family are ready. 8.2 TTAs: Insulin depending on regimen either: Levemir cartridges Pre-filled 3 ml/flexpens x 1 box. or Lantus Solostar x 1 box 3ml Pre-filled pens and Humalog Lispro Kwik pens or 3 ml Cartidges or Novorapid 3 ml Cartridges 3ml Pre-filled/Flexpens x 1 box or Apidra 3ml Pre-filled insulin pens x1 box Plus: Accuchek Fastclix lancets x 1 box Hypostop x 2 boxes Glucagen x 1 pack BD- 5mm or Novo fine 6 mm needles x 1 box. Ketsitix x 1 bottle Accuchek- Aviva Test strips x 2 boxes (check with meter given in the pack. Sharps box small x1 8.3 The diabetic nurse will supply the blood glucose machines, if it has not already been provided from the starter pack. 8.4 Any advice regarding diabetes management as an inpatient needs to be discussed with a member of the Children's Diabetes team. 6

7 9.0 Differential Diagnosis 9.1 Type 1 diabetes classic triad of polyuria, polydipsia and weight loss. High blood glucose levels with ketonuria signifying insulin deficiency. 95%+ of children presenting with suspected diabetes will have Type Type 2 diabetes look for risk factors signifying insulin resistance i.e. obesity, ethnicity, family history, acanthosis nigricans. Hyperglycaemia tends to be mild rather than grossly elevated. Discuss with diabetic consultant. 9.3 Maturity-Onset Diabetes of the Young (MODY) think of in mild hyperglycaemia, no evidence of insulin deficiency and a family history of DM in at least one parent. Discuss with diabetic consultant. 9.4 Stress Hyperglycaemia is associated illness 9.5 Genetic syndromes accompanied by diabetes mellitus 10.0 Staff Training 10.1 All medical and nursing staff are to ensure that their knowledge, competencies and skills are up-to-date in order to complete their portfolio for appraisal During induction process junior medical staff will receive instruction on current polices and guidelines At case presentation and junior doctor teaching will discuss diabetes cases and learn from the outcomes Where a patient s notes have demonstrated that the appropriate action has not been taken a risk event form is to be completed. This will address any further training needs for staff that requires updating Infection Prevention 11.1 All staff should follow Trust guidelines on infection prevention ensuring that they effectively decontaminate their hands before and after each procedure All staff should ensure that they follow Trust guidelines on infection prevention using Aseptic Non-Touch Technique (ANTT) when carrying out procedures Audit and Monitoring 12.1 Audit annually the management of newly diagnosed children with non DKA diabetes against this guideline Communication 13.1 Approved guidelines are published monthly in the Trust s Focus Magazine that is sent via to all staff Approved guidelines will be disseminated to appropriate staff via after ratification of guideline. 7

8 14.0 References ISPAD (International Society for Peadiatric and Adolescent Diabetes) 2009 NICE guidelines Type 1 diabetes

9 Appendix 1 NEW DIABETIC FLOW CHART Junior Doctor notified of new patient Inform: Phoenix Ward Diabetes Team Patient arrives to Phoenix Ward: Rapid assessment by doctor/spr Clerking by SHO Notify Diabetes Team Initial observations obtained (incl. Blood glucose, ketones) Bloods (no need for cannula in well children) Diabetic Ketoacidosis DKA Dehydrated (mild) with Large Ketones Well with up to moderate ketones DKA protocol Deterioration/ DKA Correction dose of insulin Novorapid 0.1U/kg Encourage oral fluids Improving DKA corrected Eating and drinking Start routine insulin when next injection would be due Total daily dose (tdd): U/kg/day for over 5 years old 0.5 U/kg/day under fives Basal bolus regimen Levemir or Lantus - 50% of total dose before evening meal Humalog Lispro/ Apidra or Novorapid - 50% of tdd divided as: 30% before breakfast 30% before lunch 40% before evening meal Don t forget to write up the TTAs! 9