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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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