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Introduction
Diabetes mellitus is a syndrome of disturbed energy homeostasis caused by a deficiency of insulin or of its action resulting in abnormal metabolism of carbohydrate, protein, and fat Diabetes mellitus is the most common endocrine-metabolic disorder of childhood and adolescence
Introduction
Individuals affected by insulin-dependent diabetes confront serious burdens that include an absolute daily requirement for exogenous insulin, the need to monitor their own metabolic control, and the need to pay constant attention to dietary intake
Introduction
Morbidity and mortality stem from metabolic derangements and from longterm complications that affect small and large vessels and result in retinopathy, nephropathy, neuropathy, ischemic heart disease, and arterial obstruction with gangrene of the extremities
Classification
Type I Diabetes (insulin-dependent diabetes mellitus, IDDM)
characterized by severe insulinopenia and dependence on exogenous insulin to prevent ketosis and to preserve life onset occurs predominantly in childhood probably has some genetic predisposition and is likely autoimmune-mediated
Classification
Type II Diabetes (non-insulin-dependent diabetes mellitus, NIDDM)
patients are not insulin dependent and rarely develop ketosis generally occurs after age 40, and there is a high incidence of associated obesity As the prevalence of childhood obesity increases, more adolescents are presenting with NIDDM insulin secretion is generally adequate; insulin resistance is present no associated genetic predisposition
Classification
Secondary Diabetes
occurs in response to other disease processes:
exocrine pancreatic disease (cystic fibrosis) Cushing syndrome poison ingestion (rodenticides)
Muscle:
Suggested Reading
Glaser N, et al. Risk factors for cerebral edema in children with diabetic ketoacidosis. NEJM 355;4:264-269. Menon RK, Sperling MA. Diabetic Ketoacidosis. In: Fuhrman BP, Zimmerman JJ, ed. Pediatric Critical Care. Second Edition. St. Louis: Mosby-Year Book, Inc., 1998:84452. Kohane DS, Tobin JR, Kohane IS. Endocrine, Mineral, and Metabolic Disease in Pediatric Intensive Care. In: Rogers, ed. Textbook of Pediatric Intensive Care. Third Edition. Baltimore: Williams & Wilkins, 1996:1261-72. Magee MF, Bhatt BA. Management of Decompensated Diabetes: Diabetic Ketoacidosis and Hyperglycemic Hyperosmolar Syndrome. In: Zaloga GP, Marik P, ed. Critical Care Clinics: Endocrine and Metabolic Dysfunction Syndromes in the Critically Ill. Volume 17:1. Philadelphia: W.B. Saunders Company, 2001: 75-106.
Case Scenario #1
A 10 y/o male (~30 kg) presents to the ED with a one-day history of emesis and lethargy. Vitals show T 37C, HR 110, RR 25 BP 99/65. Patient is lethargic, but oriented x 3. Exam reveals the odor of acetone on the breath, dry lips, but otherwise unremarkable Labs: pH 7.05 PaCO2 20, PaO2 100, BE -20, Na+ 133, K + 5.2, Cl 96 CO2 8. Urine shows 4+ glucose and large ketones
Case Scenario #1
How much fluid would you administer as a bolus? Would you administer bicarbonate? What is the true serum sodium? How much insulin would you administer? What IVF would you start? At what rate?
Case Scenario #2
A 4 y/o female in the PICU is undergoing treatment for new onset IDDM and DKA. She is on an insulin infusion at 0.1 u/kg/hr, and fluids are running at 2400 cc/m2/day. Over the last hour, she has been complaining about increasing headache. She is now found to be unresponsive with bilateral fixed and dilated pupils, HR is 50 with BP 150/100. What is your next step in management?