Chapters Transcript Video Managing the Storm: Sick Day Strategies for Pediatric Type 1 Diabetes Without further ado, uh, it's my great pleasure to introduce our long-awaited speaker, uh, Doctor Anthony Parish. Doctor Parish is a pediatric endocrinologist and assistant professor here at uh at UCSF Children's Oakland. He is a Bay Area native and he was even once a patient here at UCSF Pediatric diabetes clinic for his type one diabetes. He completed his medical training at Rush Medical School in Chicago. Followed by his pediatric residency at LA County Medical Center, then his pediatric Eochronology fellowship at Children's Hospital at LA. His clinical duties of research interests uh have been in supporting children and adolescents with chronic endocrine conditions, um, with a passion for medical education and equitable care. Um, and without further ado, our speaker, uh, speaking about, uh, managing the storm sick day strategies for pediatric type one diabetes. Oh, I think you're on mute. Great start. Um, thank you, Jay. I really appreciate uh the intro, and I'm so happy to be here and, and thank everyone for joining me today for our grand rounds topic. Um, definitely an important topic, um, in terms of, uh, how we manage our, our kiddos with type one diabetes, um, and this talk is, is really meant to be for all pediatricians and, and for, um, anyone who kind of Uh, it comes in contact with these kids, um, to be armed with, with some important knowledge about how to manage, um, them and keep them from the brink of of hospitalization and, and worse, so. Um, without further ado, You get this. OK. So I'm gonna be presenting, um, Managing the STORM, uh, sick day Management in Children with type one diabetes. Um, I have no, uh, relevant financial relationships, uh, or commercial interests to disclose regarding this talk. Um, so why does sick day management matter, um, to begin with? So, um, during illness in type one diabetes, there's an increased risk of diabetes-related ketoacidosis or DKA. Um, decay is the leading cause of hospitalization and death in children with type one diabetes. Um, yeah, we also know that many episodes are preventable and, um, overall sick day management is not just for endocrinologists, as I mentioned. Um, it's for, it's really involves preventative care, um, for all, um, providers and, and, um, medical personnel who are coming in contact with, with patients with type one diabetes. Um, so effective management can reduce hospital admissions, complications in mortality. Um, education of patients is really, um, key in establishing a, um, preventative approach, and, um, we also know that health disparities contribute to higher DKA rates in historically marginalized populations and low income patients. Um, most DKA in patients with established type one diabetes is not from just getting insulin, it's from barriers like access, insurance, and, uh, again, misunderstanding uh of sick day protocols and. And and education, um, and I think we really need to think about sick day, um, like CPA, like CPR, essentially, um, you want the family to learn it in a calm setting before it's an actual emergency. Um, so our learning objectives today, um, at the end of the presentation, um, I hope that learners will be able to identify key sick day management principles based on our ISPAD guidelines. Uh, demonstrate insulin adjustments based on blood glucose and ketone levels. Recognize warning signs requiring emergency care. Um, adapt recommendations for diverse cultural and socioeconomic backgrounds. And then address implicit bias in sick day management and ensure equitable care. Um, so in regards to epidemiology of sick days, um, as I mentioned, DK remains the leading cause of hospitalizations in children with type one diabetes, um. In patients again who have established type 1, there's a risk of about 1 to 10% of recurrent DKA per patient year, um, and again it's, it's, um, we have to think about insulin omission and interrupted insulin delivery in the case of insulin pumps, but again thinking about those broader questions about um about medical context and the system issues that are uh creating barriers for our patients. Um, There's a higher incidence of recurrence among patients who have an A1C above 9, and then also those that are under resourced and minority populations. Um, disproportionately affecting black and uh Latinx children and again prevention really starts with education and, and thinking about these um systems. Um, and in the US, um, the decay rate is around 7.1% episodes per patient uh year and um. This again is has been uh pretty stable, but, uh, you know, still higher than we would like despite improvements in technology. Um, so this article by DA in 2022, um, was an urban, uh, pediatric endocrine clinic that implemented standard sick day rules, um, including education at visits, discharges, and having a phone triage line. Um, they found that DKA rates dropped from 19.1 to 12.4 per 100 patient years, so, um, a pretty significant decrease, um, over three years, so between 2015 to 2017, um, but again, despite, um, these interventions, most of the DK episodes occurred in African American or black children. Um, Medicaid insured patients, um, and then youth with A1C is above 11%. Um, education alone is not enough, and again, uh, we have to think about the socioeconomic stressors and mistrust or limited engagement with care that our patients may be experiencing. Um, this article by uh Maxwell Aal in 2021, um, found there's, uh, even with these protocols in place, disparities again it it uh exist and and uh DK emissions remain high, especially in these underserved populations. Um, the DK risk increased 22%, um, for every 10% rise in neighborhood poverty. So, um, youth with public insurance were 2 2.7 times, almost 3 times higher, um. Uh, odds of having DKA if you had public versus private insurance, um, so pretty big uh difference there, and then, um, again, uh, this data really is meant to think beyond just cultural explanations and more towards the structural accountability in our our health care system, and you can't really just help educate your way out of a systemic barrier we need um to improve access and not just give advice. Um, So ISPA, which um is the International Society for Pediatric and Adolescent diabetes, um, provides pretty um comprehensive guidelines in terms of um diabetes care, but also in particular sick day management. Um. These are really 5 pillars that um this pad provides that I'll kind of be returning to throughout our our um presentation and uh have some cases to illustrate them. But, um, essentially, we need to think about frequent blood glucose and ketone monitoring during acute illness. Um, never stop insulin, um, which is again a principle I'll, I'll come back to a few times. Um, we need to adjust insulin doses as needed based on blood sugar and, uh, ketone level, um, maintain hydration with appropriate fluids, and then, uh, having knowledge of when to escalate care, um, when it's inappropriate to be managing at home. Um, so during illness, um, blood glu glucose can be affected, um, in several ways, as you can, can imagine. Um, so we often can think about these increase in stress hormones, in particular cortisol and, uh, epinephrine that will, uh, increase insulin resistance, and then, uh, that leads to more hyperglycemia, um. You also have increased risk of ketogenesis. So again, if you're in an insulin deficient state, as someone with type one diabetes is, there's a lower threshold to start lipolysis, um, and then, uh, produce ketones, and then that uh as those build up will increase risk of decay. Um, and then we also have to think about hypoglycemia, especially in the context of gastroenteritis, um, and reduced PO intake, uh, which can then again lead to increased risk of low blood sugars, and we'll talk a little bit about how to manage that situation, um. So just starting simply, um, we have a case, this is a 3 year old, um, who missed her basal insulin dose, um, and has vomited one time. Her blood sugar is 90, um, she does not have any ketones at this time, um. Thinking about management, um, in this situation. So again, her blood sugar is in the normal range. We don't have ketones, but she didn't get her insulin and did have one episode of vomiting and has overall decreased PO intake. So, um, Thinking about management, um, this is a time where we can think about easily digestible carbohydrates, um, if she's able to drink some juice, um, with sugar containing, uh, fluids, uh, a thing like a lollipop that again might be a little bit easier to, um, to get glucose to absorb rather than having to eat and potentially cause more vomiting. Um, but also we have a great tool called mini dose glucagon, which I'll get into. Um, but really important point is to not stop the basal insulin. Um, I think parents often think, you know, my kid's not eating, there's no food going in, so we don't need to give insulin. Um, but that is just gonna exacerbate our, um, ketogenesis and then further lead to risk of DKA, um, and again, that's where we think about mini dose glucagon as a game changer, um. So many glucagon can be given via syringe or nasal spray. Glucagon, um, if you don't know, is our, our really rescue hormone medication for hypoglycemia, especially in cases of severe hypoglycemia where the patient may have altered mental status or um be unresponsive. Um, however, we also have, um, this technique where we don't give the full dose, but we give a mini dose of glucagon, um, and, uh, this can again be helpful in the context of mild hypoglycemia, um, in kids who are not eating a lot, but we wanna still provide them with insulin. And so it's a way to get their blood sugar up and and then um increase their insulin requirements so that they're getting insulin to again reverse ketosis, and it's, it can be kind of counter counterintuitive, cause again we are are inducing higher blood sugar so that we can get more insulin. And again, if, if your kid is not eating and their blood sugar is normal, it could be hard to um for some families to understand that reasoning. Um, but again, when we, um, use it in in the mini dose way, it can be really effective in in again staving off, um, ketosis. Um, so for kids under 2 years old, um, we do 2 units on the insulin syringe, so you, you mix the glucagon, um, as if you were gonna be giving the emergency shot, but then rather than, uh, providing the IM shot with the needle that comes with the kit, you're gonna use uh an insulin syringe, which is much smaller and subcutaneous and Um, you're just gonna draw two units on that syringe, um, versus if the kid is between 2 to 15, we just, um, do 1 unit per year of age, um, so that makes it a little bit easier to remember, um, when we're we're talking to families on the phone, um, and then if if a kid's an older teenager over 15, um, we just stop at 15 units on the syringe. Um, in terms of pathophysiology of ketosis and DKA, again, this is a bit of a review, um, but this is what's happening behind the scenes is without insulin, fat basically starts to be broken down, um, because glucose is not able to be used in cells for energy and then this um leads to free fatty acid release. Um, pre-fatty acids are then converted to ketone bodies, um, like beta hydroxybutyrate and aceto acetate in the liver, and then this ketone accumulation leads to metabolic acidosis, um, and then dehydration and imbalance of electrolytes. Um, Signs um that decay is is um already occurring and um and being compensated for would be co small respirations, um, which are these deep rapid breaths, um, that are essentially compensation for the acidosis to help expel CO2. Um, Severe acidosis um can lead to mental status change, um, coma, and even death if untreated, and this is again why it's one of our, um, biggest emergencies in endocrinology. Um, this is just meant to go over, um, again, our, our sort of, uh, pathophysiology behind DKA which I, I went over, but again, in insulin deficiency, you have these counter regulatory hormones that are that are released in the setting of a stress or infection, um. And then uh those uh will increase lipolysis. You'll have decreased glucose utilization, increased proteolysis and and decreased protein synthesis, and then increased glycogenolysis. Um, these all contribute to hyperglycemia as well as which then can create pro-inflammatory changes and insulin resistance. Um, you're gonna have osmotic diuresis, um, which is where the polyuria comes into play, especially over 180. Um, you'll start spilling glucose into the urine. Um, that then leads to this loss of water and electrolytes and subsequent dehydration, and patients can become hyperosmolar, have impaired renal function. Um, increase in lactate in the setting of dehydration, which can then further contribute to acidosis, um, and ketogenesis, and, um, and then the cycle sort of continues in that way. Um, so just quickly, blood versus urine ketones. So, um, blood ketones are measuring beta hydroxybutyrate. Um, this is a real-time measurement, so it's more accurate, it's um nice tool, especially in, um, insulin pumps to detect um ketosis early, um, and can also confirm resolution of ketosis, whereas, um, and it's also preferred by ISPAT and the American Diabetes Association, um. Urine ketones, uh, detect aceto acetate, so not beta hydroxybutyrate, and this can actually lag behind the ketone status. Um, usually, um, it's better than nothing and so a lot of patients will have this, but, um, we again would prefer blood testing, however, um, Uh, it can, it can be sometimes difficult to, um, to get covered by insurance and patients may have to pay out of pocket, um, but again, it can really help with real-time decision making to have those that more immediate blood ketone, um, uh, number so we know what to do in terms of our management. Um, common illnesses that we see that affect glucose again, fevers and infections often raise insulin needs due to the stress hormones. Um, gastroenteritis, as I mentioned earlier, can reduce your insulin needs and increase risk of hypoglycemia. Um, Uh, so again, less food, but ongoing ketone production, um, and then this even at lower blood sugars can increase, uh, decay risk. Um, surgical stress, use of steroids, as well as dehydration can also um make uh us need to adjust insulin. And so being aware of all these different situations is, is really vital for our patients and families, um, but also for their um their medical providers. Respiratory illnesses can be a little bit more variable. Um, again, depending on if there's a fever and patient's activity level overall. Um, Preparation is really key here, um, so, um, we again really want to think about reinforcing education frequently. So when families first come in, they're very overwhelmed um with everything they're learning when it comes to diabetes. And so, you know, we do talk about ketones and and sick day management, but, um, like anything in medicine, repetition is, is important and they're gonna forget a lot of, of, of the first day, um, teaching, and so we want to really reinforce this as much as possible at our visits, um, at least, you know, yearly, um, but really as frequently as possible. Um, having written clear sick day plans or electronic sick day plans is also um important. Just giving families something that's really easy to follow, accessible instructions. They don't need to know the path of physiology, they just want the plain language and, and some visual aids to know what to do in this situation. Um, having contact info for our, um, our clinic and our emergency numbers are, is also important and it's provided to every patient, um. In our clinics, um, on their, um, paperwork, which as we know, patients lose that often, so we also often will tell them to just put it in their phone and have easy access to that. Um, but obviously you need structure and um a team of, of nurses and um CDs and um and diabetes educators who are familiar with sick day management and the protocols to be able to Um, feel those calls and then, um, again, you know, like annual, um, flu vaccine and just general health maintenance are also important for, um, preventing, uh, viral illness and, and, um, illness in general so that um we can avoid these types of situations. Um, having adequate supplies, um, is also a, a really important part of sick day preparation. Um, so we need to think about glucose monitoring supplies, whether you're using a glucometer or a continuous glucose monitor, um, having adequate ketone supplies, again, uh, urine keto sticks, um, if you don't have a, a blood ketone monitor. Um, and then again, having a, a sick day management plan, um, with quick guidance on what to do for fluids, um. Ketones, uh, and glucose monitoring frequency, what to do if you do have ketones in, in what level, what to do for low blood sugars, um, if they have, uh, diabetes technology like insulin pumps and CGMs, how to troubleshoot, and then again emergency contact numbers, um. I try to make it routine to just check for um ketone strips and and things like glucagon and basky, which is the inhaled glucagon, um, almost like you would check for albuterol refills and asthma, um, and also checking with families like, do you know where these are in your home and, and, um, and is everything uh up to date and not expired and, and again just using those, those calm moments in clinic to check in. Um, In terms of, you know, a situation where a kid is ill and has a loss of appetite, um, again, the presence of elevated ketones, um, can also contribute to decreased appetite just because they can cause stomach discomfort and nausea. So thinking about easily digestible foods, things like rice with broth, um, crackers, noodles, rice, yogurt, um, things that are, are kind of like rat diet, um. Also, um, thinking again about hydration, so we generally recommend around 4 to 6 mL per kilogram per hour or 100 mL per hour. Um, sometimes, um, it, it may be easier to say just take a sip of, of, you know, water or or electrolyte solution every like 15 to 20 minutes, um, and again, um, even if a kid isn't eating, they still need insulin. Um. This is the time, you know, again, if their blood sugar is low, they can have something um like a like they think of as a treat, things like Skittles, glucose tabs, which aren't really a treat, they're pretty chalky and and gross, but um jelly beans, um, suckers, um frosting can be easy to just kind of get in their um in their mouth, and a lot of it can absorb through the mucosa, honey. Um, so again, there's a lot of different like quote unquote low snacks, but this, this will be a time again to think about that, um, to help raise their blood sugar, to give them insulin. And then again thinking about um uh sports drinks, Gatorade, um. Maybe soft drinks. I don't love those um necessarily in terms of sick day management, but, um, again, if that's what you have around. For monitoring guidelines, so, um, we generally would recommend checking blood glucose every 3 to 4 hours. Um, we recommend checking ketones. Again, blood over urine is preferred every 2 to 4 hours, um, and then maintaining target glucose levels, uh, between 70 to 180. Um, in terms of adjusting our insulin, um, so we can think of it sort of as, um, mild, moderate, and severe hyperglycemia. And so, um, in the setting of mild hyperglycemia, so blood sugar between 180 to 250, and without ketones, um, we can either continue the same plan or we can think about increasing the insulin by 5 to 10%. Um, for moderate hyperglycemia with a blood sugar, um, 250 to 300, but, uh, small ketones are present. Um, we might increase insulin more by 10 to 20%. And then for severe hyperglycemia, um, with blood sugars above 300, with moderate or large ketones, we would increase our insulin by 1020 to 30% and then monitor really every 2 hours. Um, It's important to to again use simple language when discussing this with patients. Um, they're not gonna necessarily um wanna do math in that moment and so sometimes, um, doing the math for them or again giving a really uh easy to follow plan and these different scenarios can be helpful, um, with the actual dose for um for each situation written out. Um, so there's just different methods, um, of how you can adjust the insulin. So there's the total daily dose, um, percent increase. There's a fixed increase for, um, just depending on ketones and then, um, adjusting just based on the um standard correction. Um. So usually if um there's a predictable dose escalation um in a patient with a, with a with a insulin regimen, um you can use the percent of total daily dose increase for the day. Um, you can use weight base more when there's um uh ketones or uh insulin delivery is, is sort of in question and you're giving a manual injection if if they're on a pump. Um, If um they are a pump user, we often will recommend giving a subcutaneous injection, especially if ketones are moderate or large, um, or if there's any suspicion that the um pump site is uh malfunctioning, and I'll talk a little more about that later too. Um, just in the example here, so again, if we're using the total daily dose method. Um, a patient gets um 30 units of, uh, insulin daily, so that's gonna be our basal insulin plus our um rapid acting insulin for the day. Um, so if the patient's total daily dose is about 30 units, um, for, for a 30 kg kid, um, we're gonna add 3 to 9 units over the course of the day. Um, if we're doing sort of a weight-based, again, the kid's 30 kg, um, you would give a 0.05 to 0.15 units per kg as an immediate correction, um, and so that would come out to 3 units of Q. And then, um, if we're doing, um, uh, you know, for patients with um insulin pumps or multiple daily injections, where, um, We may not necessarily adjust things, um, if it's only hyperglycemia and not necessarily having ketones. Um, but sometimes in real time I use weight-based corrections, um, in, in more urgent settings or emergency settings, um, when again, patients have this more moderate, um, uh, or high ketone level, it's, um, a little bit easier to just calculate the per dose and, and, um, and go from there. Um, this is more just an overview of what I, what I just talked about and just sort of a different visual, um, um, but again, uh, we need to think about when do we need to advise escalation of care and transfer to medical facility, and that's typically, um, not taking PO and having large ketones, um, that's definitely a red flag. Um, so for this case, um, we have an 8 year old with type 1 diabetes, who's on multiple daily injections. Uh, she was diagnosed 2 years ago, has had 1 day of runny nose and a cough and fatigue with decreased appetite. Still drinking fluids, but, uh, and not having vomiting or abdominal pain or any fever. Blood sugar is 240, our urine ketones are small. Um, So management in this situation. So again, as we discussed her, um she does have hyperglycemia with small ketones, but otherwise is still taking fluids, um, not having fevers or, or vomiting. Um, this just overall shows us that um when patients are still able to um take in fluids, still able to take PO generally that is safe for home management. Of course, there's gonna be exceptions, but in, in general, that's um what we're thinking in this case. Um, and then again based on the fact that uh they they have hyperglycemia and their ketones are small, we would um continue basal insulin and then give 10 to 15% of total daily dose. Um, as well as sugar-free fluids, um, and then monitoring blood sugar and ketones every 2 to 3 hours, and then if, um, those ketones or symptoms worsen, especially not taking PO, we would escalate care. Um, then, um, we also find that patients in the family live in Hidden Valley Lake, California, so this is a, a pretty rural area and far away from any, um, 24 hour medical care. Um, we, the patient calls back and 4 hours later, blood sugar is 280. Um, now she has moderate urine ketones and has nausea. Um, the family has transportation challenges. Um, again, they're living in a pretty rural area and there's only one, truck in the family. Um, next steps. So, Now, she has moderate ketones, so we're gonna again increase our insulin by 15 to 20%. We're gonna continue to encourage small frequent sips of sugar-free Gatorade, um, consider, um, an antiemetic like ondansetron, um, to have, again, in this situation, it it it's all about preparation cause it, it may be difficult for them to go and run to the pharmacy to pick that up, so. Um, in patients that um have these sort of challenges that hopefully you can assess in clinic, before it's an emergency, you can maybe provide them um with some backup, um, antiemetic in case of these situations. Um, and then again, it's really important to educate caregivers on when to escalate care in the situation and don't wait until it's too late to get in the car and try to drive to the 4 hours away, um, hospital, um, because that may be, um, too late and very dangerous, and, and so, um. Having patients in this situation to have really clear idea of, of, you know, when your kid is vomiting or have mental status changes or persistent high glucose and ketones, it's time to, to um go seek care. Um, again, uh, Just thinking about is home management appropriate. Um, if their, if their overall symptoms are pretty minimal, they're tolerating fluids, um, we have a clear insulin adjustment plan, and they have adequate diabetes supplies, um, and, uh, especially if they're younger kids, there's a parent or caregiver who's available to be with them, and, um, there's not any, you know, it's not like a daycare with uh someone who may not be as comfortable and familiar. Um. So, uh, again, in terms of patient education, things that we want to check in during clinic, um, is make sure their insulin is, um, is not expired and they have, um, fresh supplies, um, hasn't been, you know, laying out in the hot sun or left in their car, um, making sure again they don't stop insulin, which is, um, which is gonna be a point I keep coming back to. Um, again, the 4 to 6 mLs per kg per hour, small sips of, um, of fluids. Again, if their blood sugar is lower, you're gonna recommend sugar containing fluids, but if it's higher, um, you're gonna offer sugar-free fluids, um, and then just frequent monitoring of those glucose and ketone levels to help guide our management. Um, Again, uh, having really adequate support is important too, and again, uh, I mentioned all this before, but, um, having, um, plans in place again for these more rural patients, um, to expedite transfer to medical facilities, um, before they, they become, um, Even sicker, um, or if you're sensing that the family is exhausted or or or overwhelmed with the care, um, And then, uh, again, making sure they have those 24 hour phone uh contact numbers and support, um, and then really just frequent um contact with families. And again, we're lucky, um, here at Children's Oakland because we have an amazing team of of uh certified diabetes educators who um help so so much with our families to prevent a lot of DKA. Um, next case, um, so this is a 16 year old, they scam, they skipped their Lantus dose last night. Blood sugar is 290, um, and they have moderate blood ketones. Um, the patient has nausea but no vomiting. Um, so in this situation, we're gonna increase insulin by about 20%. Um, again, think about an antiemetic, um, prescription to help with the nausea, um, so that they can take fluids in, and then frequent monitoring and rechecking glucose every 2 to 3 hours. Um, and really I think the thing with this, um, is to think about when, you know, adolescents and teens are skipping insulin. It's often, um, More about being overwhelmed and and burnout than just being defiant and um and forgetful even. Um, and so this is a time when really building trust is important and asking, you know, what, what made it hard to take your insulin that night and, and what barriers are preventing you from taking your insulin so that we can really focus in and and personalize our um management for that patient. Um, in terms of the diabetes technology, so we have these amazing, um, tools now, um, for type one diabetes, um, with, uh, insulin pumps and continuous glucose monitors, um, with automated insulin delivery or AID, um, so in these, um, hybrid closed loop systems, um, the Um, glucose sensor is, um, communicating with the insulin pump, which um has a, a control algorithm, and then, um, adjusting basal insulin, um, and even providing um uh bolus insulin for um hyperglycemia or suspending insulin for hypoglycemia, um. The important thing um with technology is it's not foolproof, um, and it, although it's made managing diabetes a lot um easier for families, um, it does take some tech savviness and, and, um, uh, and some knowledge on the part of the family, um. We really advise continuing to wear the pump in the setting of illness, um, unless the patient's having vomiting or known site failure or or essentially suspected insulin delivery failure. Um, so whenever we know patients on an insulin pump, the first thing you have to think about is infusion site issues. Um, often, uh, even if it's not alarming that there's an occlusion or there's a a kink in the tubing. Um, you can have, um, uh, a kink in the, in the, um, The subcutaneous uh catheter, um, that's preventing insulin from effectively being delivered or being delivered at all. And so again, um, even if, uh, the sensor was just the site was just changed, um, you want to suspect that pretty quickly, um, but then especially if patients are smelling insulin or they, they are having irritation at the area, those may also be clues that um the site is not viable. Um. In those cases, we need to think about manual corrections, either um Leading the um automated insulin function in the pump, um or the the um automated mode, um, to do just manual mode in the pump again in the setting where you're pretty confident the site is, is viable and working, but low threshold to um switch over to subcutaneous um correction. So again, having all these supplies, even if they're on a pump um with backup pens is really, really important. Um, these newer algorithms, um, there's a new, um, Control IQ plus that allows for, um, a temporary basal rate while you're in the automated mode. Um, so that's nice. It's, it's a very new feature, so we don't have a ton of kids on it yet, but hopefully things, these changes will make um managing um sick days on pumps a little bit easier, um. Again, if it's still functioning and the site is viable, just keep the, the pump on. Um, but again, without, um, uh, when it's in automated mode, they're not gonna automatically adjust for ketones and vomiting, um, so we still need to keep that in mind, um. Again, providing a manual correction if needed, but again, thinking about what are our ketone levels and how will that guide our next steps um on the pump. And so if you have normal to small ketones, you're gonna continue business as usual via the pump, um, checking every 2 hours, um, but if your glucose is over 250, um, And your ketones are low, just change the infusion set and you can give a um new correction through the infusion set and into the pump again every 2 hours until the glucose is back into range. Um, if it's over 250 and your ketones are now rising, that's when we need to go to the next steps. And so, Usually with moderate or large ketones, we want to then think about giving an injection, uh, subcutaneous via syringe or a pen, um, not through the pump because now we're in a moderate to large ketone territory, um, we don't want to mess around with the pump and and potentially, um, Provide insulin that's not being delivered and um it'll look like you have a lot of insulin on board on the pump, but you're you're actually not seeing that much insulin. And so, at least with the manual correction, we know what's going in, we know that you now have insulin on board and can start helping to reverse that ketosis. Um, in the meantime, you can change your infusion set, drink water, and then again recheck ketone and glucose, um, every 2 hours. And then if we have large ketones, um, again, we're gonna give the uh injection of subcutaneously, not through the pump, um, and then, uh, you want to change the infusion set and really follow the same steps as above, but also call our team, and if, uh, ketones are not decreasing after about 2 hours, um, we typically would recommend they they come into the emergency room. Um, again, uh, if unsure, you can switch into manual mode, um, but this is all Uh, in the context of a, of working uh pump site. Um, so this case is an 11 year old who's on Omnipod 5, which is a hybrid closed loop system. Um, A1C is 7%. Um, the patient lives with both, uh, parents, and they both have PhDs, so they're pretty, uh, tech savvy and educated. Blood sugar is 290, our ketones are 1.8, um, so moderate, and then, uh, we don't have any occlusion alarm and her sight appears to be intact. Um, the parents tell you that the um pump keeps giving insulin, um, but the blood sugar is just not improving. So the plan here, um, if you again trust that the site is functioning properly, which can be hard to do over the phone, you wanna switch out of that um the automated mode and manually override the algorithm. So we're gonna give manual corrections through the pump based on our sick day plan, um, and based on the ketones, um. The uh main thing to know is that the hybrid closed loop algorithm can sometimes underdeliver during sick days and it'll lag behind, um, and again, it's not going to compensate for the rising ketones. Um, in this case, we also wanna change the infusion site immediately, even if the site looks fine, I think we need to, um, I understand that she does have ketones already and we have to consider that site failure is very likely. Um, and, and provide her with a manual subcutaneous injection. And then again, oral hydration. Um, this slide is just meant to show you that again, this technology is amazing. Um, continuous glucose monitors are, um, really changing how we manage diabetes, and they, um, we know that real-time CGM use can decrease DKA episodes in patients with type one diabetes. Um, and again, this just showed, um, Um, compared to non-CGM users, this in this study by Foster and all, um, there was just much lower DKA rates, um, 1% versus 3%, um, in the 6 to 12 year age group, 13 to 17 year age group, um, was 2% to 4%, so about half the rate, and then 18 to 25% um group was also about half the rate. Um, This is overall associated with better glycemic control and earlier interventions, and then it's encouraged by ISPAT as well. Um, it's really a tool for equity, um, and not just for convenience, um, so we have to really make sure our kids who are on public insurance, um, uh, are appealing to get CGMs and, and make sure that this is part of their, um, their care as long as they're tolerating it. Um, and again, access to this technology is a big part of um safe sick day management. Um, so in terms of emergency management, we have a 10 year old diagnosed 4 years ago on multiple daily injections, history of one prior DKA, hospitalization, had 24 hours of vomiting, um, and abdominal pain, and blood sugar is currently 370, does have large urine ketones. He's also to Kipnik with a fruity breath. So next steps, So, this patient has vomiting, large ketones, um, and, uh, this really is DKA until proven otherwise. Um, so we're gonna call EMS or recommend uh transportation to the emergency room in this situation. Um, again, we're thinking to refer to the ED or escalate care if the patients had severe vomiting over 2 hours, persistent blood ketones that are large and not decreasing. Altered mental status with again this, these two small respirations, um, and signs of severe dehydration. Um, so decreased urine output, um, uh, despite previously being probably polyuric, um, tacky mucous membranes, um, and just overall poor um PO intake. Um, and again, you could see with co small breathing, um, it's these deeper but more rapid, um, respirations. Um, this case, um, is a 16 year old. Uh, last clinic visit was over a year and a half ago. There's been a lapse in their insurance coverage. The family speaks Yemeni Arabic, um, the patient understands a small amount of English. They present um to the ED The pH is 7.1, bicarb um is 8, and our blood sugar is 366. This is their fourth episode of DKA in the past year and a half. Um, so in this situation, um, we obviously need to manage the DKA acutely, but we need to really think about, um, education, how do we address language barriers, do what is the, the medical, um, literacy of this family and the patient and so providing visuals, um, involving social work, um, and then again, uh, really reinforcing our sick day plan. Um, so that we can prevent future episodes of this, but again, digging into why, um, what happened with insurance, as well as, um, were there any other barriers or transportation issues that prevented them from coming to clinic. Um, so again, interpreter use, um, access to our, our hotline are important, um, aspects for these patients who may feel intimidated, um, by calling in, especially if they don't speak um English, um, addressing their health literacy with again visuals, um, for carb counting, visuals for um ketone monitoring, um, again, having kind of like a green. Yellow, red type of um display for them to know um how to manage in those those sick day settings um using teach back method methods to validate understanding and then um again avoiding assumptions about noncompliance because there's often much more. To the story and um really um having some cultural humility and asking how health is discussed in the family, who is, who's managing and helping the child at home, who's the decision maker, um, what are their health beliefs, especially on sick days and um trying to again address that in clinic, um, which is, um, you know, can be difficult with time restraints, but that's why, you know, we have an awesome team to, to reinforce things like this. Um, Not sure if I have too much time left, um, but, uh, this case was, is meant to just again illustrate, um, some health care disparities. Um, so we have a 14-year-old black male who's brought to the emergency department. He's in DKA. He's had diabetes for 3 years, A1C is over 12. He's had 3 ED visits in the past year. Blood sugar is 430, his large ketones, and his pH is 7.18, so, um, in acidosis. Um, you read the ED note and it says no adherent to insulin regimen, missed multiple endocrinology appointments, family declined CGM previously. Um, we then find out the pharmacy benefits are not covered for CGM, um, without a prior off. The grandma didn't understand sick day instructions at our last visit and felt really rushed rushed during the clinic visit. Um, prior clinic notes often lacked any documentation about barriers to care. Um, So thinking about where bias could show up. So again, reading the note, um, seeing terms like non-adherence, but um or refused or declined or noncompliant, um, they're pretty loaded words and so you really want to explore access and again barriers in in situations like this, um. Again, uh, they labeled the family as declining technology instead of recognizing these barriers, um, and then using this, this, um, language can be, um, really negative, especially if it's repeatedly using the chart and kind of um. Predispose other providers to using the same language. Um, so again, using a trauma informed and equity focused language, asking about these barriers, providing the plain language sick day plans with visuals and engaging community health workers um proactively. Um, And then this chart is really just meant to be hopeful that um consistent sick day reinforcement at our clinic visits at hospital discharge, at uh during triage calls, um, and emergency calls, um, shows that education works, and so, um. Among children who had decay in 2015, um, this study, which is, uh, uh, by DAA in 2021, um, showed that patients with multiple decay episodes steadily declined over three years. Um, by 2018, um, There was a proportion with no additional, the proportion who had no additional DKA had increased, um, which is this blue here. So again in 2015, um, as our baseline, we don't have a blue bar, but then you see that the steady increase of no DKA episodes, um, and again, um, repeated education and support, um especially for our vulnerable patients is, is just, um. Uh, imperative in, uh, preventing ketoacidosis and um helping our patients live a healthy, happy life. Um, so these are just final takeaways, um, So never stop basal insulin, even if the kid is not eating. Monitor blood glucose and ketones every 2 to 4 hours during illness. Adjust insulin doses based on ketones and blood sugar. Um, hydration is essential, using, um, sugar-free, um, or carb containing fluids appropriately depending on um the situation. Um, sick day plans that are written out, um, and very clear, um, and then verifying understanding with teach back, um, uh, techniques is also important, and then again addressing these health disparities um in terms of access, um, language barriers, literacy support, um, and technology, and knowing that structural inequities are, um, not, uh, uh, consistent with individual failure, and then we gotta know when to escalate care. Uh, these are just some resources and otherwise, thank you for your attention. Thank you so much, Doctor Parish. I think we got a couple of questions coming in, um. First question, um, Was, can we go to slide 40 again and just review that for a second? Is it this case or? Yeah. I think one side. Behind that one. Like 40, 0, OK. This I'm not sure the question asker just said uh. Flight 40 again labeled case 6, but actually the 7th case. Mhm. Yeah, not sure about the actual question on that one. Uh, but if we can elaborate, uh, we can get to that. Another question we had was what percentage of admissions, uh, do we know are due to a malfunction? Is that a common thing that you guys see, uh, or is this a little bit we're getting better as the technology is improving? Yeah, I mean, it's, as I, I was kind of discussing, it's, it's overall, um, Pumps and diabetes technology have done a lot in in management of diabetes in maintaining, you know, um, improved A1Cs, improving uh glycemia overall. Um, however, um, I wouldn't say a majority of our patients that get admitted are are pump users from pump site failure, but Of the patients that use pumps, that's generally gonna be the number one reason they have DKA is pump site failure. And so whenever, you know, a patient again, if they're coming to the ED and they have been using a pump, that's really the first thing you should suspect. Um, and hopefully again if the family is, um, paying attention, they can give you a little bit of detail about um what they think is going on with the pump site, and if they made any changes recently when they last changed it. All those are important to know in terms of how we're gonna manage it going forward, but at the same time, um, again, I, I think still, you know, it's our pump users are not gonna be a majority of our patients getting admitted in DKA, but that is, um, what's gonna cause it this pump site failure. Gotcha. And then I had a a question about the calculation for increasing the based on the glucose and. Um, the ketones, um, you may have went over, but I may have missed it, but when we're increasing by a certain percentage, like 10% for the mild, 20% for the moderate, 30% as high as 30% for the severe, that's in the total daily insulin increase. Are we splitting that up, uh, between the Uh, the basal insulin, but also if we're using like a sliding scale with ICRs, or how, how does that work if we're putting it into the ICR we're just increasing the ICR by that percentage too? Yeah, so it, it can, it essentially requires recalculating. All of their doses and having that as their sinus sick day plan. So again, if, if that hasn't already been done in the moment, like when patients call, I often will just do the um the sort of, uh, weight-based more and, and I do that 15, you know, to or 10 to 30% adjustment just based on the correction or the hyperglycemia insulin. Um. But again, if, if we have a sick day plan right now, it's or for patients on pumps, sometimes you can have a separate um uh regimen or plan in the pump program then or again if they're, if they're doing injections, you can have a A plan right now based on a, you know, the different total daily dose increase so that they know, yes, you would then increase your basil by this much and your corrections and your insulin for food. Um, so it's gonna affect kind of all all the different um parts of the regimen rather than in more just like the, the fixed ketone dose, it's just gonna be based on the adjustment um for that correction for hyperglycemia or ketones. But for the immediate correction, and then we maxed out. At 15 units for the immediate correction for the ketones, uh, based on weight. And then there's not really a max, um, cause again, some of our, our older adolescents, um, may need pretty big doses, especially when you're when you're doing these adjustments. Um, a quick way I often will tell patients is, um, Just calculate your insulin exactly how you would in a normal situation, and then multiply that by 1.3 or 1.2 or 1.1 to give that, you know, 10%, 20%, 30% increase, um. Again, they may need multiple of those um to get the ketones cleared and down, but um at least we're, you know, compensating and, and giving them that extra amount, um, in the moment, but it may not, it may be too late that they already got their basal insulin for the day, so we can't really adjust that anymore, so you're really just gonna be adjusting for um the blood sugar and ketones. Gotcha, gotcha. Um, we have, uh, a question about, uh, if there's an interruption of insurance, uh, is, is there any sort of safety net for getting insulin and insulin supplies if they can't afford it? Yeah services we can point our families to in low resources communities. Yeah, I mean, it's, it's hard. I mean, we're trying to do a lot of that in clinic and make sure again when they're, when they're there, um, in a non-emergency situation, we're checking in on their supplies, making sure we're addressing any access to their, their prescriptions and making sure they have a really solid supply at home, so that's, it doesn't come down to like, you know, it's Friday night at 8 p.m. and they ran out of completely insulin, um, that happens, you know, but those situations, um. Often, you know, we can, uh, pharmacies have a lot of um benefits, especially if a patient can't afford it where they can get discounts, um, sometimes they, they, um, can talk to us as well on call and we can, we can help arrange to make sure that they get benefits um or compensated later by social work. Um, so we, we in our clinic try to address those, again, it's, it's a bigger systemic issue of, of, you know, How do we make sure this never happens? How do we make insulin affordable, which, um, you know, is being worked on, but it's still presents as a barrier for a lot of people. And so, um, if they're nearby, you know, patients can, can come to children's, um, sometimes we can give them like during work hours, you know, an extra sensor, maybe some pump supplies, um, but, uh, insulin can be a little bit laminated just in terms of what, what we even have in our clinic. So, Again, worst case scenario, they would have to go to the emergency room, but obviously we, we wanna try to prevent that um in terms of just like utilization of resources, um, but yeah, it's, it's, it can be, it can be definitely difficult and again trying as much as possible in clinic to address those barriers and make sure they have adequate supplies before it's a problem like. Perfect. Thank you so much. Uh, we've run out of time, um, but our last, uh, question was, it wasn't really a question but a comment. Uh, excellent presentation. Thank you so much. Uh, please do a conference on management of prediabetes elevated, uh, uh, HbA1Cs and hyperinsulin anemia and metformin. They would love to hear you more as a speaker. So thank you so much for your time, Doctor Parish, um. Lovely and very well timed going into summer break with all these kids probably catching some stuffs are no longer there for these kids, so we may see some increases so everyone be on your toes. Perfect. Thank you so much. Have a good morning. Created by
