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Question:

From Gandhidham, Gujarat, India:

I have a four-year-old patient who was diagnosed with type 1 diabetes. Laboratory results include an HbA1c of 10.16; S. Acetone ++++; S. Sodium, 136; S. Potassium 2.7; Acid base Hb oxygen status; PH 7.23; PCO2 17; PO2, 69; HCO3 7; TC 113000, USB abd NAD - at present he is on six hourly Actrapid injections. Can you give me a second opinion about his treatment, diet, exercise, etc.?

Answer:

The very first part of your letter is unclear. What was transmitted was "one pt pe n4 yrs" and I regret I was not completely certain what was trying to be conveyed, but I am summarizing that you are describing a male patient, aged four years and that you need assistance is interpreting the laboratory reports of his recent diagnosis of type 1 diabetes. I am also assuming that in the time since you wrote this letter, therapy has been instituted and that you wouldn't have written to an "informal" patient support web site for specific medical management.

On the other hand, you do indicate that you are a physician and are seeking a second opinion regarding management. I must admit that this surprises me a little, doctor. So, my initial reaction would be that you quickly refer the patient or otherwise confer with a pediatric endocrinology sub-specialist within your own area/region. A children's hospital likely exists where such a specialist can commonly be found.

I noticed that, oddly, you did not provide units of measurement for some of the laboratory values supplied. This makes interpretation much more difficult, as you know.

For the sake of our lay readers, I will now address your letter in a more comprehensive way.

The HbA1C was "10.16." This probably is 10.16%. This is a measurement of how much the blood protein hemoglobin subtype A1c (HbA1C) has been glycolated, i.e., how much glucose has "stuck" to it. There is ALWAYS hemoglobin in the blood and there is always glucose in the blood and there is ALWAYS some glucose that gets attached to hemoglobin. For humans (after infancy through adulthood), the amount of hemoglobin that normally gets attached to glucose is about 6% or less. Assuming that your patient does not have a known disorder of hemoglobin, which typically you might already know in a four-year-old, your patient's HbA1c value of 10.16% indicates that the AVERAGE serum glucose over the previous 10 to 12 WEEKS has been about 284 mg/dL (16 mmol/L), which is abnormally elevated.

The "S.Acetone" was "++++." This is a very semi-quantitated estimate of the presence of acetone in the patients blood serum (S). Acetone is a chemical in the "ketone" family. Ketones are natural breakdown products of fat, but too much can be dangerous and affect the brain and the gastrointestinal tract. It would not be surprising in the normal individual to have NO acetone/ketone detectable in the serum. The grading system of positivity commonly is given as a range of "+" signs from none to four. So, a value given as "++++" means "A LOT" of acetone, which not only is abnormal, can be dangerous, as it reflects the potential metabolic abnormality of uncontrolled type 1 diabetes referred to as "diabetic ketoacidosis" ("DKA"), which can be FATAL if left unchecked.

"S.Sodium 136" means that the patients serum sodium was 136 mmol/L. The value itself is normal (typical reference range about 135 to 145), but in a patient with diabetes, must be interpreted relative to the concurrent serum glucose concentration, which was not provided. There is a special formula that helps determine this, which is not typically done for laboratory reports; the clinician must do it. Too high or too low a serum sodium has very important considerations for the patient's degree of hydration and risk of brain swelling, blood clotting potential, and others.

"S.Potassium 2.7" means that the patient's serum potassium was 2.7 mmol/L. Normal is about 3.5 to 5.0 or so. While this value is low, it is not "dangerous" but could become significant quickly. During the process of uncontrolled diabetes, especially DKA, the body loses a lot of potassium through the kidneys. Potassium is critical for electrical actions of cells and their cell membranes, among many other things. A very low potassium can quickly lead to a disturbance in the heart's rhythmic beating. What's worse, as one initially begins to treat the poorly controlled diabetes (with fluids and insulin, as a start), the serum potassium will actually get LOWER. This patient needs a slow intravenous infusion with LOTS of potassium now. (See below).

The following indicate that a "blood gas" was done. This was probably from a vein and not an artery (which is not typically important in diabetes management), but does make interpretation of the values different.

"PH 7.23" this should read "pH." This refers to the degree of acidity vs alkalinity of the blood. This is a logarithmic scale so any change of "1" is actually about 100 fold. The normal blood pH ranges from about 7.35 to 7.45. The lower the value, the more acidic; the higher the value, the more alkaline. Your patient has a moderate-to-severe degree of excess acidity. Your patient is in DKA, which could be fatal if left unchecked. (But you did indicate that short-acting insulin was being. More comments below.)

"PCO2" is the partial pressure of carbon dioxide in the blood or the amount of C02 gas dissolved in the blood. A normal value is about 40 millimeters of mercury. The value of 17 IN THIS PARTICULAR SCENARIO really means that the patient, in an attempt to self-treat his own increased acid level, is breathing quickly to "blow off" more C02 (thus lowering the number), since CO2 is quickly transformed to acids (and even some alkaline sources), and the patient is trying to decrease his own serum acids.

"PO2 69" means that the amount of oxygen dissolved in the blood is 69. If this were from venous blood, the value would be normal. If this were from arterial blood, the value would be very, very low and suggests a problem with the lungs (or even the heart) to help extract oxygen from the air (e.g., pneumonia). As I noted, usually, DKA is not associated with oxygen problems so I am assuming this value is from a vein.

"HCO3" is the amount of bicarbonate (a normal alkaline agent) dissolved in the blood. Your patient's value was 7, extremely low. A normal value is about 25 to 30. Your patient has "used up" the normal "buffering" capacity of this alkaline to try to offset all the acids. This natural response of your patient was extremely normal, but he has lost that battle and the acids still accumulate (see above). He needs intravenous fluids "now" to help (recognizing again that by the time this forum can respond to a letter, time has significantly passed.

"TC 113000." This was hard. Is this total cholesterol? If so, the value is astronomically high which has implications about heart disease, etc. When measured in mmol/L, the normal serum cholesterol range is about 2.6 to 6.5; if measured in mg/dL (as commonly done in the U.S.), the reference range is about 100 to 250. This value must be repeated while in this immediate recovery period with intravenous fluids and insulin, and then after there is control of the blood glucoses. I'd wonder about family cholesterol levels and their genetics. High cholesterol can also be associated with high triglycerides (fat particles), sometimes abbreviated "TG". High TG can be associated with potentially deadly pancreatitis. Otherwise, I regret that I am unable to decipher the "TC".

"USG abd NAD" I really cannot decipher the abbreviations you gave here. Perhaps it means an UltraSound of the "abd"men was performed and No Abnormalities were Detected? If so, that's good, especially given the potential elevations in TC and TG.

You indicate that the patient was treated with short-acting insulin. I do not know if you meant six units every hour or some other dosage given every six hours. Commonly, the amount of insulin given is based on the patient's body weight and, then, adjustments are made based on many things, including the serum glucose level and how it changes. Such insulin now is most commonly given as a continuous infusion of insulin directly into the veins. An older, but still tenable regimen includes to give the insulin into the muscle periodically. In DKA, it is commonly given hourly.

While I will not give a discourse in the management of DKA here, I will indicate that DKA management (and this patient is in moderate to severe DKA!) requires immediate intervention and includes proper fluid replacement (typically as an intravenous solution containing some sodium and [a lot] of potassium salts along with some chloride and some acetate, or phosphate) and a lot of careful medical supervision. Insulin is absolutely mandatory. A generally reasonable initial treatment of DKA would be to give 10 to 20 cc per kilogram of the patient's weight as a one time bolus of 0.9% normal saline into the veins over about one hour. This would be followed by changing the intravenous fluids to "maintenance" to include 0.45% normal saline with additional potassium. In this case, I would add about 40 to 60 mmol/L of potassium as either potassium chloride, acetate, or phosphorus or combinations thereof. The blood chemistries should be monitored at least every four hours to start (may be more frequently) while the glucose is assessed every hour. As the measured serum glucose approaches 300 to 250 mg/dL [16.7 to 13.9 mmol/L],, then glucose is added to the intravenous fluids in the form of D5% or D10%. The rate of this maintenance would not exceed the calculate rate of 4 liters per meter square body surface area per day. A rough estimate of this would be about 1.5 times the "normal" maintenance rate given hourly. This would, of course, change, based on the patient's weight, which was not provided. The intravenous therapies could be switched off and the insulin changed to subcutaneous insulin when the patient was no longer acidotic and the potassium and other chemistry values were more normal and stable.

Finally, you asked: "Can you give me a second opinion regarding treatment, diet, exercise, etc?"

This is for the daily (including home) regimen after the patient has completely recovered from the DKA without any ill-effects.

The patient requires daily subcutaneous injections of insulin. This can be accomplished a number of ways. It, of course, requires the education of the patient (if age appropriate) and the home caregivers. A common insulin regimen employed now involves the administration of a VERY LONG acting insulin (such as insulin detemir or glargine) once (sometimes twice) daily and then injections of very RAPID acting insulin (insulin lispro, aspart, or glulisine) at each meal, with the amount given hinging on how much the patient is expected or did eat at that specific meal/snack. Thus, teaching how to accomplish carbohydrate assessment in foods ("carbohydrate counting") is critically important.

Another older, but effective, insulin regimen might include giving an INTERMEDIATE acting insulin (such as Neutral Protamine Hagedorn [NPH] insulin twice a day PLUS concurrent administration of a short-acting (NOT a "rapid"-acting) insulin, such as the regular "Actrapid" insulin you are giving now.

The amount of daily insulin required commonly is associated with patient's age and weight. In broad terms, a four-year-old might require 0.5 to 1.0 units of insulin for every kilogram of body weight per day.

The family/patient must be taught how to check the patient's serum glucose with a home monitor. This is easy to learn. They would check four to eight times daily, at least, depending on the patient's meal and insulin plans, and when looking for too low a glucose ("hypoglycemia"). They must be taught how to react to a low glucose value.

The family/patient must be taught how and when to check for ketones (e.g., acetone) in the blood or urine. Urine testing is cheaper and easier. Blood testing requires a special meter for home that may not be available to you. They must be taught how to react to ketones.

Daily activity is equally critical. It really does not matter what type of exercise, as long as it is fairly routine. It is also age dependent. You probably will not be able to make a four-year-old be more active than any other four-year-old. But, a 14-year-old, for example, could (and should) participate in athletics, if possible.

I would STRONGLY advise you to send the patient to a pediatric diabetes team, likely at a children's hospital and/or university medical center. If they cannot travel, then you must at least confer with one.

DS

DTQ-20081227115259
Original posting 29 Dec 2008
Posted to Diagnosis and Symptoms and Daily Care

  
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Last Updated: Tuesday April 06, 2010 15:10:18
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