Transcript Urine Metabolic Screening an useful screening tool?

Standards of Diabetes Camp
Dr Elaine Kwan
QMH
16 September 2004
Mission of diabetes camps for
children and adolescents
• To allow for a camping experience in a safe
environment
• To enable children with diabetes to meet and
share their experiences with one another
• To learn to be more personally responsible for
their disease
Mission - for patients and families
• To be enjoyable
• To increase the confidence in both physical
and social activities
• To promote diabetes education in a more
relaxed and non-structural setting
• To review their management skill in daily life
• To impart a more positive attitude in coping
with chronic illness
Mission - for patients and families
• To promote communication / understanding
with staff and sharing of difficulties and
feelings in coping with disease
• To allow parents a ‘vacation’ off diabetes care
• To allow campers to gain perspective on their
own family dynamics
• To establish ongoing peer support networks
Mission - for medical staff
• To have better understanding of the struggles
and difficulties that patients face in their
daily living
• To build a good rapport and relationship with
the patients and families
• To provide an opportunity to work as a team in
running an educational camp
• To encourage sharing of responsibilities in
diabetes care
• To gain practical experience in diabetes care
Diabetes camps for children and
adolescents
• Should be an integral component of overall
care and support
• Organised using an agreed set of standards
and protocols specifying responsibilities, staff
ratios etc
• Skilled medical and camping staff to ensure
optimal safety and an integrated camping
/educational experience
• A standardised medical information form
should be completed for each campers
Diabetes camps for children and
adolescents
• Often associated with increased physical
activity
• Goals of glycaemic control more related to
avoidance of hypoglycaemia than optimization
of overall control
• Balance insulin dosage with activity level and
food intake
Standardised Information before
camp
• Past medical history
• Immunisation record
• Diabetes regimen including home insulin dosage
• Blood glucose record for the week before camp
• History of poor control and severe hypoglycaemia
• Previous HbA1c levels
• Other medications
• Psychological issues
Written camp management plan
• Include camp policies and medical management
procedures
• General diabetes management
• Insulin injections/ pump therapy and BS
monitoring
• Nutrition, timing, and content of meals &
snacks
• Routine and special activities
Written camp management plan
• Hypoglycaemia and treatment
• Hyperglycaemia/ketosis and treatment
• Medical forms
• Assessment and treatment of intercurrent
illness
• Psychological issues at camp
Written camp management plan
• When to notify parents and chief care
physicians
• Risk management plan
• Universal precautions and policies for needle
sticks
• Handling of infectious wastes
• Monitoring of medical equipment
• Incident/ accident reporting
• Policies for camp closure and returning home
Written camp management plan
• Emergency procedures (including natural
disasters)
• Prevention of physical, sexual and
psychological abuse
• Risk management plan
Standardised record during camp
and feedback
• All blood glucose levels and insulin dosages
• Degree of activity
• Food intake
• Any major alterations during the camp
• Copy of camp record sent to health care team
of patient
• To return to their pre-camp
regiment
Camp Leader
• Led by someone with expertise in diabetes
care, in paediatric care and in camping
– Appropriateness in working with children
• Be responsible for daily reviewing of blood
glucose results, insulin logs and other
medications to make appropriate adjustments
• Overseeing all medical emergencies
• To ensure that the medical program is
integrated into the overall camping experience
Camp Staff Composition
• Diabetes educators
• Dietitians
• Students
• Volunteers
• Camping experts
Training of staff
• All staff should undergo testing to ensure
appropriateness of working with children
• All staff should receive training concerning
routine diabetes management issues and the
treatment of diabetes-related emergencies
before camp (hypoglycaemia and DKA)
• Familiar with signs and symptoms of hypo/
hyperglycaemia, indications for blood glucose
testing, and treatment of hypoglycaemia including
administration of glucagon
• Camp policies and job descriptions available before
camp
Facilities
• Routine first aid
• For treatment of intercurrent illnesses
(allergies, asthma, sore throats, diarrhoea/
vomiting, minor trauma)
• Diabetes supplies (insulin, pen, pump, battery,
catheters, glucose monitoring machine,
stripes, lancets, syringes, alcohol swabs, gauze,
glucagon, intravenous glucose solutions, simple
sugar, urine ketone stripes, stethoscopes,
thermometer)
Management protocol at camps - insulin
• To balance insulin dosage with activity level
and food intake to ensure stable blood glucose
• 20% or more reduction of insulin dosage
• Extra reduction for extreme physical activity,
prolonged hikes or water sports
• Pre- and post-camp insulin dose advice
– Small reduction of 10% for immediate
pre-camp dose
Management protocol at camps monitoring
• Multiple BS determinations made throughout
24 hour period
– Before meals, at bedtime, after or during
prolonged and strenuous activity and in the middle
of the night (for BS < 5.6 before bed), after
extra doses of insulin or with symptoms of
hypoglycaemia
• Daily record of camper’s progress
– Insulin dosages, BS levels, degree of
activity and food intake
Management protocol at camps - diet
• 3 meals and 3 snacks should be given at set times
each day
• Meals balanced, with composition, carbohydrate
component, exchange value, and/or calorie count
taught to campers
• Enable campers to learn how to balance food and
activity
• Supervision of food intake of younger
children
• Give extra snacks for BS < 6.7 mmol/L
• Signs of eating disorders
Management protocol - others
• Universal precautions (appropriate containers
for disposal of sharps)
• Formal relationship with a nearby medical
facilities for emergencies
Hypoglycaemia
• No clear definition, usually defined as PG < 4
mmol/L
• Varies with metabolic control (threshold at
higher BG level for poor control)
• Result of a mismatch between insulin, food and
exercise
• Symptomatic/ asymptomatic
• Mild/ moderate/ severe
– Moderate - requires help from someone else
– Severe - semi-conscious/ unconscious/ coma/
convulsion
Hypoglycaemia related to exercise
• Hypo can occur
– During exercise
– Immediately after exercise or
– 6-8 hours after exercise
• The BS lowering effect is extremely variable
and severity depends on many factors
• Recommendations for individuals can only be
made on the basis of their age, size, individual
experience and ‘trial and error’
Prevent exercise induced hypoglycaemia
• Extra snacks before and after exercise
– Small rapidly absorbed carbohydrate for light
exercise
– Slowly absorbed carbohydrate for strenuous
and prolonged exercise
– Extra snack before bed for strenuous exercise
in the afternoon or evening
• Reduce insulin dose
• Change injection site
• Monitor BG before exercise
High-risk sport when hypoglycaemia
would be potentially dangerous
• Water sports, climbing, skiing, diving, riding
bicycle etc
• Must do BS monitoring before , during and after
exercise
• BS targets may be temporarily relaxed
• Extra rapidly absorbed carbohydrate must be
available throughout the period
• Young people should perform strenuous exercise in
the presence of a companion/ supervisor familiar
with the recognition and treatment of hypo
Treatment of hypoglycaemia
• All measures to avert severe hypoglycaemia
(give extra snacks for BS < 6.7 mmol/L)
• A set protocol for treatment of mild-tomoderate hypoglycaemia so that hypoglycaemia
is consistently managed
• Repeat BS testing performed within 30 min to
ensure resolution of hypoglycaemia
Guideline for management of
hypoglycaemia in camp
• Check dextrostix if condition not critical
• Dextrostix 3-3.9: give 10 gm simple sugar, repeat
after 3-5 min if necessary
• Dextrostix < 2.2: give 20 gm simple sugar, give
another 10-20 gm if still symptomatic after 3-5
mins
• Give extra 10 gm CHO if no meal within 1 hour
• Unconscious: give glucagon imi (0.5 mg for < 6
years, 1 mg for > 6 years)
• Keep record of BS reading and inform i/c medical
staff before next injections
Extra carbohydrate before and during
exercise
Exercise
Low intensity
or < 30 min
Moderate
BS before (mmol/L)
<7
>7
<7
Strenuous
<7
7-12
> 12
> 15
Extra CHO
10 g
No extra CHO
10-15 g before
10 g for every 30 min
20 g before
10 g for every 30 min
10 g before
No extra CHO
Exercise should be avoided
Treatment of ketoacidosis
• Measure urine/serum ketone if BS persistently > 15
mmol/L (2 consecutive readings if asymptomatic) or
if there is intercurrent illness
• Oral or intravenous hydration (oral: 2 L water/day)
• Extra insulin (10-20% of total daily dose as fast
acting/ ultra-fast acting insulin bolus) if BS and
ketone +ve
• Avoid exercise
• Dextrostix and urine/serum ketone every 4 hours
• Flow sheet for documentation of progress
• To medical facilities if vomiting or if ketosis does not
resolve within 8 hours
Diabetes Education and Psychological
issues at camp
• Camp setting an ideal place for teaching
diabetes self management skills
• Education programs should be developmentally
appropriate
• Improve psychological well-being of campers
Diabetes Education - topics
• Insulin injection techniques/ insulin pumps
• Blood glucose monitoring
• Recognition and management of hypo/hyperglycaemia and
ketosis
• Insulin dosage adjustment
• Carbohydrate counting
• Diabetes complications
• Importance of diabetes control
• Lifestyle issues (especially weight control and exercise)
• Sexual activity and preconception issues
• New therapies
• Problem solving skills
Research at camp
• Must not interfere with integrity of camping
program
• Parents and campers should have a copy of the
research protocol
• Informed consent
Thank you !
See you at the camp !