Professional Documents
Culture Documents
Tutorial
Dr Amir Babiker
MBBS, MRCPCH (UK), CCT (UK),
Msc Endocrinology and Diabetes
(Queen Mary University, London,
UK)
Consultant Paediatric
Endocrinologist, KKUH
and Assistant Professor, KSU
Objectives
Definition of polyuria
Causes of polyuria and Approach
Types of diabetes: Assessment and Mmt
Emergency management: DKA &
hypoglycaemia
Clinical Scenarios
Definition
Excessive or abnormally large production or
passage of urine (usually > 2000 ml/m2/day)
or (> 5 ml/kg/hr).
Surface area= Ht(cm) X Wt(kg)/3600
Increased production and passage of urine
may also be termed diuresis.
Frequency is usually an accompanying
symptom.
Polydipsia (increased thirst)= Cause or effect.
Causes
(1) Increased fluid intake.
(2) Increased urinary solute
execration.
(3) Impaired urinary concentration.
(4) Physiological
Iatrogenic
Compulsive water drinking (Psychogenic polydipsia)
SALT LOSS:
1.
2.
3.
4.
Adrenal insufficiency
Aldosterone resistance
Diuretics
Cerebral salt wasting (CSW) or salt diuresis
- RENAL DISORDERS:
1.UTI
2. Renal tubular acidosis (RTA)
3. Bartter and Gitelman Syndromes
4. Renal glucosuria
5. Chronic renal failure
Approach
History
History
Increased ICP: CNS tumors
Rash, Seborrhoea: Histiocytosis
Psychological problems: Psychogenic
polydipsia
Polyuria, shock in newborn period: CAH
Muscle weakness: Hypokalaemia, RTA, Bartter
Constipation, paresthesia: Hypercalcemia
Abdominal cramps, arthralgia, etc: Sickle cell
anaemia
Examination
Look for signs of dehydration and
shock..
Examination
Investigations
24 hr hour urine output
2L/m2/day or >5ml/kg/hr
POLYURIA
Further investigations
Investigations
Urine:
WBCs: UTI
Sugar: DM
Specific gravity: <1.015 DI
Urine Osmolality: <300 mOsm/kg DI
DI Vs Psychogenic
polydipsia
DI - Likely
DI - Unlikely
Water
deprivation
test
Psychogenic
polydipsia
Posm,
able to concentrate
urine
Central
DI
Posm,
DI
Not able to
concentrate urine
DDAVP
response
test
Nephrogenic DI
Management
Central DI responds to DDAVP (IV, oral,
Intranasal).
NDI: DDAVP is ineffective.
Hydrochlorothizide (HCTZ) +/- Amiloride
and indomethacin OR ttt of the cause
Adequate hydration is important.
CWD: Psycological and behavioural
treatment
DM
Diabetes mellitus is characterized by recurrent or persistent hyperglycaemia,
and is diagnosed by demonstrating any one of the following:[
2 hour
glucose
Fasting
glucose
HbA1c
mmol/l(mg/dl)
mmol/l(mg/dl)
<7.8 (<140)
<6.1 (<110)
<6.0
Impaired fasting
<7.8 (<140)
glycaemia
6.1(110) &
<7.0(<126)
6.06.4
Impaired
glucose
tolerance
<7.0 (<126)
6.06.4
Condition
Normal
7.8 (140)
DM
11.1
OR Symptoms of hyperglycaemia
and casual plasma glucose 11.1 mmol/l
7.0 (126) 6.5
(200)
(200 mg/dl)
A positive result, in the absence of unequivocal hyperglycemia, should be
confirmed by a repeat of any of the above methods on a different day.
Types of DM
T1DM (IDDM, Juvenile DM):
Autoimmune, idiopathic
T2DM (NIDDM, Adult onset):Obesity,
Acanthosis nigricans, FH.
Gestational DM
Other: Monogenic, congenital,
neonatal, 2ry..etc
Other
Other
Endocrinopathies
Growth hormone excess (acromegaly)
Cushing syndrome
Hyperthyroidism
Pheochromocytoma
Glucagonoma
Infections
Cytomegalovirus infection
Coxsackievirus B
Drugs
Glucocorticoids
Thyroid hormone
-adrenergic agonists
Statins
Genetic syndromes: Downs, Klinefilter, Laurence Moon Biedel, Prader Willi,
Turner synd.
Management
Insulin:
Regular and NPH (1/3 and 2/3)
Analogues (Mixed, ultra short, Detemir & Glargine)
Insulin pumps (CSII): Open and closed loops.
Life style:
Diet (CHO = 50 - 60%, Fats: < 30%, Proteins 10
20%)
Sensible exercise
Concepts
Honeymoon phase or partial remission:
weeks to 2 years, due to B cell hyperplasia.
DKA
Children with T1DM who have:
Hyperglycaemia (BG >11 mmol/l)
pH < 7.3
Bicarbonate < 15 mmol/l
With ketonaemia and/ or ketonuria.
and who has:
Acidotic respiration, dehydration, drowsiness
and/or
abdominal pain/vomiting
DKA
They can die from :
Cerebral oedema: This is unpredictable,
occurs more frequently in younger children
and newly diagnosed diabetes and has a
mortality of around 25%.
Hypokalaemia: This is preventable with
careful monitoring and management
Aspiration pneumonia: NGT.
DKA
Emergency management
1. Resuscitation
2. Confirm diagnosis
3. Investigations
Full Clinical Assessment
1. Assessment of dehydration (weight)
2. Conscious level
3. Physical examination (C oedema, infection,
ileus)
4. Role of PICU (Age, LOC, severe acidosis,
shock, staff)
DKA
Management:
Fluids volume, rate, type, oral fluids
Insulin: 0.1 units/kg/hour
(0.1ml/kg/hour: Start after 1 hr of IV
fluids.
Potassium: 40 mmol/l, when the pt PU
Bicarbonate: rarely required, PH < 6.9
Phosphate: Not usually required.
Continuing management.
DKA
Fluid volume:
Requirement = Maintenance + Deficit
Resus
Deficit (ml) = % dehydration x body weight
(kg) x 10
Maintenance requirements:
0 - 2 yrs
80 ml/kg/24 hrs
3-5
70 ml/kg/24 hrs
6-9
60 ml/kg/24 hrs
10 - 14
50 ml/kg/24 hrs
adult (>15)
30 ml/kg/24 hrs
DKA
Fluids required:
Blood Glucose Level
>14 mmol/l
4 14 mmol/l
Type of Fluid
Normal saline
During 1st 6 hours
5% Dex+ 0.9%
saline
saline <4mmol/l
DKA
Observations to be carried out:
Ensure full instructions are available to nursing staff emphasising the need for :
strict fluid balance: Input/Output
testing for glucose & ketones
hourly BP and basic observations
hourly capillary blood glucose measurements
U&E: after 2 hrs initially, then 4 hrly.
twice daily weight.
DKA
Cerebral Oedema
headache & slowing of heart rate
change in neurological status (restlessness, irritability,
increased drowsiness, incontinence)
specific neurological signs (eg. cranial nerve palsies)
rising BP, decreased O2 saturation
abnormal posturing
More dramatic changes such as convulsions,
papilloedema, respiratory arrest are late signs associated
with extremely poor prognosis
Cerebral Oedema
Management
If suspected inform senior staff immediately.
The following measures should be taken immediately while arranging
transfer to PICU:
Hypoglycaemia
Target blood glucose: 4 8 mmol/l.
Treat all blood glucose below 4
mmol/l to avoid hypo unawareness.
Symptoms:
Sympathetic: pallor, tachycardia,
sweating, tremors
Neuroglycopoenic: irritability, headache,
nausea, seizure, stupor, coma
Hypoglycaemia
Causes:
Treatment:
Oral CHO: glucose tabs, gel and fluids
I/M glucagon
10% Dx 2 ml/kg bolus
CASE 1
A 14 yr old girl had recurrent severe
hypoglycaemias with 2 episodes
leading to convulsions and hospital
admission. She was diagnosed with
T1DM at 9 yrs of age and was treated
with BD injections of Novomix 30 at
30 U am and 18 U pm. No recent
change in her diet or level of activity
and she does not drink alcohol.
HbA1c
CD (TTG)
AAA
TFT
Case 2
An 11-year-old boy presented with an 8-week history of
polyuria and polydipsia. He was otherwise well apart
from recent headaches. Investigations in clinic
demonstrated the following:
Summary
Polyuria:
Definition
Causes
Approach
DI Vs Psychogenic polydipsia
DM and its complications
Discussion