DIABETIC KETOACIDOSIS (DKA) TREATMENT

Transcription

1 DIABETIC KETOACIDOSIS (DKA) TREATMENT ALGORITHM. Management f Diabetic Ketacidsis Algrithm fr the Management f Diabetic Ketacidsis (DKA) Immediate Assessment Clinical Histry Plyuria Plydipsia Weight lss Vmiting Abdminal pain Cnfusin Fatigue Clinical Signs Assess dehydratin Deep sighing respiratin (Kussmaul) Smell f ketnes Lethargy/drwsiness + vmiting DKA diagnsis cnfirmed by initial labs: Hyperglycemia with glucse greater than (>)200 mg/dl ph less than (<)7.3 r HC03 less than (<)15, and Ketnemia r ketnuria Cntact diabetes physician If nt DKA, but the patient has diabetes r hyperglycemia, cntact diabetes physician Yes Shck? N Shck (reduced peripheral pulses) Reduced cnscius level/cma Resuscitatin Airway + NG tube Breathing (100% xygen) Circulatin (0.9% saline ml/kg ver 1-2hr and repeat until circulatin is restred. D nt exceed 40mL/Kg) Nt in shck Dehydratin greater than (>)5% Initial Interventins Saline 0.9% ml/kg blus Obtain ECG if K is ver 6 r under 3 meq/l Start regular insulin IV at 0.1 units/kg/hur after blus cmplete IV fluids at 1.5X maintenance *Ptassium Supplementatin Table Serum ptassium Greater than Less than 3.0 Ptassium in the fluids Nne 20 meq/l K-Acetate + 20mEq/L KPhs 30 meq/l K-Acetate + 30mEq/L KPhs Cntact diabetes physician Mnitring Hurly POC bld glucse Strict I/Os Neurlgical status at least hurly VBG and BMP q2-4 hurs Obtain ECG if K is ver 6 r under 3 If acidsis nt imprving r If deteriratin, Cntact diabetes physician Re-evaluate IV fluid calculatins Insulin delivery system and dse Need fr additinal resuscitatin Cnsider sepsis Bld glucse greater than > less than <100 % f rate frm 3/ % f rate frm D10-3/ 4NS + KAc + KPhs 4NS + KAc + KPhs DKA Reslutin ph greater than (>)7.3 Serum bicarbnate greater than (>)18 meq/l and Clinically well, tlerating ral fluids Transitin t SC insulin Cntact diabetes physician fr dses and timing Final dextrse Cncentratin % Change t D12.5-3/4NS + KAc + KPhs at 100% ttal rate * see ptassium supplementatin table abve *Fr fluids in the NOC, see page 6 If neurlgical WARNING SIGNS headaches, slwing heart rate, irritability, decreased cnscius level, incntinence, r specific neurlgical signs are present Then, exclude hypglycemia Is it cerebral edema? Management Elevate head f bed Give mannitl g/kg r hypertnic saline Restrict IV fluids by ne-third Cntact ICU and diabetes physician Cnsider cranial imaging nly after patient stabilized Page 1 f 16

2 SUMMARY Diabetic ketacidsis (DKA) is a life-threatening medical emergency requiring immediate evaluatin and treatment. Please ntify the diabetes physician n call thrugh One Call fr all patients with knwn r suspected DKA. DIAGNOSIS Triage Assessment in the Emergency Department Triage as Level 2 Immediate clinical evaluatin Vital signs Histry regarding presentatin DKA is defined by: Hyperglycemia with bld glucse (BG) greater than 200 mg/dl, and ph less than (<) 7.3 r HCO3- less than (<) 15 meq/l, and Ketnemia r ketnuria Mnitring Vital signs Neurlgic assessment including Glasgw Cma Scale Pint-f-care bld glucse (POC BG) TREATMENT Clinical Management in the Emergency Department r Urgent Care Place IV Place cardi-respiratry mnitrs NPO Initial labs: venus bld glucse (VBG), basic metablic panel (BMP), Mg, Phs, beta-hydrxybutyrate (BOHB), urinalysis (UA), hemglbin A1C Place rders using the ED DKA rder set: insulin, intravenus fluids (IVF), lab mnitring Suspect cerebral edema if patient has the fllwing: Persistent vmiting, severe headache, mental status changes, GCS less than 13, r fcal neurlgic abnrmalities Inpatient Clinical Management Vital signs mnitring and neurlgic checks Maintain n cardi-respiratry mnitrs Place rders using the ED DKA rder set: insulin, intravenus fluids (IVF), lab mnitring Transitin t subcutaneus insulin Timing Types f insulin Page 2 f 16

3 TABLE OF CONTENTS Algrithm Summary Target Ppulatin Backgrund Definitins Emergency Department Clinical Assessment Diagnstic Tests Labratry Studies Clinical Management Inpatient Ward Clinical Assessment Diagnstic Tests Labratry Studies Clinical Management Pediatric Intensive Care Unit (PICU) Clinical Assessment Diagnstic Tests Labratry Studies Clinical Management Transitin t Subcutaneus Insulin Parent Caregiver Educatin References Clinical Imprvement Team TARGET POPULATION Inclusin Criteria Children up t 21 years f age Patients referred fr admissin fr diabetic ketacidsis Patients admitted fr evaluatin and treatment f diabetic ketacidsis Patients identified with diabetic ketacidsis during their hspital stay BACKGROUND DEFINITIONS Diabetic ketacidsis (DKA) is a life-threatening cnditin. Almst 1 in 100 children with DKA will develp cerebral edema, which has a mrtality rate f 21-24%. Thse with severe DKA have a much higher mrtality and risk f cmplicatins. Meticulus attentin t the details f therapy and the child's clinical curse can decrease this risk. A patient wh is unrespnsive t vcal cmmands r presents with hyptensin is rare and requires immediate critical care in a hspital. Urgent critical care and diabetes cnsultatin shuld be btained. DKA is defined by: Hyperglycemia with glucse greater than (>) 200 mg/dl, and ph less than (<) 7.3 r HCO3- less than (<) 15, and Ketnemia r ketnuria Page 3 f 16

4 IN THE EMERGENCY DEPARTMENT Please ntify the diabetes physician n call thrugh One Call fr all patients with knwn r suspected DKA Clinical Assessment Initial assessment and treatment: Weigh patient, vitals, Glasgw Cma Scale, and pupil assessment Check bedside glucse (pint-f-care bld glucse r POC BG) Assess signs/symptms f DKA, which may include (but may nt necessarily be present): plyuria/plydipsia, weight lss, breath with fruity dr (smell f ketnes), Kussmaul breathing, altered mental status, abdminal pain, vmiting, fatigue, r candidiasis. D a full exam t lk fr cncurrent infectin, including GU t assess fr candidiasis/abscesses. Admissin t the PICU: In general, admissin t the PICU is recmmended if the ph is less than (<) 7.15, HCO3- is less than (<) 5 meq/l and/r the child has mental status changes but the decisin t admit shuld be based n clinical judgment f the diabetes physician and PICU attending. Cerebral edema Mental status changes may be difficult t assess in yung children. Cnsider admissin t the PICU fr children under 5 years f age based n the clinical judgment f the ED attending, PICU attending and diabetes physician. Initial respnse t medical therapy shuld be used in admissin decisin-making. Suspect cerebral edema if the patient has persistent vmiting, severe headache, mental status changes, GCS less than (<) 13, r fcal neurlgic abnrmalities. Rapid changes in serum Na, in either directin, als increase risk and shuld prmpt increased vigilance fr ther signs f edema. If cerebral edema is suspected, cnsider the fllwing: Elevate the head f the bed. Decrease fluid rate t 0.75x maintenance and switch t istnic fluids. Hypertnic saline (3%) ml/kg IV ver 15 minutes r mannitl 1 g/kg IV ver 15 minutes Cnsider endtracheal intubatin fr GCS less than (<) 8. Fr intubatin, use ICP precautins and target ETCO2 matching the patient s pre-intubatin pco2 r n higher than mmhg CALL PICU FOR ASSISTANCE with ETCO2 targets and ventilatr settings. D NOT give dexamethasne r sdium bicarbnate. D NOT delay treatment f cerebral edema t btain imaging. Cntact the diabetes physician n call and PICU. Diagnstic Tests Labratry Studies Initial Labs: Stat venus bld glucse (VBG), basic metablic panel (BMP), Mg, Phs, beta-hydrxybutyrate (BOHB), urinalysis (UA) If glucse is greater than (>) 600 mg/dl, draw a serum smlality HbA1C Any additinal labs as warranted by clinical presentatin Page 4 f 16

5 Osmlality can be calculated by: 2(Na + K) + glucse The gal is t decrease the smlality gradually (~10 mosm/hr) serum glucse 100 Na crrectin fr elevated glucse = serum Na + (1.6) 100 Obtain a serum lipase if patient has persistent nausea, vmiting r abdminal pain NOTE: Cntact the n call diabetes physician nce the initial labs have returned Labs fllwing IV blus(es) VBG, BMP every 2 hurs Cnsider BOHB nce bicarbnate is greater than (>) 14 meq/l Stp VBG nce ph is greater than (>) POC glucse every hur (POC glucse must als be btained after NS blus(es) and prir t starting insulin drip If POC glucse greater than (>) 600 mg/dl, send sample t lab fr serum glucse Clinical Management Order set and initial clinical management If yu suspect DKA, place rders using the ED DKA rder set. NOTE: sme patients may be enrlled in a research study with a separate rder set Place PIV Diet: NPO Mnitrs: place n cardi-respiratry mnitrs Initial Fluids Administer a 10mL/kg nrmal saline blus ver 60 minutes (a 20ml/kg blus may be given ver 60 minutes fr significant dehydratin r rapidly if the patient is in shck r hyptensive). Repeat as necessary t maintain adequate circulatin. Unless impaired circulatin persists, d nt give mre than 40 ml/kg in blus fluids in the first 4 hurs. Fllwing IV NS Blus(es) Vitals and neurlgical assessment (nursing) Fllwing IV NS blus(es), place a secnd PIV fr frequent labratry sampling Insulin Discnnect insulin pump if patient is currently n their hme insulin pump. Start IV regular insulin at 0.1 units/kg/hr d NOT give a blus f insulin. Insulin therapy shuld be started 1 hur after the initial rehydratin blus was started but shuld nt be delayed fr mre than 2 hurs after starting IV hydratin. D NOT start while blus is still running. If unable t start a secnd IV, DO NOT DELAY INSULIN DRIP! Insulin is cmpatible with the MIVF and can be Y-ed in with fluids. Cntact pharmacy fr questins regarding medicatins, fluids, and cmpatibility. Fluids Prir t selecting intravenus fluid cmpsitin and rate, assess fr cerebral edema and renal functin (see specifics belw). Standard IV are 3/4 NS + 20 meq/l ptassium acetate + 20 meq/l ptassium phsphate run at 1.5X maintenance. Als, rder a bag f D10 + 3/4 NS + 20 meq/l ptassium acetate + 20 meq/l ptassium phsphate t have at the bedside. Page 5 f 16

6 Write a ttal fluid rder This may vary based n medicatin shrtages r physician judgment. Cnsider lwer fluid rates if increased risk fr cerebral edema is suspected (e.g. patient has already received significant fluid resuscitatin, altered mental status, rapid fall in glucse). Fluids may need t be adjusted based n serum ptassium. Ptassium supplementatin If hyperkalemia (K greater than 6) r hypkalemia (K less than 3), perfrm an ECG t assess T-waves. Serum ptassium Ptassium in the fluids Greater than (>) 5.5 Nne meq/l K-Acetate + 20 meq/l Kphs meq/l K-Acetate + 30 meq/l Kphs Less than (<) 3.0 Cntact diabetes physician When the bld glucse is appraching r is less than (<) 250 mg/dl, the dextrse cntaining bag (bag 2) will need t be Y-ed int bag 1. The gal is t keep ttal fluids at 1.5x maintenance Gal bld glucse range is mg/dl. Gal fr fall in bld glucse: shuld nt exceed 100 mg/dl/hur (after initial nrmal saline blus is given). Titrate the tw bags based n current bld glucse and rate f bld glucse fall t maintain the bld glucse within the gal. D NOT decrease the insulin unless the dextrse rate is at its maximum (D12.5 at 100% f fluids) r yu have spken t the n-call diabetes physician. The chart belw is a suggestin fr rates: Bld glucse (mg/dl) Bag 1: % f rate frm 3/4NS + KAc + KPhs Bag 2: % f rate frm D10% + 3/4NS + KAc+KPhs Greater than (>) Final dextrse cncentratin Less than (<)100 Change t D12.5% +3/4NS + KAc + KPhs at 100% f ttal rate Alternative chart fr Netwrk f Care lcatins r when the abve fluids are nt available: The fllwing chart is fr reference nly, cnsult the n-call diabetes prvider fr specific fluid recmmendatins and insulin drip rates: Bld glucse (mg/dl) Bag 1: % f rate frm NS+20KCl Bag 2: % f rate frm D5NS+20KCl Bag 3: % f rate frm D10W Final dextrse cncentratin > Cnsult the n-call diabetes prvider fr dextrse cncentratin and insulin drip rate prir t transfer. <100 Page 6 f 16

7 IN THE INPATIENT UNIT Please ntify the diabetes physician n call thrugh One Call fr all patients with knwn r suspected DKA. Clinical Assessment Assessment Weigh patient, vitals, Glasgw Cma Scale Place n cardi-respiratry mnitrs Neurlgic checks every hur Cerebral edema: If a patient with DKA develps symptms suggestive f cerebral edema (GCS greater than (>)13, mental status changes, fcal neurlgic abnrmalities, wrsening vmiting, severe headache, inapprpriate bradycardia r hypertensin): Call RRT and/r cde as apprpriate. Elevate the head f the bed t 45 degrees. Decrease the ttal IV fluid rate t 0.75X maintenance. Cntact the inpatient attending and diabetes physician. Diagnstic Tests Labratry Studies Labs POC BG every hur while n an insulin drip VBG, BMP every 2 hurs Cnsider BOHB nce bicarbnate is greater than (>) 14 meq/l Stp VBG nce ph is greater than (>) 7.3 and stp BMP nce bicarbnate is greater than r equal t (>) 18 Clinical Management Order Set Place admissin rders using the MED IP DKA ADMISSION rder set. NOTE: If the patient is n a study prtcl, yu will need t rder medicatins per study prtcl. Insulin Cntinue IV regular insulin at 0.1 units/kg/hur. Fluids Standard IVF are 3/4 NS + 20 meq/l ptassium acetate + 20 meq/l ptassium phsphate run at 1.5X maintenance. Als, rder a bag f D10 + 3/4 NS + 20 meq/l ptassium acetate + 20 meq/l ptassium phsphate t have at the bedside. These may vary based n medicatin shrtages r physician judgment Cnsider lwer fluid rates if increased risk fr cerebral edema suspected (e.g. patient has already received significant fluid resuscitatin, altered mental status, rapid fall in BG). Fluids may need t be adjusted based n serum ptassium. Ptassium supplementatin If initial serum K is greater than (>)5.5, liguria, acute renal failure, r cardiac arrest: d NOT put ptassium in fluids. Page 7 f 16

8 If hyperkalemia (K greater than 6, K>6) r hypkalemia (K less than 3, K<3) is present, perfrm an ECG t assess T-waves. Serum ptassium Ptassium in the fluids Greater than (>) 5.5 Nne meq/l K-Acetate + 20 meq/l Kphs meq/l K-Acetate + 30 meq/l Kphs Less than (<) 3.0 Cntact inpatient attending and diabetes physician When the bld glucse is less than (<) 250 mg/dl r appraching 250 mg/dl, the dextrse cntaining bag (bag 2) will need t be Y-ed int bag 1, keeping ttal fluids at 1.5X maintenance. Gal bld glucse range is mg/dl. Gal fr fall in bld glucse: shuld nt exceed 100 mg/dl/hur (after initial nrmal saline blus is given). Titrate the tw bags based n current bld glucse and rate f bld glucse fall t maintain the bld glucse within the gal. D NOT titrate the insulin unless the dextrse rate is at its maximum (D12.5 at 100% f fluids) r yu have spken t the n call diabetes physician. The chart belw is a suggestin fr rates: Bld glucse (mg/dl) Bag 1: % f rate frm 3/4NS + KAc + KPhs Bag 2: % f rate frm D10% + 3/4NS + KAc + KPhs Greater than (>) Final dextrse cncentratin Less than (<)100 Change t D12.5% +3/4NS + KAc + KPhs at 100% f ttal rate If the bld glucse cntinues t drp while patient is running bag 2 (the dextrse fluids) at 100% f ttal fluids, stp the insulin drip and recheck BG every 15 minutes until the BG is greater than (>) 150 mg/dl, and restart the insulin drip with D12.5% fluids running at 100%. If D12.5% fluids are nt available, decrease the insulin drip by 0.02 units/kg/hur every 30 minutes until BG is greater than (>) 100. If IVF are running at 100% with D12.5% fluids and BG is less than (<) 100, stp the insulin drip and recheck BG every 15 minutes until the BG is greater than (>) 150 mg/dl and restart the insulin drip at 0.02 units/kg/hur lwer than the previus rate. D nt decrease IV insulin belw 0.04 units/kg/hur unless lng-acting insulin has been given. Page 8 f 16

9 IN THE PICU Please ntify the diabetes physician n call thrugh One Call fr all patients with knwn r suspected DKA. Clinical Assessment Assessment Weigh patient, vitals, assess pupillary reflexes, Glasgw Cma Scale Place n cardi-respiratry mnitrs Neurlgic checks every hur Cerebral edema: If a patient with DKA develps symptms suggestive f cerebral edema (GCS less than (<)13, mental status changes, fcal neurlgic abnrmalities, wrsening vmiting, headache, inapprpriate bradycardia r hypertensin): Ntify PICU attending Elevate head f the bed t 45 degrees Decrease the ttal IV fluid rate t 0.75X maintenance and switch t istnic fluids. Give hypertnic saline (3%) ml/kg IV ver 15 minutes r mannitl 1 gm/kg IV ver 15 minutes. Cnsider endtracheal intubatin fr GCS less than (<) 8 r rapidly declining cardirespiratry r mental status. Fr intubatin, use RSI with ICP precautins and ventilate initially t target ETCO2 matching the patient s spntaneus pre-intubatin pco2 but n higher than mmhg. D NOT delay treatment f cerebral edema t btain imaging. Ntify diabetes physician f clinical situatin. Diagnstic Tests Labratry Studies Initial Lab Schedule POC BG every hur while n insulin drip VBG, BMP every 2 hurs Cnsider BOHB nce bicarbnate is greater than (>) 14 meq/l Stp VBG nce ph is greater than (>) 7.3 and stp BMP nce bicarbnate is greater than r equal t (>) 18 Clinical Management Order Set Place admissin rders using the MED IP DKA ADMISSION rder set. NOTE: If the patient is n a study prtcl, yu will need t rder medicatins per study prtcl. Insulin Cntinue IV regular insulin at 0.1 units/kg/hur. Fluids Standard IVF are 3/4 NS + 20 meq/l ptassium acetate + 20 meq/l ptassium phsphate run at 1.5X maintenance. Als, rder a bag f D10 + 3/4 NS + 20 meq/l ptassium acetate + 20 meq/l ptassium phsphate t have at the bedside. These may vary based n medicatin shrtages r physician judgment. Page 9 f 16

10 Cnsider lwer fluid rates if increased risk fr cerebral edema suspected (e.g. patient has already received significant fluid resuscitatin, altered mental status, rapid fall in BG). Ptassium supplementatin If initial serum K is greater than (>)5.5, liguria, acute renal failure, r cardiac arrest: d NOT put ptassium in fluids. Serum ptassium Ptassium in the fluids Greater than (>) 5.5 Nne meq/l K-Acetate + 20 meq/l Kphs meq/l K-Acetate + 30 meq/l Kphs Less than (<) 3.0 Cntact PICU fellw r attending When the bld glucse is less than (<) 250 mg/dl r appraching 250 mg/dl, the dextrse cntaining bag (bag 2) will need t be Y-ed int bag 1, keeping ttal fluids at 1.5X maintenance. Gal bld glucse range is mg/dl. Gal fr fall in bld glucse: shuld nt exceed 100 mg/dl/hur. Titrate the tw bags based n current bld glucse and rate f bld glucse fall t maintain the bld glucse within the gal. D NOT titrate the insulin unless the dextrse rate is at its maximum (D12.5 at 100% f fluids) r yu have spken t the PICU and diabetes physician. The chart belw is a suggestin fr rates: Bld glucse (mg/dl) Bag 1: % f rate frm 3/4NS + KAc + KPhs Bag 2: % f rate frm D10% + 3/4NS + KAc + KPhs Greater than (>) Final dextrse cncentratin Less than (<)100 Change t D12.5% +3/4NS + KAc + KPhs at 100% f ttal rate If the bld glucse cntinues t drp while patient is running bag 2 (the dextrse fluids) at 100% f ttal fluids, stp the insulin drip and recheck BG every 15 minutes until the BG is greater than (>)150 mg/dl, and restart the insulin drip with D12.5% fluids running at 100%. If D12.5% fluids are nt available, decrease the insulin drip by 0.02 units/kg/hur every 30 minutes until BG is greater than (>) 100. If IVF are running at 100% with D12.5% fluids and BG is less than (<)100, stp the insulin drip and recheck BG every 15 minutes until the BG is greater than (>)150 mg/dl and restart the insulin drip at 0.02 units/kg/hur lwer than the previus rate. D nt decrease IV insulin belw 0.04 units/kg/hur unless lng-acting insulin has been given. Page 10 f 16

11 TRANSITION TO SUBCUTANEOUS INSULIN Fr patients n subcutaneus insulin injectins Order their subcutaneus insulin using the INSULIN SUBQ *INJECTION* + HYPOGLYCEMIA rder set, which includes rders fr HYPOGLYCEMIA. Timing f transitin: When ph is greater than (>) 7.3 and serum bicarbnate (n BMP) is greater than r equal t (>) 18 mml/l, the patient can transitin t subcutaneus insulin. If bicarb remains less than (<) 18 but acidsis has reslved, btain a BOHB and readiness t transitin t subcutaneus insulin with the n-call diabetes physician. Obtain a serum lipase if patient has persistent nausea, vmiting r abdminal pain. The diabetes physician may recmmend giving lng-acting subcutaneus insulin (e.g. Lantus, glargine) t patients while they are STILL n the insulin drip; ask the diabetes physician abut the timing f the first dse f lng-acting SQ insulin during the day when pssible. Recmmendatins will be dcumented in chart ntes fr reference. If the patient has already received lng-acting insulin while n the insulin drip: Yu may turn ff the insulin drip nce ketacidsis has reslved (serum bicarb greater than r equal t (>) 18 meq/l. Remain n the dextrse IVF fr n mre than 15 minutes after the insulin drip has been turned ff, then turn ff dextrse IVF. Cntinue nn-dextrse cntaining fluids t run at maintenance vernight. If patient has nt yet received lng-acting insulin, keep patient n insulin drip until the first meal has arrived. Order the carbhydrate cunting diet and allw patient t rder a meal. Once fd has arrived, but PRIOR t eating, check pre-prandial glucse and give the subcutaneus lng-acting and shrt-acting insulin (pre-prandial glucse crrectin and carbhydrate cverage) and turn ff the insulin drip at this time. If glucse is less than (>) 100, keep dextrse-cntaining IVF n fr an additinal 15 minutes, therwise turn IVF ff as well. Allw the patient t eat. If there is any cncern fr nausea/vmiting r patient s ability t eat (especially in a child less than 5 years f age), then cnsider a PO trial prir t discharge and pssibly prir t administratin f subcutaneus insulin. New nset patients are typically discharged in the mrning t g directly t the Barbara Davis Center (BDC), while knwn patients with diabetes are usually discharged t hme. Clarify the plan with the n call diabetes physician. Breakfast is NOT available at the BDC and, therefre, if the patient is discharged t the BDC, please have the patient bring breakfast t the BDC. Insulin can be given at the BDC. Fr NEW ONSET patients, prvide printed instructins, including a map t the BDC Page 11 f 16

12 Types f insulin (NOTE: insulin in BOLD is available n the frmulary) Type Insulin Name Onset Peak Duratin Lng-acting (prvides Lantus (insulin 1-2 hurs N peak hurs basal cverage) glargine) Lng-acting (prvides basal cverage) Levemir (insulin detemir) 1-2 hurs N peak Less than 24 hurs Lng-acting (prvides Tresiba (insulin 1 hur N peak Up t 42 hurs basal cverage) degludec) Intermediate-acting NPH 1 hur 4-6 hurs 8-16 hurs Rapid-acting Humalg (insulin minutes hurs 3-4 hurs lispr) Rapid-acting Nvlg (insulin aspart) & Apidra (insulin glulisine) minutes hurs 3-4 hurs NOTE: the cncentratin f all f the types f insulin listed abve is 100units/mL General principles regarding SQ insulin regimens Carbhydrate cunting + bld glucse crrectin Give rapid-acting (Humalg/lispr) insulin t cver the amunt f carbhydrates the child is abut t eat + additinal rapid-acting insulin t bring the bld glucse dwn. Example 1. Carbhydrate cunting: If a child is n a 1:15 gram carbhydrate cverage (1 unit f rapid-acting insulin fr every 15g f carbhydrates cnsumed) and eats a 60g pancake breakfast, s/he needs 4 units f rapid-acting insulin befre breakfast (60g/15g = 4 units). 2. Crrectin factr: If the child has a crrectin factr f 1 fr every 100 starting at 150, that means if the child s bld glucse is 130 befre a meal s/he des nt need any additinal rapid-acting insulin n tp f the insulin given t cver carbhydrates. Hwever, if the bld glucse is prir t their meal, s/he needs 1 unit f rapid-acting insulin in additin t the insulin given t cver the carbhydrates. If her/his bld glucse is , s/he needs 2 units f rapid-acting insulin in additin t the insulin t cver carbhydrates, etc. Sliding scale Ideally, rapid-acting insulin shuld be given minutes befre eating (t match nset f actin), but fr yung children (especially yunger than 3 years f age), children with newly diagnsed diabetes, r children wh may nt finish their meal r vmit, it is acceptable t give insulin immediately after the meal and within minutes f STARTING t eat. D NOT give rapid-acting insulin injectins fr bld sugar crrectin mre ften than every 4 hurs unless specified by endcrinlgy as this can cause insulin stacking and puts the child at risk fr hypglycemia (think abut the duratin f rapid-acting insulins). This is essentially carbhydrate cunting + crrectin factr but written tgether t simplify calculatins. This is rarely used in the inpatient setting This wrks best fr children wh eat a fixed amunt f carbhydrates at every meal (a cnsistent carb diet) and is ften used fr families wh have a child with new nset diabetes r therwise have nt learned carbhydrate cunting yet. Page 12 f 16

13 Fr patients n an insulin pump Order insulin pump rders using the INSULIN SUBQ *PUMP* + HYPOGLYCEMIA rder set, which includes rders fr HYPOGLYCEMIA. Pumps use nly rapid-acting insulin that is delivered cntinuusly (basal rate) and as bluses that cver elevated glucse and carbhydrates. A family member must be present wh knws hw t use the pump in rder t restart the child n her/his pump. The family must bring their wn set f new pump supplies (e.g. infusin set, reservir, and inserter) and must use a cmpletely new set. The patient cannt use the pump set that may have failed prir t cming t the hspital. When the patient is medically ready t restart the insulin pump, have the family member cnnect and restart the pump as the nurse discntinues the IVF and insulin drip. If there is n family member present t recnnect the pump r pump supplies are nt available, the child will need t be started n subcutaneus insulin injectins. Nte: There may be reasns nt t restart the pump (i.e. psychscial issues, family/patient knwledge deficit n pump use r site insertin, etc.) and a plan fr subcutaneus insulin injectins will need t be made. PARENT CAREGIVER EDUCATION The Barbara Davis Center (BDC) fr Diabetes - The Juvenile Diabetes Research Fundatin (JDRF) Page 13 f 16

14 REFERENCES Cnsensus Guidelines Wlfsdrf et al. Diabetic Ketacidsis in Infants, Children and Adlsecents. A Cnsensus Statement frm the American Diabetes Assciatin. Diabetes Care (5): Wlfsdrf et al. ISPAD Clinical Practice Cnsensus Guidelines 2014 Cmpendium. Diabetic Ketacidsis and Hyperglycemic and Hypersmlar State. Pediatric Diabetes (Suppl. 20): Danne et al. ISPAD Clinical Practice Cnsensus Guidelines 2014 Cmpendium. Insulin Treatment in Children and Adlescents with Diabetes. Pediatric Diabetes (Suppl.20): DKA Zeitler P, Haqq A, Rsenblm A, Glaser N; Drugs and Therapeutics Cmmittee f the Lawsn Wilkins Pediatric Endcrine Sciety. Hyperglycemic hypersmlar syndrme in children: pathphysilgical cnsideratins and suggested guidelines fr treatment. J Pediatr Jan;158(1):9-14, 14.e1-2. Edge JA et al. Cnscius level in children with diabetic ketacidsis is related t severity f acidsis and nt t bld glucse cncentratin. Ped Diab 2006; 7: Rewers A, Chase HP, Mackenzie T, Walravens P, Rback M, Rewers M, Hamman RF, Klingensmith G. Predictrs f acute cmplicatins in children with type 1 diabetes. JAMA May 15;287(19): Dabelea D, Rewers A, Staffrd JM, Standifrd DA, Lawrence JM, Saydah S, Imperatre G, D'Agstin RB Jr, Mayer-Davis EJ, Pihker C; SEARCH fr Diabetes in Yuth Study Grup. Trends in the prevalence f ketacidsis at diabetes diagnsis: the SEARCH fr diabetes in yuth study. Pediatrics Apr;133(4):e PubMed PMID: Cengiz E, Xing D, Wng JC, Wlfsdrf JI, Haymnd MW, Rewers A, Shanmugham S, Tambrlane WV, Willi SM, Seiple DL, Miller KM, DuBse SN, Beck RW; T1D Exchange Clinic Netwrk. Severe hypglycemia and diabetic ketacidsis amng yuth with type 1 diabetes in the T1D Exchange clinic registry. Pediatr Diabetes Sep;14(6): PubMed PMID: Cerebral Edema Muir AB, Quisling RG, Yang MC, Rsenblm AL. Cerebral edema in childhd diabetic ketacidsis: natural histry, radigraphic findings, and early identificatin. Diabetes Care Jul;27(7): Glaser N et al. Risk Factrs fr Cerebral Edema in children with diabetic ketacidsis. The Pediatric Emergency Medicine Cllabrative Research Cmmittee f the American Academy f Pediatrics. N Engl J Med, 344:264-9, Insulin Treatment Danne et al. ISPAD Clinical Practice Cnsensus Guidelines 2014 Cmpendium. Insulin Treatment in Children and Adlescents with Diabetes. Pediatric Diabetes (Suppl.20): Page 14 f 16

15 CLINICAL IMPROVEMENT TEAM MEMBERS G. Tdd Alns, MD Barbara Davis Center Paul Wadwa, MD Barbara Davis Center Natalie Nkff, MD Fellw in Pediatric Endcrinlgy Christina Chambers, MD Endcrinlgy Tdd Carpenter, MD Medical Directr PICU Beth Wathen, BSN, RN, CCRN Clinical Practice Specialist PICU Leah Bmesberger, BSN, BS, RN Clinical Nurse II PICU Rbin Thmas, RN Clinical Nurse IV PICU Grace Kelley, BSN, RN, CPN Clinical Nurse IV Jennifer Jrgensen, PharmD Clinical Pharmacist Pam Reiter, PharmD Clinical Pharmacist Aimee Bernard, PhD Clinical Care Guideline Crdinatr APPROVED BY Clinical Care Guideline and Measures Review Cmmittee n/a Insulin Safety Cmmittee Nvember 25, 2015 Pharmacy & Therapeutics Cmmittee January 12, 2016 MANUAL/DEPARTMENT ORIGINATION DATE Clinical Care Guidelines/Quality May 5, 2015 LAST DATE OF REVIEW OR REVISION January 12, 2016 APPROVED BY Lalit Bajaj, MD, MPH Medical Directr, Clinical Effectiveness REVIEW/REVISION SCHEDULE Scheduled fr full review n January 12, 2020 Clinical pathways are intended fr infrmatinal purpses nly. They are current at the date f publicatin and are reviewed n a regular basis t align with the best available evidence. Sme infrmatin and links may nt be available t external viewers. External viewers are encuraged t cnsult ther available surces if needed t cnfirm and supplement the cntent presented in the clinical pathways. Clinical pathways are nt intended t take the place f a physician s r ther health care prvider s advice, and is nt intended t diagnse, treat, cure r prevent any disease r ther medical cnditin. The infrmatin shuld nt be used in place f a visit, call, cnsultatin r advice f a physician r ther health care prvider. Furthermre, the infrmatin is prvided fr use slely at yur wn risk. CHCO accepts n liability fr the cntent, r fr the cnsequences f any actins taken n the basis f the infrmatin prvided. The infrmatin prvided t yu and the actins taken theref are prvided n an as is basis withut any warranty f any kind, express r implied, frm CHCO. CHCO declares n affiliatin, spnsrship, nr any partnerships with any listed rganizatin, r its respective directrs, fficers, emplyees, agents, cntractrs, affiliates, and representatives. Page 15 f 16

16 Page 16 f 16