East of England Children & Young People s (CYP) Diabetes Network

Transcription

1 East of England Children & Young People s (CYP) Diabetes Network Management for Children and Young People with diabetes (>6months old 18 th birthday) during Illness Note: This version of the guideline is modified for Mid Essex Hospital to accommodate the needs of the local team. The change is on page 14, 5.1 and is in red colour. Appendix 3 is included and is attached. If any further clarification is required, contact Dr Sharon Lim, Consultant Peadiatrician. Date of Modification: 21 st August 2018 Authors: 2 nd edition: August 2018 Updated by Kalika Shah-Enderby, Paediatric diabetes specialist nurse, Bedford Hospital Contributions: Jacqueline Angelo-Gizzi, Barbara Piel, Babita Khetriwal, Cristina Matei & Vikki Grimes 1 st edition: - May 2013 Nadeem Abdullah, Consultant in Paediatric Diabetes, Addenbrookes Hospital, Cambridge Vipan Datta, Consultant Paediatrician, Norfolk and Norwich University Hospitals NHS Trust, Norwich Ronald Misquith, Consultant Paediatrician, Luton and Dunstable Hospitals NHS Turst, Luton Sharon Lim, Consultant Paediatrician, Mid Essex hospital NHS Trust, Chelmsford Text East of England CYP Diabetes Network Management of Diabetes During Illness in Children and Adolescents. June 2018 v2 page 1 of 16

2 Contents Page 1 Section 1: About the guidelines Scope 1.2 Purpose 1.3 Introduction 2 Section 2: General principles of illness management 2.1 Capillary blood glucose (CBG) monitoring 2.2 Blood ketones monitoring 2.3 Maintaining hydration 2.4 Specific medical management Section 3: Management of hyperglycaemia 3.1 Patients on insulin injections and insulin pumps/continuous subcutaneous insulin infusion (CSII) 3.2 Flow chart 1 Interpretation and management of blood glucose and blood ketone levels during illness for patients on insulin injections - Calculating total daily dose and insulin sensitivity factor 3.3 Flow chart 2 Interpretation and management of high blood glucose and ketone levels for patients on insulin pumps Section 4: Management of Hypoglycaemia during illness 4.1 Patients on insulin injections and insulin pumps 4.2 Hypoglycaemia in CYP with vomiting or unable to tolerate any oral fluids during illness 4.3 Table 1 Hypoglycaemia management in the hospital 4.4 Table 2 Hypoglycaemia management in the home 4.5 Table 3 Examples of carbohydrates (CHO) for hypoglycaemia treatment Section 5: Management in hospital upon admission 5.1 Maintenance IV fluids/variable rate intravenous insulin infusion (VRIII) 5.2 Safe preparation and administration of VRIII - Table 4 VRIII rates 5.3 Transferring from VRIII to subcutaneous insulin Section 6: Appendices Management of Diabetes During Illness in Children and Adolescents. June 2018 v2 page 2 of 16

3 Appendix 1: Parenteral maintenance fluids Appendix 2: Commonly used insulin preparations Management of diabetes during illness in children and adolescents 1.1Scope For the use by all health care professionals to manage illness and high blood glucose levels for all children between the ages of 6 months and 18 years with diabetes mellitus. 1.2 Purpose To enable health professionals to provide safe advice to children and families on managing diabetes during illness. Nice guidelines recommend that clear guidance should be available to children and young people with type 1 diabetes for management during periods of illness. To prevent children and young people becoming unwell with diabetic ketoacidosis (DKA), but also reduce the need for hospital admission during periods of illness. 1.3 Introduction Many illnesses, especially those associated with fever, raise blood glucose levels because higher levels of stress hormones promote gluconeogenesis and insulin resistance. This effect leads to insulin deficiency, causing an increase in ketone body production. Illness associated with vomiting and diarrhoea may lower blood glucose with the possibility of hypoglycaemia. Decreased food intake, poor absorption and slower emptying of the stomach during gastroenteritis may contribute to the hypoglycaemia. Significant ketone bodies can still be produced with hypoglycaemia during gastroenteritis. There can be increased insulin requirements during the incubation period of an infection for a few days before the onset of the illness. The increased need for insulin may persist for a few days after the illness has passed due to insulin resistance. 2 General principles during illness: Never stop or omit insulin the dose may need adjustment depending on the blood glucose and ketone levels Check - blood glucose levels every 2 hours, including through the night. Aim for capillary blood glucose (CBG) target of 4-10mmols/L during illness stabilisation Check ketone levels whenever a child is ill, regardless of blood glucose levels. If blood ketone levels are >0.6mmols/L, repeat the test 2 hourly. Give additional fast acting insulin if blood glucose level is above target or ketones are high (See flowchart 1 on Page 6) Hydration and nutrition drink plenty of fluids. Water or sugar-free fluids are best if blood glucose levels are normal or high. Management of Diabetes During Illness in Children and Adolescents. June 2018 v2 page 3 of 16

4 Sugary fluids are necessary if blood glucose levels are low. Carbonated drinks should be avoided. If unable to eat or appetite is reduced, it is important to drink plenty of fluids. Inform the diabetes team as soon as possible to seek advice, and treat the underlying condition where appropriate. 2.1 Capillary blood glucose monitoring (CBG) Blood glucose (BG): Frequent monitoring facilitates optimal diabetes management during illness. BG should be monitored at least every 4 hours and sometimes every 1-2 hours, particularly if ketones are raised or additional doses of insulin have been given. 2.2 Blood ketones (BK) Ketone bodies (beta-hydroxybutyrate, acetoacetate and acetone) are produced by the liver for two reasons: a) When blood glucose levels are low (starvation ketones) b) When insulin is lacking to initiate the transport of glucose from the blood stream into the cells (ketones act as an alternative energy source for the cells). N.B. Urine strips measure only acetoacetate (AcAc), while blood strips measure beta-hydroxybutyrate (BOHB). In acute ketoacidosis the BOHB levels raise quickly and in response to insulin therapy, BOHB levels commonly decrease long before AcAc levels do. Blood ketone measurement therefore is superior to urine and should be used for illness management, rather than urine ketone measurements. BLOOD KETONE LEVEL Below 0.6 mmol/l Between 0.6 and 1.5 mmol/l Above 1.5 mmol/l ADVICE Readings in normal range. No further action. CAUTION. If blood glucose level is > 14mmol/L with a blood ketone level in this range, it may indicate the development of a problem. See pages 6,7,& 8 for advice ACTION. If blood glucose level is > 14mmol/L with a blood ketone level in this range, child/young person is at risk of developing ketoacidosis (DKA). See page 6, 7 & 8 for advice Interpretation of blood ketone results and actions For those on insulin injections see Flowchart 1 on page 6 For those on insulin pump therapy see Flowchart 2 on page Maintaining hydration Hyperglycaemia, fever, excessive glycosuria and ketonuria increase fluid losses. Elevated levels of ketones, whether associated with low CBG(starvation) or high BG(insulin deficiency), contribute to nausea and vomiting, leading to decreased food and fluid intake, further elevated ketones, dehydration and ketoacidosis. Management of Diabetes During Illness in Children and Adolescents. June 2018 v2 page 4 of 16

5 Liquids for hydration should contain salt and water and not just plain water if there are ongoing losses like vomiting or diarrhoea (e.g. Dioralyte, diet soft drink). If appetite is decreased or CBG is falling below 5mmols/L, sugar containing fluids should be considered to avoid starvation ketosis (e.g. Sports drinks, diluted fruit drinks, normal usual soft drinks). It is best to shake the bubbles out of the sugar containing carbonated drinks to minimise indigestion and advise patients to take sips rather than a large amount at a time( little and often). If nausea, vomiting or diarrhoea are persistent, intravenous fluids may be required (see IV Fluid and VRIII on page 13). 2.4 Specific Medical Management: Shock and/or dehydration: o Admit o Treat shock with a bolus of 20ml/kg of 0.9% sodium chloride o Correct dehydration The underlying illness should, if known, be treated as it would be for a child without diabetes, i.e. UTI, tonsillitis, gastroenteritis, etc. Consider sugar free antipyretics to manage fever, malaise, headaches and pain. Unknown or uncertain alternative medicine co-prescription should be avoided. NB: Children and young people who have poor oral intake or are unable to tolerate any oral fluids during illness and are NOT ketoacidotic remember they may have ketonaemia Diabetic Ketoacidosis (DKA) can occur in patients with euglycaemia (CBG levels in, or slightly above, target range). Any CYP with euglycaemia, elevated BK and sudden onset of headache, nausea, vomiting, abdominal pain or difficulty in breathing should be assessed urgently at local A&E. 3. Management of hyperglycaemia (high blood glucose levels) 3.1 Patients on insulin injections and insulin pumps/continuous subcutaneous insulin infusion (CSII): Hyperglycaemia is any CBG level above 7mmol/L. However, in illness often the blood glucose is much higher. Additional doses of rapid acting insulin (e.g. Humalog or Novorapid or Apidra ) are required with careful monitoring to prevent ketoacidosis Dose and frequency of the injections will depend on the level of the CBG and blood ketones (for injection therapy see flow chart on page 6, for pump therapy see flow chart on page 8). Most CYP use their smart blood glucose meters to calculate the doses of rapid acting insulin for corrections of high blood glucose levels. If they do not have a smart meter or the CYP is under the care of general paediatric staff, the insulin sensitivity factor (ISF) / correction factor or 100 rule should be used page 7. Management of Diabetes During Illness in Children and Adolescents. June 2018 v2 page 5 of 16

6 If pre-mixed insulin is used and patient does not have rapid acting insulin admit for correction with rapid acting insulin using the 100 rule. ALL patients with type 1 diabetes must keep rapid acting insulin with them at all times. Consider increasing the usual amount of insulin during the course of the illness Pump patients - If blood glucose levels are high, make the standard checks on the pump i.e. check for occlusions, disconnection, battery failure, suspended delivery, etc. Management of Diabetes During Illness in Children and Adolescents. June 2018 v2 page 6 of 16

7 3.2 Flowchart 1: Management and interpretation of blood glucose levels and blood ketone levels during illness for patients on injections. NB: if the CYP is an inpatient any insulin dose adjustments must be made using the BG reading obtained from the Trust calibrated (Point of Care) BG meter. CHECK CBG & BLOOD KETONE LEVELS BG level Blood ketone < 0.6mmol/L Blood ketone mmol/L Blood ketone > 1.5mmol/L 4 10 mmol/l mmol/l > 14 mmol/l No need to worry, no need to give extra insulin Give correction dose of rapid acting insulin as per smart meter OR Use '100 rule', - see page 7 Give next planned/usual dose of insulin as normal Management of Diabetes During Illness in Children and Adolescents. June 2018 v2 page 7 of 16 Give correction dose of rapid acting insulin as per smart meter OR 5-10% of total daily dose (TDD) Starvation ketones. Extra carbs needed (sugary fluids if not able to eat) Starvation ketones. Extra carbs needed (sugary fluids if not able to eat) Check CBG & Ketones every 2 hours If vomiting - try oral fluid challenge as per local hospital policy. If unable to tolerate fluids, admit CYP according to local guideline, i.e. A&E or direct access to the ward. Give correction dose of rapid acting insulin as per smart meter using illness function OR Use '100 rule', - see page 7 Give correction dose of rapid acting insulin as per smart meter OR 5-10% of total daily dose (TDD) Give correction dose of rapid acting insulin as per smart meter using 'illness function' OR 10% of total daily dose (TDD) Encourage sugar free fluids little and often Give next planned/usual dose as normal Encourage sugar free fluids little and often Encourage sugar free fluids - little and often Check CBG & Ketones every 2 hours If vomiting - try oral fluid challenge as per local hospital policy. If unable to tolerate fluids, admit CYP according to local guideline, i.e. A&E or direct Give correction dose of rapid acting insulin as per smart meter using illness function OR 5-10% of total daily dose (TDD) Give next planned/usual dose as normal. Encourage sugar free fluids little and often access to the ward. Give correction dose of rapid acting insulin as per smart meter using 'illness function' OR 10-20% of total daily dose (TDD) Give correction dose of rapid acting insulin as per smart meter using 'illness function' OR 20% of total daily dose (TDD) Encourage sugar free fluids - little and often Encourage sugar free fluids - little and often Check CBG & Ketones every hour If vomiting - try oral fluid challenge as per local hospital policy. If unable to tolerate fluids, admit CYP according to local guideline, i.e. A&E or direct access to the ward. NOTE: If blood ketones 3.0mmol/L (starvation ketones usually < 3.0mmol/L) there is immediate risk of developing DKA. After extra insulin has been given, the blood ketone level may temporarily increase by 10 20% for the first hour but should be expected to decrease thereafter. If CYP has nausea, vomiting, abdominal pain, headache or is unable to eat or drink advice to attend local A&E ASAP. If CYP has altered level of consciousness, laboured breathing or there are immediate concerns for safety call 999

8 To calculate the total daily dose (TDD): For those on insulin injections add up all the insulin given on a daily basis (basal and bolus) For those on insulin pumps TDD can be found in the pump memory function To calculate the insulin sensitivity factor using the 100 rule 100 Rule: Divide 100 by total daily dose (i.e. total basal (long-acting) + total bolus (rapid-acting) insulin) e.g. if total daily dose is 50 units, ( = 2). This means that 1 unit of rapid acting insulin (Humalog or NovoRapid or Apidra ), would drop BG by 2mmol/L. (i.e. ISF = 2). Aim to drop CBG TO 7 mmol/l. Example: If CBG= 17, target CBG =7 and ISF=2 (Actual CBG Target CBG) ISF (17 7) 2 = 5 Patient would need 5 units of rapid acting insulin to drop CBG from 17 to 7mmol/L. Always check CBG 1 hour after the correction dose of rapid acting insulin to ensure CBG levels are reducing. NB: If CYP is NOT using a smart meter OR is under the care of acute general paediatric staff, rapid-acting insulin doses MUST be 2 hours apart. Management of Diabetes During Illness in Children and Adolescents. June 2018 v2 page 8 of 16

9 3.3 Flowchart 2: Management of blood glucose levels 14mmol/L and blood ketone levels for patients on insulin pumps (CSII) Check pump for occlusions, disconnection, battery failure, suspended delivery etc. CHECK BLOOD KETONES BLOOD KETONES < 0.6mmol/L Give correction dose given by pump Test BG in 2 hours CBG level reduced CBG not reduced Continue as normal may need to test 2-4 hourly if illness continues BLOOD KETONES 0.6mmol/L Give correction dose of insulin by pen use the same sensitivity factor as in the pump OR use 100 rule (pg.7) to correct BG to 4 7mmol/L Change entire set system (new reservoir, infusion set and cannula). Check insulin pump (self-test). Check CBG hourly & BK in 2hours. Drink plenty of sugar-free fluids. If vomiting - try oral fluid challenge as per local hospital policy. If unable to tolerate fluids, admit CYP according to local guideline, i.e. A&E or direct access to the ward. BK < 0.6mmol/L BK 0.6mmol/L and/or CBG 14mmol/L Start temporary basal rate of 125% (Medtronic & Roche), +25%Omnipod for 2hours. Give bolus correction via pump (Roche use illness function. Check CBG hourly & BK in 2hrs. Drink plenty of sugar-free fluids. If vomiting - try oral fluid challenge as per local hospital policy. If unable to tolerate fluids, admit CYP according to local guideline, i.e. A&E or direct access to the ward. CBG levels within target range Consider reducing temporary basal rate. CBG levels reducing or the same Continue with temporary basal rate. Give bolus correction via pump (Roche use illness function). CBG levels rising Increase basal rate to 150% (or +50%). Give bolus correction via pump (Roche use illness function). Check CBG hourly & BK in 2hrs. Drink plenty of sugar-free fluids. If vomiting - try oral fluid challenge as per local hospital policy. If unable to tolerate fluids, admit CYP according to local guideline, i.e. A&E or direct access to the ward. CBG levels reducing or within target range Continue as normal may need to test 2-4 hourly if illness continues. CBG levels rising or the same Increase basal rate to 175% (or +75%) (max 200% or +100%) Give bolus correction via pump (Roche use illness function). NOTE: If BK are 3.0mmol/L there is immediate risk of developing DKA. If the child has nausea, vomiting, abdominal pain, headache or is unable to eat or drink advise them to attend local A&E ASAP. If child has altered level of consciousness, laboured breathing or there are immediate concerns for safety call 999. Management of Diabetes During Illness in Children and Adolescents. June 2018 v2 page 9 of 16

10 4. Management of hypoglycaemia during illness, e.g. gastroenteritis 4.1 Patients on insulin injections and insulin pumps: Hypoglycaemia is defined as CBG of <4mmol/L. It is mild/moderate if the child or young person is alert and able to tolerate oral fluids/dextrose gel. It is severe hypoglycaemia if the child or young person is unable to swallow, unconscious or fitting. Illnesses associated with nausea and vomiting with or without diarrhoea can lead to hypoglycaemia. Replacing meals with frequent small volumes of sugary drinks and monitoring CBG carefully helps to avoid hypoglycaemia. Give parents alternatives for carbohydrate like sugary drinks if child is unable to tolerate food Reduction in boluses with meals may be required if oral intake is reduced. However, if doses are lowered too much, there is a risk of developing insulin deficiency leading to ketosis and ketoacidosis. Check ketones regularly to see that the CYP has sufficient carbohydrate/sugar intake. Ketones associated with gastrointestinal illness and hypoglycaemia usually reflect inadequate energy supply rather than insulin deficiency (i.e. starvation ketones). Monitor CBG 2 hourly and encourage fluids containing sugar. If oral fluids cannot be tolerated and CBG are <4mmols/L, the child or young person should be admitted. If they are drowsy or conscious level is reduced, then call 999 for an ambulance and advise to give IM Glucagon see table 2 on page 11 for dose, OR if already in hospital see page 10. Hypoglycaemia management in hospital Table 1 see page 10 Hypoglycaemia management at home Table 2 see page 11 Examples of carbohydrates (CHO) for hypoglycaemia treatment Table 3 see page Hypoglycaemia in CYP with vomiting or unable to tolerate any oral fluids during illness BG <4mmol/L Follow Tables 1 or 2 for hypo management (page 10-11). Give parents alternatives for carbohydrate, like sugary drinks, if child is unable to tolerate food If unable to tolerate food or drink - ADMIT If BG levels continue to be low and ketones remain <0.6mmols/L: Consider reducing the next bolus dose of insulin by 20-30% (mix insulin in twice daily regiment and rapid acting insulin in basal/bolus regimen. If BG levels continue to be low despite the above, consider reducing basal insulin by 20-50% at next dose Pump patients consider reduced temporary basal rates for 4 hours, then reassess (Medtronic, Roche 75% to 50%; Animas, Omnipod -25% to -50%) If BG continues to be <4mmol/L despite sugary drinks & reduced insulin, OR ketones increase >0.6mmols/L: Admit and consider IV glucose (see page 15) NB: Never omit the insulin Management of Diabetes During Illness in Children and Adolescents. June 2018 v2 page 10 of 16

11 4.3 Table 1 - Hypoglycaemia management in the hospital Ask the parents/carers the following questions: Assess Signs & symptoms Co-operative & ABLE to tolerate oral treatment Pale, feels wobbly, headache, unsteady, irritable Unco-operative but conscious and REFUSES oral treatment Poor concentration, confusion, irritable, weakness, drowsy, unsteady, headache, difficulty focusing and speaking Management of Diabetes During Illness in Children and Adolescents. June 2018 v2 page 11 of 16 UNABLE TO SWALLOW Unconscious or fitting (or not responded to treatment in amber boxes)? Unconscious, seizures GUIDE Blood glucose mmol/L Blood glucose mmol/L Blood glucose below 2.0mmol/L Treatment Reassess Good to go! ADMINISTER FAST ACTING GLUCOSE See table on page 12 for amount Wait 15 minutes then recheck glucose level. If level still below 4mmol/L or if no clinical improvement, repeat treatment. (CBG MUST be above 5mmol/L if young person is driving). Do not omit insulin at meal time ADMINISTER FAST ACTING GLUCOSE IN THE FORM OF GLUCOGEL See table on page 13 for amount Squirt tube content in the side of each cheek evenly and massage gently from outside enabling the glucose to be swallowed and absorbed DO NOT give Glucogel to an unconscious or fitting child/ young person Wait 15 minutes then recheck glucose level. If level still below 4mmol/L or if no clinical improvement, repeat treatment. Do not omit insulin at meal time. If clinical condition worsens, follow the red column (CBG MUST be above 5mmol/L if young person is driving). Check airway, breathing and circulation. Place patient in recovery position. Gain IV access and give bolus of IV 10% glucose of 2ml/Kg (to a maximum of 5ml/Kg). If IV access is not quickly achieved, give IM injection of Glucagon < 25Kg : 0.5mg (1/2 syringe) > 25Kg : 1mg (whole syringe) If there is a delay in recovery call senior doctor. Check blood glucose after 5 minutes, 15 minutes and then every 30 minutes until CBG is stable above 4mmol/L. If CYP not improving call senior doctor. Consider repeat IV bolus. In severe hypoglycaemia the pump can be stopped for a maximum of one hour. When blood glucose level is at least 4.0mmol/L (or above 5mmol/L if driving) and patient has recovered, give a long-acting carbohydrate 10-20g snack, e.g. a slice of toast, a plain biscuit or a glass of milk (200mls). Pump therapy: Long-acting carbohydrate is NOT necessary following treatment of hypoglycaemia for CYP who use an insulin pump. Once hypo has been treated, recommence pump therapy. Failure to resume the pump will result in DKA. NOTE: insulin should NEVER be omitted following an episode of hypoglycaemia but dose adjustment may be necessary.

12 4.4 Table 2 Hypoglycaemia management at home Ask the parents/carers the following questions: Assess Signs & symptoms Co-operative & ABLE to tolerate oral treatment Pale, feels wobbly, headache, unsteady, irritable Unco-operative but conscious and REFUSES oral treatment Poor concentration, confusion, irritable, weakness, drowsy, unsteady, headache, difficulty focusing and speaking UNABLE TO SWALLOW Unconscious or fitting (or not responded to treatment in amber boxes)? Unconscious, seizures GUIDE Blood glucose mmol/L Blood glucose mmol/L Blood glucose below 2.0mmol/L ADMINISTER FAST ACTING GLUCOSE IN Place CYP on their side. THE FORM OF GLUCOGEL See table on page 13 for amount Call 999 Treatment Reassess Good to go! ADMINISTER FAST ACTING GLUCOSE See table on page 12 for amount Wait 15 minutes then recheck glucose level. If level still below 4mmol/L or if no clinical improvement, repeat treatment. (CBG MUST be above 5mmol/L if young person is driving). Do not omit insulin at meal time Squirt tube content in the side of each cheek evenly and massage gently from outside enabling the glucose to be swallowed and absorbed DO NOT give Glucogel to an unconscious or fitting child/ young person Wait 15 minutes then recheck glucose level. If level still below 4mmol/L or if no clinical improvement, repeat treatment. Do not omit insulin at meal time. If clinical condition worsens, follow the red column (CBG MUST be above 5mmol/L if young person is driving). If confident give Glucogen HypoKit : Under 8years : 0.5mg (1/2 syringe) Over 8years: 1mg (whole syringe) This may take up to 15 minutes to work. Do NOT give any fluids, tablets or glucogel by mouth. Check blood glucose after 5 minutes, 15 minutes and then every 30 minutes until CBG is stable above 4mmol/L. In severe hypoglycaemia the pump can be stopped for a maximum of one hour. When blood glucose level is at least 4.0mmol/L (or above 5mmol/L if driving) and patient has recovered, give a long-acting carbohydrate 10-20g snack, e.g. a slice of toast, a plain biscuit or a glass of milk (200mls). Pump therapy: Long-acting carbohydrate is NOT necessary following treatment of hypoglycaemia for CYP who use an insulin pump. Once hypo has been treated, recommence pump therapy. Failure to resume the pump will result in DKA. NOTE: insulin should NEVER be omitted following an episode of hypoglycaemia but dose adjustment may be necessary. Management of Diabetes During Illness in Children and Adolescents. June 2018 v2 page 12 of 16

13 4.5 Table 3 Examples of carbohydrates (CHO) for hypoglycaemia treatment Co-operative & ABLE to tolerate oral treatment Unco-operative but conscious & REFUSES oral treatment WEIGHT UP TO: g CHO REQUIRED (0.3g/Kg) GLUCOTABS 4g/tablet GLUCOJUICE 15g/ 60ml GLUCOGEL 10g CHO/tube DEXTROSE TABS 3g/tablet JELLY BEANS 2g/sweet SKITTLES 1.1g/sweet JELLY BABIES 5g/sweet FRUIT PASTILLES /REFRESHERS 3g/sweet COLA 10.6g/100ml LUCOZADE (Energy Original) 9.2g/100ml LUCOZADE (Energy Orange) 8.4g/100ml FRUIT JUICE 10kg 20kg 30kg 40kg 50kg 60kg 10kg 20kg 30kg 40kg 50kg 60kg 3g 6g 9g 12g 15g 18g 3g 6g 9g 12g 15g 18g NOT SUITABLE ml 25ml 35ml 50ml 60ml 75ml ½ tube ½ tube 1 tube 1½ tube 1½ tube 2 tube ½ tube ½ tube 1 tube 1½ tube 1½ tube 2 tube NOT SUITABLE NOT SUITABLE NOT SUITABLE NOT SUITABLE NOT SUITABLE NOT SUITABLE NOT SUITABLE NOT SUITABLE NOT SUITABLE ml 90ml 110ml 140ml 170ml 65ml 100ml 130ml 160ml 200ml 70ml 110ml 140ml 180ml 210ml 60ml 90ml 120ml 150ml 180ml Squirt tube content in the side of each cheek evenly and massage gently from outside enabling the glucose to be swallowed and absorbed DO NOT give Glucogel to an unconscious or fitting child/ young person Management of Diabetes During Illness in Children and Adolescents. June 2018 v2 page 13 of 16

14 5.0 Management in hospital upon admission 5.1 Maintenance IV fluids/variable rate insulin infusion (VRIII) The choice of IV fluids depends on the blood glucose levels. Usual fluid is 5% glucose in 0.9% sodium chloride with 10mmol (0.15%) KCL in 500mls. The previously used term Sliding scale for IV insulin has been replaced by the term Variable Rate Intravenous Insulin Infusion (VRIII use IV fluids chart, appendix 3). The insulin infusion used here is significantly less than the one used in the BSPED DKA guideline because these children and young people are not ketoacidotic. If they are ketoacidotic, then the East of England (EoE CYPDN) DKA guidelines should be followed. Aim and principles of VRIII Aim: To maintain the blood glucose level 6-10mmol/L. It is important that patients with diabetes have a constant level of insulin to prevent ketosis. Indications: For an unwell CYP with diabetes, surgery requiring a starvation period more than one missed meal, or emergency surgery. If in DKA use BSPED DKA guideline14 (failure to do this is a critical incident). Principles: When an intravenous insulin infusion is used, fluids containing dextrose (Appendix 1) should be infused continuously until the patient is eating and drinking. The initial insulin infusion rate is determined by the CBG (see Table 4, page 14). The CBG should be monitored at least hourly. The rate of fluid must be set to deliver the hourly fluid requirements. 5.2 Safe Preparation and administration of VRIII: An insulin syringe must be used to measure and prepare insulin for an intravenous infusion. Add soluble insulin (Actrapid ) 50 units to 49.5ml sodium chloride 0.9%, making a solution of 1 unit insulin/ml. The bed pole, on to which the fluid is hung, must always be present to allow safe transfers. The mobile drip stand must always be present to promote stabilisation. Delivery of the glucose solution and the VRIII must be via a single cannula with appropriate one- way and anti-siphon valves. 50 ml leuer-lock Syringe Insulin Syringe 50ml leuer lock Syringe Management of Diabetes During Illness in Children and Adolescents. June 2018 v2 page 14 of 16

15 49.5ml Sodium Chloride 0.9% + 50 Units Actrapid Insulin = Final volume 50ml (1 unit of insulin / ml) Start VRIII according to the CGB as in the table below: Table 4 VRIII rates: CBG Insulin infusion rate 6 7.9mmol/L 0.025ml/kg/hr (i.e units/kg/hr) mmol/L 0.05ml/kg/hr (i.e. 0.05units/kg/hr) mmol/L 0.075ml/kg/hr (i.e units/kg/hr) >15mmol/L 0.1ml/kg/hr (i.e. 0.1unit/kg/hr) Adapted from ISPAD Clinical Practice Consensus Guidelines 2014 Compendium, Pediatric Diabetes 2014: 15 (Suppl. 20): Monitor CBG hourly while on IV fluids and VRIII If CBG is < 6mmols/L, infuse 10% dextrose in 0.9% sodium chloride with 10mmol of KCL in 500mls If CBG is <4mmol/L give 2 ml/kg of 10% dextrose over 5 minutes. Retest CBG after 15 minutes to ensure that the level of blood glucose is safe, otherwise repeat 10% dextrose bolus as above. Consider reducing the insulin infusion to 0.01units/kg/hr (0.01ml/kg/hr), particularly in a very young child, if CBG continues to be below 5mmols/L despite the boluses. If CBG continue to drop and are low, consider using 10% glucose with 0.45% sodium chloride and 10mmol KCL in 500mls. To prepare 500ml of 10% glucose in 0.9% sodium chloride with 10mmol KCL withdraw and discard 50mls of fluid from a 500ml bag of 5% glucose in 0.9% sodium chloride and 10mmols KCL. Add 50ml of 50% glucose into this 500ml bag and mix well. If CBG is >14mmols/L, use 0.9% sodium chloride with 10mmol KCL in 500ml and increase the insulin infusion rate. Once CBG has dropped below 14mmols/L, change the fluids to 5% dextrose with 0.9% sodium chloride and 10mmols KCL in 500mls. Monitor electrolytes daily to avoid hyponatraemia. If hyponatraemia develops, always discuss with the consultant. There is evidence that the risk of acute hyponatremia may be increased when using hypotonic parental maintenance fluid (i.e. < 0.9% saline) in hospitalised children. Compromise would be to administer 0.45% saline with 5% glucose, carefully monitor electrolytes and change to 0.9% saline with 5% glucose if plasma sodium concentration is falling. When fluids and food are tolerated, start the usual subcutaneous insulin regime as below. 5.3Transferring from VRIII to subcutaneous insulin: Once the patient is able to tolerate food orally give S/C insulin. Discontinue the insulin infusion 30 minutes after the subcutaneous dose if using rapid acting, mixed (biphasic) insulin (Appendix 2) or 60minutes after recommencing insulin pump therapy. Discontinue the insulin infusion 60 minutes after the subcutaneous dose if using basal insulin (Appendix 2). Management of Diabetes During Illness in Children and Adolescents. June 2018 v2 page 15 of 16

16 Consult the diabetes team if the CBG is outside the acceptable range (5-10mmol/L) despite adjustment of the VRIII rates as above Management of Diabetes During Illness in Children and Adolescents. June 2018 v2 page 16 of 16

17 Appendix 1: Parenteral maintenance fluids Choice of intravenous fluid These recommendations are modified from the results of a recently conducted randomised control trial12 and from ISPAD clinical practice consensus guidelines. Hospital acquired hyponatraemia is common, and children undergoing surgery are at particular risk. It is recognised that hyponatraemia is associated with severe neurological morbidity. Those in favor of isotonic PMF argue that it supports the role of sodium during illness by maintaining plasma tonicity, whereas hypotonic PMF results in excess electrolyte free water (EFW) in patients with an already impaired ability to excrete EFW. Those who favour hypotonic PMF argue that hyponatraemia results from excessive PMF volume (as opposed to type of PMF) and there are risks with isotonic PMF, such as hyperchloremic metabolic acidosis. Our consensus for this guideline is that the standard intravenous fluid to run alongside the VRIII is 5% dextrose in 0.9% saline with 10mmol/500ml KCl. Monitor electrolytes daily to avoid hyponatremia The fluid infusion rate is calculated according to body weight using the Holiday-Segar nomogram13 (4ml/kg/hr for the 1st 10kg body weight, 2ml/kg/hr for the 2nd 10kg of weight, 1ml/kg/hr for the remaining weight). Availability of pre-made 5% dextrose in 0.9% saline with 0.15% KCl / 500ml bags 5% glucose in 0.9% saline with 0.15% KCl and without KCl in a 500ml bag is available The potassium containing fluid is quite expensive but this outweighs the risk of having to add potassium in some hospital settings. Some units allow addition of potassium in the fluid. All units would need to make their own arrangements regarding the availability of these fluids. Management of Diabetes During Illness in Children and Adolescents. June 2018 v2

18 Appendix 2: Commonly used insulin preparations Commonly used Insulin preparations Rapid acting insulin analogues Insulin lispro (Humalog ) Insulin aspart Short acting Insulin Regular [Soluble] (Actrapid /or Humulin S ) Intermediate acting Insulatard /or Humulin I /or Insuman Long acting basal insulin analogue Insulin glargine (Lantus ) Insulin detemir (Levemir ) Insulin degludec (Tresiba) Biphasic Insulins (Mixed insulin) Biphasic insulins are pre-mixed insulin preparations containing various combinations of short acting or rapid acting and intermediate acting insulin. These preparations are normally used in 2 and 3 injections a day insulin regimens (see below). Twice Daily Mix Insulin Regimen: CYP on this regimen receive one injection of the Mixed (biphasic) insulin preparation in the morning and one at tea time or in the evening. In some centres patients are managed on 3 injections of Mixed (biphasic) insulin at breakfast, lunch and with tea. Twice Daily Free Mix Insulin Regimen: Rarely CYP take free mix injections of rapid acting e.g. Humalog, NovoRapid and intermediate acting e.g. Insulatard, Humulin I. Three Injections a Day Insulin Regimen: CYP on 3 injections a day receive Mixed (biphasic) insulin with breakfast, rapid acting insulin with tea and basal insulin in the evening. MDI Insulin Regimen: CYP on MDI insulin regimen take once daily basal insulin in the morning or evening (and sometimes split the basal insulin in the morning and evening), and rapid acting insulin with each meal and for blood glucose correction Management of Diabetes During Illness in Children and Adolescents. June 2018 v2

19 Appendix 3 Hospital No: DOB: PAEDIATRIC NON DKA INTRAVENOUS INSULIN AND FLUID CHART for children not able to tolerate oral fluids. First Name: VARIABLE RATE INSULIN INFUSION DOSES Capillary Blood Glucose Level Insulin dose/rate mmols/litre 0.025units/kg/hour (0.025mls/kg/hour) mmols/litre 0.05units/kg/hour (0.05mls/kg/hour) mmols/litre 0.075units/kg/hour (0.075mls/kg/hour) More than 15 mmols/litre 0.1units/kg/hour (0.1mls/kg/hour) INSULIN BY SYRINGE PUMP: Pre filled Soluble insulin syringes with 50 units of soluble insulin in 50mls of 0.9% Sodium Chloride are available from pharmacy If no prefilled syringes are available do not delay treatment. Using an insulin syringe at 50units of the prescribed insulin to 49.5mls of 0.9%saline in a 50ml syringe and mix well. Date/Time Soluble Human Insulin units/kg/hour (0.025mls/kg/hour) Dose in mls/hr Doctor s Signature/ Name Infusion Batch No. Drug Batch No. Date/Time started Date/time stopped Signatures Date/Time Date/Time Date/Time Soluble Human Insulin 0.05 units/kg/hour (0.05mls/kg/hour) Soluble Human Insulin units/kg/hour(0.075mls/kg/hour) Soluble Human Insulin 0.1units/kg/hour (0.1mls/kg/hour) Management of Diabetes During Illness in Children and Adolescents. June 2018 v2

20 PAEDIATRIC NON DKA INTRAVENOUS INSULIN AND FLUID CHART Hospital No: DOB: First Name: Last Name: Date/Time: Weight: kg Run Fluids at: ml/hours Doctors Signature Print Name Bag Ref Intravenous Fluid Use bag 1 when blood glucose is more than 14 mmols/litre Doctor s Signature/ Name Infusion Batch No Drug Batch No Administration Time/Date Started Time Stopped Signatures 1 Sodium Chloride 0.9% + Potassium (KCL) 10mmol in 500ml 1 Sodium Chloride 0.9% + Potassium (KCL) 10mmol in 500ml Use bag 2 when blood glucose is less than 14 mmols/litre 2 Sodium Chloride 0.9% / Glucose 5% + Potassium (KCL) 10mmol in 500ml 2 Sodium Chloride 0.9% / Glucose 5% + Potassium (KCL) 10mmol in 500ml Use bag 3 when there is concern about hypoglycaemia or the blood glucose is less than 6 mmols/litre despite adjusting the variable rate insulin. If blood glucose less than 4 mmol/l treat with 2ml/kg 10% Dextrose. To make up bag 3 (f not available pre made), withdraw 50ml from 500ml bag of 0.45 Saline in 5% Dextrose, replace with 50ml 50% glucose and add 10mmol KCL. 3 Sodium Chloride 0.9% / Glucose 10% + Potassium (KCL) 10mmol in 500ml 3 Sodium Chloride 0.9% / Glucose 10% + Potassium (KCL) 10mmol in 500ml Management of Diabetes During Illness in Children and Adolescents. June 2018 v2