Emergency Department Clinical Pathway for Evaluation/Treatment of Children with Type 1 Diabetes Mellitus (DM) and Acute Illness
- Initial MD/APP/RN Team Assessment
- MS, ABCDE
- Monitors, VS
- Hydration status
- Recent
- Blood glucose
- Urine ketones
- Insulin doses
- Further diagnostic testing as clinically indicated
BOHB | Recommendations |
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0 - 0.9 |
|
1-1.9 |
|
> 2 |
|
Diabetes Care Flow Chart: DKA, Diabetic Ketosis, Routine Diabetic Care |
Goal | Use rehydration, 2 doses of SubQ rapid-acting insulin given 2 hours apart to clear ketones 1st dose of insulin is weight-based Flow Chart for RN Care of Diabetic Ketosis |
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Initial Labs | POC blood glucose, POC blood BOHB For patients with BOHB > 2 mmol/L: Send VBG, BMP to evaluate for DKA, Diabetes Type 1, with DKA |
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First Insulin Dose (weight-based) | Use SubQ rapid-acting insulin only (Aspart) 1st dose: 0.15 unit/kg |
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Insulin Pump | Verify and document recent infusion site change or have family/patient change site Continue insulin basal rate Bolus doses should be ordered by FLOC and given via Aspart injection Do not use pump for boluses Insulin Pump Management |
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Second Insulin Dose (Endocrine consult) | Review recent home regimen, recent doses with patient/family/EPIC Discuss 2nd insulin dose with Endocrine Fellow Insulin Dosing Ketone Dose, Correction Factor, Correction Bolus Diabetes Care Flow Chart: DKA, Diabetic Ketosis, Routine Diabetic Care |
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PO Hydration |
Patient to drink 1 ounce per age in years every hour
|
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IV Hydration | Encourage PO hydration Consider ondansetron if nausea, vomiting present For patients with BOHB > 2 mmol/L (if BOHB unavailable, give IV fluids if large urine ketones): Give NS bolus 10 mL/kg, repeat as clinically indicated Add glucose to IVF if blood glucose < 200 |
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RN Monitoring | Hourly VS, I/O | ||||
Subsequent Labs | Check POC blood glucose and POC blood BOHB every 2 hours |
Admit to Endocrine
Discharge
- Inability to tolerate oral fluids
- Persistence of blood BOHB ≥ 1
after 2 doses of rapid-acting insulin
- Tolerating PO fluids
- Reassuring vital signs and
physical examination - BOHB < 1
Evidence
- Sick Day Management in Children and Adolescents with Diabetes
- Ketone Bodies: a Review of Physiology, Pathophysiology and Application of Monitoring to Diabetes
- Insulin Treatment in Children and Adolescents with Diabetes
CHOP Programs
Educational Media
Related Links