Paediatric and Adolescent Diabetes – Management (not ...health.act.gov.au/sites/default/files/new_policy_and_plan... · Web viewThis guideline aims to guide the: management of moderate

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Canberra Hospital and Health ServicesClinical Guideline Paediatric and Adolescent Diabetes – Management (not neonates)Contents

Contents....................................................................................................................................1

Guideline Statement.................................................................................................................3

Scope........................................................................................................................................ 3

Section 1 – Management of Diabetic Ketoacidosis in Infants (not neonates), Children and Adolescents...............................................................................................................................3

1.1 Assessment.................................................................................................................4

1.2 Diagnosis of DKA.........................................................................................................5

1.3 Management of DKA..................................................................................................5

1.4 Monitoring and care...................................................................................................6

1.5 Pathology....................................................................................................................6

1.6 Fluid Management – Key Points.................................................................................7

1.7 Fluid Management – IV fluids.....................................................................................7

1.8 Electrolyte replacement.............................................................................................8

1.10 Insulin therapy and subsequent IV fluid therapy..................................................11

1.12 Suspected Infection..............................................................................................12

1.13 Cerebral oedema..................................................................................................12

1.14 Weaning insulin infusion:......................................................................................13

1.15 Family Support and Discharge Planning:...............................................................14

Section 2 – Hyperglycaemia – Management in Children and Adolescents during Insulin Pump Therapy................................................................................................................................... 14

2.1 For BGL above 15mmol/L.........................................................................................14

Section 3 – Management of Children with Diabetes during Surgery and Fasting...................15

3.1 Elective Minor Surgery.............................................................................................15

3.2 Stabilisation prior to surgery....................................................................................17

3.3 Ongoing management..............................................................................................19

3.4 Emergency Surgery...................................................................................................19

Implementation...................................................................................................................... 19

Related Policies, Procedures, Guidelines and Legislation.......................................................19Doc Number Version Issued Review Date Area Responsible PageCHHS17/050 1 05/04/2017 01/03/2022 WY&C –

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Do not refer to a paper based copy of this policy document. The most current version can be found on the ACT Health Policy Register

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References.............................................................................................................................. 20

Definition of Terms................................................................................................................. 21

Search Terms.......................................................................................................................... 21

Attachments............................................................................................................................21

Attachment 4 - Initial Assessment and Management of DKA..............................................22

Attachment 5 - Ongoing assessment and management of DKA..........................................23

Attachment 6 - Diabetic Ketoacidosis Pathology Results Flow Chart – Child and Adolescent Clinical form........................................................................................................................24

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Guideline Statement

This guideline aims to guide the: management of moderate to severe Diabetic Ketoacidosis (DKA) in infants (not

neonates), children and adolescents under the care of a paediatrician clinical management of a child/adolescent with an insulin pump who has

hyperglycaemia management of children and adolescents with Type 1 Diabetes undergoing surgery or a

procedure that requires fasting.

Back to Table of Contents

Scope

This document applies to the following Canberra Hospital Health Services (CHHS) staff working within their scope of practice: medical officers registered nurses medical and nursing students under supervision.


Section 1 – Management of Diabetic Ketoacidosis in Infants (not neonates), Children and Adolescents

DKA is the combination of hyperglycaemia, metabolic acidosis and ketonaemia. It may be the first presentation for a child with previously undiagnosed diabetes. It can also be precipitated by illness, or poor compliance with taking insulin.

A diagnosis of DKA can be made when the biochemical assay reflects the following: Blood glucose level >11 mmol/L Venous pH <7.3 Bicarbonate <15 mmol/L Ketonaemia > 3 mmol/L

Note: Hyperglycaemia without ketosis is not considered to be DKA, nor is the presence of ketonuria or ketonaemia in the absence of acidosis considered to be DKA. DKA may occur in patients with only mildly elevated blood glucose levels (i.e. > 11.1mmol/L).

All patients with DKA should be managed in consultation with the CHHS Paediatric Endocrinologist on-call (telephone 0466 655 068). See Attachment 1 & 2 for flow charts on initial and ongoing assessment and management.


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1.1 AssessmentAs with any patient, a systematic clinical assessment should be undertaken, including specific considerations for a patient with DKA:Airway: Consider that the patient with DKA may have impaired consciousness with decreased

ability to maintain a patent airway.

Breathing: Assess rate, depth and character of respirations. Patients with DKA may exhibit

Kussmaul (sighing/hyperventilation) respirations as a compensatory mechanism for metabolic acidosis.

Assess the smell of the patient’s breath – ketoacidosis can cause ‘acetone’ (like nail polish remover) or ‘fruity’ smelling breath.

Circulation: Assessment of hydration is vital, as dehydration due to vomiting, polydipsia (excessive

thirst) and polyuria (excessive urination) are expected problems (see section below on fluid management). Central capillary refill should be documented with each set of vital signs.

Disability/Neurological: Cerebral oedema may occur at any stage during treatment, with variable signs and

symptoms (see section below on cerebral oedema) Neurological assessment (level of consciousness, mental state, including changes over

time as well as development of headache) and monitoring of vital signs (especially heart rate (HR) & Blood Pressure (BP) are important.

Assessment for the underlying cause of DKA should be undertaken. While this may be due to missed insulin or undiagnosed type 1 diabetes mellitus, other precipitants including sepsis should be considered.

Assessment of Hydration StatusDehydration – in DKA it is rare to have 10% dehydration (although this may occasionally occur). More often, severe acidosis will affect cardiac output hence making the signs of dehydration look more severe.

When assessing the severity of dehydration in young children and predicting at least 5% dehydration and acidosis useful clinical indicators include: prolonged capillary refill time (> 3 seconds) abnormal skin turgor (tenting or inelastic skin) respiratory pattern suggesting compensation for acidosis (hyperpnoea).


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1.2 Diagnosis of DKADetermine the severity of DKA using the following criteria:

Mild Moderate SevereNeurological status Alert Drowsy, lethargic Obtundation, comaTachypnoea Absent Present - Mild SevereHypovolaemia None or mild

< 3 %Mild-to-moderate~6 %

Severe> 9 %

Venous pH < 7.3 < 7.2 < 7.1Plasma bicarbonate (mmol/L)

< 15 < 10 < 5

Anion gap* 18 – 20 20 -25 > 25*Anion gap = serum sodium – (serum chloride + bicarbonate)

1.3 Management of DKAMild DKAPatients who present with DKA without vomiting can be treated using oral fluids and subcutaneous insulin.

DKA requiring resuscitationThe resuscitation principles of airway, breathing, circulation and disability are to be followed: assess airway patency and breathing give oxygen to patients with severe circulatory compromise or shock in rare cases where a patient with DKA presents in shock, rapid rehydration with boluses

of 20mL/kg sodium chloride 0.9% may be given (see section below on cerebral oedema regarding careful fluid resuscitation).

Alert: ‘Shock with haemodynamic compromise is uncommon in childhood diabetic ketoacidosis’. Children and adolescents presenting with DKA rarely require fluid resuscitation with 20mL/kg as the presence of acidosis results in poor peripheral perfusion. Serious harm from cerebral oedema can result from overzealous fluid resuscitation, especially where hypotonic fluids are used, or initial starting sodium is low. commence fluid resuscitation with 10mL/kg sodium chloride 0.9% given as a bolus; a

repeat bolus may be administered if required patients with impaired consciousness or recurrent vomiting should have a nasogastric

tube inserted to prevent the aspiration of gastric contents’ gastric ileus is very common in severe DKA

insert a bladder catheter if the child or adolescent is unconscious or unable to void on request (i.e. infants and very young children)

attach a monitor for continuous ECG monitoring to assess for evidence of hyperkalaemia or hypokalaemia – o hypokalaemia is characterised by flattening of the T wave, widening QT interval and

the appearance of U waves on an ECG monitoro hyperkalaemia is characterised by tall peaked symmetrical T waves and shortening

QT interval Doc Number Version Issued Review Date Area Responsible PageCHHS17/050 1 05/04/2017 01/03/2022 WY&C –

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consider antibiotics for febrile patients or where an obvious septic focus is present after obtaining the relevant cultures.

1.4 Monitoring and carePatients with moderate or severe DKA will be cared for in the High Care Unit and have: 2 x IV cannulas – one for fluids and one for blood sampling Nil by mouth (NBM) status until clinically stable hourly blood glucose level (BGL) monitoring 2nd hourly blood ketone level monitoring continuous cardiorespiratory and SaO2 monitoring, with hourly recording of vital signs;

assess ECG for T-wave changes indicative of hypokalaemia or hyperkalaemia hourly blood pressure monitoring hourly assessment of neurological status – elevate head of bed 30° hourly temperature monitoring until normal – underlying infection may be the causative

factor of DKA, and hypothermia is not uncommon in severe DKA regular assessment of perfusion and hydration (including strict fluid balance chart);

patients may need an indwelling catheter (IDC) for accurate assessment of urine output; polyuria may cause further dehydration

percentiles (including bare weight); compare weight with recent measurements.

1.5 PathologyDocument results on Diabetic Ketoacidosis Pathology Results Flow Chart – Child and Adolescent Clinical form 60795 (see Attachment 3).

Initial bloods should include: regular analysis of blood glucose levels (BGL) and ketones using glucometer formal serum analysis of glucose, potassium, sodium, chloride, magnesium, urea,

creatinine, pH, pCO2, bicarbonate, base deficit, calcium, phosphate, FBC (Note: white cell count (WCC) may be raised due to demargination of neutrophils due to

stress and may not be a reliable indication of infection), haematocrit, anion gap [anion gap = serum sodium – (serum chloride + bicarbonate)]

Note: If the ketones are < 3 mmol/L there is no need to proceed to Venous Blood Gases (VBG) and IV fluids may not be required (particularly during the day and the patient is not vomiting).

Ongoing bloods (1 – 2 hourly, as patient condition indicates): regular analysis of BGL and ketones using glucometer formal serum analysis of glucose, bicarbonate, pH, lactate, sodium (actual and

corrected), potassium, urea, and creatinine. If BGLs are measured using capillary blood, the analysis may be inaccurate due to poor peripheral circulation and acidosis

electrolyte and acid base balance should be measured every 2 hours until the bicarbonate level is rising steadily and is > 12mmol/L (then every 4 hours).


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Where indicated (at initial diagnosis of Type 1 Diabetes) further pathology may be ordered to include: insulin auto antibodies (IAA), GAD antibodies, IA-2 antibodies, coeliac screen, (IgA,

Endomysial Ab, Tissue Transglutaminate Ab) and thyroid peroxidase and thyroglobulin antibodies and Thyroid Function test (TSH and free T4), 25OH VitD, LFT’s, HbA1c.

1.6 Fluid Management – Key PointsThe aim of fluid management is to: restore circulating volume clear ketones correct electrolyte disturbance.

Resuscitation fluid: if required, use boluses of 10mL/kg sodium chloride 0.9% to normalise lactate levels rehydration fluids: sodium chloride 0.9% commence insulin infusion following fluid resuscitation commence potassium replacement therapy when commencing insulin infusion

o younger children start with potassium chloride 40mmol/L o older children, and those with severe DKA and those with starting potassium levels <

4mmol/L may require potassium chloride 60mmol/L change IV fluids to sodium chloride 0.9 and glucose 5% when BGL decreases by more

than 5mmol/hr and/or when BGL < 18 mmol/L patients with severe DKA or those in whom the corrected sodium is low or trending

down, require sodium chloride 0.9% for longer and glucose 5% should be added to this when a blood glucose levels of 18mmol/L is reached.

1.7 Fluid Management – IV fluidsFollowing initial resuscitation: calculate the total fluid volume requirements [maintenance + deficit] for the next 48

hours sodium chloride 0.9% is the recommended IV fluid used in DKA, except in the presence

of hypernatraemia (Na+ > 150mmol/L), when sodium chloride 0.45% and glucose 5% may be appropriate (in consultation with a paediatric endocrinologist)

**Note: Accurate assessment of dehydration can be difficult. The rate of fluid volume replacement will rarely exceed 1.5 – 2 times the usual daily requirements. the resuscitation fluid volume is included in the total volume of fluid required urinary output amounts are not routinely included when calculating replacement fluid

volumes initially patients are to remain NBM (but may be given ice to suck if conscious state

permits) once oral fluids are tolerated the IV fluid rate is titrated to ensure the total hourly input

rate does not exceed the total rehydration fluid required.

Table 1. Rehydration fluid requirements for weight and severity of dehydration Doc Number Version Issued Review Date Area Responsible PageCHHS17/050 1 05/04/2017 01/03/2022 WY&C –

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Weight(kg)

Mild/Nil dehydration (mL/hour)

Moderate dehydration (mL/hour)

Severe dehydration (mL/hour)


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5 24 27 317 33 38 438 38 43 50

10 48 54 6212 53 60 7014 60 65 8016 65 75 8518 70 80 9520 75 85 10522 80 90 11024 80 95 11526 85 100 12028 85 105 12530 90 110 13532 90 110 14034 95 115 14536 100 120 15038 100 125 15540 105 130 16042 105 135 17044 110 135 17546 115 140 18048 115 145 18550 120 150 19052 120 155 19554 125 160 20556 125 160 21058 130 165 21560 133 171 22062 136 175 22664 139 179 23266 140 185 24068 145 185 24570 150 190 250

1.8 Electrolyte replacementSodium: serum sodium measurements may be unreliable due to the fluid shift from extracellular

to intracellular and the dilutional effect created by the hyperglycaemia. Use the corrected sodium formula:

Corrected (i.e. actual) Na = measured Na + 0.3 (glucose - 5.5) mmol/l i.e. 3 mmol/l of sodium to be added for every 10 mmol/l of glucose above 5.5 mmol/l

if corrected sodium > 150 mmol/L (i.e. hypernatraemia) electrolyte correction should occur over 48 – 72 hours.


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Alert: If the serum sodium level decreases unexpectedly as the serum glucose decreases, overzealous fluid volume correction using hypotonic fluids such as glucose 2.5% or glucose 5 % and sodium chloride 0.45%, with insufficient electrolyte replacement has occurred.

Potassium: serum potassium measurements may be low, normal or high on presentation but overall

there is a deficit of total body potassium; potassium replacement must occur with the introduction of insulin and correction of acidosis; the timing and amount of replacement is guided by the initial and subsequent blood pathology

potassium replacement should commence once initial fluid boluses are complete and should continue throughout IV therapy; the replacement amount is determined by serial measurement of serum potassium

timely and appropriate potassium replacement in patients with DKA is very important, and any potential delays due to considered risks should be discussed with the paediatric endocrinologist; potassium replacement should commence before the administration of insulin if initial potassium levels are <4mmol/L, or in conjunction with insulin if potassium levels are >4mmol/L; it should never wait until the patient is frankly hypokalaemic.

potassium levels < 3mmol/L and > 5.5mmol/L require 2 hourly formal blood pathology monitoring

CHHS stocks IV fluid bags which are pre-loaded with varying concentrations of potassium – consider using these in clinically appropriate circumstances

patients receiving potassium replacement therapy must have continuous cardiorespiratory monitoring for ECG interpretation.

Hypokalaemia: patients with ketoacidosis will have a total body potassium deficiency; those whose

initial potassium level is <3.5mmol/L have severe hypokalaemia; potassium replacement is to commence at the time of fluid volume expansion and prior to commencement of insulin therapy

if indicated (initial K < 3.5 - 4), potassium may be added to resuscitation fluid; consult with the paediatric endocrinologist on-call (telephone 0466 655068) for dosage requirements

if severe hypokalaemia persists despite the maximum rate of potassium replacement, the insulin infusion rate may be decreased following consultation with the paediatric endocrinologist; this is an interim measure only.

Without hypokalaemia potassium replacement should be initiated following fluid replacement and rehydration

together with the commencement of insulin therapy: o potassium chloride 40mmol/L should be given as maintenance fluid initially for all

children < 30 kg and 60mmol/L for all children > 30kg in weight; if the patient is hyperkalaemic or has not passed urine (possibly requiring insertion of an IDC), potassium replacement should be discussed with a paediatric endocrinologist and


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may need to be delayed until urine has been passed and serum electrolytes are available.

ALERT for IV POTASSIUM CHLORIDE for DKA ManagementAdministration of IV potassium chloride for the management of DKA should be guided by the paediatric endocrinologist on call.

IV potassium is associated with a number of known risks, including cardiac arrhythmia. Patients should be in High Dependency and must have cardiac monitoring.

1.9 Administration of high dose IV potassium chloride Must involve the nursing Team Leader and discussion with the Paediatric

Endocrinologist on call. Doses of potassium chloride up to 60mmol/L can be administered via peripheral IVC

using ready-made commercial 60mmol Potassium Chloride/1Lbags where possible; the maximum concentration of potassium deliverable in the Paediatric Unit is 60mmol/L; doses exceeding 60mmol/L require an ICU consultation, but dosing should not be withheld whilst awaiting consult:o A medical officer should be present in the High Care Ward during infusion of doses

greater than 60mmol/Lo the maximum recommended rate of potassium infusion should not exceed

0.5mmol/kg/hr o best practice suggests that the administration of > 60mmol/L should be via a Central

Venous Access Device (CVAD) wherever possible; administration of any concentration above 60mmol/L via a peripheral cannula must be approved by the paediatric endocrine consultant on call; the risk of peripheral administration of high dose potassium should be balanced with the clinical risk of not administering potassium versus the risk of a CVAD (i.e. venous thrombosis – particularly in haemoconcentrated states like DKA).

potassium is a vesicant and the IV site should be monitored closely; increase frequency of site check and ensure the site is in view at all times

Where possible ready-made commercial bags should be used. When ready-made bags are not available: within business hours, Pharmacy IV Room will make up the fluids, and after hours, the fluids may be made up in the clinical area.

Bicarbonate replacement: bicarbonate replacement increases intracellular acidosis in the brain and is a risk factor

for cerebral oedema; it is rarely necessary and consultation with the paediatric endocrinologist must occur

should bicarbonate therapy be used, only correct to a pH of ~ 7-7.1 in very severe cases hyperchloraemic acidosis can persist following correction of DKA; this is a benign

condition and results from the extra chloride content of rehydration fluids used and delay in regeneration of bicarbonate by the kidneys.


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1.10 Insulin therapy and subsequent IV fluid therapyGeneral Principles: rehydration contributes to a decrease in the BGL, however insulin therapy is required to

normalise BGLs and arrest the lipolysis and ketogenesis insulin infusion is commenced following fluid resuscitation run the infusion using a smart infusion pump with medication safety software the IV insulin infusion must be prescribed short acting insulin such as Actrapid® or Humulin® R should be prescribed draw up 50 units of insulin in an insulin syringe and add to 49.5mL normal saline to

make up a 50mL solution of 1 unit/mL insulin infusion must be clearly labelled (as per the National ACSQHC Labelling

Recommendation for User-applied Labelling of Injectable Medicines, Fluids and Lines) the Drug Library on a smart infusion pump with medication safety software must be

used for the insulin infusion. program the smart infusion pump with medication safety software as follows:

o Drug Library: Yeso Ward: Paediatric Generalo Drug Category: Othero Drug: Insulin (Actrapid® Paediatric)

Note: If ‘Insulin (Actrapid® Adolescent)’ is selected, the patient’s weight will not be taken into account. Insulin concentration: 50 unit/50mL (should be pre-programmed)

children and adolescents: 0.1 unit/kg/hr IV infants and younger children (<3yrs): start with 0.05units/kg/hr due to their sensitivity

to insulin maintain the insulin dose at 0.1 unit/kg/hr until the ketoacidosis resolves i.e. (pH>7.3,

bicarbonate > 15mmol/L or ketones < 1.5mmol/L) as the glucose levels fall to below 18mmol/L the managing consultant should be

contacted regarding the addition of extra glucose to the infusion fluid to prevent hypoglycaemia

insulin is essential to stop ongoing ketone production and must not be ceased or decreased in rate until the ketones have largely cleared; any changes should be discussed with on call paediatric endocrinologist.

1.11 IV fluid therapyFollowing the initial fluid rehydration when plasma glucose levels will fall more rapidly (plasma glucose should fall by 2 to 5mmol/L/hr), and not earlier than 12 hours into treatment, and if corrected sodium is >140mmol/L: continue 0.9% sodium chloride with the required concentration of potassium until the

BSL is <18mmol/L where corrected sodium falls outside the normal reference range, paediatric

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at CHHS, ongoing use of glucose 5% and sodium chloride 0.9% for the first 12 hours may be ordered; this decision is based on the initial serum sodium, the level of consciousness and the serial trend in corrected sodium and the rate of glucose fall.

Note: Aim to maintain the BGL between 6-12mmol/L

if the BGL falls rapidly (> 5mmol/L/hr) glucose 5% may need to the added to the IV fluid before the BGL falls below 18mmol/L (this will be guided by the managing consultant).

when children present unwell with high glucose levels and the glucose level declines rapidly, glucose may be added earlier; it may be necessary to infuse 7.5%-10% glucose while continuing the insulin infusion to correct the metabolic acidosis

the insulin infusion may run as a side line to the rehydration and maintenance IV fluids.

1.12 Suspected InfectionUnderlying infection may cause DKA. If infection is suspected, the following investigations should be undertaken: blood cultures as per the Blood Culture Collection procedure, located on the policy

register urine for microscopy, culture and sensitivity (M,C & S) and other specimens or imaging

as clinical picture dictates.

1.13 Cerebral oedemaCerebral oedema is a life threatening complication in children with DKA: the aim is prevention onset of clinical cerebral oedema occurs suddenly, usually between 6-12 hours after the

initiation of therapy, but can occur between presentations and as late as 24 hours after treatment starts

without appropriate and rapid intervention cerebral oedema can be fatal or may result in permanent disabilities.

Warning signs:Cerebral oedema is more common in children and adolescents: on first presentation of DKA with a history of poor control aged younger than 2 years.

Increased risk factors for cerebral oedema include: on presentation:

o greater hypocapnoea (after adjustment for degree of acidosis)o increased serum urea nitrogen o more severe acidosiso lower baseline sodium

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greater fluid volume administration (especially if this is hypotonic –i.e. has ‘free’ water) administration of insulin in the 1st hour of fluid management (especially if given as IV

bolus).

Signs and symptoms of cerebral oedema: change in neurological status – restlessness, confusion irritability, increasing drowsiness,

incontinence thermal instability headache slowing heart rate, hypertension or irregular respiration are late signs.

Prevention of cerebral oedema: correct fluid and electrolyte imbalance slowly – avoid excessive fluid boluses avoid early introduction of sodium chloride 0.45% – use sodium chloride 0.9% initially as

fluid of choice monitor serum sodium levels and calculate corrected sodium levels the rate of blood glucose and osmolality decrease should not exceed 5mmol/L nurse children with the head of the bed elevated to 30 degrees older children should be asked questions regarding the presence of a headache, as this

can be an early sign.

Treatment of cerebral oedema: urgently engage extra support - MET call/ ICU and paediatric endocrine consultation commence treatment immediately; do not wait for a CT scan for confirmation give IV mannitol 20% (0.5-1g/kg) over 20 minutes; if there is no response, consider

repeating the dose. cease or reduce IV fluid rate to one third of initial rate elevate the head of the bed to 30 degrees following initial treatment initiate a MRI or CT scan to confirm diagnosis and exclude

other causes.

1.14 Weaning insulin infusion: offer oral fluids once condition allows titrate IV fluid rate as oral fluid intake increases cease insulin infusion when serum glucose is < 10mmol/L & ketones < 1mmol/L

Prior to ceasing insulin infusion: administer subcutaneous (subcut) insulin dose prior to ceasing the insulin infusion to

prevent rebound hyperglycaemia: o align the subcut insulin administration with main mealtimes depending on the type

used e.g. rapid acting insulin give 5-30 minutes prior to ceasing the insulin infusion, regular acting insulin give 1 - 2 hours prior to ceasing the infusion

o for intermediate or long acting insulin, the overlap should be longer and the IV insulin rate is gradually decreased

o the dose of subcut insulin administered is usually around 0.25 units/kg but will be determined by the paediatric endocrinologist on-call (telephone 0466 655068)


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o to avoid marked hyperglycaemia or hypoglycaemia, frequent blood monitoring of glucose levels is required.

1.15 Family Support and Discharge Planning:Notify the multidisciplinary diabetes team members as earlier as possible-including: diabetes educator social worker diabetes dietician.


Section 2 – Hyperglycaemia – Management in Children and Adolescents during Insulin Pump Therapy

2.1 For BGL above 15mmol/L1. Check blood for ketones.2. Check for problems with the infusion site, cannula, tubing, insulin or pump and correct.3. Check that the patient gave their last meal bolus.4. If no problems are detected, ketones < 0.6mmol/L and it is not within 2 hours of the last

bolus the patient needs a correction bolus. The parent or carer can administer the correction dose as calculated by the insulin pump. The registered nurse will record dose administered on insulin pump documentation chart.

5. Recheck the patient’s BGL in 1 hour after the bolus. If the BGL is unchanged or higher, recheck blood ketones and contact the Consultant and follow the guidelines for ‘ketones >0.6mmol/L’.

Blood Ketone reading (mmol/L)Less than 0.6 Negative or trace only

(insulin sensitivity unlikely to be affected)0.5 – 1.5 Small to moderate ketonesAbove 1.5 Moderate to large ketones

If the patient has ketones >0.6mmol/L at any stage contact the consultant for a dose of rapid acting insulin (this is usually 10-25% of total daily dose).1. Remove the insulin pump and pump cannula (unless another obvious cause is identified

and can be corrected).2. Administer subcutaneous insulin as prescribed via subcutaneous injection route.3. Recheck BGL every hour.4. Patient/carer to change cannula site and resume insulin pump use. Insulin needs will be

higher than usual until ketones are clear and glucose below 10.0mmol/L If BGL remains high and/or there are ketones contact the consultant.



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Section 3 – Management of Children with Diabetes during Surgery and Fasting

3.1 Elective Minor Surgery Before booking the procedure: review diabetes control; if diabetes control is poor (HbA1C > 9.5%), review diabetes

management and compliance; defer elective procedure until control improved plan a morning procedure whenever possible.

Group APatients on twice daily or multiple daily insulin injectionsFor very short procedures (under 30 minutes) where rapid recovery is expected.

Early morning procedure: schedule procedure for 8am.

The night before: patient can eat usual dinner give insulin dose as per the paediatric endocrinologist.

The morning of: delay normal insulin injection and breakfast until after the procedure (provided that

food is tolerated by 10am) monitor BGL hourly via finger prick if there is any delay in the procedure or in establishing oral intake following the

procedure, notify the paediatric endocrinologist on-call (telephone 0466 655068) ); it may be necessary to commence IV maintenance fluids with glucose as in Section 1, and insulin as per guidance by the endocrinologist

resume usual diet and insulin regime as soon as possible after completion of procedure

Afternoon procedure Give insulin with breakfast as below: if on twice daily insulin: give 50% of usual insulin dose if on basal bolus: give usual dose of breakfast insulin with an early breakfast provided no

recent history of hypoglycaemia give basal insulin dose at usual dose and time.


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Group BPatients continuing with their insulin pump therapy An insulin pump is operated by the patient or carer, and worn 24 hours a day but may

be disconnected for short periods of no more than 1 – 2 hours (providing blood glucose levels are stable; between 4 – 8mmol/L) e.g. showering, exercise, swimming or short clinical procedures.

Insulin pumps must not be directly exposed to X-ray beams or strong magnetic fields such as MRI. The pump must be temporarily disconnected and kept outside the room for all radiological procedures or use of image intensifier in theatre. Ultrasound transducers should not be pointed directly at the insulin pump or site. If pump or site is directly in range of transducer, the pump should be temporarily disconnected.

Intra-operative use of insulin pump therapy may be considered after discussion between paediatric endocrinologist and anaesthetist, specifically consideration regarding placement of cannula site or glucose sensor (if used) to ensure out of operative field and away from potential diathermy pad placement. Intra-operative management of glucose and insulin is the responsibility of the anaesthetist.

The day before the elective surgical procedure: The patient should change the subcutaneous infusion site. This should be done in time

to have at least 2 subsequent BGL checks on that day that indicate the line is working well. The site should also be well away from any potential operative field as well as away from diathermy pad.

The night before the elective surgical procedure: Patient can eat and drink normally and give insulin according to their individual pump

settings until midnight the night before. Continue insulin administration using the usual basal infusion rates overnight (unless

there is a history of recent nocturnal or fasting hypoglycaemia).

The morning of the elective surgical procedure: Whilst fasting glucose target should be 6-12mmol/L, consider reducing basal rate if

glucose levels are trending downwards.

Early morning procedure (e.g. 8am-9am): At approximately 0600 check BGL. If between 5-12mmol/L, temporarily reduce basal rate

to 70% in consultation with the paediatric endocrinologist on call.

Afternoon procedure: At approximately 6:30am on the morning of the procedure, the patient may have a light

breakfast. A BGL reading should be entered into the insulin pump and pre-meal insulin given based

on the usual insulin pumps settings. Monitor BGL hourly by finger prick:

o if BGL < 6mmol/L or > 10mmol/L, inform registrar and discuss with paediatric endocrinologist after first treating hypoglycaemia


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The subcutaneous infusion site should be secured tightly prior to going to theatre to prevent dislodgement and interruption to insulin delivery intra-operatively.

After the elective surgical procedure: Once the patient is able to eat or drink or if the glucose levels are rising progressively,

the temporary basal rate can be discontinued or adjusted in discussion with the paediatric endocrinologist and the patient should recommence pre-meal or pre-snack insulin administration using their usual insulin pump settings.

3.2 Stabilisation prior to surgery If control is poor or diabetes is unstable, a period of stabilisation may be needed prior to surgery, and should be discussed with the managing specialist. Prevention of hypoglycaemia and correction of ketosis are the aims of stabilisation. Involve the paediatric endocrinologist on-call (telephone 0466 655 068) early for

appropriate planning If surgery is urgent and cannot be delayed, then discussion should occur early between

specialists. The patient should be admitted the day before and ideally surgery should take place on

a morning list. An IV cannula should be inserted on the day of admission. The patient can eat normally and have their usual subcutaneous insulin the evening

prior or continue their pump at normal rates before the procedure unless there has been recent nocturnal or fasting hypoglycaemia.

If there has been recent nocturnal or fasting hypoglycaemia, discussion must occur with diabetes team to adjust insulin. Involve the paediatric endocrinologist on-call (telephone 0466 655 068)

BGL should be checked routinely before bed and at 3am and 6am At all times, management of hypoglycaemia takes precedence over fasting. If hypoglycaemia (BGL < 4mmol/L) occurs while fasting, give a 2mL/kg bolus of glucose

10% and start maintenance IV fluids sodium chloride 0.45% and glucose 5% If on an insulin pump, a temporary basal rate may be set. Prepare insulin infusion (if required) as per directions below. Commence IV insulin

infusion and maintenance IV fluids at least 2 hours prior to procedure.

Preparation of insulin infusion: Two lines are to be maintained for the duration of the infusion: mainline (insulin); and a sideline (glucose and sodium chloride – ideally sodium chloride 0.9%, and no LESS than

sodium chloride 0.45%.

To be given via the same cannula (or central catheter). This is to avoid any interruption to glucose while insulin is still running.


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Mainline (insulin): the IV insulin infusion must be prescribed short acting insulin such as Actrapid® or Humulin® R should be prescribed draw up 50 units of insulin in an insulin syringe and add to 49.5mL sodium chloride 0.9%

to make up a 50mL solution of 1unit/mL insulin infusion must be clearly labelled (National ACSQHC Labelling Recommendation

for User-applied Labelling of Injectable Medicines, Fluids Lines). the Drug Library on the smart infusion pump with medication safety software must be

used for the insulin infusion program the smart infusion pump with medication safety software as follows:

o Drug Library: Yeso Ward: Paediatric Generalo Drug Category: Othero Drug: Insulin (Actrapid Paediatric)

Note: If ‘Insulin (Actrapid Adolescent)’ is selected, the patient’s weight will not be taken into account.

o Concentration: 50unit/50mL (should be pre-programmed)o Weight: Patient’s accurate weight is essential.o Dose: 0.02units/kg/hr (BGL < 10 mmol/L)

0.03units/kg/hr (BGL > 10 mmol/L)Note:This dose is significantly less than that used to treat DKA. If other dose is required, consult with the paediatric endocrinologist.

Alter the Dose setting (units/kg/hr) when adjusting insulin infusion.

Sideline (glucose): the IV fluid infusion must be prescribed, preferably by the Anaesthetist in consultation

with the paediatric endocrinologist the IV fluid infusion must be administered through a smart infusion pump with

medication safety software using the drug library a fluid balance chart must be maintained if the patient’s diabetes is usually managed with an insulin pump, insulin via the insulin

pump should be discontinued when IV insulin is commenced BGLs should be monitored hourly while on an insulin infusion; a separate IV cannula for

blood sampling may be necessary aim to keep BGLs between 5 and 10mmol/L adjust insulin infusion according to the following table, in consultation with the

paediatric registrar/endocrinology team.


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3.3 Ongoing management Adjust insulin infusion according to the following table, in consultation with the paediatric registrar/endocrinology team.

If BGL is Do this with Insulin Infusion Additional Action> 15mmol/L Increase by 0.005-0.01unit/kg/hr

(with rate change determined by rate of rise and whether ketones are present)

Check blood ketones. Discuss ketones >1 with endocrinology team.

> 10mmol/L for 2 consecutive hours

Increase by 0.005-0.01unit/kg/hr(with rate change determined by rate of rise and presence of ketones)

5.1 – 10mmol/L Leave unchanged4 - 5mmol/L Decrease by 0.005-0.01unit/kg/hr. If the insulin rate is already at

0.02unit/kg/hr, increase the glucose concentration of maintenance fluids in consultation with endocrinology team.

< 4mmol/L Cease insulin infusion.Check BGL in 30 minutes.

Discuss with endocrinology team

3.4 Emergency SurgeryThe paediatric endocrinologist call should be contacted (telephone 0466 655 068) about all paediatric patients with diabetes who require emergency surgery, when the decision is made to admit them, regardless of the time of day. If possible, emergency surgery should be delayed in any patient with ketoacidosis and treatment should commence according to the Section 1 of this document - Paediatrics - Diabetic Ketoacidosis in Infants, Children and Adolescents (Not Neonates).


Implementation

The publication of this guideline will be communicated to all staff who may be involved in caring for paediatric patients with Type 1 Diabetes who are fasting for a procedure, and the content of the Guideline will be incorporated into the existing training program for Paediatric nursing and medical staff.


Related Policies, Procedures, Guidelines and Legislation

Procedures Blood Culture Collection Clinical Procedure Blood Glucose and Ketone Point of Care Testing Clinical Procedure


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Guidelines National ACSQHC Labelling Recommendation for User-applied Labelling of Injectable

Medicines, Fluids and Lines

Legislation Carers Recognition Act 2010 ACT Human Rights Act 2004


References

1. Ambler, G. & Cameron, F. (2010) Caring for Diabetes in Children and Adolescents - a parent’s manual, 3rd Edition, Children’s Diabetes Service of NSW, Australia.

2. Australian Paediatric Endocrine Group, and The Australian Diabetes Society (2011) National Evidence-Based Clinical Care Guidelines for Type 1 Diabetes in Children, Adolescents and Adults.

3. ISPAD Global IDF/ISPAD Guideline for Diabetes in Childhood and Adolescence 2011. International Diabetes Federation. Belgium. Also downloadable: http://www.idf.org/sites/default/files/Diabetes-in-Childhood-and-Adolescence-Guidelines.pdf

4. Gardner, D.G. & Shoback, D: Access Medicine from The McGraw-Hill companies, 2012, Greenspan’s Basic & Clinical Endocrinology 9e, (9th Ed) Chapter 24. Endocrine Emergencies.

5. Holt, R & Hanley, N: (2012) Essential Endocrinology and Diabetes, 6th Edition. Wiley-Blackwell

6. Katz, M.A. N Engl J Med, 1973; 289:843-844 Hyperglycemia-Induced Hyponatremia – Calculation of Expected Sodium Depression ; also available from http://www.nejm.org/doi/full/10.1056/NEJM197310182891607

7. Powers, A.C. Access Medicine from The McGraw-Hill companies, 2012. Harrison’s On-line Part 16 Endocrine and Metabolism, Section 3, Chapters 417-419. Available from http://accessmedicine.mhmedical.com/book.aspx?bookID=1130

8. Rewers, M, Chase, P.H & Eisenbarth, G.S. Access Medicine from The McGraw-Hill companies, 2012. Current Diagnosis & Treatment, Pediatrics, Chapter 35. Diabetes Mellitus. Also available from: http://accessmedicine.mhmedical.com/content.aspx?bookid=497&sectionid=40851702

9. Royal Children's Hospital, Melbourne, Australia, Clinical Practice Guideline on Diabetes Mellitus, [Internet; cited 16th December, 2016, Available from: http://www.rch.org.au/clinicalguide/guideline_index/Diabetes_mellitus/

10. Royal Children's Hospital, Melbourne, Australia, Clinical Practice Guideline on Diabetes Mellitus and Surgery, [Internet; cited 16th December, 2016, Available from: http://www.rch.org.au/clinicalguide/guideline_index/Diabetes_Mellitus_and_Surgery/

11. Royal Children's Hospital, Melbourne, Australia, Clinical Practice Guideline on Diabetes Mellitus and Endoscopy, [Internet, Last updated May 2011; cited 16th December, 2016, Available from:


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http://www.rch.org.au/clinicalguide/guideline_index/Diabetes_Mellitus_and_Surgery/

http://www.rch.org.au/clinicalguide/guideline_index/Diabetes_mellitus/

http://accessmedicine.mhmedical.com/content.aspx?bookid=497&sectionid=40851702

http://accessmedicine.mhmedical.com/content.aspx?bookid=497&sectionid=40851702

http://accessmedicine.mhmedical.com/book.aspx?bookID=1130

http://www.idf.org/sites/default/files/Diabetes-in-Childhood-and-Adolescence-Guidelines.pdf

http://www.idf.org/sites/default/files/Diabetes-in-Childhood-and-Adolescence-Guidelines.pdf

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http://www.rch.org.au/clinicalguide/guideline_index/Diabetes_mellitus_and_endoscopy/Sydney Children’s Hospital Network, Sydney, Australia, Practice Guideline on Diabetic Ketoacidosis, [Internet, last updated 1st October 2015; cited 16th December 2016, Available from: http://www.schn.health.nsw.gov.au/_policies/pdf/2015-9075.pdf


Definition of Terms

HbA1C: Is a blood test that is regarded as the gold standard for assessing the long term overall control of blood glucose. A normal non-diabetic HbA1C is 3.5-5.5%. In diabetes about 6.5% is considered acceptable.

Neonate: Any baby from birth to 28 days.


Search Terms

Diabetes, DKA, Diabetic Ketoacidosis, Paediatrics, Ketoacidosis, Children, Endocrinologist


Attachments

Attachment 1 - Initial Assessment and Management of DKAAttachment 2 - Ongoing assessment and management of DKAAttachment 3 - DKA pathology results flow chart

Disclaimer: This document has been developed by Health Directorate, Canberra Hospital and Health Services specifically for its own use. Use of this document and any reliance on the information contained therein by any third party is at his or her own risk and Health Directorate assumes no responsibility whatsoever.

(to be completed by the HCID Policy Team)Date Amended Section Amended Approved ByEg: 17 August 2014 Section 1 ED/CHHSPC Chair


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http://www.schn.health.nsw.gov.au/_policies/pdf/2015-9075.pdf

http://www.rch.org.au/clinicalguide/guideline_index/Diabetes_mellitus_and_endoscopy/

http://www.rch.org.au/clinicalguide/guideline_index/Diabetes_mellitus_and_endoscopy/

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Attachment 4 - Initial Assessment and Management of DKA


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Attachment 5 - Ongoing assessment and management of DKA


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Attachment 6 - Diabetic Ketoacidosis Pathology Results Flow Chart – Child and Adolescent Clinical form


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Paediatric and Adolescent Diabetes – Management (not ...health.act.gov.au/sites/default/files/new_policy_and_plan... · Web viewThis guideline aims to guide the: management of moderate