Sick Day Management Diabetes (Non DKA) Pathway

7/24/2019 Sick Day Management Diabetes (Non DKA) Pathway

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Inclusion CriteriaType 1 Diabetes (or at Endocrine

attending discretion for CF-related or

steroid-induced hyperglycemia)

AND

Moderate to large urine ketones ORBlood BOHB 0.6mmol/L

Exclusion CriteriaDiabetic ketoacidosis (DKA) (use instead

DKA Pathway)

Intravenous insulin

Insulin Sick Day Management for Diabetes (Non-DKA) v. 2.0

Treatment

Continue basal and rapid-acting insulin. Rapid-acting can be given for glucose

correction every 2-3 hours.

Maintain good hydrationGive fluids, may require alternating carbohydrate-free and carb-containing fluids

Consider IV fluids if patient is unable to tolerate PO

Do not use glucagon for hypoglycemia while ketones present

BOHB 0.6 mmol/L OR moderate to large urine ketones

Call Provider to evaluate for Diabetic Ketoacidosis (DKA)

Has provider ordered Sick Day Management?NO

YES

Insulin dose = insulin to

cover carbs + 1.5x(insulin to

correct glucose)

Sick Day Management


cover carbs + 2x(insulin to

correct glucose)

Provider consider insulin

dose adjustment

BOHB >1.5 mmol/L* ORLARGE urine ketones

within previous 1 hour

BOHB 0.6-1.5 mmol/L* OR

MODERATE urine ketones

within previous 1 hour

Monitoring

Ensure unused IV available for blood draws

Check serum BG and serum BOHB every 3 hours

If BOHB results unavailable after 30 minutes, check urine ketones

If serum glucose unavailable after 30 minutes or if concern for hypoglycemia,

check fingerstick BG

Watch for signs of DKA (vomiting, persistent ketones not decreasing); evaluate for

DKA (pH, electrolytes, BOHB) if signs are present

Call inpatient provider to discontinue Sick Day Management

(ED Sick Day calculator will discontinue after each one-time insulin dose is used)

2013 Seattle Childrens Hospital, all rights reserved, Medical Disclaimer

For questions concerning this pathway,

contact: [email protected]


cover carbs + insulin to

correct glucose

BOHB 250 mg/dL x 2

(or >500 mg/dL x 1) AND

BOHB 0.6 mmol/L (or

moderate to large urine

ketones)

!

Watch for signs of

DKA, evaluate if present
http://child.childrens.sea.kids/Policies_and_Standards/Clinical_Standard_Work_Pathways_and_Tools/Diabetes_DKA.aspxhttp://child.childrens.sea.kids/Policies_and_Standards/Clinical_Standard_Work_Pathways_and_Tools/Diabetes_DKA.aspxhttp://child.childrens.sea.kids/Policies_and_Standards/Clinical_Standard_Work_Pathways_and_Tools/Diabetes_DKA.aspxhttp://child.childrens.sea.kids/Policies_and_Standards/Clinical_Standard_Work_Pathways_and_Tools/Diabetes_DKA.aspxhttp://child.childrens.sea.kids/Policies_and_Standards/Clinical_Standard_Work_Pathways_and_Tools/Diabetes_DKA.aspxhttp://child.childrens.sea.kids/Policies_and_Standards/Clinical_Standard_Work_Pathways_and_Tools/Diabetes_DKA.aspxhttp://child.childrens.sea.kids/Policies_and_Standards/Clinical_Standard_Work_Pathways_and_Tools/Diabetes_DKA.aspxhttp://child.childrens.sea.kids/Policies_and_Standards/Clinical_Standard_Work_Pathways_and_Tools/Diabetes_DKA.aspxhttp://child.childrens.sea.kids/Policies_and_Standards/Clinical_Standard_Work_Pathways_and_Tools/Diabetes_DKA.aspxhttp://child.childrens.sea.kids/Policies_and_Standards/Clinical_Standard_Work_Pathways_and_Tools/Diabetes_DKA.aspxhttp://child.childrens.sea.kids/Policies_and_Standards/Clinical_Standard_Work_Pathways_and_Tools/Diabetes_DKA.aspxhttp://child.childrens.sea.kids/Policies_and_Standards/Clinical_Standard_Work_Pathways_and_Tools/Diabetes_DKA.aspxhttp://child.childrens.sea.kids/Policies_and_Standards/Clinical_Standard_Work_Pathways_and_Tools/Diabetes_DKA.aspxhttp://child.childrens.sea.kids/Policies_and_Standards/Clinical_Standard_Work_Pathways_and_Tools/Diabetes_DKA.aspxhttp://child.childrens.sea.kids/Policies_and_Standards/Clinical_Standard_Work_Pathways_and_Tools/Diabetes_DKA.aspxhttp://child.childrens.sea.kids/Policies_and_Standards/Clinical_Standard_Work_Pathways_and_Tools/Diabetes_DKA.aspxhttp://child.childrens.sea.kids/Policies_and_Standards/Clinical_Standard_Work_Pathways_and_Tools/Diabetes_DKA.aspxhttp://child.childrens.sea.kids/Policies_and_Standards/Clinical_Standard_Work_Pathways_and_Tools/Diabetes_DKA.aspxhttp://www.seattlechildrens.org/terms-of-use#medicalhttp://www.seattlechildrens.org/terms-of-use#medicalhttp://www.seattlechildrens.org/terms-of-use#medicalhttp://www.seattlechildrens.org/terms-of-use#medicalhttp://www.seattlechildrens.org/terms-of-use#medicalhttp://www.seattlechildrens.org/terms-of-use#medicalhttp://child.childrens.sea.kids/Policies_and_Standards/Clinical_Standard_Work_Pathways_and_Tools/Diabetes_DKA.aspxhttp://child.childrens.sea.kids/Policies_and_Standards/Clinical_Standard_Work_Pathways_and_Tools/Diabetes_DKA.aspx


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Self-AssessmentDiabetes Non DKA: Sick Day Management

Completion qualifies you for 1 hour of Category II CME credit. If you are taking this self-assessment as a

part of required departmental training at Seattle Childrens Hospital, you MUST logon to Learning Center.
http://learningcenter/TPOnline/TPOnline.dll/Homehttp://learningcenter/TPOnline/TPOnline.dll/Homehttp://learningcenter/TPOnline/TPOnline.dll/Homehttp://learningcenter/TPOnline/TPOnline.dll/Homehttp://learningcenter/TPOnline/TPOnline.dll/Homehttp://learningcenter/TPOnline/TPOnline.dll/Home


7/18

Self-AssessmentDiabetes Non DKA: Sick Day Management

Completion qualifies you for 1 hour of Category II CME credit. If you are taking this self-assessment as a

part of required departmental training at Seattle Childrens Hospital, you MUST logon to Learning Center.
http://learningcenter/TPOnline/TPOnline.dll/Homehttp://learningcenter/TPOnline/TPOnline.dll/Homehttp://learningcenter/TPOnline/TPOnline.dll/Homehttp://learningcenter/TPOnline/TPOnline.dll/Homehttp://learningcenter/TPOnline/TPOnline.dll/Homehttp://learningcenter/TPOnline/TPOnline.dll/Home


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Answer KeyDiabetes Non DKA: Sick Day Management


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Executive Summary

Executive Summary Pg 2


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Executive Summary

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Evidence Ratings

We used the GRADE method of rating evidence quality. Evidence is first assessed as to

whether it is from randomized trial, or observational studies. The rating is then adjusted inthe following manner:

Quality ratings are downgradedif studies: Have serious limitations

Have inconsistent results If evidence does not directly address clinical questions If estimates are imprecise OR

If it is felt that there is substantial publication bias

Quality ratings can be upgradedif it is felt that: The effect size is large If studies are designed in a way that confounding would likely underreport the magnitude

of the effect OR If a dose-response gradient is evident

Quality of Evidence: High qualityModerate quality

Low quality Very low quality

Expert Opinion (E)

Reference: Guyatt G et al. J Cl in Epi 2011: 383-394

To Bibliography


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Summary of Version Changes

Version 1 (5/21/2013):Go live

Version 1.1 (8/20/2013):Sick Day Management added

Version 1.2 (8/22/2013): ED wording changes, clarified sick day lab orders

Version 2.0 (2/10/2014):Added a yellow alert triangle to sick day management page for a

reminder to initiate


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Medical Disclaimer

Medicine is an ever-changing science. As new research and clinical experience

broaden our knowledge, changes in treatment and drug therapy are required.

The authors have checked with sources believed to be reliable in their efforts to

provide information that is complete and generally in accord with the standards

accepted at the time of publication.

However, in view of the possibility of human error or changes in medical sciences,

neither the authors nor Seattle Childrens Healthcare System nor any other party

who has been involved in the preparation or publication of this work warrants that

the information contained herein is in every respect accurate or complete, and

they are not responsible for any errors or omissions or for the results obtained

from the use of such information.

Readers should confirm the information contained herein with other sources and

are encouraged to consult with their health care provider before making any

health care decision.


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Bibliography

255 records identified through

database searching

11 additional records identified

through other sources

265 records after duplicates removed

265 records screened 160 records excluded

105 full-text articles assessed for eligibility

65 full-text articles excluded,

20 did not answer clinical question

29 were older studies

16 did not meet quality threshold

40 studies included in pathway

Identification

Screening

Elgibility

Included

Flow diagram adapted from Moher D et al. BMJ 2009;339:bmj.b2535

Literature Search

Studies were identified by searching electronic databases using search strategies developed and executed

by a medical librarian, Susan Klawansky. Searches were performed in December 2012 in the following

databaseson the Ovid platform: Medline and Cochrane Database of Systematic Reviews; elsewhere:

Embase, Clinical Evidence, National Guideline Clearinghouse and TRIP. Retrieval was limited to 2007

(date of then-current ISPAD guideline) to date, humans, and English language. In Medline and Embase,

appropriate Medical Subject Headings (MeSH) and Emtree headings were used respectively, along with

text words, and the search strategy was adapted for other databases as appropriate. Concepts searched

were type 1 diabetes mellitus and ketones, ketone bodies, keto acids, hyperglycemia, hospitalization,

inpatients. All retrieval was further limited to certain publication types representing high order evidence.

Additional articles have been identified by project team members and added to the retrieval.

Susan Klawansky, MLS, AHIP

May 16, 2013

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Bibliography

Return to Home To Bibliography, Pg 3

This pathway was developed primarily based on:

ADA. I. Classification and Diagnosis. Diabetes Care 2013;36(suppl 1).

IDF/ISPAD 2011 Global Guideline for Diabetes in Childhood and Adolescence, available at http://www.ispad.org/

resources/idfispad-2011-global-guideline-diabetes-childhood-and-adolescence, last accessed 5/10/2013.

ISPAD Clinical Practice Consensus Guidelines Compendium 2009 (Pediatr Diabetes 2009; 10 (Suppl 12): 1-210).

This supporting literature was also cited:

American Diabetes A, Clarke W, Deeb LC, Jameson P, Kaufman F, Klingensmith G, et al. Diabetes care in the

school and day care setting. Diabetes Care [Insulin Dosing]. 2013 Jan;36(Suppl 1):S75-9.

American Diabetes A, Lorber D, Anderson J, Arent S, Cox DJ, Frier BM, et al. Diabetes and driving. Diabetes Care

[Insulin Dosing]. 2013 Jan;36(Suppl 1):S80-5.

American Diabetes A. Diagnosis and classification of diabetes mellitus. Diabetes Care [Insulin Dosing]. 2013

Jan;36(Suppl 1):S67-74.

American Diabetes A. Standards of medical care in diabetes--2013. Diabetes Care [Insulin Dosing]. 2013

Jan;36(Suppl 1):S11-66.

Aschner P, Horton E, Leiter LA, Munro N, Skyler JS, Global Partnership for Effective Diabetes,Management.

Practical steps to improving the management of type 1 diabetes: Recommendations from the global partnership

for effective diabetes management. Int J Clin Pract [Insulin Dosing]. 2010 Feb;64(3):305-15.

Brink S, Laffel L, Likitmaskul S, Liu L, Maguire AM, Olsen B, et al. Sick day management in children and

adolescents with diabetes. Pediatr Diabetes [Insulin Dosing]. 2009 Sep;10(Suppl 12):146-53.

Clarke W, Jones T, Rewers A, Dunger D, Klingensmith GJ. Assessment and management of hypoglycemia in

children and adolescents with diabetes. Pediatric Diabetes [Insulin Dosing]. 2009;10:134-45.

Davidson PC, Hebblewhite HR, Steed RD, Bode BW. Analysis of guidelines for basal-bolus insulin dosing: Basal

insulin, correction factor, and carbohydrate-to-insulin ratio. Endocr Pract [Insulin Dosing]. 2008 Dec;14(9):1095-

101.

Edge J, Ackland FM, Payne S, McAuley A, Hind E, Burren C, et al. Inpatient care for children with diabetes: Are

standards being met?. Arch Dis Child [Insulin Dosing]. 2012 Jul;97(7):599-603.

To Bibliography, Pg 1


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Bibliography

Return to Home

This supporting literature was also cited:

Elisaf MS, Rizos EC. Editorial: Current topics on the epidemiology, pathogenesis, and treatment of diabetes mellitus

and its complications. Curr Vasc Pharmacol [Insulin Dosing]. 2012 Mar;10(2):138-9.

Executive summary: Standards of medical care in diabetes--2013. Diabetes Care [Insulin Dosing]. 2013

Jan;36(Suppl 1):S4-10.

Exubera: Inhaled insulin for diabetes. Drug Ther Bull [Insulin Dosing]. 2007 Jan;45(1):5-8.

Fendler W, Hogendorf A, Szadkowska A, Mlynarski W. Non-coding glucometers among pediatric patients with

diabetes: Looking for the target population and an accuracy evaluation of no-coding personal glucometer. Pediatr

Endocrinol Diabetes Metab [Insulin Dosing]. 2011;17(2):57-63.

Gosden C, Edge JA, Holt RI, James J, Turner B, Winocour P, et al. The fifth UK paediatric diabetes services survey:

Meeting guidelines and recommendations?. Arch Dis Child [Insulin Dosing]. 2010 Oct;95(10):837-40.

Grajower MM. Management of diabetes mellitus on yom kippur and other jewish fast days. Endocr Pract [Insulin

Dosing]. 2008 Apr;14(3):305-11.

Haas L, Maryniuk M, Beck J, Cox CE, Duker P, Edwards L, et al. National standards for diabetes self-management

education and support. Diabetes Care [Insulin Dosing]. 2013 Jan;36(Suppl 1):S100-8.

Hanberger L, Samuelsson U, Bertero C, Ludvigsson J. The influence of structure, process, and policy on HbA(1c)

levels in treatment of children and adolescents with type 1 diabetes. Diabetes Res Clin Pract [Insulin Dosing]. 2012

Jun;96(3):331-8.

Jonsson L, Hallstrom I, Lundqvist A. A multi-disciplinary education process related to the discharging of children

from hospital when the child has been diagnosed with type 1 diabetes--a qualitative study. BMC Pediatr [Insulin

Dosing]. 2010;10:36.

King AB. Continuous glucose monitoring-guided insulin dosing in pump-treated patients with type 1 diabetes: A

clinical guide. J Diabetes Sci Technol [Insulin Dosing]. 2012 Jan;6(1):191-203.

King AB. Re: Analysis of guidelines for basal-bolus insulin dosing: Basal insulin, correction factor, and carbohydrate-

to-insulin ratio. Endocr Pract [Insulin Dosing]. 2009 May-Jun;15(4):383.

Lassmann-Vague V. Clavel S. Guerci B. Hanaire H. Leroy R. Loeuille GA. Mantovani I. Pinget M. Renard E. Tubiana-

Rufi N. Societe francophone du diabete (ex ALFEDIAM). When to treat a diabetic patient using an external insulin

pump. expert consensus. societe francophone du diabete (ex ALFEDIAM) 2009. Diabetes Metab [Insulin Dosing].

2010 Feb;36(1):79-85.

Leelarathna L, Guzder R, Muralidhara K, Evans ML. Diabetes: Glycaemic control in type 1. Clin Evid (Online) [Insulin

Dosing]. 2011 May 9;2011:0607.

Lexi-comp pediatric and neonatal lexidrugs: Glucagon [Internet]. Available from: http://www.crlonline.com/lco/action/doc/retrieve/docid/pdh_f/130114.

Lopes Souto D, Paes de Miranda M. Physical excercises on glycemic control in type 1 diabetes mellitus. Nutr Hosp

[Insulin Dosing]. 2011 May-Jun;26(3):425-9.

Management of hyperglycemia in hospitalized patients in non-critical care setting: An endocrine society clinical

practice guideline [Internet]. Rockville MD: Agency for Healthcare Research and Quality (AHRQ); cited 12/4/2012

2:06:33 PM]. Available from: http://guideline.gov/

content.aspx?id=35255&search=diabetes+and+%22type+1%22+and+hyperglycemia;.

To Bibliography, Pg 4To Bibliography, Pg 2


18/18

Bibliography

Margeirsdottir HD, Larsen JR, Kummernes SJ, Brunborg C, Dahl-Jorgensen K. The establishment of a new national

network leads to quality improvement in childhood diabetes: Implementation of the ISPAD guidelines. Pediatr

Diabetes [Insulin Dosing]. 2010 Mar;11(2):88-95.

Matthews JB, Staeva TP, Bernstein PL, Peakman M, von Herrath M, ITN-JDRF Type 1 Diabetes Combination

Therapy Assessment,Group. Developing combination immunotherapies for type 1 diabetes: Recommendationsfrom the ITN-JDRF type 1 diabetes combination therapy assessment group. Clin Exp Immunol [Insulin Dosing].

2010 May;160(2):176-84.

McIver FB, Mitchell CA, Finn CP, Kamp MC. Standardising practices through form design and education improves

insulin management. Aust Health Rev [Insulin Dosing]. 2009 Aug;33(3):434-41.

Mooradian AD, Bernbaum M, Albert SG. Narrative review: A rational approach to starting insulin therapy. Ann

Intern Med [Insulin Dosing]. 2006 Jul 18;145(2):125-34.

National evidence-based clinical care guidelines for type 1 diabetes for children, adolescents and adults [Internet].;

2011 [updated /1; cited 12/10/2012 4:18:24 PM]. Available from: http://www.nhmrc.gov.au/_files_nhmrc/

publications/attachments/ext004_type1_diabetes_children_adolescents_adults.pdf.

Pratoomsoot C, Smith HT, Kalsekar A, Boye KS, Arellano J, Valentine WJ. An estimation of the long-term clinical and

economic benefits of insulin lispro in type 1 diabetes in the UK. Diabet Med [Insulin Dosing]. 2009 Aug;26(8):803-

14.

Reiter J, Wexler ID, Shehadeh N, Tzur A, Zangen D. Type 1 diabetes and prolonged fasting. Diabet Med [Insulin

Dosing]. 2007 Apr;24(4):436-9.

Russell-Minda E, Jutai J, Speechley M, Bradley K, Chudyk A, Petrella R. Health technologies for monitoring and

managing diabetes: A systematic review. J Diabetes Sci Technol [Insulin Dosing]. 2009 Nov;3(6):1460-71.

Sacks DB, Arnold M, Bakris GL, Bruns DE, Horvath AR, Kirkman MS, et al. Guidelines and recommendations for

laboratory analysis in the diagnosis and management of diabetes mellitus. Clin Chem [Insulin Dosing]. 2011

Jun;57(6):e1-e47.

Scheiner G, Sobel RJ, Smith DE, Pick AJ, Kruger D, King J, et al. Insulin pump therapy: Guidelines for successful

outcomes. Diabetes Educ [Insulin Dosing]. 2009 quiz 28S, 42S-43S; Mar-Apr;35(Suppl 2):29S-41S.

Shogbon AO, Levy SB. Intensive glucose control in the management of diabetes mellitus and inpatient

hyperglycemia. Am J Health-Syst Pharm [Insulin Dosing]. 2010 May 15;67(10):798-805.

Standards of medical care in diabetes. V. diabetes care [Internet]. Rockville MD: Agency for Healthcare Research

and Quality (AHRQ); cited 12/4/2012 1:41:24 PM]. Available from: http://guideline.gov/

content.aspx?id=35248&search=diabetes+and+%22type+1%22+and+ketosis;.

Summary of revisions for the 2013 clinical practice recommendations. Diabetes Care [Insulin Dosing]. 2013

Jan;36(Suppl 1):S3.

Tonella P, Fluck CE, Mullis PE. Metabolic control of type 1 diabetic patients followed at the university children's

hospital in berne: Have we reached the goal?. Swiss Med Wkly [Insulin Dosing]. 2010;140:w13057.

Vigeral C, Sola-Gazagnes A, Nejjar S, M'Bemba J, Boitard C, Slama G, et al. Ambulatory 24-hour fast using flexible

insulin therapy in patients with type 1 diabetes. Diabetes Metab [Insulin Dosing]. 2011 Dec;37(6):553-9.

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Sick Day Management Diabetes (Non DKA) Pathway