Insulin Sick Day Management for Diabetes (Non-DKA) v. 2.

Inclusion Criteria
Type 1 Diabetes (or at Endocrine
attending discretion for CF-related or
steroid-induced hyperglycemia)
AND
Moderate to large urine ketones OR
Blood BOHB 0.6 mmol/L

!
Reminder
to initiate,
BG > 250 mg/dL x 2
(or >500 mg/dL x 1) AND
BOHB 0.6 mmol/L (or
moderate to large urine
ketones)

Exclusion Criteria

Watch for signs of

DKA, evaluate if present

Diabetic ketoacidosis (DKA) (use instead

DKA Pathway)
Intravenous insulin

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

Provider consider insulin

dose adjustment

YES

Discharge Criteria

Sick Day Management

Treatment
Continue basal and rapid-acting insulin. Rapid-acting can be given for glucose
correction every 2-3 hours.
Maintain good hydration
Give 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
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
BOHB <0.6 mmol/L* OR
NEGATIVE to SMALL urine ketones
within previous 1 hour

BOHB 0.6-1.5 mmol/L* OR

MODERATE urine ketones
within previous 1 hour

BOHB >1.5 mmol/L* OR

LARGE urine ketones
within previous 1 hour

Insulin dose = insulin to

cover carbs + insulin to
correct glucose

Insulin dose = insulin to

cover carbs + 1.5x(insulin to
correct glucose)

Insulin dose = insulin to

cover carbs + 2x(insulin to
correct glucose)

Sick day
management RN
teaching and
education, in
collaboration with
Diabetes Nurse
Educator

* If BOHB and urine ketone

results differ, base correction
dose on BOHB

Call inpatient provider to discontinue Sick Day Management

(ED Sick Day calculator will discontinue after each one-time insulin dose is used)
For questions concerning this pathway,
contact: DiabetesNonDKA@seattlechildrens.org
2013 Seattle Childrens Hospital, all rights reserved, Medical Disclaimer

Last Updated: 02/10/2014

Valid until:05/21/2016

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Self-Assessment Diabetes 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.

Self-Assessment Diabetes 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.

Answer Key Diabetes Non DKA: Sick Day Management

Executive Summary

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Executive Summary Pg 2

Executive Summary

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Executive Summary Pg 3

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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 in
the following manner:
Quality ratings are downgraded if 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 upgraded if 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 quality
Moderate quality
Low quality
Very low quality
Expert Opinion (E)
Reference: Guyatt G et al. J Clin Epi 2011: 383-394

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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
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
databases on 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

Identification
255 records identified through
database searching

11 additional records identified

through other sources

Screening
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

Elgibility

Included
40 studies included in pathway
Flow diagram adapted from Moher D et al. BMJ 2009;339:bmj.b2535

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Bibliography
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):1095101.
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.

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Bibliography
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.
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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
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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 carbohydrateto-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. TubianaRufi 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].
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Leelarathna L, Guzder R, Muralidhara K, Evans ML. Diabetes: Glycaemic control in type 1. Clin Evid (Online) [Insulin
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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.
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practice guideline [Internet]. Rockville MD: Agency for Healthcare Research and Quality (AHRQ); cited 12/4/2012
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