Diabetic Ketoacidosis (DKA) Clinical Pathway — Emergency Department, ICU and Inpatient

Transitioning to Subcutaneous Insulin when DKA is Resolved

Definition of Resolution of DKA	MS, VS improved, tolerating sips HCO3 > 15 mmol/L or HCO3 < 15 and BHOB < 2 mmol/L Anion gap < 10

Steps to Transition to Subcutaneous Insulin

Obtain dose from Endocrine
Review if Lantus dose has already been given
Administer the first rapid-acting (aspart) subcutaneous insulin dose
Allow the child to start eating
Wait 20 mins, then stop the insulin infusion and IVF if PO intake adequate

Insulin Dosing

Review child-specific dosing with Endocrine
- New-onset DM: doses based on weight
- Known DM: resume home insulin dose
Most children are not transitioned directly back to their insulin pump

Basal-bolus Insulin Regimen

Lantus (Basal)	Long-acting or basal insulin that lasts 24 hr Crucial for preventing ketosis and the development of DKA Administer before discontinuation of insulin infusion Otherwise, likelihood of recurrent DKA is high Given 1-2 times daily
Aspart (Bolus)	Rapid-acting bolus, used to cover carbohydrates eaten and correct high blood sugars and ketones Insulin to carbohydrate ratio Amount of insulin that covers carbohydrates eaten e.g., 1:6g = 1 unit is administered for every 6 grams of carbohydrates Insulin sensitivity factor (Correction factor) Amount in mg/dL that blood glucose is lowered by 1 unit of insulin e.g., 1:50 with a target of 100 = 1 unit will lower the blood sugar 50 points to a target of 100 Ketone dose Amount of insulin administered every 2 hrs when ketones are present Ketone Dose, Insulin Sensitivity Factor, and Correction Bolus Calculation

Lantus
(Basal)

Long-acting or basal insulin that lasts 24 hr
Crucial for preventing ketosis and the development of DKA
Administer before discontinuation of insulin infusion
- Otherwise, likelihood of recurrent DKA is high
Given 1-2 times daily

Aspart
(Bolus)

Rapid-acting bolus, used to cover carbohydrates eaten and correct high blood sugars and ketones
Insulin to carbohydrate ratio
- Amount of insulin that covers carbohydrates eaten
- e.g., 1:6g = 1 unit is administered for every 6 grams of carbohydrates
Insulin sensitivity factor (Correction factor)
- Amount in mg/dL that blood glucose is lowered by 1 unit of insulin
- e.g., 1:50 with a target of 100 = 1 unit will lower the blood sugar 50 points to a target of 100
Ketone dose
- Amount of insulin administered every 2 hrs when ketones are present
Ketone Dose, Insulin Sensitivity Factor, and Correction Bolus Calculation

Diabetic Ketosis without Acidosis BOHB ≥ 1	Most children will continue to have elevated serum ketones Frequent subcutaneous doses of insulin and additional fluids are required to clear ketones Check POC glucose, BOHB every 2 hrs until ketones are cleared Consult Endocrine to review ketone dose and management plan Diabetes Type 1 with Acute Illness Pathway Diabetic Ketosis without Acidosis Pathway
Routine Diabetic Care BOHB < 1	Blood glucose checks Before meals, bedtime and 2 a.m. POC BOHB or urine ketones For glucose > 300 mg/dL Administer aspart insulin Mealtimes to cover carbohydrates, correct high blood sugar Do not administer aspart insulin more frequently than every 3-4 hrs Administer Lantus Nightly or as directed by Endocrinology Flow Chart: DKA Treatment and Transitioning to SQ Insulin

If you have questions about any of the clinical pathways or about the process of creating a clinical pathway, please contact us.

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The clinical pathways are based upon publicly available medical evidence and/or a consensus of medical practitioners at The Children’s Hospital of Philadelphia (“CHOP”) and are current at the time of publication. These clinical pathways are intended to be a guide for practitioners and may need to be adapted for each specific patient based on the practitioner’s professional judgment, consideration of any unique circumstances, the needs of each patient and their family, and/or the availability of various resources at the health care institution where the patient is located.

Accordingly, these clinical pathways are not intended to constitute medical advice or treatment, or to create a doctor-patient relationship between/among The Children’s Hospital of Philadelphia (“CHOP”), its physicians and the individual patients in question. CHOP does not represent or warrant that the clinical pathways are in every respect accurate or complete, or that one or more of them apply to a particular patient or medical condition. CHOP is not responsible for any errors or omissions in the clinical pathways, or for any outcomes a patient might experience where a clinician consulted one or more such pathways in connection with providing care for that patient.

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Diabetic Ketoacidosis (DKA) Clinical Pathway — Emergency Department, ICU and Inpatient

Transitioning to Subcutaneous Insulin when DKA is Resolved

Steps to Transition to Subcutaneous Insulin

Insulin Dosing

Basal-bolus Insulin Regimen

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Innovation and your child

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Diabetic Ketoacidosis (DKA) — Transitioning to Subcutaneous Insulin — Clinical Pathway: Emergency Department, ICU and Inpatient

Diabetic Ketoacidosis (DKA) Clinical Pathway — Emergency Department, ICU and Inpatient

Transitioning to Subcutaneous Insulin when DKA is Resolved

Steps to Transition to Subcutaneous Insulin

Insulin Dosing

Basal-bolus Insulin Regimen