ED Pathway for Evaluation/Treatment of Children
with Type 1 DM and Acute Illness
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Initial MD/APP/RN Team Assessment
  • MS, ABCDE
  • Monitors, VS
  • Hydration status
  • Recent: blood glucose
      urine ketones
      insulin doses
Complete History and Physical

Further diagnostic testing as
clinically indicated

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Beta-hydroxybutyrate (BOHB)
Blood ketones clear more quickly than urine ketones and more accurately reflect the patient's degree of ketosis
BOHB Recommendations
0 - 0.9
  • Assure hydration
  • SubQ insulin as clinically indicated
1-1.9
  • Give 1st dose rapid acting SubQ insulin, 0.15 unit/kg
> 2
  • Send VBG, BMP
    (See evaluate for DKA in order set)
  • NS 10 mL/kg IV
  • If clinical suspicion for DKA is low, give 1st SubQ insulin, 0.15 unit/kg
  • DKA Pathway
Goal Use rehydration, 2 doses of SubQ rapid-acting insulin given 2 hours apart to clear ketones
1st dose of insulin is weight-based
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
First Insulin Dose (weight-based) Use SubQ rapid-acting insulin only (Aspart)
1st dose: 0.15 unit/kg
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
Second Insulin Dose (Endocrine consult) Review recent home regimen, recent doses with patient/family/EPIC
Discuss 2nd insulin dose with Endocrine Fellow
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 < 300
PO Hydration Patient to drink 1 ounce per age in years every hour
Blood sugar ≥ 200 Sugar-free fluids
Blood sugar < 200 Sugar-containing fluids
RN Monitoring Hourly VS, I/O
Subsequent Labs Check POC blood glucose and POC blood BOHB every 2 hours
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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

Posted: June, 2010
Revised: September, 2011, March, 2016, May 2017
Authors: A. Ackerman, MD, K. Lord, MD, S. Gaines, RN, C. Jacobstein, MD, N. Patel, PharmD, M. Orenstein, MD, M. Vajravelu, MD, J. Lavelle, MD

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