Inpatient Clinical Pathway for Evaluation/Treatment of Children with Diabetic Ketosis without Acidosis

  • Endocrine Consult
  • Obtain for patients with DM receiving insulin if not on the Endocrine service
  • Initial Assessment
  • Check POC glucose
  • Check POC Ketones by:
    • Blood β-hydroxybutyrate (BOHB) or
    • Urine Ketones
  • Do not Hold Basal Insulin
  • Review History and Physical Exam
Ketones Blood Glucose Treatment Reassessment
BOHB 1-3
Urine ketones
moderate 40-79
  • > 200
  • Every 2 hours until BOHB < 1 or
  • Urine Ketones < small (trace or negative):
    • Check POC Glucose
    • Check POC BOHB or urine ketones
    • Dose insulin if BG > 70
  • If ketones not decreasing after 2 insulin doses
  • If acidosis is present
  • 70-200
  • < 70
  • Patient to take 15 gm carbohydrate
  • Re-check blood glucose in 20 minutes
  • Administer insulin once BG > 70
> 3
Urine ketones:
large (> 80)
  • Obtain venous blood gas (VBG), BMP
  • Evaluate for DKA, refer to the Child with Suspected DKA Pathway
    • If patient is not in DKA, initiate treatment based on blood glucose as above
  • BOHB < 1 or Urine ketones < Small
    • End Pathway Treatment
    • Start Regular Day Diabetes Management
      • If patient is requesting to eat, check BG and dose insulin for carbohydrate intake and glucose correction. Otherwise resume pre-feed glucose checks
Calculating the Insulin Dose
Administer ketone dose or correction bolus, whichever is greater, but not both.
Calculation Description Equation
Ketone Dose
  • Dose of rapid-acting insulin (Aspart) given to prevent progression to ketoacidosis in a patient with ketones present
  • Estimating the ketone dose using TDD
    • 10% of total daily dose (TDD) of insulin
    • TDD can also be estimated by Lantus dose X 2.25
  • Patient’s TDD is unknown
    • Estimate the ketone dose to be 0.1 units/kg
  • Administer
    • Ketone dose or correction bolus, whichever is greater, but not both.
    • If patient is due to eat, carbohydrate coverage should be given with the ketone dose.
Correction Bolus
  • Rapid-acting insulin administered as a correction bolus to lower blood glucose to a specified target
  • (Current Blood Glucose - Target Blood Glucose) Correction factor
Correction Factor
  • Number of points that 1 unit of insulin will lower the blood glucose
  • Per Endocrine letter
  • or
  • 1800/total daily dose of insulin
    • for patients with new onset diabetes or unknown correction factor
Posted: October 2017
Last Revised: May 2024
Authors: K. Lord, MD; S. Dumser, RN, CNS; M. Killberg, MD; J. Phillips, RN