This pathway guides the care of patients in all hospital inpatient units, and includes:

• Patients with type 1 or type 2 diabetes
  • Admitted to any service in the hospital with blood glucose > 300 or illness
  • Admitted for a non-diabetes related concern and require endocrinology consultation due to illness/infection
  • Patients newly diagnosed with diabetes
  • Patients who presented with DKA who are no longer acidotic and are transitioning off of IV insulin

Exclusion Criteria

• Pathway to be stopped if acidosis develops
• Patient is being treated with an insulin infusion
• Patient with cystic fibrosis-related diabetes (CFRD)
• Patient with medication-induced diabetes

Diabetic Ketosis without Acidosis (DK no A)

• Patients with type 1 or type 2 diabetes
• Diabetic ketosis (DK) occurs when insulin deficiency leads to alternative fuel metabolism, producing ketones
• Ketones are measured by:
  • Blood beta-hydroxybutyrate (BOHB) or
  • Urine acetoacetate
• Blood BOHB clear more quickly than urine ketones and are a more accurate reflection of the patient's degree of ketosis
• If the blood glucose < 180 mg/dL and moderate to large ketones are present, ketosis due to starvation should be considered. Sugar-containing fluids are critical.

Diabetic Ketoacidosis (DKA)

• High levels of ketones lead to a metabolic acidosis
• Treat with an insulin infusion rather than subcutaneous insulin
• A diabetic patient with the following is usually considered to have DKA and requires an insulin infusion:
  • Positive ketones
  • Blood pH < 7.30 or bicarbonate < 15 mEq/L
• Refer to the Child with Suspected DKA Pathway

Insulin Deficiency

• Due to insulin omission or increased insulin requirements (relative insulin resistance) due to illness, certain medications (glucocorticoids), or significant hyperglycemia
• Ill children with diabetes are at increased risk for ketosis
• When children with diabetes have high blood sugar, test for ketones to determine whether they have DK no A or possibly DKA