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Royal Hospital for Sick Children Edinburgh
Integrated Care Pathway: Diabetic KetoacidosisDATE: WARD:
This Integrated Care Pathway was developed by the Diabetes Team, Royal Hospital for Sick Children, Edinburgh for the management of children with Type I Diabetes attending the Royal Hospital for Sick Children, Edinburgh. The Integrated Care Pathway does not provide all training required for individual personnel to be competent in the management of paediatric diabetes. The Integrated Care Pathway should be regarded as providing only one component of any recipient organisation’s own comprehensive training programme. Lothian Health Board uses reasonable endeavours to ensure the accuracy and reliability of the Integrated Care Pathway but no guarantees are made that the information contained in the Integrated Care Pathway is accurate, complete or current at any given time. Any information in the Integrated Care Pathway is used as general information and is not warranted by Lothian Health Board or any other health organisation, nor should it be taken as advice. No responsibility can be accepted by Lothian Health Board or any other health organisation for action or in-action as a result of information contained in the Integrated Care Pathway. Specific advice should be sought in specific situations from a suitably qualified expert.
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Lothian University Hospitals Division – Children’s Services
THIS DOCUMENT MUST NOT BE COPIED
1. Purpose of this document
To ensure that all staff have clear guidance to follow when a child or young person up to 16 years of age presents in diabetic ketoacidosis (either newly diagnosed patient or patient with known diabetes).
2. Who should use this document
All medical and nursing staff, and professionals allied to medicine within Children’s Services.
3. To whom this document applies
All medical and nursing staff, and professionals allied to medicine within Children’s Services.
4. Contact point
Dr Kathryn Noyes, Associate Specialist – Paediatric DiabetesDr Louise Bath, Lead Consultant in Paediatric and Adolescent DiabetesDr Harriet Miles, Consultant in Paediatric and Adolescent DiabetesMrs. Marion Henderson, Senior Secretary, Diabetes TeamDiabetes Team Members
5. Further reference
International Society of Paediatric and Adolescent Diabetes (ISPAD) Clinical Practice Consensus Guidelines 2014 Compendium:Diabetic Ketoacidosis and hyperglycaemic hyperosmolar state.Pediatric Diabetes 2014: 15 (Suppl.20): 154-179doi:10.1111/pedi.12165
Also available at www.ispad.org (under guidelines)
Hydroxybutyrate near-patient testing to evaluate a new end-point for intravenous insulin therapy in the treatment of diabetic ketoacidosis in children. Pediatric Diabetes 2007 Jun:8[3]: 150-6.
Review group
Dr Kathryn Noyes, Associate Specialist – Paediatric DiabetesDr Louise Bath, Lead Consultant in Paediatric and Adolescent DiabetesDr Sarah Kiff, Paediatric Speciality RegistrarDr Omair Malik, PICU Speciality Doctor
Proceed with presenting history and clinical examination of child• For children on pump therapy stop the pump when starting DKA treatment.
Admit to HDU (to start insulin infusion) within 2 hours of presentation• Start IV insulin infusion 1-2 hours after starting fluid replacement therapy (p21)• Management of insulin infusion (p25-26)• Hourly POCT glucose and ketones
Royal Hospital for Sick Children Edinburgh
Diabetic Ketoacidosis Integrated Care Pathway Flowchart
Confirm the diagnosis – immediate capillary blood sample (p9)• POCT glucose usually >11mmol/l plus• Blood gas pH <7.3 and/or• Standard bicarbonate <15mmol/l and/or impaired
consciousness plus• POCT blood ketones >3mmol/lInform Senior Dr on call
Initial Assessment + Resuscitation (p8)• Fluid resuscitation only if shocked (p8) to restore
peripheral circulation• Nil by mouth
End Point for IV Insulin Therapy• Continue IV insulin infusion until pH > 7.3 and 2 consecutive POCT ketone readings
thereafter are <1.0mmol/l (p27)• Commence subcutaneous insulin regimen and transfer to Medical Ward – use
appropriate follow-on pathways (ICP 2 or ICP 3)
Junior Medical Staff Actions• 2-4 hourly Na, K, Urea + glucose to lab• Maintain plasma K 4-5mmol/l (p22)• Watch for falling plasma Na (p23)• 2-4 hourly venous blood gas until pH > 7.3 (p28)
POCT = Point Of Care Testing, i.e. using test strip + hand-held meter.Glucose POCT may be inaccurate with severe dehydration/acidosis. Check with a venous lab glucose.
Too rapid rehydration may cause cerebral oedema with significant risk of mortality/morbidity.
IV Fluid Management to commence in A&E (p16)• Commence 0.9% sodium chloride within 1 hour of admission
Observe closely for signs of cerebral oedema (p31)• If suspected, initiate treatment immediately.
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Royal Hospital for Sick Children Edinburgh
Integrated Care Pathway: Diabetic KetoacidosisDATE: WARD:
All staff using this pathway must complete this section, before initialling completed care. This allows you to use only your initials throughout Pathway.
This document represents expected care for the patient. Staff using this pathway may need to modify treatment for individual patients, therefore use clinical and professional judgement.
Any alteration to the care outlined in this pathway must be recorded as a ‘variation’.
Integrated Care Pathway: Diabetic KetoacidosisDATE: WARD:
Affix ID label or complete
PATIENT NAME:
UNIT NO.:
D.O.B.:
4. Disability (neurology)Pupillary reaction to light normal. Right: Yes No Left: Yes No
AVPU (please circle)Alert Voice Pain Unresponsive
Insert and complete neuro observation (GCS) chart (see Appendix 1):
5. POCT ResultsPOCT Blood Tests Time 0: Time+1hr:
Glucose
Ketones
Blood Gas Time 0: Time+1hr:
pH
pCO2
HCO3
Initial blood tests to be taken in A+E: 4 ml blood required
USE DKA ORDER FORM on TRAK. Record results on p33. (Diabetes order sets: new diabetes admission paediatric diabetes RHSC)
2ml Li Hep 1ml plain 0.5ml flox 0.5ml EDTA
DKA MAY BE PRECIPITATED BY SEPSIS AND FEVER IS NOT PART OF DKA
A raised WCC and a raised amylase are common in DKA but do not confirm sepsis/acute abdominal pathology. Take blood for blood cultures if febrile.Antibiotics are not given as routine unless a bacterial infection is suspected.Continuing abdominal pain is common and may be due to liver swelling, gastritis, bladder retention and ileus.
Severity of DKA is categorized by degree of acidosis1. Mild: Venous pH <7.3 or bicarbonate <15mmol/L
2. Moderate: Venous pH <7.2 or bicarbonate <10mmol/L
• Documented medical review required at least 4 hourly p29 (check blood glucose falling as expected and conscious level normal - Appendix I).
• Check biochemistry, blood pH, and laboratory blood glucose 2 hours after the start of resuscitation, and then at least 4 hourly.
• Record all blood results (p33) and document any actions required.
• Review the fluid composition and rate according to each set of electrolyte results (p22 & 23).
• Review fluid balance: Urinary catheterisation should be avoided but may be useful in the child with impaired consciousness. If a massive diuresis continues, and the patient is in negative balance, fluid input may need to be increased.
• Review hourly IV insulin infusion rate and rate of fall of blood ketones.
Aim to correct metabolic abnormalities slowly: too rapid reversal may cause cerebral oedema with significant mortality/morbidity.
Integrated Care Pathway: Diabetic KetoacidosisDATE: WARD:
Affix ID label or complete
PATIENT NAME:
UNIT NO.:
D.O.B.:
INTRAVENOUS INSULIN INFUSION
Remember: Insulin is essential to switch off ketogenesis and reverse the acidosis
• Transfer to HDU/ITU for insulin infusion to commence 1-2 hours after starting fluid replacement therapy. There is some evidence that cerebral oedema is more likely if insulin is started early.
Integrated Care Pathway: Diabetic KetoacidosisDATE: WARD:
Affix ID label or complete
PATIENT NAME:
UNIT NO.:
D.O.B.:
DATE: TIME:
DATE: TIME:
CONTINUING CARE INSULIN
End point of IV insulin infusion is reached when pH >7.3 and 2 consecutive POCT blood ketone readings thereafter are <1 mmol/L, indicating resolution of ketoacidosis.
Aim to change to subcutaneous insulin just prior to a mealtime; breakfast, tea, lunch or supper.
A. For newly diagnosed child in DKA: commence basal bolus regimen
Start ICP 3 to prescribe insulin doses
B. For known patients in DKA: re-commence own insulin regimen
Start ICP 2 to prescribe insulin doses
Points to note:
• Sign insulin prescribing sheet on follow on ICP when insulin administered.
• Ensure prescribed amount of carbohydrate (carbs) provided.
• Discontinue the insulin infusion 10 minutes after the first Novorapid/Humalog injection is given to avoid rebound hyperglycaemia.
• Discontinue the IV fluids after the IV insulin infusion has been stopped and the child has been able to eat prescribed amount of carbohydrate.
Date and time that child is ready to transfer to Ward 1
Integrated Care Pathway: Diabetic KetoacidosisDATE: WARD:
Affix ID label or complete
PATIENT NAME:
UNIT NO.:
D.O.B.:
MANAGEMENT OF CEREBRAL OEDEMA
Warning signs and symptoms of cerebral oedema include:
1. Headache and slowing of heart rate
2. Change in neurological status (restlessness, irritability, increasing drowsiness and incontinence). A falling GCS is abnormal (see Appendix I).
3. Specific neurological signs (e.g. cranial nerve palsies)
4. Rising blood pressure
5. Decreasing oxygen saturation
6. Abnormal posturing
More dramatic changes (convulsions, papilloedema, respiratory arrest) are late signs associated with an extremely poor prognosis.
Management
Exclude hypoglycaemia as a possible cause of any behavioural change, then:
Elevate head of bed.Restrict IV fluids to 50% maintenance and replace deficit over 72 hours instead of 48 hours.After child is stable consider CT scan to exclude other intracerebral events (thrombosis, haemorrhage or infarction).+ CAUTION: Confirm patency of IV access as risk of extravasation with these fluids
Scan report
Either +Hypertonic (2.7%) sodium chloride (5ml/Kg over 5-10 mins)
10% *+Mannitol 0.25 – 1.0g/Kg (2.5 – 10ml/Kg over 20 mins)*Check Mannitol for particles and warm fluid if crystals present
OR
If suspected inform on call medical consultant and liaise with PICU staff. Initiate treatment immediately
Integrated Care Pathway: Diabetic KetoacidosisDATE: WARD:
Affix ID label or complete
PATIENT NAME:
UNIT NO.:
D.O.B.:
APPENDIX II - Troubleshooting
A. Blood glucose less than 4 mmol/L:• Ensure IV insulin running at correct rate
• Ensure IV fluids appropriate and running correctly
• If pH ≥ 7.3 give 10g glucose powders orally in 20mls water
• If pH < 7.3 give IV 10% glucose 2ml/Kg bolus
• Decrease insulin infusion rate by 20% if no issues identified
B. Blood KetonesExpect blood ketone levels to fall as insulin therapy switches off ketogenesis
However at presentation it may take several hours to begin to see a fall in levels
If levels not falling:
• check infusion lines
• check the calculation and dose of insulin
• consider sepsis and inadequate fluid input if sufficient insulin is being given
C. AcidosisAcidosis will almost certainly correct with correction of fluid balance. Remember pH is a log scale and therefore small improvements in pH are significant.
If acidosis is not correcting, consider the following:
• Insufficient insulin to switch off ketones
• Inadequate resuscitation
• Sepsis
• Hyperchloraemic acidosis
• Salicylate or other prescribed or recreational drugs
D. Corrected Sodium levelsNote: a failure to increase the corrected sodium level = a risk of cerebral oedemaSimplified corrected sodium formula:
Corrected sodium = plasma sodium plus (0.3 x (glucose – 5.5))
Corrected sodium should rise with therapy (0.5 – 1 mmol/hr)