UNMH Pediatric Diabetic Ketoacidosis Pathway

3-Bag System and Starting Rates DKA Triage Screening Tool Blood Glucose > 200 Altered Mental Status? Positive = Seizure? Shock? Known or SUSPECTED AND History MD/RN SWARM SWARM concerning Bag 1 Bag 2 Bag 3 Type I Diabetes Mellitus See critical care for DKA strategies on last page • Abdominal Pain YES • Altered Mental Status* • Extreme Thirst TRIAGE B • Fatigue Bicarbonate or Lantus

1,4 NS+/- Insulin Bolus 6 5 Insulin additives PLUS ONE OF • Frequent Urination 10-20 mL/kg NS Bolus (over 1 hr ) SQ OK additives

(including SQ) +/- D10 NS • Kussmaul Breathing iStat Chemistry, iStat gas • Respiratory Distress* • Vomiting1 Note*: Ketones in urine is needed • Weight Loss pH < 7.3 or CO < 15 Exit Guideline for diagnosis, but treatment may 2 POC Bag 1 Bag 2 Bag 3 AND NO Diabetic NOT in DKA vs start before confirmation at Ketones in urine* Alternate Diagnosis6 > 300 FR 0 physician discretion. YES 150-300 ½FR ½ FR DKA TREATMENT GOALS: 0.1 Rapid diagnosis of DKA

Repeat POC glucose after bolus <150Units/kg/hr 0 FR Insulin Drip for DKA Hourly glucose checks on insulin drip Use 3-bag system PHYSICIANS Do not drop glucose > 100 per hour NURSES Appropriate disposition USE DKA POWERPLAN No bicarbonate treatment Use 3-bag system (on right) Order insulin drip, labs, Finish bolus before starting insulin and TWO bags of IV fluids! (details next page) Hourly POC blood sugars 1 PICU Criteria Q15 min Neuro checks for first hour Fluid Rate (FR) = 1.5 x maintenance See additional treatment (next page) Notify MD if glucose drops > 100/hr pH < 7.1 Altered Mental Status Do NOT slow insulin rate! K+ < 2.5 Dysrhythmia If pt glucose drops > 100 in one hour, Age < 2 years Intubation ↑ proporon of IV fluids with dextrose!1,6 Insulin DOES NOT RUN If pt glucose drops > 100 in one hour, ↑ Profound shock Cerebral Edema 1,6 Admit Patient (see PICU Criteria on left) WITHOUT other fluids! proportion of fluids running with dextrose! Floor patients must have a bed on PSCU/6-East! Insulin pump = Stop pump, call peds endo! H&P AND TREATMENT INFORMATION ORDER INFORMATION

LAB ORDERS HISTORY AND PHYSICAL All If New Diabetic Review of Systems Polyphagia, Polydypsia, Polyuria, Weight Loss, Anorexia, VBG Islet Cell Antibodies Vomiting, Fatigue, Malaise Chem 7, Mg, Phos Insulin antibodies Known Diabetic Insulin Use, most recent dose, insulin pump CBC with diff TSH

Home glucose/ketone measurements Hemoglobin-A1c FT4 Age at dx, prior hospitalizations, previous DKA Ionized Calcium (iCa) Celiac Disease Reflex Other Infectious sx, Ingestions, Trauma Urinalysis (UA) Panel Teenage females Risk of Pregnancy, STI Q1 hour POC Glucose Physical Exam Airway If Severe DKA add a Lactate Breathing: Tachypnea, Kussmaul breathing Circulation: Capillary refill, pulses IV FLUID ORDERS1 Neuro: Pupils, CN exam, motor, GCS, Mental Status ALWAYS ORDER a bag with AND a bag without dextrose! Vital Signs (including temperature) K > 5.5 K < 5.5 ADDITIONAL TREATMENT Normal Saline NS + 20 mEq/L KCl + 20 mEq/L KPhos < 35 kg AND AND Assure good IV access but avoid central lines due to risk of thrombus D10 NS D10 + NS + 20 mEq/L KCl + 20 mEq/L KPhos Neurologic assessments every 15 minutes for first hour or until stable Normal Saline NS + 40 mEq/L KCl + 20 mEq/L KPhos > 35 kg AND AND Reeval for need for 2nd bolus D10 NS D10 + NS + 40 mEq/L KCl + 20 mEq/L KPhos Start 1.5 MIVF NS until 3-bag system ready IF K < 2.5 or > 5.5 order an EKG K Acetate instead of KCl is allowed Start insulin infusion at least 1 hour AFTER 1st bolus started1,4,6 USE THE FOLLOWING INITIAL RATE Add glucose to fluids when blood sugar drops below 300 mg/dL or if dropping POC Glucose NS +/- additives D10 NS +/- additives > 100/hr > 300 1.5 maintenance Bag at bedside 0.2 U/kg Lantus now if new diabetic. Otherwise order their regular home 150 - 300 0.75 maintenance 0.75 maintenance dose. < 150 Bag at bedside 1.5 maintenance 1,4 Do NOT give bicarbonate OR insulin boluses Nurses need BOTH bags to start insulin drip Specialized fluids take time, start with NS at 1.5 maintenance while waiting Add antibiotic coverage if febrile for insulin and supplemental fluids CRITICAL CARE STRATEGIES Diabetic Ketoacidosis Criteria6 CEREBRAL EDEMA RISK FACTORS3 Mild Moderate Severe Risk Factors Age < 3 years Bolus Insulin administration pH 7.21 – 7.3 pH 7.11 – 7.2 pH < 7.1 OR Prior Hx of DKA Insulin infusion within 1 hours OR OR CO2 < 5 OR pH < 7.0 of 1st fluid bolus CO2 11-15 CO2 6-10 Altered Mental Status Na fails to correct as sugar ↓ Bicarbonate administration Initial glucose > 1000 mg/dL CEREBRAL EDEMA DIAGNOSIS3 = 1 Major + 2 Minor or 1 Diagnostic + 2 Major References:

Diagnostic Abnl verbal/motor to pain CN Palsy (usually III, IV, or VI) 1. Cooke DW, Plotnick L. Management of Diabetic Ketoacidosis in Children. Pediatrics in Review. Dec Posturing (e.g. decorticate) Cheyne-Stokes respirations 2008,29(12)415-416. Major Altered/fluctuating Sustained bradycardia consciousness (GCS ≤ 13) Age-inappropriate incontinence 2. Muir AB, Quisling RG, Yand MCK, Rosenbloom AL. Cerebral Edema in Childhood Diabetic Ketoacidosis Natural history, radiographic findings, and early identification. Diabetes Care 2004 Jul: 27(7): 1541-1546. Minor Vomiting Does not easily wake Headache Diastolic bp > 90 mmHg Age < 5 years 3. Palladino A, Srinivasa V, Lord K, Jacobstein C, Gaines S, Lavelle J. November 2015. ED Pathway for the Evaluation/Treatment of the Child With Suspected DKA. https://www.chop.edu/clinical-pathway/diabetes- Cerebral Edema Treatment: type1-with-dka-clinical-pathway. Accessed September 20, 2018. Elevate head of bed 3% NS over 30 minutes 5 mL/kg 4. Wolfsdorf JI. The International Society of Pediatric and Adolescent Diabetes guidelines for management Mannitol 0.5g/kg of diabetic ketoacidosis: do the guidelines need to be modified? Pediatric Diabetes 2014: 15: 277-286. Consider a slower initial insulin drip rate4 0.05 units/kg/hr Consider head CT AFTER initial treatment 5. Harrison VS, Rustico S, Palladino AA, Ferrara Christine, Hawkes CP. Glargine co-administration with Call PICU attending if intubation or treatment for cerebral edema is required intravenous insulin in pediatric diabetic ketoacidosis is safe and facilitates transition to a subcutaneous Shock Treatment: regimen. Pediatric Diabetes. 2017 Dec: 18(8): 742-748. NS or LR boluses until perfusion restored 20 mL/kg (up to 3) 6. Wolfsdorf JI, Glaser N, Angus M, Fritsch M, Hanas R, Rewers A, Sperling MA, Codner E. ISPAD Clinical Dopamine (Cold shock) 3 mcg/kg/min (Max 20) Practice Consensus Guidelines 2018: Diabetic ketoacidosis and the hyperglycemia hyperosmolar state. Epinephrine (Cold shock) 0.03 mcg/kg/min (Max 1) Norepinephrine (Warm shock) 0.03 mc/kg/min (Max 1) ISPAD Clinical Practice Consensus Guidelines. 11 April 2018. Fever See UNMH PED Sepsis Pathway Possible alternate diagnoses: Stress response due to bacteremia, pneumonia, sepsis, metabolic disorder, or trauma