In this section : Diabetes and Endocrinology
Paediatric Diabetic Ketoacidosis (DKA) Guideline
Paediatric Ketone Correction Guideline
Insulin Correction Factor Table (Paediatrics)
Management of Hypoglycaemia in Children with Type 1 Diabetes
Newly diagnosed diabetic – not in DKA (Walking wounded)
Prescribing Advice on Admission – Insulin
Diabetic Retinopathy
Adrenal Insufficiency
Hyperglycaemia & Steroids
Variable Rate Insulin Infusion
In-patient Hyperglycaemia Management
Hyperthyroidism
Newer Antidiabetic Drugs
Hypoglycaemia
Diabetic Ketoacidosis
Switching from VRII
Insulin Pumps
Diabetes Mellitus
The Diabetic Foot
Subcutaneous Insulin
Diabetes and Acute Coronary Syndrome
Hyperosmolar Hyperglycaemic State
Diabetic Ketoacidosis
Last updated 3rd December 2020
Diagnostic Criteria and Alerts
Management
- This is described in detail on the flow charts available on wards D8, CCU & CAU.
- Ideally transfer patient to CCU
- Saline, Insulin and Potassium are the mainstays of treatment – see below
Saline in first 4 hours
- First hour – 1L N Saline starting within 30 mins of admission
- Second hour – 1L N Saline 0.9% + KCL (see below)
- Third and Fourth hour – 500ml N Saline/hour + KCL
- Coprescribe Glucose 10% with added K if Blood Glucose falls to ≤14 mol/L in first 4 hours – see below.
Insulin in first 4 hours
- Rx Actrapid IV 6 units/hour within 30 mins of admission
- If BG falls ≤ 14 mmol/L in first 4 hours reduce insulin to 3 units/hour
- Maintain Blood Glucose >9 mmol/L and ≤14 mmol/L adjusting insulin rate as necessary
Potassium in First 4 Hours
- Serum K often high on admission (although total body K is low) but falls precipitously with insulin. Regular monitoring is mandatory.
- Suggested K replacement: – see below
- Check serum K 2 hourly in first 4 hours then twice daily thereafter unless more frequent monitoring indicated clinically
Other Investigations/Interventions to Consider
- ECG
- GCS Score
- Catheter if oliguric
- MSSU
- Blood cultures
- Central line
- Chest X-ray
- Call Consultant if deteriorates
- If protracted vomiting or reduced conscious level insert NG tube
If Blood Glucose falls to ≤14 mmol/L in first 4 hours
- Rx Glucose 10% 500ml with 20 mmol KCl at 100ml/hour
- Continue N Saline at 400ml/hour + KCl (as per K+ table above) until end of hour 4
- Reduce insulin to 3 units/hour
- Maintain BG 9-14mmol/l adjusting insulin rate as necessary
- If BG raised >14mmol/l do not stop glucose, adjust insulin to maintain level between 9 and 14mmol/l
ALWAYS Consider Cerebral oedema
- Children and adolescents are at the highest risk
- Presents with headaches, reduced conscious level
- Monitoring for signs of cerebral oedema should start from the time of admission and should continue for at least 12 hours
- Call Consultant if there is a suspicion of cerebral oedema or the patient is not improving within 4 hours of admission,
- Undertake CT scan to confirm findings
- Administer IV mannitol (100ml of 20% over 20min) or dexamethasone 8mg (discuss with Consultant)
- Consider ITU (an indication for checking arterial blood gases)
From 4 Hours to Discharge
- Prescribe usual long acting insulin (Levemir, Lantus, Insulatard, Humulin I) SC along with IV insulin
- Continue N Saline with KCl at 250ml/hr until BG <14mmol/l
- Once BG <14mmol/l Rx Glucose 10% with 20mmol K at 100ml/hr with N saline 150ml/hr containing K as per box above (NB this means giving K in Saline and in Glucose)
Supplementary Notes
- Do not use bicarbonate
- Potassium replacement – under no circumstances should KCl be administered at a rate >20mmol/hour
- WBC is often raised in DKA and antibiotics should only be given if there is clear evidence of infection
- It is reasonable to use a point-of-care BG meter to monitor BG if the previous laboratory BG is less than 20mmol/l
- Reduce insulin infusion rate with time depending on clinical circumstances and presence of long acting insulin in order to avoid a fall of >5mmol/l, as rapid falls in BG may be associated with cerebral oedema
- Consider precipitating factors. Common causes include omission of insulin, infection, newly diagnosed, myocardial infarction or combination of the above
Discharge Planning
- Revert to usual SC insulin regimen when HCO3 within normal range (23-30mmol/l), ketone free and eating normally
- Stop IV fluids and IV insulin 30min after usual injection of pre-meal SC insulin, providing you have not also stopped the long acting insulin by mistake – seek advice if you have.
- Phone/refer for specialist diabetes review before discharge. If not available, ensure specialist team gets copy of discharge summary
- Do not discharge until biochemically normal, established on usual SC regimen and eating normally