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Treatment
Diabetes New Diagnosis (Non-DKA) v. 5
Establish New Diagnosis
Diet
· Modified Diet Carbohydrate-counted (insulin dependent)
Medications
· Consider Total Daily Dose (TDD) insulin 0.3-1 units/kg/day,
adjusted according to glucose, using
· Basal insulin once or twice daily (40-50% TDD)
· Rapid-acting insulin at each meal, snacks, bedtime, and
0300
Routine Monitoring
· Check glucose 1-2 hours after first subcutaneous insulin
dose
· Check glucose at least every 3 hours 2100-0900 for first 24
hours
· Check glucose before meals, at bedtime, and 0300 AND
· At least every 3 hours if NPO
· At patient/family request
· If signs of hypoglycemia (pallor, sweating, shaking,
irritability, confusion, or seizures)
· More frequently if vomiting/diarrhea, change in dextrose
rate or concentration of IV fluids, change in feeds, or
change in medication (steroids, etc)
© 2017 Seattle Children’s Hospital, all rights reserved, Medical Disclaimer
For questions concerning this pathway,
contact: [email protected]
Discharge Criteria
· Home insulin regimen determined
· Demonstrated ability to independently administer insulin, monitor glucose and determine intervention, and prevent, identify and treat hypoglycemia, hyperglycemia and ketonuria.
· Primary care provider and endocrinology follow-up arranged within 3 weeks of discharge
· Prescriptions for insulin, glucagon, and other supplies provided
· Teaching completed
HYPOglycemia Safety
· Call provider for hypoglycemia: glucose < 60 mg/dL (For patients
that cannot tolerate enteral intake or are NPO: glucose < 80 mg/
dL)
· Follow Diabetes: (Non-DKA) Hypoglycemia Management for
glucose < 80 mg/dL
HYPERglycemia Safety
· For glucose > 500 mg/dL x 1 or > 250 mg/dL x 2
· Check BOHB or urine ketones
· Call provider with glucose and ketone results to evaluate for
DKA
Diabetes Self-Management Education and Support
Consults
· Endocrine (if not primary service)
· Nutrition
· Social work
Discharge Appointment
· Follow-up with Endocrinology 2-3 weeks after discharge
Inclusion Criteria· New diabetes diagnosis requiring
teaching for insulin use
Exclusion Criteria· Diabetic ketoacidosis (DKA) (use
instead DKA Pathway)
· Continuous insulin infusion
· Intravenous insulin (for hyperkalemia,
in TPN)
· Sliding scale insulin
Discharge Instructions· Call the diabetes nurses'
line at (206) 987-5452 to
review blood glucoses within
48 hours after discharge.
· Call the endocrinologist on
call at (206) 987-2000 for
urgent questions about
blood glucose.
Establish New Diagnosis
· Follow Diabetes: (Non-DKA) Hypoglycemia Management for
glucose < 80 mg/dL
DKA
Diabetes Self-Management Education and Support
· More frequently if vomiting/diarrhea, change in dextrose
rate or concentration of IV fluids, change in feeds, or
change in medication (steroids, etc)
Last Updated: January 2017
Next Expected Revision: May 2018
Summary of Version ChangesApproval & Citation Explanation of Evidence Ratings
Inclusion Criteria· Glucose LESS THAN 80 mg/dL
· Patient receiving subcutaneous
insulin (by pump or injection) or
insulin in parenteral nutrition
Exclusion Criteria· Patient on IV continuous insulin
infusions (including diabetic
ketoacidosis (DKA))
Hypoglycemia (Insulin-Related, Non-DKA) Management v. 5
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© 2017 Seattle Children’s Hospital, all rights reserved, Medical Disclaimer
For questions concerning this pathway,
contact: [email protected]
Blood glucose less than 80 mg/dL identified
Patient safe to have simple carbohydrates administered orally or by feeding tube?
Loss of consciousness
or seizure with
glucose < 60 mg/dL?
NO
YES
Hold meal tray
Give simple carbohydratesAge ≤ 5 years: 10 g (2.7 oz = 81 mL
fruit juice)
Age > 5 years: 15 g (4 oz fruit juice)
Continue glucose checks
every 15 minutes
Contact provider for plan.
Provider decides to treat?
Treat hypoglycemia (IV, IM)
YES YES
Administer D10W bolus
IV access No IV access
Check glucose
15 minutes post intervention
Check glucose
15 minutes post intervention
Resume routine monitoring
per physician orderCover carbohydrates in meal.
Do not correct glucose value after
hypoglycemia treatment.
Blood glucose
80 mg/dL or greater
Blood glucose 80 mg/dL or greater
Blood glucose
80 mg/dL or greater
Glucose
< 80 mg/dL
Signs of hypoglycemia:
pallor, sweating, shaking,
irritability, confusion, or
seizures
!Notify
Contact
Provider for
glucose < 60 mg/dL,
OR cannot tolerate
enteral intake with
glucose < 80 mg/dL
Glucose
< 80 mg/dL
NO
Treat hypoglycemia (oral)
Last Updated: January 2017
Next Expected Revision: May 2018
Administer IM glucagon
(may give up to 2 doses per
episode)
Check glucose
15 minutes post interventionCheck glucose every 30 minutes
for 2 hours. Consider starting IV
!Call a
CODE BLUE
Glucose
< 80 mg/dL,
consider
placing IV
If more than
one hour until
next meal
give 10-15 carb snack
without insulin coverage
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Approved August 2013
CSW Diabetes (Non DKA) Pathway Team:
Endocrinology, Owner: Kate Ness, MD
Emergency Department (ED): Anne Slater, MD
Chief Resident: Jeremiah Davis, MD
Chief Resident: Eric Johnson, MD
Endocrinology Fellow: Debika Nandi-Munshi, MD
Endocrinology Fellow: David Weary, MD
Chief Medical Informatics Officer: Troy McGuire, MD
Medical Unit Clinical Nurse Specialist: Kristi Klee, DNP MSN RN CPN
ED Clinical Nurse Specialist: Elaine Beardsley, RN, MD
Pharmacy: Kara Niedner, PharmD
Clinical Effectiveness Team:
Consultant: Jen Hrachovec, PharmD MPH
Project Manager: Jennifer Magin, MBA
Data Analyst: Suzanne Spencer, MBA MHA
Information System Analyst: Heather Marshall
Informatician: Mike Leu, MD MH MHS
Librarian: Susan Klawansky, MLS
Literature Reviewer: Eileen Reichert, ARNP
Program Coordinator: Ashlea Tade
Executive Approval:
Sr. VP, Chief Medical Officer Mark Del Beccaro, MD
Sr. VP, Chief Nursing Officer Susan Heath, MN, RN, CNAA
Retrieval Website: http://www.seattlechildrens.org/pdf/new-diagnosis-diabetes-non-DKA-
pathway.pdf
Please cite as: Seattle Children’s Hospital, Ness K, Hrachovec JB, Klee K, Leu MG, Magin J. 2013
August. Diabetes New Diagnosis (Non-DKA) Pathway. Available from: http://
www.seattlechildrens.org/pdf/new-diagnosis-diabetes-non-DKA-pathway.pdf
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Diabetes New Diagnosis (Non-DKA) Pathway
Citation and Approval
Evidence Ratings
To Bibliography
This pathway was developed through local consensus based on published evidence and expert
opinion as part of Clinical Standard Work at Seattle Children’s. Pathway teams include
representatives from Medical, Subspecialty, and/or Surgical Services, Nursing, Pharmacy, Clinical
Effectiveness, and other services as appropriate.
When possible, we used the GRADE method of rating evidence quality. Evidence is first assessed
as to whether it is from randomized trial or cohort studies. The rating is then adjusted in the
following manner (from: Guyatt G et al. J Clin Epidemiol. 2011;4:383-94.):
Quality ratings are downgraded if studies:
· Have serious limitations
· Have inconsistent results
· If evidence does not directly address clinical questions
· If estimates are imprecise OR
· If it is felt that there is substantial publication bias
Quality ratings are upgraded if it is felt that:
· The effect size is large
· If studies are designed in a way that confounding would likely underreport the magnitude
of the effect OR
· If a dose-response gradient is evident
Guideline – Recommendation is from a published guideline that used methodology deemed
acceptable by the team.
Expert Opinion – Our expert opinion is based on available evidence that does not meet GRADE
criteria (for example, case-control studies).
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Summary of Version Changes
· Version 1 (5/21/2013): Go live
· Version 1.1 (8/20/2013): Sick Day Management added
· Version 1.2 (8/22/2013): ED wording changes, clarified sick day lab orders
· Version 2.0 (2/10/2014): Sick Day Management: added a yellow alert triangle to for a remind to
initiate
· Version 3.0 (7/30/2014): Established Diagnosis: added guidance and recommendations for
unreliable oral intake (Post-op, NPO) or vomiting
· Version 3.1 (10/9/2014): Established Diagnosis: added basal insulin to Unreliable Oral Intake or
NPO for clarity
· Version 4.0 (3/30/2015): Perioperative Management added
· Version 4.1 (10/25/2016): Added warning triangle to hypoglycemia page
· Version 5 (1/6/2017): Rapid-acting insulin to be given at 0300 (removed instructions to give only
if glucose >300mg/dL)
Medical Disclaimer
Medicine is an ever-changing science. As new research and clinical experience broaden our
knowledge, changes in treatment and drug therapy are required.
The authors have checked with sources believed to be reliable in their efforts to provide information
that is complete and generally in accord with the standards accepted at the time of publication.
However, in view of the possibility of human error or changes in medical sciences, neither the
authors nor Seattle Children’s Healthcare System nor any other party who has been involved in the
preparation or publication of this work warrants that the information contained herein is in every
respect accurate or complete, and they are not responsible for any errors or omissions or for the
results obtained from the use of such information.
Readers should confirm the information contained herein with other sources and are encouraged to
consult with their health care provider before making any health care decision.
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Bibliography
Literature Search
Studies were identified by searching electronic databases using search strategies developed and
executed by a medical librarian, Susan Klawansky. Searches were performed in December
2012 in the following databases – on the Ovid platform: Medline and Cochrane Database of
Systematic Reviews; elsewhere: Embase, Clinical Evidence, National Guideline Clearinghouse
and TRIP. Retrieval was limited to 2007 (date of then-current ISPAD guideline) to date, humans,
and English language. In Medline and Embase, appropriate Medical Subject Headings (MeSH)
and Emtree headings were used respectively, along with text words, and the search strategy was
adapted for other databases as appropriate. Concepts searched were type 1 diabetes mellitus
and ketones, ketone bodies, keto acids, hyperglycemia, hospitalization, inpatients. All retrieval
was further limited to certain publication types representing high order evidence. Additional
articles have been identified by project team members and added to the retrieval.
Susan Klawansky, MLS, AHIPMay 16, 2013
Return to Home To Bibliography, Pg 2
Identification
Screening
Eligibility
Included
Flow diagram adapted from Moher D et al. BMJ 2009;339:bmj.b2535
255 records identified
through database searching
14 additional records identified
through other sources
269 records after duplicates removed
268 records screened 160 records excluded
65 full-text articles excluded,
20 did not answer clinical question
29 did not meet quality threshold
16 outdated relative to other included study
108 records assessed for eligibility
43 studies included in pathway
Bibliography
Return to Home To Bibliography, Pg 3
This pathway was developed primarily based on:
American Diabetes A. Diagnosis and classification of diabetes mellitus. Diabetes Care [Insulin
Dosing]. 2013;36(Suppl 1):S67-74. Accessed 20121224; 3/14/2013 6:01:49 PM. http://
dx.doi.org/10.2337/dc13-S067.
American Diabetes A. Standards of medical care in diabetes--2013. Diabetes Care [Insulin
Dosing]. 2013;36(Suppl 1):S11-66. Accessed 20121224; 3/14/2013 6:01:49 PM. http://
dx.doi.org/10.2337/dc13-S011.
IDF/ISPAD 2011 Global Guideline for Diabetes in Childhood and Adolescence, available at
http://www.ispad.org/resources/idfispad-2011-global-guideline-diabetes-childhood-and-
adolescence, last accessed 5/10/2013.
ISPAD Clinical Practice Consensus Guidelines Compendium 2009 (Pediatr Diabetes 2009; 10
(Suppl 12): 1-210).
This supporting literature was also cited:
Executive summary: Standards of medical care in diabetes--2013. Diabetes Care [Insulin
Dosing]. 2013;36(Suppl 1):S4-10. Accessed 20121224; 3/14/2013 6:01:49 PM. http://
dx.doi.org/10.2337/dc13-S004.
Summary of revisions for the 2013 clinical practice recommendations. Diabetes Care [Insulin
Dosing]. 2013;36(Suppl 1):S3. Accessed 20121224; 3/14/2013 6:01:49 PM. http://
dx.doi.org/10.2337/dc13-S003.
National Evidence-Based Clinical Care Guidelines for Type 1 Diabetes for Children, Adolescents
and Adults. . http://www.nhmrc.gov.au/_files_nhmrc/publications/attachments/
ext004_type1_diabetes_children_adolescents_adults.pdf. Updated 2011.
Exubera: Inhaled insulin for diabetes. Drug Ther Bull [Insulin Dosing]. 2007;45(1):5-8.
Lexi-Comp pediatric and neonatal Lexidrugs: Glucagon. . http://www.crlonline.com/lco/action/
doc/retrieve/docid/pdh_f/130114. Accessed 3/14/13, 2013.
American Diabetes A, Clarke W, Deeb LC, et al. Diabetes care in the school and day care
setting. Diabetes Care [Insulin Dosing]. 2013;36(Suppl 1):S75-9. Accessed 20121224; 3/14/
2013 6:01:49 PM. http://dx.doi.org/10.2337/dc13-S075.
American Diabetes A, Lorber D, Anderson J, et al. Diabetes and driving. Diabetes Care [Insulin
Dosing]. 2013;36(Suppl 1):S80-5. Accessed 20121224; 3/14/2013 6:01:49 PM. http://
dx.doi.org/10.2337/dc13-S080.
Aschner P, Horton E, Leiter LA, Munro N, Skyler JS, Global Partnership for Effective
Diabetes,Management. Practical steps to improving the management of type 1 diabetes:
Recommendations from the global partnership for effective diabetes management. Int J Clin
Pract [Insulin Dosing]. 2010;64(3):305-315. Accessed 12/7/2012 7:01:01 PM.
Betts P, Brink S, Silink M, Swift PG, Wolfsdorf J, Hanas R. Management of children and
adolescents with diabetes requiring surgery. Pediatr Diabetes. 2009;10(Suppl 12):169-174.
Accessed 20090916. http://dx.doi.org/10.1111/j.1399-5448.2009.00579.x.
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