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: DiabetesNonDKA@seattlechildrens.org

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: DiabetesNonDKA@seattlechildrens.org

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.

Return to Home

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

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American Diabetes A. Standards of medical care in diabetes--2013. Diabetes Care [Insulin

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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/

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American Diabetes A, Lorber D, Anderson J, et al. Diabetes and driving. Diabetes Care [Insulin

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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:

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Betts P, Brink S, Silink M, Swift PG, Wolfsdorf J, Hanas R. Management of children and

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