Diabetes and Sick Day Management
Many of the questions/comments that I receive pertain to the "sick day" management of diabetes. As I have never devoted an entire blog to this most important topic, it seems that this information would be most handy when needed unexpectedly. The key to management is to avoid:
3. hyperglycemia without ketones
4. hyperglycemia with ketones leading to DKA
5. treatment of constitutional symptoms
Insulin management is specific to each insulin regime under the direction of your diabetes team. However, I will provide the Children's National Medical Center diabetes team guidelines that you may apply with the modification of your own healthcare team.
1. Dehydration: It is important to maintain hydration when ill, due to the propensity of decreased oral input along with associated symptoms of nausea, vomiting, and diarrhea.
a. Try to drink liquids: if running low, consume beverages with carbohydrate. If high, consume carbohydrate free liquids. If vomiting, consume small amounts frequently to avoid aggravating the gastro-colic reflex. With diarrhea, drink large amounts of fluid less frequently. It is not necessary to eat solids as long as you are consuming fluids.
b. Danger signals
i. Decreased or no urination in 8 hours
ii. Lack or decreased tears
iii. Dry mucous membranes (mouth)
iv. Persistent vomiting
a. Decreased oral intake can lead to hypoglycemia. It is important to consume beverages to increase serum blood glucose levels and to avoid ketones that may develop secondary to starvation ketosis. These ketones will resolve after consuming fluids with carbohydrates.
b. Fluids that would be acceptable include juice (4 0z=15 grams of carbohydrate), Gatorade with carbs, popsicles (with glucose), Jell-O, etc.
c. Glucose gel or cakemate if necessary
d. "Low dose glucagon" - a method to safely increase serum glucose with your emergency glucagon kit. Mix the powder in the vial with provided diluent in the syringe and then draw up the mixture from the vial in an insulin syringe: 1 unit/year (age) of your child up to 15 units. (for example, 4 year old= 4 units of glucagon, 15 year old =15 units of glucagon). This treatment may be repeated in 20 to 30 minutes. The mixed glucagon must be tossed after 24 hours. This treatment should be done in conjunction with your diabetes team, as frequent contact will be required.
3. Hyperglycemia without ketones
a. Insulin management
i. Split mixed insulin: Apply your sliding scale if provided. If you do not have a sliding scale, a rule of thumb is to give 10 percent of your total daily dose (add up all the NPH and regular/rapid acting insulin) as either the fast acting (regular) or rapid acting (humalog, novolog or apidra). This may be repeated every 4 to 6 hours (regular) or 3 hours if rapid acting is used.
ii. If there is the presence of moderate/large urine ketones or >1.0 blood ketones (precision extra blood ketone strips), it is important to provide the necessary fluids: 8 oz every one hour and insulin every 3 to 4 hours depending on insulin (rapid acting or regular). I would suggest providing an extra 20 percent of the total daily dose as rapid acting or regular insulin every 3 to 4 hours.
1. Total daily dose examples
a. 12 NPH/6 regular/rapid acting at breakfast
b. 4 regular/rapid acting at dinner
c. 4 NPH at bedtime
Total amount of insulin= 26 units
d. Hyperglycemia: no ketones: @ 2.5 units
Regular or rapid acting
e. Hyperglycemia: moderate/large ketones or >/= 1.0 serum ketones: @ 5.0 units regular or fast acting.
iii. Basal/Bolus: insulin pump/multiple daily injections with Lantus/rapid acting
1. Hyperglycemia without ketones: use correction factor (insulin sensitivity factor) every 3 hours as necessary.
Such as: Blood sugar (400)-target (150)/ CF (50)= 5 units
2. Hyperglycemia with ketones (moderate/large or serum ketones >/=1.0.
Such as: Blood sugar (400)-target (150)/ CF (50)= 5 units PLUS an extra 20 percent (of the 5 units)= 6 units.
NOTE: If on an insulin pump, give dose by injection and then change infusion set and site.
Drink 8 oz every hour to help clear ketones as it is important to administer both fluids and insulin.
1. Persistent ketones despite administering insulin by injection
2. Persistent vomiting and increasing abdominal pain
3. Weakness and changed mental state
4. Decreased urination
5. Rapid respirations (Kussmaul respirations)
4. Treatment of constitutional symptoms:
a. Feel free to use fever reducing medications (acetaminophen, Advil etc.) Do NOT use aspirin as it has been associated with Reyes Syndrome. Don't worry too much if there is glucose in the medication; you can always administer more insulin.
b. Increase fluids- if blood sugar is low, use fluids with carbs. If blood sugar is high, use carb-free liquids.
c. Do NOT omit insulin (especially basal), as you need the insulin despite illness to avoid the development of ketones.
d. CALL your diabetes team with any worrisome symptoms as described above in DANGER SIGNALS, as they will give you specific instructions unique to your particular diabetes regimen.
BE SAFE! And always remember to talk to your physician!
If you're in the DC area, be sure to purchase a ticket to the April 25 game between the Washington Nationals and Los Angeles Dodgers and support children with diabetes!