Sick day rules for diabetes

You receive a phone call from the mother of a 7-year-old child with diabetes – he’s been unwell all day with temperatures and coryza symptoms, and he’s off his food.

The BSLs have been creeping up all day and are now 16 mmol/l.She’s not sure what else to do, so they are on their way to the hospital.

You’re the paediatric registrar on, and it’s down to you to manage this before he gets into DKA. Are you up to the task?

What happens to blood sugar levels when children with diabetes get an intercurrent illness?

The BSLs can be high or low.

With vomiting and diarrhoea, the BSLs may well be low due to reduced intake but also poor absorption from oral intake.

Although it might seem counterintuitive, BSLs often go high even though the child is unwell and not eating as much as normal (particularly with pyrexial illnesses).  The body’s stress response is to produce more glucose and this is often resistant to insulin.

Where does ketone monitoring come in?

When your patient has high BSLs (>15 mmol/l) and is unwell, the main focus is to monitor ketone levels, as the illness could lead to DKA if not managed correctly – blood ketones are preferable to urine ketones because they appear earlier.

If ketones are present and BSL > 15 mmol/l, give extra insulin as below, then check again in 2 hours.  Don’t go overboard with checking every five minutes!

How do I manage the unwell diabetic?

There are three key aims of management: to prevent dehydration, DKA, and hypoglycaemia.

• Encourage the patient to drink fluids (carbs if BSL<8 mmol/L and sugar-free if BSL>8 mmol/l) – go for small volumes often.
• Keep the normal insulin doses going if sugars are high!

How much insulin should I give?

Give extra doses according to the table.  Add up the total number of units per day, then calculate the percentage accordingly (e.g., if the patient has 20 units of insulin per day, then 10% is 2 units).  If you need to give repeated doses, then make sure the consultant is aware.

Table reconstructed from the wonderful book by Ambler and Cameron (see refs).

What if the blood sugar is low?

Use Gatorlyte or Hydralyte and additional carbs if needed.  Follow the guide in the table.

If you really cannot push oral intake and the BSL is <4 mmol/l, then consider glucagon

1 unit of glucagon per year of age (i.e. 7 units for a 7-year-old) – administer just like an insulin injection. Then recheck BSL in 30 mins.

References

Ambler G, Cameron F. Caring for diabetes in children and adolescents. Blue Star Print Group: 3rd edition. 2010:p 98.