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Mar.05.2020

Hyperglycemia (Pediatric ED)

Clinical Description

  • Care of the emergency department pediatric patient seeking treatment for an elevated blood glucose level.

Key Information

  • It is essential to differentiate between DKA (diabetic ketoacidosis) and HHS (hyperosmolar hyperglycemic state) to treat underlying cause successfully. Both usually require fluid and insulin therapy; however, HHS may not require insulin therapy after fluid resuscitation. Precipitating factors must be identified and treated.
  • Insulin therapy can cause an intracellular shift of potassium, further decreasing potassium levels resulting in cardiac dysrhythmia. Consider potassium replacement before insulin therapy, if potassium serum levels are low normal or low after fluid replacement.
  • Severe acute acidemia in DKA (diabetic ketoacidosis) may impact cardiac contractility and cause dysrhythmia.
  • Cerebral edema risk appears to be increased when there is severe dehydration, profound acidosis, hypocapnia and high blood glucose levels.
  • Patients with HHS (hyperosmolar hyperglycemic state) have increased risk for thrombus formation.

Threats to Life, Limb or Function

  • acute neurologic injury
  • DKA (diabetic ketoacidosis)
  • dysrhythmia
  • hemodynamic instability
  • HHS (hyperosmolar hyperglycemic state)

Clinical Goals

By transition of care

A. The patient will achieve the following goals:
  • Goal: Acute Signs/Symptoms are Managed

  • Goal: Acceptable Pain Level Achieved

    Correlate Health Status

    • Correlate health status to:

      • history, comorbidity, congenital anomaly
      • age, developmental level
      • sex, gender identity
      • baseline assessment data
      • physiologic status
      • response to medication and interventions
      • psychosocial status, social determinants of health
      • barriers to accessing care and services
      • child and family/caregiver:
        • health literacy
        • cultural and spiritual preferences
      • safety risks
      • family interaction
      • plan for transition of care

    Hyperglycemia

    Associated Documentation

    • Hyperglycemia Management

    Presentation

    • abdominal pain
    • acetone breath
    • blurred vision
    • confusion
    • excessive thirst
    • frequent urination
    • Kussmaul respirations
    • nausea and vomiting
    • stupor
    • tachycardia
    • weakness

    Associated Signs/Symptoms

    • dehydration
    • unresponsive
    • weight loss

    Potential Causes

    • acute illness
    • alcohol-induced ketoacidosis
    • illicit drug use
    • infection
    • insulin deficiency
    • insulin pump interruption
    • medication noncompliance
    • medication-induced, such as glucocorticoid
    • new-onset diabetes
    • pregnancy

    Initial Assessment

    • fluid status
    • infection signs
    • mental status
    • neurologic status
    • respiratory rate, pattern, effort

    History

    • allergies
    • comorbidities
    • immunization status
    • last menstrual period (females of childbearing age)
    • medications
    • diabetes medication and equipment access
    • insulin administration (type, dose, delivery, schedule)
    • oral antihyperglycemic agent (type, dose, schedule)
    • recent illness
    • usual glycemic control
    • weight loss

    Laboratory Studies

    • ABG (arterial blood gas)
    • anion gap
    • beta-hydroxybutyrate
    • blood glucose level
    • BUN (blood urea nitrogen)
    • Hgb (hemoglobin) A1C
    • lactic acid
    • serum creatinine
    • serum electrolytes
    • serum ketones
    • serum osmolality
    • serum pH
    • VBG (venous blood gasses)

    Diagnostics

    • ECG (electrocardiogram)

    Potential Additional Testing

    • cardiac biomarkers
    • CBC (complete blood count) with differential
    • chest x-ray
    • cultures
    • cultures (blood or urine)
    • pregnancy test (females of childbearing age)
    • radiology studies (to identify infection source)
    • serum amylase
    • urinalysis
    • urine ketones

    Problem Intervention

    Minimize and Manage Fluid and Electrolyte Deficit

    • Assess fluid status and ability to take oral fluids; if unable to provide or achieve oral intake, provide intravenous fluid therapy for fluid and electrolyte replacement.
    • Monitor intake, output and laboratory value trends; advocate for adjustment in treatment with imbalance.
    • Observe respiratory effort and breath sounds.
    • Monitor ECG (electrocardiogram), cardiovascular, neurologic and hemodynamic status; watch for rhythm changes that may indicate fluctuation in serum electrolyte levels, such as potassium.
    • Perform frequent neurologic assessment for signs of cerebral edema, such as restlessness, irritability or pupillary changes.
    • Provide treatment for nausea, vomiting and pain to decrease worsening dehydration and promote patient comfort.

    Problem Intervention

    Monitor and Manage Blood Glucose Level

    • Prepare for medication administration, which may include intravenous or subcutaneous insulin therapy. Begin rehydration before insulin therapy.
    • Perform frequent glucose checks; monitor trends and assess for hypoglycemia risk.
    • Monitor physiologic response.

    Education

    General Emergency Education

    Teaching Focus

    • symptom/problem overview

    • risk factors/triggers

    • self-management

    • assistive device

    • diagnostic test

    • diet modification

    • medical device/equipment use

    • medication administration

    • opioid medication management

    • orthopaedic device

    • safe medication disposal

    • smoking cessation

    • wound care

    Population-Specific Considerations

    Forensics and Legal

    • Utilize local, state/province, federal requirements and hospital policy and protocols to manage patient care involving forensics, protective services, workman’s compensation and mandatory reportable events and illness.

    Human Trafficking

    • Human trafficking victims most frequently seek healthcare services from Emergency Departments. Healthcare professionals, alert to signs of trafficking, can guide supportive care for victims.
    • Trafficked individuals may be male or female and engaged in sex work or other forced labor. High-risk signs requiring more direct questioning about exploitation include, among others, current employment in a high-risk industry, prior sexually transmitted infections, recent immigration and other vulnerable and minority populations, as well as children who are homeless, runaways or in foster care.

    Age-Related

    • Cerebral edema is more common in children less than 5 years of age and is associated with a high mortality rate. If the patient survives, there will likely be permanent neurologic injury. There is no consensus on treatment or actual cause.

    Pregnancy

    • Beyond 20 weeks gestation, supine position should be avoided. Maternal position should be lateral or lateral tilt to prevent compression of the inferior vena cava and aorta by the pregnant uterus.
    • Pregnant women with diabetes can develop DKA (diabetic ketoacidosis) at lower blood glucose levels than nonpregnant diabetic patients. Left untreated it can have severe effects on the fetus and the mother.

    References

    • American Diabetes Association. Standards of medical care in diabetes. Diabetes Care. 2020;43(Supplement 1), S1-S211. doi:10.2337/dc20-SPPC Source[Quality Measures,Clinical Practice Guidelines]
    • American Heart Association; The American Academy of Pediatrics. (2016). Pediatric advanced life support provider manual. United States: American Heart Association. [Review Articles,Expert/Committee Opinion,Core Curriculum,Position Statements,Practice Bulletins]
    • Andrade-Castellanos, C. A.; Colunga-Lozano, L. E.; Delgado-Figueroa, N.; Gonzalez-Padilla, D. A. Subcutaneous rapid-acting insulin analogues for diabetic ketoacidosis. Cochrane Database of Systematic Reviews. 2016;(1) doi:10.1002/14651858.CD011281.pub2 [Metasynthesis,Meta-analysis,Systematic Review]
    • Beltran, G.. Diabetic emergencies: New strategies for an old disease. Emergency Medicine Practice. 2014;16(6), 1-19. [Review Articles,Expert/Committee Opinion,Core Curriculum,Position Statements,Practice Bulletins]
    • Centers for Medicare & Medicaid Services (CMS). (2017). NQF 0495. Median Time from ED Arrival to ED Departure for Admitted ED Patients. Source[Quality Measures,Clinical Practice Guidelines]
    • Centers for Medicare & Medicaid Services (CMS). (2017). NQF 0496. Median time from ED arrival to ED departure for discharged ED patients. Source[Quality Measures,Clinical Practice Guidelines]
    • Chua, H. R.; Schneider, A.; Bellomo, R. Bicarbonate in diabetic ketoacidosis-a systematic review. Annals of Intensive Care. 2011;1(1), 43123. [Metasynthesis,Meta-analysis,Systematic Review]
    • Emergency Nurses Association. (2018). Emergency nursing core curriculum. St. Louis: Elsevier. [Review Articles,Expert/Committee Opinion,Core Curriculum,Position Statements,Practice Bulletins]
    • Emergency Nurses Association. (2020). Sweet, V.; Foley, A (Eds.), Sheehy's Emergency Nursing Principles and Practice. St. Louis: Mosby, Elsevier. [Review Articles,Expert/Committee Opinion,Core Curriculum,Position Statements,Practice Bulletins]
    • Fayfman, M.; Pasquel, F. J.; Umpierrez, G. E.. Management of hyperglycemic crises: Diabetic ketoacidosis and hyperglycemic hyperosmolar state. Medical Clinics of North America. 2017;101(3), 587-606. doi:10.1016/j.mcna.2016.12.011 Source[Review Articles,Expert/Committee Opinion,Core Curriculum,Position Statements,Practice Bulletins]
    • Glaser, N.; Kuppermann, N. Fluid treatment for children with diabetic ketoacidosis: How do the results of the pediatric emergency care applied research network Fluid Therapies Under Investigation in Diabetic Ketoacidosis (FLUID) Trial change our perspective?. Pediatric Diabetes. 2019;20, 10-14. doi:10.1111/pedi.12795 Source[Review Articles,Expert/Committee Opinion,Core Curriculum,Position Statements,Practice Bulletins]
    • Greenbaum, J.. Identifying victims of human trafficking in the emergency department. Clinical Pediatric Emergency Medicine. 2016;17(4), 241-248. [Review Articles,Expert/Committee Opinion,Core Curriculum,Position Statements,Practice Bulletins]
    • Hammond, B. B.; Zimmermann, P. G. (2013). Sheehy's manual of emergency care. St. Louis: Mosby, Elsevier. [Review Articles,Expert/Committee Opinion,Core Curriculum,Position Statements,Practice Bulletins]
    • Long, B.; Koyfman, A. Emergency medicine myths: Cerebral edema in pediatric diabetic ketoacidosis and intravenous fluids. Journal of Emergency Medicine. 2017;53(2), 212-221. doi:https://doi.org/10.1016/j.jemermed.2017.03.014 [Review Articles,Expert/Committee Opinion,Core Curriculum,Position Statements,Practice Bulletins]
    • Moritz, M. L.; Ayus, J. C. Maintenance intravenous fluids in acutely ill patients. New England Journal of Medicine. 2015;373(14), 1350-1360. doi:10.1056/NEJMra1412877 [Review Articles,Expert/Committee Opinion,Core Curriculum,Position Statements,Practice Bulletins]
    • National Institute for Health and Care Excellence. (2015). Intravenous fluid therapy in children and young people in hospital. (NICE guideline [NG29]). Source[Quality Measures,Clinical Practice Guidelines]
    • Siddiqi, L.; VanAarsen, K.; Iansavichene, A.; Yan, J. Risk factors for adverse outcomes in adult and pediatric patients with hyperglycemia presenting to the emergency department: A systematic review. Canadian Journal of Diabetes. 2019;43(5), 361-369. [Review Articles,Expert/Committee Opinion,Core Curriculum,Position Statements,Practice Bulletins]
    • Skitch, S. A.; Valani, R.. Treatment of pediatric diabetic ketoacidosis in canada: A review of treatment protocols from canadian pediatric emergency departments. Canadian Journal of Emergency Medicine. 2015;17(6), 656-661. doi:10.1017/cem.2015.56 [Review Articles,Expert/Committee Opinion,Core Curriculum,Position Statements,Practice Bulletins]
    • Troiano, N. H.; Witcher, P. M.; McMurtry Baird, S.. (2019). AWHONN: High-risk & critical care obstetrics. Philadelphia: Wolters Kluwer. [Review Articles,Expert/Committee Opinion,Core Curriculum,Position Statements,Practice Bulletins]
    • U. S. Department of Health and Human Services. (2017). Human trafficking webinar for health care providers: SOAR to health and wellness. Source[Review Articles,Expert/Committee Opinion,Core Curriculum,Position Statements,Practice Bulletins]
    • Wolfsdorf, J. I.; Glaser, N.; Agus, M.; Fritsch, M.; Hanas, R.; Rewers, A.; Sperling, M. A.; Codner, E. ISPAD Clinical Practice Consensus Guidelines 2018: Diabetic ketoacidosis and the hyperglycemic hyperosmolar state. Pediatric Diabetes. 2018;19(Suppl 27), 155-177. doi:10.1111/pedi.12701 [Quality Measures,Clinical Practice Guidelines]

    Disclaimer

    Clinical Practice Guidelines represent a consistent/standardized approach to the care of patients with specific diagnoses. Care should always be individualized by adding patient specific information to the Plan of Care.