Sick Day Management
Lori Laffel, MD, MPH
Endocrinology and Metabolism Clinics of North America. 2000;29
(4):707-723.
Never Omit Insulin
- Insulin must be taken during illness, even if eating is greatly
diminished.
- Infection promotes insulin resistance; therefore, increased or supplemental
doses of insulin are often required to manage hyperglycemia and ketosis.
- Monitors that measure ß-hydroxybutyrate are now available and may help
determine the appropriate dosage of supplemental insulin and may improve
sick-day management.
Prevent Dehydration and Hypoglycemia
- Oral hydration is preferred.
- During times of nausea and vomiting, attempts at oral hydration with
frequent small quantities of clear fluids are recommended.
- If vomiting persists, the patient's healthcare team should be notified
immediately.
- Blood sugar levels will determine whether patients should consume
sugar-containing or sugar-free fluids.
Monitor Blood Sugar Frequently
- Blood sugar monitoring should be performed at least every 2-4 hours.
- If blood sugar is low, more frequent monitoring is recommended.
- Careful records should be maintained to track illness progression and
detect early signs of decompensation before the development of frank
ketoacidosis.
Monitor for Ketosis
- The availability of blood monitors that measure ß-Hydroxybutyrate has
revealed the weaknesses of urine ketone testing.
- Blood measurement of ß-Hydroxybutyrate "may be a better guide to
insulin therapy in home management of ketosis".
- "Ketone testing is reccommended for all people with type 1 diabetes
during periods of acute illness, when preprandial glucose levels are elevated
(>14.0 mmol/L) and when symptoms of diabetes ketoacidosis (DKA) sych as
nausea, vomiting or abdominal pain are present 2".
- "If all of the above conditions are present, ketone testing should be
considered for type 2 patients as DKA may occur also in these
individuals2"
.
Provide Supplemental Fast-Acting or Rapid-Acting Insulin
- During any period of intercurrent illness, blood sugar and ketone levels
should be monitored every 2-4 hours.
- "Supplemental doses of fast-acting (regular) or rapidly acting (lispro)
insulin should be administered in addition to usual insulin dosages whenever
hyperglycemia and ketosis are present".
Treat Underlying Triggers
- Viral infections not requiring specific prescriptive therapy may still
elevate blood glucose and produce ketosis, making sick-day management
necessary.
- Patients with a history of recurrent diabetic ketoacidosis (DKA), known
eating disorders or psychosocial problems, or poor glycemic control are at risk
for decompensation.
- These patients should call their health care team at the first sign of
illness or decompensation.
Maintain Frequent Contact With the Medical Team
- Patients and family members need to look for signs that medical attention
is needed, including:
- Continued vomiting lasting more than 2-4 hours
- Persistent ketones for more than 12 hours
- Signs of dehydration, including dry mouth, weight loss or sunken eyes
- Symptoms of DKA development, including nausea, abdominal or chest pain,
ketotic breath, hyperventilation or altered consciousness
Conclusions
- Sick-day management requires increased monitoring of blood glucose and
assessment for ketosis.
- The American Diabetes Association states that blood ketone testing is
preferred over urine ketone testing as a more reliable method of diagnosing
diabetic ketoacidosis. 1
References
1 © 2004 American Diabetes Association. From Diabetes Care, Vol. 27,
Supplement 1, 2004; S91-S93. Reprinted with permission from The American
Diabetes Association. This is not intended to be taken as an endorsement by the
American Diabetes Association.
2. Canadian Diabetes Association. 2003 Clinical Practice Guidelines for the
Prevention and Management of Diabetes in Canada. This is not intended to be
taken as an endorsement by the Canadian Diabetes Association.