Nationwide Children's

Diabetes Sick Day Protocol

We know that some days you don’t feel your best. Having diabetes can make those sick days even more challenging. Whether you manage your diabetes with an insulin pump or injections, this quick 5 step tool will provide you and your caregiver with recommendations for dealing with diabetes when you are sick.

BEGIN

Small to Large Ketones

Give a hyperglycemia correction bolus* PLUS a keton correction bolus.
Continue to sip on carbohydrate-FREE fluids.
Go back to start of Sick Day Protocol every 3 hours.

*Only if it has been 3 hours since last carb and/or rapid-acting insulin dose.

Negative to Trace Ketones

Give hyperglycemia correction bolus*.
Continue to sip on carbohydrate-FREE fluids.
Go back to start of Sick Day Protocol every 3 hours.

*Only if it has been 3 hours since last carb and/or rapid-acting insulin dose.

Test for Ketones

Small to Large Ketones

Negative to Trace Ketones

Small to Large Ketones

Give a hyperglycemia correction bolus* PLUS a ketone correction bolus.
Continue to sip on carbohydrate-FREE fluids.
Go back to start of Sick Day Protocol every 3 hours.

*Only if it has been 3 hours since last carb and/or rapid-acting insulin dose, or if using active insulin feature on pump.

Negative to Trace Ketones

Give hyperglycemia correction bolus*
Continue to sip on carbohydrate-FREE fluids.
Go back to start of Sick Day Protocol every 3 hours.

*Only if it has been 3 hours since last carb and/or rapid-acting insulin dose, or if using active insulin feature on pump.

Check for Ketones

Small to Large Ketones

Negative to Trace Ketones

Moderate to Large Ketones

Go to the Emergency Room!

Negative to Small Ketones

1. Sip on carbohydrate-CONTAINING fluids, 1-2 tablespoons every 15-20 minutes. Do not give insulin for these carbs.

2. If NOT ABLE to treat low blood glucose or vomit immediately after treating, Call your diabetes doctor.

3. Recheck blood glucose in 15 minutes.

If BELOW 100, go back to step 1 (Sip on carb...)

If ABOVE 100, continue to sip on carbohydrate-FREE fluids and go back to start of Sick Day Protocol every 3 hours.

Test for Ketones

Moderate to Large Ketones

Negative to Small Ketones

Check Blood Glucose

High: Above 150

Normal: 80-150

Low: Below 80

Negative to Trace Ketones

1. Give hyperglycemia correction bolus* (plus carb bolus, if eating).

2. Go back to start of "Sick Day Protocol" every 3 hours.

*Only if it has been 3 hours since last carb and/or rapid-acting insulin dose.

Small to Large Ketones

1. Give a hyperglycemia correction bolus* PLUS ketone correction bolus (plus a carb bolus, if eating).

2. Give 8 oz. of CARBOHYDRATE FREE fluids every 30-60 minutes.

3. Go back to start of "Sick Day Protocol" every 3 hours.

*only if it has been 3 hours since last carb and/or rapid-acting insulin dose.

Test for Ketones

Negative to Trace Ketones

Small to Large Ketones

1. Give a hyperglycemia correction bolus PLUS ketone correction bolus (plus a carb bolus, if eating).

2. Give 8 oz. of CARBOHYDRATE FREE fluids every 30-60 minutes.

3. Go back to start of "Sick Day Protocol" every 3 hours.

*only if it has been 3 hours since last carb and/or rapid-acting insulin dose.

Negative to Trace Ketones

1. Give hyperglycemia correction bolus* (plus carb bolus, if eating).

2. Go back to start of "Sick Day Protocol" every 3 hours.

*Only if it has been 3 hours since last carb and/or rapid-acting insulin dose

Test for Ketones

Small to Large Ketones

Negative to Trace Ketones

1. Recheck blood glucose in 15 minutes.

If BG ABOVE 80:

1. Restart Sick Day Protocol every 3 hours.

If BG BELOW 80:

1. Treat with 15 grams of carbohydrate. Do not give insulin for these carbs.

2. Recheck blood glucose in 15 minutes. If still below 80, continue to treat with 15 grams of carbohydrates and recheck blood glucose in 15 minutes until above 80.

Positive Ketones

1. Encourage carbohydrate-containing fluids. Do not give insulin for these carbs.

2. Recheck blood glucose in 15 minutes.

If BG ABOVE 80:

1. If ketones are small to large, give a ketone correction bolus

2. Restart Sick Day Protocol every 3 hours.

If BG BELOW 80:

1. Treat with 15 grams of carbohydrate. Do not give insulin for these carbs.

2. Test for Ketones.

If Negative to Trace Ketones, start from the top.
If Positive Ketones, encourage carbohydrate-containing fluids. Do not give insulin for these carbs. Restart at top.

15 grams of carbohydrates, No Insulin, Check for Ketones

Negative to Trace Ketones

Positive Ketones

Check Blood Glucose

High: Above 150

Normal: 80-150

Low: Below 80

Are you able to drink?

No

Yes

Small to Large Ketones

Drink carbohydrate containing fluids to raise blood sugar above 150.
Change infusion set.
Recheck blood sugar in 30 minutes. If over 150, give ketone correction.
Give 8oz. of CARBOHYDRATE FREE fluids every 30-60 minutes.
Go back to start of "Sick Day Protocol" every 3 hours.

*only if it has been 3 hours since last carb and/or rapid-acting insulin dose, or if using active insulin feature on pump.

Negative to Trace Ketones

1. Give hyperglycemia correction bolus* (plus carb bolus, if eating).

2. Go back to start of "Sick Day Protocol" every 3 hours.

*Only if it has been 3 hours since last carb and/or rapid-acting insulin dose, or if using active insulin feature on pump.

Test for Ketones

Small to Large Ketones

Negative to Trace Ketones

Small to Large Ketones

1. Use an insulin syringe/pen to give a hyperglycemia correction bolus* PLUS ketone correction bolus (plus a carb bolus, if eating).

2. Change infusion set.

3. Give 8 oz. of CARBOHYDRATE FREE fluids every 30-60 minutes.

4. Go back to start of "Sick Day Protocol" every 3 hours.

*only if it has been 3 hours since last carb and/or rapid-acting insulin dose, or if using active insulin feature on pump.

Negative to Trace Ketones

Give carb bolus, if eating.
Drink 8oz. CARBOHYDRATE FREE fluids every 30-60 minutes.
Go back to start of "Sick Day Protocol" every 3 hours.

*Only if it has been 3 hours since last carb and/or rapid-acting insulin dose, or if using active insulin feature on pump.

Test for Ketones

Small to Large Ketones

Negative to Trace Ketones

Positive Ketones

Encourage carbohydrate-containing fluids. Do not give insulin for these carbs.
Recheck blood glucose in 15 minutes.

If BG ABOVE 80:

If ketones are small to large, give a ketone correction bolus
Restart "Sick Day Protocol" every 3 hours.

If BG BELOW 80:

Use temporary basal rate decrease by 10% for 2 hours
Treat with 15 grams of carbohydrate. Do not give insulin for these carbs.
Recheck blood sugar in 30 minutes. If over 150, give ketone correction.
Give 8oz. of CARBOHYDRATE FREE fluids every 30-60 minutes.
Restart "Sick Day Protocol".

Negative to Trace Ketones

1. Recheck blood glucose in 15 minutes.

If BG ABOVE 80:

1. If ketones are small to large, give a ketone correction bolus.

2. Restart Sick Day Protocol every 3 hours.

If BG BELOW 80:

1. Decrease basal rate by 10% for 2 hours

2. Treat with 15 grams of carbohydrate. Do not give insulin for these carbs.

3. Test for Ketones.

If Negative to Trace Ketones, start from the top.
If Positive Ketones, encourage carbohydrate-containing fluids. Do not give insulin for these carbs. Restart at top.

15 grams of carbohydrates, No Insulin, Check for Ketones

Positive Ketones

Negative to Trace Ketones

Check Blood Glucose

High: Above 150

Normal: 80-150

Low: Below 80

Small to Large Ketones

Use an insulin syringe/pen to give hyperglycemia correction bolus* PLUS a ketone correction bolus.
Change infusion set.
Continue to sip on carbohydrate-FREE fluids.
Go back to start of Sick Day Protocol every 3 hours.

*Only if it has been 3 hours since last carb and/or rapid-acting insulin dose, or if using active insulin feature on pump.

Negative to Trace Ketones

Give hyperglycemia correction bolus*.
Continue to sip on carbohydrate-FREE fluids.
Go back to start of Sick Day Protocol every 3 hours.

*Only if it has been 3 hours since last carb and/or rapid-acting insulin dose, or if using active insulin feature on pump.

Test for Ketones

Small to Large Ketones

Negative to Trace Ketones

Small to Large Ketones

Use an insulin syringe/pen to give hyperglycemia correction bolus* PLUS a ketone correction bolus.
Change infusion set.
Continue to sip on carbohydrate-FREE fluids.
Go back to start of Sick Day Protocol every 3 hours.

*Only if it has been 3 hours since last carb and/or rapid-acting insulin dose, or if using active insulin feature on pump.

Negative to Trace Ketones

Give carb bolus, if eating.
Drink 8oz. of CARBOHYDRATE FREE fluids every 30-60 minutes.
Go back to start of "Sick Day Protocol" every 3 hours.

*Only if it has been 3 hours since last carb and/or rapid-acting insulin dose, or if using active insulin feature on pump.

Test for Ketones

Small to Large Ketones

Negative to Trace Ketones

Moderate to Large Ketones

Go to the Emergency Room!

Negative to Small Ketones

Use temporary basal rate decrease of 10%.
Sip on carbohydrate-CONTAINING fluids, 1-2 tablespoons every 15-20 minutes. Do not give insulin for these carbs.
If NOT ABLE to treat low blood glucose or vomit immediately after treating, Call your Diabetes doctor.
Recheck blood glucose in 15 minutes

If BG BELOW 150, go back to top (Step 1 above).

If BG ABOVE 150, continue to sip on carbohydrate-FREE fluids and go back to start of Sick Day Protocol every 3 hours.

Test for Ketones

Moderate to Large Ketones

Negative to Small Ketones

Check Blood Glucose

High: Above 150

Normal: 80-150

Low: Below 80

Are you able to drink?

Yes

No

How are you managing your insulin?

Insulin Injection

Insulin Pump

Disclaimer

Nationwide Children’s Hospital’s Diabetes Sick Day Protocol is for informational purposes only. Your use and access to this tool is subject to the following terms and conditions:

The use and information from the Diabetes Sick Day Protocol, should not be used in place of consultation with your physician or other health care provider. These materials are for informational purposes only and are not intended to be a substitute for professional medical advice, diagnosis or treatment. You should always seek the advice of your physician or other qualified health care provider prior to stopping or adjusting any treatment. If you have any questions regarding your medical treatment you should contact your physician or health care provider immediately.

Nationwide Children’s Hospital is not responsible for any consequences resulting from the use or misuse of the information contained on this website, or for injuries or damages you may incur as a result of stopping or adjusting medical treatment, or your failure to obtain medical treatment.

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