To identify patients with hyperglycemia and/or mild ketoacidosis and initiate treatment per algorithm To create a sick day plan for patients able to orally rehydrate, create sick day plan for them upon discharge with close follow-up with their diabetes specialist CLINICAL PEARLS AND PITFALLS Fasting laboratory plasma glucose of greater than 126 mg/dL or a random glucose greater than 200 mg/dL on two separate occasions is diagnostic of diabetes in an otherwise healthy person This definition was developed by specialists in adult diabetes and may not be completely applicable to the pediatric population Hyperglycemia in ED setting can result from numerous triggers including intercurrent illness or trauma in patient with known DM, new-onset DM, other illnesses associated with hyperglycemia, spurious blood sample, and medication effect For purposes of definition, a patient with hyperglycemia does not have DKA if venous pH is greater than 7.3 and serum bicarbonate is greater than 15 mEq/L Current Evidence As noted in the previous section on diabetes and the following section on hypoglycemia, glucose homeostasis reflects the balance between glucose input (from gut absorption, hepatic glycogen breakdown, or gluconeogenesis) and disposal (via storage or oxidation) With the exception of gut absorption, this process is largely regulated by insulin, although counterregulatory hormones also have a significant effect Furthermore, tissue factors and medication also impact the insulin effect Clinical Considerations Clinical Recognition Plasma glucose concentrations in the 200 to 300 mg/dL range rarely result in symptoms This level of hyperglycemia may be accompanied by intermittent increased frequency of urination; however, parents are rarely aware of their child’s frequency of urination once the child is toilet trained unless the frequency becomes disruptive (e.g., nocturia or “accidents” at school) Children and adolescents have no sense of what is the normal frequency of urination, so they rarely complain unless the frequent urination is accompanied by dysuria Higher levels of glucose (greater than 300 mg/dL) may be associated with subtle clinical findings, such as blurring of vision or dryness of oral membranes Significant hyperglycemia may occur without significant symptoms and can be tolerated for a prolonged period without clinical signs Triage Generally, these patients are asymptomatic and very well appearing Care must be taken to distinguish from patients with more severe diabetic ketoacidosis and possible cerebral edema Initial Assessment/H&P