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Question:

From Sacramento, California, USA:

When children with diabetes have flu and vomiting, my experience has been that IV fluids turn them around quickly, both in eliminating ketones and reducing blood sugar levels. Why do physicians insist on keeping these kids at home for so long when it is inevitable anyway? Why is there no outpatient IV therapy?

Answer:

The question you ask is an interesting one. The two commonest causes of serious acidosis in young people are still intercurrent infections and failure to take their insulin for psychosocial reasons. Twenty years ago in this center we nearly always admitted them, usually only for 24 hours and after a few hours of intravenous fluids and insulin with specific treatment for the infection, if appropriate, they were ready to go home. Because of the inconvenience to parents and to some extent because of the cost, we then started to manage these problems as outpatients. This took only four to six hours; but it did mean that it was necessary to divert nursing time from the routine clinic and of course it was much less costly. The final phase, which has greatly reduced the need for any sort of hospitalization has been to ensure ready access to a nurse, a physician assistant and if necessary a doctor 'at the drop of a hat' so to speak. Parents and teenagers are encouraged to get in touch right away if they have blood sugars above 250 mg/dl and have moderate ketones. In the great majority of cases, with two hourly phone contact and extra fluids orally as well as insulin, both inpatient and out patient care can be avoided. Of course this approach is not feasible when there is no one to stay home with the child and especially in teenagers and where these episodes are repeated it is very important to involve the medical social worker in a search for psychosocial issues.

I am sure that in these days of 'managed care' cost is a factor; but certainly in those instances where prevention has not worked and vomiting has not been contained by suppository medication there should be no hesitation in instituting intravenous therapy.

DO'B

[Editor's comment: In my patients (who are adults), I always advise that they plan to go to the ER at the second episode of any vomiting illness, to get IV fluids. But many times the patients are too stubborn (or too mentally befuddled by the acute illness) to go. WWQ]

[Editor's comment: As the parent of a child with diabetes, I have never been reluctant to take my daughter to the hospital if I felt it was needed and have never had a physician, pediatrician or endocrinologist, who balked at my suggestion. In the few instances when we did go to the hospital for IV glucose, my daughter was experiencing severe vomiting with low blood sugar that could not be restored to normal levels. JH]

Original posting 29 Jul 97

  
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Last Updated: Tuesday April 06, 2010 15:08:54
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