Mercy Hospital and Medical Center Diabetic Ketoacidosis Treatment Guidelines Monitor TEST Blood glucose monitoring POC Vital signs (Pulse, heart rate, respirations) Chem 12 Monitor intake / output Chem 7 Phosphorous level CBC w/ auto differential Magnesium level Arterial blood gas Urinalysis w/ microscopic EKG Chest X-ray Blood culture, if febrile Urine culture, if febrile OTHER testing, as clinically indicated APRIL 2012 FREQUENCY Q1 hour Q1 hour Stat once Q1 hour Q2 hours (if stable, and corrected CO2 >15, then q4 hours Stat, if abnormal, then q4 hours Stat, prn Stat, prn Stat, prn Stat, prn Stat, prn Diet Orders   NPO NPO with ice chips and sips of water Fluids and Electrolytes □ Initiate 0.9NS IL IV @ 15mL/kg/hr for 1-2 hours and then 7.5mL/kg/hr □ Call physician for IVF orders for hemodialysis (or heart failure patients) IVF Options □ 0.9% NS 1L at ____ mL/hour □ 0.45% NS 1L at ____mL/hour □ 0.9% NS with 20mEq/L at ____ mL/hour □ 0.9% NS with 40mEq/L at ____ mL/hour □ 0.45% NS with 20mEq/L at ____ mL/hour □ 0.45% NS with 40mEq/L at ____ mL/hour □ D5W / 0.45% NS 1L at ____ mL/hour □ D5W / 0.45% NS 1L with 20mEq/L at ____ mL/hour □ D5W / 0.45% NS 1L with 40mEq/L at ____ mL/hour □ D10W / 0.45% NS 1L at ____ mL/hour □ Other _________________________ at ____ mL/hour MEDICATIONS: pH < 7.0  For pH 6.9 - 7: Sodium Bicarbonate 50mEq IV in 0.45% NS 250mL IV over 1 hr  For pH < 6.9: Sodium Bicarbonate 100mEq IV in 0.45% NS 500mL IV over 2 hr Initial Potassium Replacement Potassium < 3.3 Peripheral access:  KCl 40mEq in 500mL over 4 hours  KPhos 30 mmol in 500 mL over 4 hours (consider if phos is <2.5) Central access:  KCl 40mEq in 100mL over __ hours (recommend 1-4 hour infusion)  KPhos 30 mmol in 250 mL over _____ hours Potassium 3.3 – 4, add KCL 40 mEq / L to maintenance IVF  0.45% NS 1L + potassium chloride 40mEq IV at ____mL/hour  0.9% NS 1L + potassium chloride 40mEq IV at ____mL/hour Potassium 4.1 – 5, add KCL 20 mEq / L to maintenance IVF  0.45% NS 1L + potassium chloride 20mEq IV at ____mL/hour  0.9% NS 1L + potassium chloride 20mEq IV at ____mL/hour When K > 3.3, Start Insulin drip  Regular insulin IV Bolus  Regular insulin 0.1 units/kg (IBW) IV x1  Regular insulin ___units/kg (IBW) IV x1  Regular insulin 100 units / 0.9% NS 100 mL continuous IV infusion  Initiate drip at 0.1 units/kg/hour (IBW) IV  Initiate drip at ___units/kg/hour (IBW) IV Mercy Hospital and Medical Center DKA Management Algorithm (Nursing and Physician Guidance Document) Nursing Management of Insulin Infusion      When initiating insulin infusion, prime tubing by running 30mL through infusion tubing before connecting to patient Use Ideal Body Weight (IBW) for dosing If K+ < 3.3 at the time of insulin administration, promptly notify physician Initiate insulin drip at 0.1 units/kg/hour (or other dose written by physician) Monitor glucose q1 hour. Titrate insulin drip using the below table TABLE 1: Insulin Drip Titration (for use after insulin drip initiation) Glucose (mg/dL) Insulin Drip (units/hr) Increase drip by 4 units/hr (or 25 %, which ever increase is less) >500  251-500   151-250  When the plasma glucose reaches 250 mg/dl in DKA, decrease the insulin infusion rate to 0.05 - 0.1 unit/kg/h (or 3–6 units/h) IV fluids should contain D5W if glucose is <250mg/dL. Call physician, if needed. Decrease insulin drip by 50% 101-150 Hold insulin drip for 1 hour (if still 71-100 at next hour, continue to hold and call MD) 71-100 <70 Do not adjust rate if blood glucose is decreasing by 50-75 mg/dL/hr If blood glucose is NOT decreasing by 5075 mg/dL/hr, then increase the drip rate by 2 units/hr       Hold insulin drip (if not already held) Give dextrose 50%, 12.5 grams IV Contact physician Recheck blood glucose in 15 minutes Follow titration as above Physician may change IV fluids to D10W Transitioning from Insulin drip to subcutaneous regimen  Criteria for insulin drip discontinuation o Serum glucose < 250 o Venous CO2 content  19 o Anion gap  12 o Patient is tolerating clear liquids  Call physician for further insulin and diet orders  Start subq insulin 2 hours prior to drip discontinuation  Discontinue insulin drip 2 hours after giving basal insulin (insulin glargine or detemir) Diabetic Ketoacidosis Management Physician Guideline Initial Plan of Care   Determine hydration status Initiate 0.9 % Normal Saline at 15 mL/kg/hour for 1-2 hours and then 7.5 mL/kg/hour   Consider less aggressive fluid replacement in heart failure or chronic renal failure patients. Potassium should be repleted if K+ < 5. See Potassium Replacement section    Patient must have BUN and serum creatinine first. Patient must have urine output > 30mL/hour to initiate any potassium in the first two hours of DKA management. When K > 3.3, Start Insulin drip     Using ideal body weight, initiate insulin Consider a regular Insulin 0.1 units/kg (IBW) IV bolus x1 Then, start the insulin drip: regular insulin 100 units / 0.9% NS 100 mL continuous IV infusion at 0.1 units/kg/hour (IBW) Following serial, q1hour blood glucose values, titrate insulin drip, hydration status and potassium repletion. See below guideline table.   Nursing will titrate the insulin drip based on the below instructions Chem 7 is ordered q2hours in order to follow sodium and potassium closely. o Change IVF, as needed. o Potassium:  If K < 3.3, replete with KCL (or KPhos) IVPB given over 4+ hours  If K > 3.4, add KCl to maintenance IV fluids, until K > 5. o Phosphate: Consider total potassium replacement (KCl + K Phos), when ordering Potassium phosphate (recommend 2/3 KCl, 1/3 K Phos) TABLE 2: Physician DKA Management (for use after insulin drip initiation) Glucose (mg/dL) Insulin Drip (units/hr) IV fluids (IVF) Recommendations: Increase drip by 4 units/hr >500 (or 25 %, which ever increase is less)   251-500  151-250 Do not adjust rate if blood glucose is decreasing by 50-75 mg/dL/hr If blood glucose is NOT decreasing by 50-75 mg/dL/hr, then increase the drip rate by 2 units/hr When the plasma glucose reaches 250 mg/dl in DKA, decrease the insulin infusion rate to 0.05 - 0.1 unit/kg/h (or 3–6 units/h). Na >135: 0.45NS Na <135: 0.9NS Na >135: 0.45NS Na <135: 0.9NS Change to Na >135: D5W-0.45NS Na<135: D5W-0.9 NS Potassium Repletion: Add to maintainance fluids K > 5: none K 4.1 - 5: add 20 mEq/L K 3.3 - 4: add 40 mEq/L K <3.3: use an IVPB K > 5: none K 4.1 - 5: add 20 mEq/L K 3.3 - 4: add 40 mEq/L K <3.3: use an IVPB K > 5: none K 4.1 - 5: add 20 mEq/L K 3.3 - 4: add 40 mEq/L K <3.3: use an IVPB Decrease insulin drip by 50% 101-150 Hold insulin drip for 1 hour 71-100   <70   Hold insulin drip (if not already held). Give dextrose 50%, 12.5 grams IV Recheck blood glucose in 15 minutes Follow titration as above Na >135: D5-0.45NS Na<135: D5-0.9 NS Na >135: D5-0.45NS Na<135: D5-0.9 NS Change to D10W K > 5: none K 4.1 - 5: add 20 mEq/L K 3.3 - 4: add 40 mEq/L K <3.3: use an IVPB K > 5: none K 4.1 - 5: add 20 mEq/L K 3.3 - 4: add 40 mEq/L K <3.3: use an IVPB K > 5: none K 4.1 - 5: add 20 mEq/L K 3.3 - 4: add 40 mEq/L K <3.3: use an IVPB Transition from Insulin drip to subcutaneous regimen  Consider advancing diet, as tolerated.  Criteria for insulin drip discontinuation o Serum glucose < 250 o Venous CO2 content  19 o Anion gap  12 o Patient can tolerate clear liquids  Start subq insulin 2 hours prior to drip discontinuation  Discontinue insulin drip 2 hours after giving basal insulin (insulin glargine or detemir)