FREQUENCY Mercy Hospital and Medical Center APRIL 2012

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)