Download - STEP BY STEP MANAGEMENT OF DKA
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STEP BY STEPMANAGEMENT OF DKA
See details in the DKA protocol guidelines
Dr. D. Alvarez
February 2008
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INITIAL PROCES
1. Call from ED requesting bed2. Resident / Supervisor (if applicable)
obtains information on patients condition, on the phone or going to the ED as activity in the unit warrants. Information needed:
• Base line patient’s chronic condition - control status: last HbA1c, - last diabetic clinic visit with assessment, current
dose of insulin, time last dose.
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INITIAL PROCES(continue)
3. Describe current event.– ED assessment, labs (start laboratory flow
sheets) and therapy– Get Ht, Wt and SA ( m2) to start doing
calculations.
4. Communicate with PICU Attending and inform on patient’s condition to Nurses and Supervisor (if applicable)
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Physiological Problems that will need to be address.
Address Severity of:1. DKA /Acidemia:
CO2 PH (V) Clinical
Normal 20-28 7.35 – 7.45 Normal Base line
Mild 16-20 7.25 – 7.35 Oriented, alert but Fatigued
Moderate 10-15 7.15 < 7.25 Kussmaul Resp. Oriented, Sleepy but arousable.
Severe <10 < 7.15 Kussmaul Or Depressed Resp./Sleep/ alter Mental>Coma.
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Physiological Problems that will need to be address.
Address Severity of:
2. Hyperglycemia / Heperosmolarity• Can request to be measure directly in the lab OR
• Calculate it by formula
Osm = 2 x Na +glucose/18 + BUN /2.8
• Normal Osmolarity ~ 300
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Address Severity of:
3. Dehydration:
Mild Moderate Severe
Infant 5-7 % 10-15% 15-20 %
Younger Child
3-5 % 7-10% 15%
Older Child -Adolesc
3 % 7 % 10%
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Address Severity of:
4. Electrolyte Imbalance:– Na: correct serum sodium level as per formula
• Add 1.6 for each 100 mg/dl of glucose over 100
• Example: if Na 130 and BS of 800– Corrected Na will be 1.6 x 700 = 11.2
– 130 + 11.2 =141 (this is the true Na, still the total body sodium is low)
– K: even though the serum K may be initially high, the total body sodium is always low.
– Ph and Calcium abnormalities as well
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MANAGEMENT
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Fluid Replacement Calculations
1. Check how much and what kind of fluids patient received in ED. (usually patient should had received NS, 20 to 40 cc/kg boluses)
2. Check if patient passed urine and how much and calculated Fluid Balance
• Example: if patient received 1 Liter of NS and passed 1 liter of urine because hyperosmolarity; the balance is ZERO.
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Fluid Replacement Calculations (CONTINUES)
3. Calculate patient’s maintenance fluids (requirements); Wt. base OR per SA(m2)
• Wt base: 100 ml/kg for the first 10 kg
50 ml/kg for the next 10 kg
20 ml/kg for the rest…. kg.
• Per SA (m2) 1500 mL/M2
4. Calculate deficit for ideal (pre-illness) wt.Example: Pt. is 22.2 kg. Maintenance is 1540 mL
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Fluid Replacement Calculations (CONTINUES)
4. Calculate deficit per ideal (pre-illness wt)Example: • Pt. current (dehydrated) wt is 20 kg• Pt. is assess to be 10% dehydrated.• Ideal wt is: 22.2 kg
(20 kg is 90% >>> 100 % =100 x 20 / 90)• Deficit will be 22.2 – 20 = 2.2 Liters
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Fluid Replacement Calculations (CONTINUES)
4. To calculate IV rate: ml/hr– Add Maintenance + ½ of deficit (*)– 1540 + 1.1= 2640 mL in 24 hrs
- IV rate of 2640/24 hr = 110 cc/hr.
(*) correction should be given in 48 hrs.5. IV solution selection: use standard solution pre-
mixed by pharmacy:• There are 3 standard solutions. To select them go to> IV solution (16) > then select “IV solution (peds)” (7)
>> from Solution for DKA - 0.45 NS with 20 mEq KCl and 15 mM of KPh / Liter - D5% 0.45 NS with 20 mEq KCl and 15 mM of KPh / Liter- D 10% 0.45 NS with 20 mEq KCl and 15 mM of KPh / Liter
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Ordering Standards DKA Solutions
1. In the Order entry >Select # 18 (IV Solutions)
2. Pediatric Common IV Solutions-Order options > Select # 7 (IV sol (Ped)….
3. IV Maintenance Solution for DKA Management (Potassium, Phosphate, Potassium Chloride) > Select 5, 6, 7, Or 8
• 15 mmol kPO4 / 20 mEq KCl in NaCl 0.45 % 1000 mL• 15 mmol kPO4 / 20 mEq KCl in D5% NaCl 0.45% 1000 mL • 15 mmol kPO4 / 20 mEq KCl in D10% NaCl 0.45% 1000 mL • 15 mmol kPO4 / 20 mEq KCl in D5% NaCl 0.9% 1000 mL
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Insulin drip
1. Dose: 0.05 to 0.1 Units /kg/hr. Choice will depend on:
• the severity of the acidosis. If severe, start with 0.1 U/kg/hr
• The patient’s sensitivity to Insulin, according to age and individual response.
2. Solution Concentration: select standard solutions as per “Insulin drip guideline”.
3. RUN IT IN A SEPARATE IV LINE.
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Insulin drip order Using standard Solution Concentration1. Order entry: write insulin2. Procedure option for insulin
• Select # 12 “Insulin, Regular IV drip”3. Pediatric Dose: select according to guidelines, computer will calculate IV rate
according to entered Wt. Children > 25 kg– 50 Units/100 mL NS @ 0.05 Unit/kg/hr– 50 Units/100 mL NS @ 0.075 Unit/kg/hr– 50 Units/100 mL NS @ 0.1 Unit/kg/hr– 50 Units/100 mL NS @ ----Unit/kg/hr Children < 25 kg– 50 Units/500 mL NS @ 0.05 Unit/kg/hr– 50 Units/500 mL NS @ 0.075 Unit/kg/hr– 50 Units/500 mL NS @ 0.1 Unit/kg/hr– 50 Units/500 mL NS @ ---- Unit/kg/hr
4. Write / Copy the calculated rate (ml/hr) in the instruction fields and 5. WRITE INDICATIONS as well (DKA)6. RUN IT IN A SEPARATE IV LINE.
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FOLLOW - UP
1. Cardio-respiratory monitoring and Neuro checks• Neuro checks: observe for changes of metal status as
signs of dehydration and or complications of DKA: Cerebral edema, strokes
• Respiratory: Observe for changes/ type of respiration as sign of acidosis (Kussmaul respirations) and /or respiratory depression 2nd to CNS depression as an imminent CNS complication.
• CV: Observe for signs of dehydration and / or electrolyte abnormalities, I.e. Hyper /hypokalemia.
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FOLLOW - UP
2. Fluid Balancea) The goals of fluid therapy are:
• Initial fluid resuscitation is aim to replenish intravascular volume to reverse lactic acidosis.
• Slow rehydration (48 hr) and slow decrease in osmolarity to prevent risk of cerebral edema.
• Divide the 24 Fluid deficit by 3 to anticipate /estimated the positive 8 hour balance to achieve.
• Daily Wt will be the best objective way to assess rehydration
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FOLLOW - UP3. Acid-Base-Balance
– VVG and electrolytes including Ca and Ph every 2-3 hours until a steady improving trend, then it can be done Q 4hours till all normal.
4. FS Q1H as long patient is on insulin drip- Aim to have a slow decrease of BS /Osmolarity, may
need to add glucose containing solution and /or use NS for a longer period of time at the beginning of rehydration.
- Keep BS between 150 – 250 before changing IV solutions
- At the beginning and until the acidosis is corrected, control BS with IV solutions with or without Dext. using the “2 bag system”
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“2 bag solutions”• Acidosis improving
– No changes in Insulin drip, except for temporarily hold if low FS (< 80) until corrected with Glucose solutions.
– Adjust IV solution rates to keep FS Between ~150 (increase Dextrose Sol if < 100 or decrease if close to 200)
• Acidosis Resolved– Patient is ready to have the
insulin drip switch to SC (dose to be given by Endocrinologist) and start Diabetic Diet.
– If FS is low can decrease Insulin drip instead of increase Glucose in the IV solution.
– After the first dose of SC given and Pt. Ate. D/c insulin drip after 1 hr.
D5% Or D10% 0.45 NS with K…(Same)
0.45 Or D5% NS with K…(same)
Patient
Piggy-bag
Adjust rate.
Calculated rate: Main + deficit / mL/hr
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Switching Insulin from drip to SC• Get SC dose of insulin from Endocrinologist • Order Diet as per Endo recommendations, usually:
– If < 5 yo is 3 meals and 3 snack– If > 5 yo 3 meals and 2 snacks
• Order initial dose as instructed, – NPH dose is usually started in AM before breakfast.– Lantus is given PM
• D/C insulin drip 1 hours after SC dose given• D/C glucose in IV fluids after tolerating breakfast
and BS is within normal level.• Decrease IV fluid rate to replacement rate only.• Change schedule of FS to 7 times /day as per
diabetic protocol. (see guideline orders)
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Dextrostics (FS) monitoring when pt. in on SC insulin.
7 (times per day)1. Order entry … “dextrosticks “
(Fingersticks Glucose by Nursing)
2. Expand…
3. Choose # 7 ( _ X per day)
4. Write 7 (times per day)
5. In instructions field please Write :
As per diabetic protocol, using Glucometer
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Guidelines for ordering sliding scale Humalog insulin coverage.
1. Order entry 2. write “Humalog”3. Select (1) ____Units SC Now4. Select Expand (on the low right corner > see diagram)5. Select (5) Route ___6. Choose #76 ( subcutaneous)7. Select (3) When ... >8. Select # 34 prn___ type: “according to instructions”9. Instructions: write endocrinologist recommendations.Write your sliding scale as per endocrinology consultExample: Check BS 15 minutes before breakfast if
glucose less 50 mg/dl 0U 51-100 5U 101-150 8U 151-200 10U 201-300 12U 301-400 14U >400 16U
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Ordering insulin in relation to Carbohydrate caloric count
1. Order entry 2. write “Humalog”3. Select (1) ____Units SC Now4. Select Expand (on the low right corner > see diagram)5. Select (5) Route ___6. Choose #76 ( subcutaneous)7. Select (3) When ... >8. Select # 34 prn___ type: “according to instructions”9. Instructions: write encocrinologist recommendations.Example: 15 minutes before meal and snack administer (1) U
of Humalog for each (15) gr of carbohydrate and (1) U for each (50) mg/dl glucose level above the patient target (X) mg/dl
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Case Exercise-Example on Initial Management
• Pt. 15 yo HF, know IDDM since 10 yo, poorly controlled (HbA1C 15), admitted in severe DKA– Lethargic– VS: T 98 F, HR 150, RR 30, BP 130/75 O2Sat 96 %– Wt. 50 kg– Poor perfusion– Labs: VBG: Ph 7.0 /CO2 7 / Bic 8, BE – 20
– BMP: Na133/K5.2/Cl98/5/AG 15/BS 800 / BUN 20/ Cr 1.2, Ca 9