DKA : Diabetic Ketoacidosis & HHS: Hyperlgycemic Hyperosmolar Syndrome Protocol. Glycemic Task Force September 2014

Transcription

1 DKA : Diabetic Ketoacidosis & HHS: Hyperlgycemic Hyperosmolar Syndrome Protocol Glycemic Task Force September 2014

2 Hyperglycemic Crises: Pathophysiology DKA HHS Hyperglycemia DKA HHS Umpierrez, In Shoemaker, Textbook Critical Care 71, 797, 1999.

3 Precipitating factors for DKA Nonadherence, not taking insulin Infection MI Cocaine Pregnancy Pancreatitis Steroids

4 Diagnostic Criteria for DKA Mild Moderate Severe HHS Plasma glucose (mg/dl) ph Bicarbonate (meq/l) Urine ketones* Serum ketones* Effective serum Osmol (mosm/kg) Alteration in sensoria > positive positive variable alert or mental obtundation * Nitroprusside reaction method Calculation: 2[measured Na (meq/l)] + glucose (mg/dl)/18 > positive positive variable Alert & drowsy ADA, Kitabchi et al, Diabetes Care 24: , 2001 >250 <7.0 <10 positive positive variable Stupor- coma > 600 >7.30 > 15 small small >320

5 Clinical Presentation of DKA Symptoms Polydipsia Polyuria Weakness Weight loss Nausea Vomiting Abdominal pain Signs Hypothermia Tachycardia Tachypnea Kussmaul breathing Ileus Acetone breath Altered sensorium The onset of DKA is usually relative short, ranging from hours to a day or two. ADA, Kitabchi et al, Diabetes Care 24: , 2001

6 Diagnostic Criteria for HHS Plasma glucose >600 Arterial ph >7.30 Serum bicarbonate >18 Urine ketones: negative or small Serum ketones: negative or small Serum osmolality >320 Anion gap: variable Elevated serum creatnine and BUN Total body stores of sodium, potassium, and phosphorus are usually low

7 Initial Laboratory Studies for DKA and HHS Immediate determination of blood glucose and serum acetone ABG s OR venous ph CBC with differential Chem 10 Serum acetone Urinalysis Consider Bacterial cultures Cardiac enzymes Consider utox hcg if child bearing age

8 Serum Sodium Sodium may falsely appear to be low when blood sugar is elevated because there are more glucose molecules compared to sodium molecules and there is a movement of water into the extracellular compartment Serum glucose H 2 O H 2 O H 2 O H 2 O Na +

9 Serum Sodium in DKA patients If glucose greater than 250mg/dl, patient will have falsely low sodium This will help the provider determine what type of IV fluids the patient needs The provider needs to calculate a corrected sodium: Corrected sodium = measured sodium x (serum glucose 100)

10 IV Fluids Start with NS to replace volume, unless there is a contraindication to aggressive fluid replacement. Once hemodynamically stable (typically after 1 liter), If corrected sodium is >136, change to ½ NS If corrected sodium is <136, continue NS Change to 5% dextrose with ½ NS once blood glucose is < 200 in DKA or < 300 in HHS

11 IVF:

12 Serum Potassium Serum potassium will be falsely elevated. Lack of insulin causes potassium to shift out of the cell. Once patient is given insulin, potassium shifts back into the cell and levels will drop. Check potassium prior to starting insulin. Must be > 3.3 to start insulin drip If potassium <3.3, per protocol, give 20mEq of KCL IV before starting insulin drip If patient only has peripheral line, must infuse 10mEq x 2 If potassium , per protocol, place 20mEq/liter in IV fluid IF potassium >5.3, per protocol, no potassium in IV fluid

13 Potassium

14 Potassium During Insulin Infusion

15 Insulin Initial rate of insulin infusion will be based on patient s weight in kg Initiation can be done with or without bolus as determined by provider s order Titration will be done based on how quickly patient blood sugar is rising or falling and nurse will be directed via protocol (similar to heparin dosing protocol) Insulin rates should be rounded to the nearest 0.5 units/hr Blood sugar should not fall more than mg/dL per hour If patient becomes hypoglycemic, follow Hypoglycemia Protocol

16 Insulin Dosing Initial Dosing with bolus: Bolus regular insulin at a dose of 0.1 unit/kg IV (maximum initial bolus of 10 units) and begin regular insulin drip at a starting rate of 0.1 unit/kg/hour IV maximum initial infusion rate of 10 units/hr Initial Dosing without bolus: Begin regular insulin drip at a starting rate of 0.14 unit/kg/hour IV maximum initial infusion rate of 14 units/hr

17 Insulin

18 ADA Position Statement. Diabetes Care 26:S109-S117, 2009 Intravenous Insulin Therapy in DKA I.V. Bolus: 0.1 U/kg body Wgt I.V. drip: 0.1 U/kg/h body Wgt Glucose < 250 mg/dl I.V. drip: U/kg/h Until resolution of ketoacidosis

19 DKA/HHS Insulin Infusion Titration Current Drip Rate (units/hr) Decrease by 50% to: (units/hr) Decrease by 25% to: (units/hr) No change (units/hr) Increase by 25% to: (units/hr) Increase by 50% to: (units/hr)

20 Monitoring Parameters

21 Bicarbonate

22 Bicarbonate Therapy in DKA Randomized controlled trial in 21 patients with ph between 6.9 and 7.1 showed no benefit. 1 An additional 9 controlled studies with 434 patients were summarized with the conclusion of no benefit 2 1. Morris LR, Murphy MB, Kitabchi AE. Bicarbonate therapy in severe diabetic ketoacidosis. Ann Intern Med 1986;105: Viallon A, Zeni F, Lafond P, Venet C,Tardy B, Page Y, Bertrand JC. Does bicarbonate therapy improve the management of severe diabetic ketoacidosis? Crit Care Med 1999;27:

23 Nursing Responsibilities Inititate 2 separate IV sites Ensure labs drawn Obtain insulin drip from pharmacy. Check potassium before starting insulin drip. Make sure it is above 3.3 Monitor fingersticks every hour until transition to subcutaneous insulin

24 Transitioning off of IV insulin to subcutaneous insulin There needs to be a minimum of two hour overlap for those patients transitioning off of intravenous insulin to subcutaneous insulin (basal/bolus regime). Ordering basal insulin earlier while an insulin drip is running is encouraged After two hours, the insulin infusion can be turned off There needs to be hourly fingersticks during the overlap of therapy

25 Transition to Subcutaneous Insulin Continue IV insulin until DKA or HHS is resolved. Criteria for resolution of DKA: BG < 200 mg/dl Serum bicarbonate level 15 meq/l Venous ph > 7.3 Anion Gap <12 (primary target) Criteria for resolution of HHS: Improvement of mental status BG 300 mg/dl Serum osmolality of less than 320 mosm/kg

26 Basal-Bolus Insulin Standard of Care Basal insulin Controls glucose production between meals and overnight Nearly constant levels 50% of daily needs Bolus insulin (mealtime or prandial) Limits hyperglycemia after meals Immediate rise and sharp peak at 1 hour postmeal 10% to 20% of total daily insulin requirement at each meal

27 Basal-Bolus Insulin Standard of Care For ideal insulin replacement therapy Both components are needed Each component should come from a different insulin with a specific profile Correctional insulin (Supplemental insulin) Supplemental doses of rapid or short acting insulin to correct blood glucose elevations that occur despite use of basal and prandial insulin. Usually administered before meals together with prandial insulin.

28 Transition to Subcutaneous Insulin Avoiding Pitfalls: Timing Give the basal insulin at least 2 hours prior to stopping the insulin drip Consider continuing the drip so that the basal insulin can be given at 8am or HS

29 Transition to Subcutaneous Insulin Avoiding Pitfalls: Basal Dosing Give enough basal Limited evidence-based data regarding transitions Can use the past 6 or 12 hours of stable drip rate to calculate 80% of 24 hour averaged dose Can use a weight based approach and adjust for stress Can use the patient s usual dose adjusted for stress Stress is ~50% excess for 1 st day post DKA

30 Transition to Subcutaneous Insulin Avoiding Pitfalls: Prandial Dosing Give prandial dose if eating 50% or more of meals generally will be 1/3 of basal dose, given qac Give a correction dose ONLY AS AN ADDITION to prandial dose Check 3am FS for at least 1 night post insulin drip use

31

32

33

34