Pediatric Intensive Care Unit (PICU) Pediatric Diabetic Ketoacidosis (DKA) Admission Order Set

Transcription

1 Discontinue all previous orders Weight: kg DKA admit order set is for initial management Ongoing management required based on frequent reassessment of TFI, fluid balance and lab results. Admit to PICU under Dr Diagnosis: Diabetic Ketoacidosis (DKA) Estimated Length of Stay : 24 hours OR days Isolation Precautions: Contact Droplet/Contact Airborne Airborne Contact PLUS Eye Protection Reason: End of Life Care/POST (Physician Ordered Scope of Treatment) Patient does NOT meet target population/trigger question for POST (see associated document) End of life care reviewed MD to complete POST End of life care still to be reviewed/discussed with patient/substitute Decision Maker Consults: Dietitian Social work Physiotherapist Assess and Treat Occupational Therapy Assess and Treat _ Diet: NPO Activity: AAT OR Refer to PICU Activity Order Set Vitals Daily weight HR, RR, BP, SpO 2 q1h Neurovitals q1h Temp q4h Monitoring Cardiac Monitor Continuous SpO 2 Vitals/Monitoring Call MD if temperature greater than Celsius PICU General Admission/MD/09-15/V3.5 Page 1/5

2 Intake and Output q1h Tubes and LinesUrinary Catheter Insert indwelling catheter Secure catheter in a neutral position using securement device Site care q shift and PRN Reassess need daily Vascular Access Peripheral IV line Arterial Line _ Respiratory Respiratory As per Medical Directive #83004 OR if Medical Directive not applicable, then Administer O2 to maintain SpO2 % to % Lab Investigations Lab Investigations on Admission CBC VBG CBG ABG Na, K, Cl Calcium Magnesium Phosphate Ionized Calcium Creatinine Glucose Urea Routine Lab Investigations Capillary Blood Glucose, Blood Gas (Arterial or Venous) q1h Na, K, Cl q h Creatinine, Urea q h ion Ca, Mg, PO4 q h Urine Ketones with every void (q4h if patient has indwelling catheter insitu) PICU General Admission/MD/09-15/V3.5 Page 2/5

3 Specimens to be analyzed using PICU Point of Care analyzer Inform MD immediately if any of the following occur: Blood Glucose is less than 5 mmol/l Blood Glucose falls greater than 5 mmol/l per hour Change in neurological status including headache, irritability, decreased level of consciousness, seizure Septic Workup (specimens to be obtained within first hour of admission) Peripheral Blood C + S (bottles and volumes as per pediatric protocol) Urine R + M (midstream or catheter) if positive send Urine Culture (CUR) Nasopharyngeal Swab for virology ARO Admission Screen (As per Medical Directive #36001) (Includes transfers within MCH unless swabs completed within previous 72 hours) MRSA swab of nare, rectum and any open wounds Rectal VRE swab IV Fluids Ringers Lactate OR D5 Ringers Lactate OR 0.9% NaCl OR D5W + 0.9% NaCl OR Other With 20 mmol KCl/L OR With 40 mmol KCl/L With 20 mmol/l of K (as K phosphate) equals 13.7 mmol/l of phosphate OR With 40 mmol/l K (as K phosphate) equals 27.4 mmol/l of phosphate Initial TFI at ml/hr Guidance for INITIAL TFI (ml/hr): (Approximating 7% dehydration and replacement over 48 hours) If < 30 kg TFI = 1.5 x usual hourly maintenance rate If 30 kg TFI = 2.0 x usual hourly maintenance rate TFI should be modified based on clinical judgment, initial volume received, risk of cerebral edema **Ongoing TFI to be adjusted based on fluid balance** PICU General Admission/MD/09-15/V3.5 Page 3/5

4 Call MD if Hourly fluid balance is negative x 2 consecutive hours Urine Output less than 0.5 ml/kg/h Serum potassium less than 3.5 mmol/l or greater than 5.5 mmol/l Serum Potassium less than 3.5 or greater than 5.5 mmol/l TFI is inclusive of IV fluid rate and rate of insulin infusion. RN to adjust IV fluid rate to maintain TFI. Guidance for TFI adjustment by RN: TFI (ml/hr) = IV fluid rate (ml/hr) + IV insulin rate (ml/hr) Continuous IV Insulin Infusion *** Do NOT give a bolus of IV insulin due to risk of cerebral edema*** regular insulin (NovoLIN ge Toronto) 25 units in 250 ml 0.9% NaCl (flush any new lines with 50mL of insulin infusion prior to connecting to patient): 0.05 units/kg/h OR 0.1 units/kg/h OR units/kg/hr Antimicrobial Therapy Pain Scale Pediatrics Acetaminophen Clinical Protocol Pain and Fever Management PICU General Admission/MD/09-15/V3.5 Page 4/5

5 Pediatrics Ibuprofen Clinical Protocol PICU General Admission/MD/09-15/V3.5 Page 5/5