Pediatric Diabetic Ketoacidosis (DKA) General Pediatrics Admission Order Set

Transcription

1 Admitting MRP: Pediatrics: Dr. / Dr. on call to cover until 08:00 am Service: Medicine Team 1 Medicine Team 2 Medical subspecialty Diagnosis: Diabetic Ketoacidosis (DKA) Estimated length of stay Less than 24 hrs days Precautions: Contact Droplet Airborne 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 and place in green sleeve End of life care still to be reviewed/discussed with patient/substitute Decision Maker Allied Health Consults: Dietitian Physiotherapy Assess and Treat Social Work Occupational Therapy Assess and Treat Respiratory Therapy Assess and Treat Speech Language Pathology Assess and Treat Pharmacist Reason for Consult: Diet: NPO Activity: AAT Bed rest Head of bed at 30 Co- DKA/MD/06-17/V4 Page 1/4

2 Vitals: daily Vitals/Monitoring HR, RR, BP q 2 h Reassess in hours Temperature q4h and PRN Neurovitals: Glasgow Coma Scale and pupil reaction q 2 h Reassess in hours Monitoring: Continuous cardio respiratory monitoring (CRM) including continuous oxygen saturation monitoring (SpO2) Reason: Call if MCH Standard Alarm Limits: Alarm parameters are set based on MCH Normal Expected Ranges for Monitoring Vitals (See associated document) Intake and Output q1h Calculate Fluid balance q4h Calculate urine output ml//hr q h Notify MD if less than or greater than 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 Inform MD immediately AND consult PACE if any of the following occur: BP consistent with Vascular Decompensation see algorithm Change in neurological status including headache, irritability, decreased level of consciousness, seizure Vascular Decompensation (Shock) Term neonate (0 to 28 days) SBP less than 60 mmhg Infant (1 to 12 months) SBP less than 70 mmhg Child (1 to 10 years) SBP less than 70 + [ 2 x (age in years)] mmhg Greater than 10 years SBP less than 90 mmhg Co- DKA/MD/06-17/V4 Page 2/4

3 Lines/Tubes/Respiratory Peripheral IV line 2nd Peripheral IV line, saline lock with 3 ml 0.9% NaCl and flush q12h and PRN for bloodwork O2 to maintain SpO2 above % Insert Indwelling urinary catheter Secure catheter in a neutral position using securement device Site care q shift and PRN Reassess need daily Lab Investigations Capillary Blood Glucose via Blood Glucose Meter q 1 h OR q h Na, K, Cl, HCO3 q 2 h OR q h Venous Blood Gas q 2 h OR q h Creatinine, Urea q 12 h OR q h Urine Ketones with every void (q4h if patient has indwelling catheter insitu) IV Fluids Ensure IV bolus fluid resuscitation has been completed (see Pediatric ED Suspected DKA Order Set) Initial TFI at ml/hr Guidance for INITIAL TFI (ml/hr): (Approximating 7% dehydration and replacement over 48 hours) If less than 30 TFI = 1.5 x usual hourly maintenance rate If equal to or greater than 30 TFI = 2.0 x usual hourly maintenance rate TFI should be modified based on clinical judgment, initial volume received, risk of cerebral edema TFI is inclusive of IV fluid rate and rate of insulin infusion RN to adjust IVF to maintain TFI Guidance for TFI adjustment by RN: TFI (ml/hr) = IV fluid rate (ml/hr) + IV insulin rate (ml/hr) Co- DKA/MD/06-17/V4 Page 3/4

4 IV Fluids continued 0.9% NaCl OR D5W + 0.9% NaCl Other With 20 mmol KCl/L of IV fluid OR With 40 mmol KCl/L of IV fluid Maintain serum potassium between 4 5 mmol/l, Physician to reassess Continuous IV Insulin Infusion *** Refer to Pediatric IV Monograph for Insulin (regular) *** IV insulin infusion to be initiated only after IV fluid bolus complete and IV rehydration started to minimize risk of cerebral edema 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//h OR 0.1 units//h OR Additional Orders: One per line please or use blank online order set AVOID USE OF UNSAFE ABBREVIATIONS Do NOT Use USE Abbreviations for drug names - Write in full A trailing zero X.0 or X mg or 10 mg (no trailing zero) A lack of leading zero -.X - 0.X (use a leading zero) Do NOT Use USE U or IU - Unit cc - ml or milliliter µg - mcg or microgram QD or OD - daily QOD - every other - at Do NOT Use USE D/C - Discharge or discontinue > - greater than < - less than OS, OD, OU - Left eye, right eye, both eyes AS, AD, AU - Left ear, right ear, both ears SC, SQ, sub q - Subcut or subcutaneous Co- DKA/MD/06-17/V4 Page 4/4

5 1 Emergency Guidelines for Managing the Child with Type 1 Diabetes Diabetic Ketoacidosis (DKA) HISTORY (some or all of) Polyuria Tiredness Polydipsia Vomiting loss Confusion CLINICAL SIGNS generally include Dehydration Tachypnea, deep sighing (Kussmaul) respiration, smell of ketones on breath Nausea, vomiting, abdomen pain (may mimic an acute abdomen condition) Confusion, drowsiness PERFORM THESE TESTS: Capillary glucose STAT in ED, Urine Ketones / Glucose CBC, Venous Na, Cl, K, Glucose, Gas, Calcium, Magnesium, Phosphate, Creatinine, Urea and Beta hydroxybuterate CONFIRM DKA* Ketonuria ph < 7.3 Serum Bicarbonate < 15 mmol/l Glucose usually > 11 mmol/l VASCULAR DECOMPENSATION (shock) Hypotension (minimum SBP) = Term Neonate (0-28 days) < 60 mmhg Infant (1 to 12 months) < 70 mmhg Child (1 to 10 years) < 70 mmhg plus 2 x age in years Greater than 10 years < 90 mmhg RESUSCITATE Give 0.9% NaCl 10 ml/ IV to expand vascular space to correct shock (repeated as necessary) Bicarbonate replacement not recommended for routine use NO VASCULAR DECOMPENSATION (Normal BP) CLINICALLY DEHYDRATED OR HYPERVENTILATING OR VOMITING Give 0.9% NaCl 7 ml/ IV over 1 hr Not dehydrated and tolerating oral hydration (no fluid bolus) Start subcutaneous insulin in consultation with Pediatric Endocrinologist FLUID MANAGEMENT: Initiate rehydration with 0.9% NaCl Recommended INITIAL TFI (ml/hr) (Approximating 7% dehydration and replacement over 48 hours): < 30 : 1.5 x usual hourly maintenance rate OR 30 : 2 x usual hourly maintenance rate Hourly TFI should be modified based on clinical judgment, initial volume received, risk of cerebral edema INSULIN MANAGEMENT: DO NOT GIVE BOLUS OF INSULIN AFTER initial fluid replacement THEN start IV insulin infusion at units//h (TFI = insulin rate + IV fluid) Use solution of 25 units of Regular Insulin in 250 ml 0.9% NaCl Flush new line with 50 ml of insulin infusion prior to connecting to patient If voided within last hour and K+ < 5.5 mmol/l; add 40 mmol/l of KCl to IV fluid Aim: keep K+ between 4 5 mmol/l Continuous cardio-respiratory monitoring with EKG tracing Contact Tertiary Pediatric Center to arrange transport*** OBSERVATION AND MONITORING Capillary Blood Glucose hourly 1 hour after starting insulin infusion: Na, Cl, K, venous blood gases - then q2h (more frequently if indicated) Aim: decrease in blood glucose of 5 mmol/l/h, and ph increase of 0.03 units/h Follow Effective Osmolality = (2 X measured Na + measured blood glucose) Aim: Avoid a decrease of > 2 3 mmol/l/h in effective osmolality by increasing IV sodium concentration Calculate input/output and fluid balance hourly. Based on fluid balance, ongoing adjustment of TFI required Neuro Vitals Q 1 h x 4 NEUROLOGICAL DETERIORATION*** Headache, irritability, decreased level of consciousness, decreased HR, seizure, hypothermia First rapidly exclude hypoglycemia with stat capillary blood glucose TREATMENT FOR CEREBRAL EDEMA Hypertonic saline (3%) 2.5 5mL/ over 10 15min OR 20% Mannitol g/ (2.5-5mL/) IV over min Reduce the rate of fluid administration by 30% Contact Tertiary Pediatric Center for advice ACIDOSIS IMPROVING BUT Blood glucose < 15 mmol/l OR falls > 5mmol/L/h: Change IV to D5W + 0.9% NaCl with KCL Decrease Insulin to units//h If Blood glucose < 10 mmol/l change to D10W + 0.9% NaCl with KCL IF CLINICALLY IMPROVING, tolerating oral fluids ph greater than 7.3 and HCO3 greater than 15 mmol/l THEN start subcutaneous insulin Stop IV Insulin 1/2 hour after subcutaneous dose of Rapid Acting insulin (ie HumaLOG, Novorapid, Apidra) ACIDOSIS NOT IMPROVING (in 3 4 hrs) Check insulin delivery system and net fluid balance Consider sepsis References: * DKA severity: MILD = ph < 7.3 or HCO3 <15; MODERATE = ph < 7.2 or HCO3 < 10; SEVERE = ph <7.1 or HCO3 < 5 ** rule: For determining hourly maintenance rate (ml/hr) = (4mL/ x first 10) + (2mL/ x second 10) + (1mL/ x every 1 after) *** PICU Consult: If initial ph < 7.2, age < five years, altered mental status, hemodynamic instability and/or severe electrolyte abnormalities requiring intensive monitoring or acute intervention 2010 Ministry of Health Guidelines for Management of Child with Type 1 Diabetes- DKA has been updated based on; 1. BC Children s Hospital Diabetic Ketoacidosis Protocol for Children up to Age 19 Years. Oct 7, Canadian Diabetes Association Clinical Practice Guidelines Expert Committee. Canadian Diabetes Association 2013 Clinical Practice Guidelines for the Prevention and Management of Diabetes in Canada. Can J Diabetes 2013;37(suppl 1):S1-S Metzger, D (2010) Diabetic ketoacidosis in children and adolescents: An update and revised treatment protocol BC MEDICAL JOURNAL VOL. 52 NO. 1, JANUARY/FEBRUARY ISPAD Clinical Practice Consensus Guidelines 2014 Compendium. Pediatric Diabetes 2014: 15(Suppl. 20):