SARASOTA MEMORIAL HOSPITAL NURSING PROCEDURE

Transcription

1 SARASOTA MEMORIAL HOSPITAL NURSING PROCEDURE TITLE: ISSUED FOR: DKA / HHNS PATIENTS REQUIRING INTRAVENOUS INSULIN DRIPS -ADULTS Nursing DATE: REVIEWED: PAGES: 12/14 5/18 1 of 8 RESPONSIBILITY: *RN (Renal/Diabetes/Wound Unit, ECC and Critical Care) ONLY PURPOSE: KNOWLEDGE BASE: To provide a guideline for utilizing the IV Diabetic Ketoacidosis (DKA), or Hyperglycemic Hyperosmolar Non-ketotic Syndrome (HHNS) Insulin drip protocol for adult patients. This protocol may ONLY be used on the Renal/Diabetes/Wound unit, Emergency Care Center (ECC) or in Critical Care. RN s on the Renal/Diabetes/Wound Unit, ECC and in the ICU who have demonstrated competency with this DKA/HHNS Insulin Drip Protocol may care for these patients. On the Renal/Diabetes/Wound Unit, the Admission criteria are as follows: A medically stable patient with a diagnosis of DKA /HHNS and requiring Insulin drip (with a CO2 of 8 or higher). A pregnant patient in DKA will go to the ICU. IV Insulin drip is included in the treatment of patients experiencing Diabetic Ketoacidosis (DKA), or Hyperglycemic Hyperosmolar Non-ketotic Syndrome (HHNS) secondary to prolonged hyperglycemia. DKA is characterized by hyperglycemia, ketosis, acidosis, and dehydration. The IV fluid must be changed to an IV containing glucose when the serum blood glucose decreases to less than 200 mg/dl in DKA or less than 300 mg/dl in HHNS. The glucose level should not drop more than 100 mg/dl/hour. NOTE: A rapidly falling blood glucose level can cause cerebral edema. This problem is seen more in children than adults. Monitor the patient s mental status for signs of early cerebral edema. NOTE: Serum potassium level must be 3.3 meq/dl or greater when patients are receiving insulin infusions. Serum potassium level must be monitored very closely while administering insulin. These patients are at high risk for developing worsening hypokalemia, which can lead to cardiac arrhythmias or cardiac arrest (refer to the order set). Insulin infusion will remain off until potassium level greater than 3.3. Serum potassium will be obtained immediately after infusion

2 complete. PAGE: 2 of 8 A two RN independent-verification is needed with each Accuchek performed. Regular Human Insulin is used for this Insulin Protocol. EXCEPTIONS: Labor and Delivery (refer to nursing procedure obs25, Care of the Intrapartum Patient Receiving Continuous IV Insulin Administration ). A pregnant patient in DKA will go to the ICU. EQUIPMENT: 1. Accu-Chek testing supplies. 2. The patient should have (2) IV accesses. 3. One IV Pump (# 1) used to regulate the hydrating IV fluids 4. One IV Pump (# 2) used to regulate the Insulin Infusion 5. Pharmacy-prepared Insulin infusion bag units Regular Insulin (Human) in 50 ml. Normal Saline. (1:1 Concentration) The Pharmacy will send the insulin infusion bag attached to pre-primed IV primary tubing. PROCEDURE: 1. Verify MD order a. If the patient was started on the DKA/HHNS Insulin Drip protocol in the ECC, ensure that the patient continues at the appropriate step of the protocol upon transition to 7WT/ICU. 2. Initial Hydrating IV *The insulin must be administered with a hydrating IV. a. Follow the DKA/HHNS protocol for the type, amount, and rate of the hydrating IV (See pages 5-8 for fluid flowsheet and decision tree). NOTE: The physician may need to individualize the Hydrating IV for patients who have Renal Disease, Congestive Heart Failure, or any disease that places the patient at risk for fluid overload. b. The hydrating IV is the primary IV line. 3. Initiate the Insulin Infusion Protocol per MD order and adjust insulin within the DKA/HHNS Protocol Insulin Flowsheet. a. Insulin Infusion: Follow the Insulin Drip Flowsheet for insulin rates (See pages 5-8). b. Attach the insulin infusion bag onto the hydrating IV line, at the lowest IV med port (if no other IV access). c. Avoid antibiotics and other IV medications administration

3 through the Insulin infusion IV site PAGE: 3 of 8 4. Attachment: See attached DKA/HHNS Protocol Fluid/Potassium/Insulin Flowsheet and Decision Tree sheet (Pages 5-8). 6. Monitor for Episodes of Hypoglycemia a. Follow the procedure # dia14 (Insulin Reaction / Hypoglycemia Protocol for the Adult Patient) when the patient experiences hypoglycemia and has an Accu-Chek of less than 70 mg/dl. 7. Change the Hydrating IV a. When the blood glucose is less than 200 mg/dl in DKA or less than 300 mg/dl in HHNS, follow the Insulin Drip Order Set per MD orders to add Dextrose to the Hydrating IV (i.e. Dextrose 5%/0.9% NS). 8. Transferring the Patient on DKA Insulin Drip a. The patient may be moved between ICU and the Renal/Diabetes/Wound Unit while on the protocol. b. To transfer out of Critical Care, the Protocol must either be discontinued or the patient must meet the admission criteria for the Renal/Diabetes/Wound Unit (this may include remote telemetry). 9. Discontinue a. Discontinue per MD order under Pharmacy patient general care order criteria. Patient Education: 1. Evaluate the patient s knowledge and sick-day management skills following an episode of DKA (not monitoring glucose levels frequently enough, omitting Insulin when unable to eat, and failing to test urine for ketones are common misjudgments, and must be addressed in patient education). 2. Discuss with the patient and family what they might specifically do differently the next time to avoid hospitalization. Provide written education material as needed. 3. Consult with Dietitian for diet instruction as needed. 4. Consult with the Outpatient Diabetes Treatment Services for follow-up after discharge as needed.

4 PAGE: 4 of 8 DOCUMENTATION: SCM: 1. Glycemic Control Flow sheet 2. Education Record. 3. Nursing Care Plan. 4. Medication Administration Record (emar). REFERENCE: Kitabchi AE, Umpierrez GE, Miles JM, Fisher JN. Hyperglycemic crises in adult patients with diabetes. Diabetes Care Jul;32(7): American Diabetes Association. Standards of Medical Care in Diabetes Position Statement. Diabetes Care, Volume 33, Supplement 1, January Maghrabi, A. MD; Hamoudeh, E. MD; Hassan, T. MD; Gress, T. MD; Yaqub, A. MD; Saleem, T. Safety and Efficacy of an Algorithm-Based Protocol in the Management of Diabetic Ketoacidosis. Endocrine Practice. Volume 18, No.6. November/December SMH Nursing Procedure (obs25) Care of the Intrapartum Patient Receiving Continuous Intravenous Insulin Administration. (dia14) Insulin Reaction Hypoglycemia Protocol. SMH: AUTHOR. REVIEWING AUTHOR: Katherine Petersen, RN, Diabetes Nurse Specialist Benny Kruger, MSN, RN, CCRN, CNN, Advance Practice Program Coordinator, Disease Specific Jordan Solich, BSN, RN, NPD, 7WT APPROVAL: Clinical Practice Council 5/3/18

5 PAGE: 5 of 8 Fluid Decision Tree DKA (BG Goal mg/dl) BG greater than 200 mg/dl BG less than 200 mg/dl Fluids Rate Volume Fluids Rate Volume STAT 0.9% NS 1000 ml/hr x1 L D5NS 150 ml/hr maintenance followed by 0.9% NS 500 ml/hr x2 L followed by 0.9% NS 250 ml/hr x2 L followed by 0.9% NS 150 ml/hr maintenance Potassium Decision Tree Potassium Level Potassium Replacement Greater than 5 no potassium replacement add 20 meq KCl to each L of fluid Give Kflash 20 meq over 2 hrs PLUS add 20 meq KCl to each L of fluid Less than 3.3 Hold insulin, Call MD if K<3.0 PLUS give Kflash 20 meq over 2 hrs PLUS add 20 meq KCl to each L of fluid PLUS recheck potassium at end of Kflash administration DKA Insulin Management (BG Goal mg/dl) Defining Characteristics of Hyperglycemic Crises DKA HHS Glucose >250 >600 Bicabonate < 18 >18 Venous ph < 7.3 >7.3 Anion Gap >10 Variable Osmolality variable >320 Anion gap = (Na + ) (Cl + HCO3 ) Osmolality = 2(Na + ) + (glucose/18) Step 1 Part A: STARTING INSULIN RATE Step 1 Part B: INSULIN TITRATION PARAMETERS FOR GLUCOSE 200 mg/dl or GREATER Initial Insulin Rate Max 12 units/hr Min Max approx units/kg/hr Min Max BG falls by greater than 100 mg/dl/hr BG falls by mg/dl/hr BG falls by less than 50 mg/dl/hr Decrease rate by: No Change Increase rate by: units/hr units/hr 2 units/hr units/hr units/hr 2 units/hr units/hr units/hr 3 units/hr units/hr units/hr 3 units/hr 80 and over 12 units/hr 80 and over 4 units/hr 4 units/hr Step 2 Part A: INSULIN RATE FOR GLUCOSE LESS THAN 200 mg/dl Change insulin rate when first accucheck less than 200 mg/dl Step 2 Part B: Insulin Titration (once BG less than 200 mg/dl and to maintain between mg/dl) Glucose Greater than 350 Insulin Rate of Change Increase rate by 3 units/hr Min Max approx units/kg/hr Increase rate by 2 units/hr units/hr Increase rate by 1 units/hr units/hr Increase rate by 0.5 units/hr units/hr No change units/hr Decrease rate by 2 units/hr 80 and over 5 units/hr Less than 100 Less than 70 Hold insulin infusion, accucheck in 30 minutes. Call MD for BG<100 x2. When BG>150, restart at 1.5 units/hr Hold insulin infusion, follow hypoglycemia protocol. When BG>150, restart at 1.5 units/hr

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7 PAGE: 7 of 8 Fluids Decision Tree HHNS (BG Goal mg/dl) BG greater than 300 mg/dl BG less than 300 mg/dl Fluids Rate Volume Fluids Rate Volume STAT 0.9% NS 1000 ml/hr x1 L D5NS 150 ml/hr maintenance followed by 0.9% NS 500 ml/hr x2 L followed by 0.9% NS 250 ml/hr x2 L followed by 0.9% NS 150 ml/hr maintenance Potassium Decision Tree Potassium Level Potassium Replacement Greater than 5 no potassium replacement add 20 meq KCl to each L of fluid Give Kflash 20 meq over 2 hrs PLUS add 20 meq KCl to each L of fluid Less than 3.3 Hold insulin, Call MD if K<3.0 PLUS give Kflash 20 meq over 2 hrs PLUS add 20 meq KCl to each L of fluid PLUS recheck potassium at end of Kflash administration HHNS Insulin Management (BG Goal mg/dl) Defining Characteristics of Hyperglycemic Crises DKA HHS Glucose >250 >600 Bicarbonate < 18 >18 Venous ph < 7.3 >7.3 Anion Gap >10 Variable Osmolality variable >320 Anion gap = (Na + ) (Cl + HCO3 ) Osmolality = 2(Na + ) + (glucose/18) Step 1 Part A: STARTING INSULIN RATE Step 1 Part B: INSULIN TITRATION PARAMETERS FOR GLUCOSE GREATER THAN 300 mg/dl Initial Insulin Rate Max 12 units/hr Min Max approx units/kg/hr Min Max BG falls by greater than 100 mg/dl/hr BG falls by mg/dl/hr BG falls by less than 50 mg/dl/hr Decrease rate by: No Change Increase rate by: units/hr units/hr 2 units/hr units/hr units/hr 2 units/hr units/hr units/hr 3 units/hr units/hr units/hr 3 units/hr 80 and over 12 units/hr 80 and over 4 units/hr 4 units/hr Step 2 Part A: INSULIN RATE FOR GLUCOSE LESS THAN 300 mg/dl Change insulin rate when first accucheck less than 300 mg/dl Step 2 Part B: Insulin Titration (once BG less than 300 mg/dl and to maintain between mg/dl) Glucose Greater than 450 Insulin Rate of Change Increase rate by 3 units/hr Min Max approx units/kg/hr Increase rate by 2 units/hr units/hr Increase rate by 1 units/hr units/hr Increase rate by 0.5 units/hr units/hr No change units/hr Decrease rate by 2 units/hr 80 and over 5 units/hr Less than 100 Less than 70 Hold insulin infusion, accucheck in 30 minutes. Call MD for BG<100 x2. When BG>150, restart at 1.5 units/hr Hold insulin infusion, follow hypoglycemia protocol. When BG>150, restart at 1.5 units/hr

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