Integrated Care Pathway (ICP) for Children and Young People with Diabetic Keto-acidosis (DKA)

Transcription

1 Shared Guidelines Group: Vijith Puthi, John Hyde, Nisha Nathwani, Nadeem Abdullah, Vipan Datta, R. Misquith Integrated Care Pathway (ICP) for Children and Young People with Diabetic Keto-acidosis (DKA) This ICP forms the official care record, so file in patient s notes in clinical notes section All interventions must be documented and signed Write your name clearly next to your signature Any deviation from the care plan must be documented The BSPED guideline and this ICP is to be used in young people up till their 19 th birthday (If you are not experienced in managing children in DKA, ask for senior help now) Date of admission:..... Time of admission:... Ward admitted to: Date of Discharge Time of Discharge.. Surname:... First Name:.... Date of Birth... Address:..... Postcode:..... HospitalNumber:... NHSNumber:... Religion: Ethnic Group:... GP: GPSurgery:... Health Visitor:... Social Worker: Does the child speak English: Yes No If not what Language do they speak: Is an Interpreter needed: Yes No Mother s Full Name:... Father s Full Name:... Name of persons withparental responsibility:... Contact Number:... Other Contact Number:... ABBREVIATIONS USED BP Blood Pressure ENT Ear, Nose and Throat K Potassium CNS Central Nervous System FBC Full blood count KCl Potassium Chloride CRP C-reactive protein HbA1c Glycosylated Hb MSU Mid-stream urine CRT Capillary Refill Time HCO3 Bicarbonate Na Sodium CSF Cerebrospinal fluid HDU High Dependency Unit NG tube Naso-gastric Tube CXR Chest X-ray ITU Intensive Therapy Unit PICU Paediatric Intensive Care Unit ECG Electrocardiogram IV Intravenous U+Es Urea, Electrolytes& Creatinine This Integrated Care Pathway was developed by the Southwest Paediatric Diabetes Regional Network as a bedside tool to aid care and documentation. It is based on Guidelines of NICE 2004, British Society of Paediatric Endocrinology and Diabetes Adapted by Laurell Paul-Lockitt (Practice Facilitator)Luton & DunstableHospitaland those mentioned above.

2 Algorithm for DKA (Use DKA ICP) History Polyuria Polydipsia Weight loss Abdominal pain Lethargy Vomiting Confusion Shock, Reduced conscious level Resuscitation Airway + NG tube Breathing (100% 0 2 ) Circulation (slow bolus 10ml/kg IV 0.9% saline, Repeated until circulation restored further doses rarely needed, maximum 3 doses) Signs assess % dehydration deep sighing respiration (Kussmaul) smell of ketones Lethargy, drowsiness Confirm Diagnosis Diabetic Ketoacidosis Call Senior Staff Dehydration > 3% Clinically acidotic, Vomiting Intravenous therapy calculate fluid requirements correct over 48 hours 0.9% saline for at least first 12 hours, with or without dextrose (Bag 1,2a,or 3a) add KCl 20mmol per 500ml bag 1 hour after IV fluids commenced, start Insulin infusion 0.1U/kg/hour Biochemistry elevated blood glucose >11mmol/l acidaemia: ph<7.3, Bicarbonate <15 ketones in blood or urine check U + Es, Creatinine other tests as indicated Dehydration < 3% Clinically well Tolerating fluid orally SubcutaneousTherapy start with subcut insulin give oral fluids No improvement Ketones rising Looks unwell Starts vomiting No improvement Re-evaluate fluid balance & IV therapy if continued acidosis, may require further resuscitation fluid check insulin dose correct consider sepsis, on-going fluid losses Observations hourly blood glucose neurological status at least hourly hourly fluid input:output chart U+Es & blood gas 2 hours after start of IV therapy, then 4-hourly 2-4 hourly blood ketone levels if Blood glucose falls <14 mmol/l Blood glucose falls <8 mmol/l Neurological deterioration Warning signs: Headache, irritability, slowing heart rate, reduced conscious level, specific signs raised intra-cranial pressure Exclude hypoglycaemia Is it cerebral oedema? Subcutaneous Insulin Start s/c Insulin then stop IV Insulin infusion 10 minutes after rapid acting analogs (Novorapid/Lispro or Apidra) Intravenous therapy During initial 12 hours: use 0.9% saline 5% glucose +20mmols KCL (Bag 2a) After 12 hours: change to 0.45% saline/ 5% glucose (Bag 2b) ensure KCL 20mmol/500ml bag continue monitoring as above consider reducing Insulin 0.05U/kg/hour, only when ph>7.30 and/or Bicarbonate >15 Intravenous therapy During initial 12 hours: use 0.9% saline 10% glucose +20mmols KCL (Bag 3a) After 12 hours: change to 0.45% saline10% glucose (Bag 3b) ensure KCL 20mmol/500ml bag continue monitoring as above consider reducing Insulin 0.05U/kg/hour, only when ph>7.30 and/or Bicarbonate >15 Management secure airway, 100% 02 head up tilt to bed 2.7% Saline 5 ml/kg IVorMannitol g/kg IV call senior staff restrict IV fluids by 50% move to ITU / PICU Discuss with CATS Resolution of DKA Clinically well, drinking well, tolerating food - Blood ketones < 1.0 mmol/l or ph or bicarb normal - Inform Children s Diabetes Team 2

3 Initial Rapid Assessment Time of assessment: Urinalysis: Neuro observations Initial Bloods Temperature: GCS (see below): /15 Arterial Venous Capillary Pulse: AVPU: ph: Resp: Bicarbonate: BP: Base Excess: O 2 Saturation: Lactate: Capillary Refill: Blood glucose: Children s EWT Score Blood ketones: U &Es: Weight: Height Allergies: AVPU: Alert, Responds to Voice, or Pain, or Unresponsive Best Motor Response Best Eye Response GLASGOW COMA SCALE (GCS) Maximum score 15, minimum score 3 6 Obeys simple commands Over 5 years 1 2 years 5 Localises to pain 5 Fully orientated 5 Smiles and appropriately cries 4 Flexion or withdrawal to pain 4 Confused 4 Cries 3 Abnormal flexion in response to pain 3 Inappropriate words 3 Inappropriate crying 2 Extension in response to pain 2 Incomprehensible sounds 2 Grunting Best 1 Makes no movement in response to pain 1 None 1 No Response Verbal 3 5 years Below 1 year Response 4 Opens eyes spontaneous 5 Appropriate words & phrases 5 Appropriate non-verbal response 3 Opens eyes in response to voice 4 Inappropriate words 4 Cries only 2 Opens eyes in response to pain stimuli 3 Cries 3 Inappropriate crying 1 Does not open eyes 2 Grunts 2 Grunts 1 No response 1 No response Is the Airway Patent? Yes No Acidotic pattern? Yes No Shock? Yes No Dehydration? Yes No Signs of cerebral oedema? Yes No Dehydration 3% Just clinically detectable 5% Dry mucous membranes, reduced skin turgor 8% As above + sunken eyes + prolonged CRT Signs of Cerebral oedema (headache, irritable, drowsy, focal neurology, low pulse, high BP, papilloedema) Manage using this DKA pathway if: Blood glucose >11mmol/l, and ph <7.30/HCO3 <15, particularly if vomiting and/or drowsy Hyperglycaemia without these features: Usually managed with subcutaneous insulin - do not use this pathway (see local protocol). If unsure, discuss with consultant. If any of the following present, consider CATS Transfer to PICU: ph<7.1 with marked hyperventilation severe dehydration with shock depressed conscious level age <2years If very high glucose (e.g. >50mmol/L) think of HyperglycaemicHyperosmolarState (HHS) Calculate osmolality by: 2(Na + K) + Gluc + Urea. Normal mOsmLl; If> 340mOsmLl, seek expert advice. Record Management Decision Clinical plan: DKA Pathway Subcut Insulin Admit to: Ward HDU PICU Children s Diabetes Team informed of admission Date... For DKA: Consultant informed? Yes No If 'No' record why: Name: Signed: 3

4 History and Examination History(use extra sheets as needed) Polyuria Yes No Polydipsia Yes No Weight loss Yes No Vomiting/Abdominal pain Yes No Headache Yes No Infection Yes No Compliance Yes No Comments Other symptoms: Drug History Usual insulin regime: Other medications: Allergies Past Medical History Family history Child Protection Child with a Child Protection Plan or known concerns Yes No Not Known Name: Signed: Examination (Additional to Initial Rapid Assessment) General status: Cardiovascular: Abdomen: Respiratory/ENT: CNS: Development Mandatory Investigations For newly diagnosed patient, Other investigations if add: indicated e.g. FBC, Blood Ketones (if available) Thyroid function CRP, urine culture, Urine Ketones (if not blood) Thyroid antibodies blood culture, CXR, Name Blood Gas Coeliac screen Throat swab, Lumbar puncture, ferritin Venous Lab Glucose GAD and Islet cell Signed U&Es HbA1c 4

5 DKA Management Resuscitation If patient very ill (drowsy, shocked, marked hyperventilation), call for senior help including anaesthetic team immediately A Establish airway If coma, insert NG tube, free drainage B C Give O2 100% via face mask with reservoir bag Establish IV access, take initial bloods (consider 2nd cannula for later samples) Cardiac monitoring (peaked T waves may indicate hyperkalaemia) If prolonged CRT plus other signs of shock, give10ml/kg IV 0.9% Saline. Assess effect. More than one fluid bolus rarely needed. If circulation not improved, can give 2 nd and (rarely) 3 rd bolus (each over 30 minutes) i.e. maximum total 30ml/kg if shock persists, consult senior paediatrician & inform local anaesthetist ITU/PICU Weight: Actual Kg or Recent clinic weight Kg (date: / / ) or Estimated Kg If too ill to weigh, estimate: 1-10 years: Weight (kg) = 2 (Age + 4) >10 years: Use 50th centile weight on growth chart (If recent clinic weight and weight at presentation known, use these to estimate % dehydration) Record Resuscitation Fluid Volume Given: ml D Consider CEREBRAL OEDEMA (at presentation, or may develop in first 12 hours) If drowsy/coma, nurse in HDU discuss with Senior doctor re- transfer to PICU Headaches? Convulsions? Abnormal posturing? Rising BP, falling pulse? Poor respiratory effort? Irritability/drowsiness? Focal neurological signs? Falling GCS? Papilloedema? Falling O2 saturations? Name: Signed: CEREBRAL OEDEMA: This is the major cause of severe morbidity/mortality in childhood DKA. Often develops within 12 hours of starting treatment, may already be present before treatment. Risk factors: raised urea, low PaCO 2, >40ml/kg resus fluids within first 4 hours. Management: Inform senior staff immediately, including anaesthetic team Check blood glucose (exclude hypoglycaemia as cause of neurological signs/symptoms) Secure airway, give 100% O 2 Hypertonic 2.7 % Saline (5ml/kg IV over 5-10 mins), or Mannitol 0.5-1g/kg (2.5-5ml/kg 20% solution IV over 20 mins). Give as soon as possible if warning signs occur. Transfer to PICU Recalculate IV fluid: Use 50% of usual maintenance requirement; replace deficit over 72 not 48 hours When stable, arrange CT scan to exclude other causes of deterioration (not to confirm oedema) Document all events with dates and times 5

6 Initial Treatment CAUTION! Overrapid or excessive fluids may increase risk of cerebral oedema Do not overestimate degree of dehydration (never use >8% for calculations) Aim to rehydrate slowly over 48 hours, not 24 hours Fluid volume 1. Maintenance fluids in DKA kg 80 ml/kg/24hrs kg 65 ml/kg/24hrs kg 55 ml/kg/24hrs kg 45 ml/kg/24hrs >60 kg (or adult) 35 ml/kg/24hrs Note 1:APLS maintenance fluid rates over-estimate requirement. Don't use them in DKA. Note 2: Neonatal DKA requires special consideration and larger volumes of fluid may be needed, usually ml/kg/24 hours. 2. Dehydration deficit (i.e. 3, 5 or 8%) % dehydration x weight (kg) x 10 = fluid deficit (ml) (e.g. 10 kg child who is 5% dehydrated : 5 x 10 x 10 = 500 ml deficit) 3. Fluid requirement for 48hrs = Maintenance for 48hrs + Deficit - Resus Fluids Add maintenance for 48 hours (2 x daily maintenance) to calculated deficit; subtract volume of resus fluid already given; then infuse over 48 hours. i.e. Hourly rate (ml/hour) = 48 hour maintenance (ml) + deficit (ml) - resuscitation fluid already given (ml) 48 Do not include continuing urinary losses in calculations at this stage Record Fluid Calculation here: 1. Maintenance for 48 hours (2 x daily maintenance, above) ml PLUS + 2. Deficit (% dehydration x weight (kg) x 10) ml = ml MINUS Volume of resuscitation fluids already given ml 3. Fluid to be given in next 48 hours = ml...divided by 48 to give hourly rate = ml/hour Or for calculating fluid rates, use this link Fluid Calculator and print out for child s medical records Name: Signed: Initial Fluid type Start with 0.9% Saline + 20mmol KCl in 500ml (Bag 1) Only omit KCl if anuric at presentation, or peaked T waves - await urgent U+E result. There is always massive total body potassium depletion, although initial plasma levels may be low, normal or even high. Potassium moves rapidly into cells with rehydration and insulin, so levels will fall. KCl must be added from the start of rehydration fluids and continued. More than 20mmol KCl /500ml is sometimes needed. Continue 0.9% Saline + 20mmol KCl in 500ml (bag 1) (with added glucose if required bags 2a and 3a) for at least 12 hours. (I.e. do not switch to 0.45% Saline in 5% Dextrose (bag 2b) within first 12 hours). See page 8 for Ongoing fluid management, including action required when glucose falls <14mmol/l Insulin Do not give insulin bolus. Insulin can be run via same cannula as fluids, using Y-connector with non return valve in line. Allow 1 hour of IV fluids before starting insulin (may reduce cerebral oedema risk) Insulin infusion: 50 units Actrapid (or other rapid-acting insulin) in 49.5ml 0.9% Saline (always use an insulin syringe to draw up the insulin to be added to the saline) Infusion rate: 0.1 ml/kg/hour ( = 0.1 units/kg/hour) This rate is required to switch off ketone production and improve ph. Aim to maintain this rate (may need to add dextrose to IV fluids, page 8), until ph>7.3, HCO3 >15 mmol/l (Some clinicians prefer 0.05 units/kg/hour in very young patients, although no firm evidence to support this) 6

7 Patients with pre-existing diabetes: If on long-acting insulin stop the insulin BUT remember to re-start after discussion with Diabetes Nurse Specialist or Consultant. This is when the patient is well enough to be changed back onto sc insulin (Option: Continue Glargine/Levemir at night - may enable earlier discharge see BSPED protocol) If on insulin pump therapy, stop the pump when starting DKA treatment. Ongoing Management principles Aim to rehydrate, correct ph & electrolyte disturbances and blood glucose slowly Reassess patient frequently, specifically watching for signs of CEREBRAL OEDEMA Pay strict attention to fluid balance and electrolyte management Nursing Consider PICU/HDU if: ph <7.1 with marked hyperventilation, severe dehydration with shock, depressed consciousness, age <2years, or if staffing levels insufficient to allow adequate monitoring. If no PICU/HDU within admitting hospital, transfer to another hospital for such care may not be appropriate (unless ventilatory support necessary). All children with DKA are high-dependency patients, needing high level nursing care, usually 1:1. Monitoring: Strict input & output Hourly vital signs, neurological observations and CEWT score Cardiac monitor (observe for T wave changes) Hourly capillary blood glucose 1-2 hourly capillary blood ketones Measure all urine volumes & urine ketones Twice daily weight 2-4 hourly blood gas 2-4 hourly U+Es Consider urinary catheter (in young/very sick) If consciousness reduced - NG tube, free drainage until child conscious * Use near-patient blood ketones testing to confirm that levels are falling. If ketones are not falling check infusion lines, insulin dose and calculation - consider giving more insulin. Consider sepsis, IV insulin line blocked, inadequate insulin, inadequate fluid input, hyperchloraemic acidosis and other causes if sufficient insulin is being given. Inform medical staff immediately, including anaesthetic team if: Any change in consciousness (GCS/behaviour, or headache/slowing heart rate/rising BP) Any ECG changes (watch for peaked T waves) Urine output poor (<1.5ml/kg/hour) or excessive (>2.5ml/kg/hour) If marked rise in blood glucose e.g. >5 mmol/l in 1 hr, check calculations, insulin infusion; possibly remake infusion, re-evaluate for sepsis. Repeat Blood Tests & Gases Repeat 2 hours after starting resuscitation, and 4 hourly thereafter until acidosis resolved and electrolytes normal. Record all results on flow sheet, page 10. 7

8 Ongoing insulin & IV Fluid & Electrolyte Management Ensure each 500ml fluid bag contains 20mmol KCl (40mmol/litre) unless anuric or peaked T waves. Alter potassium replacement according to U&Es. More potassium than 20mmol KCl in 500ml occasionally required. Falling Glucose level Addition of glucose to IV fluids is required when glucose falls <14mmol/L. (Some suggest adding glucose even before this if the initial rate of fall of blood glucose is greater than 5-8 mmol/l per hour, but there is no good evidence for this, and blood glucose levels will often fall quickly purely because of rehydration.) When glucose falls <14mmol/L, add glucose to IV fluids as follows (don't reduce insulin infusion): If within first 12 hours Continue 0.9% Saline + KCl 20mmol/L (bag1) as patient still sodium-depleted, but add glucose. Bags of 500ml 0.9% Saline in 5% Dextrose + 20mmol KCl (bag 2a) should be available from Pharmacy (it can be obtained as an unlicensed bag from Baxter- Order Code FKB2486). If not, make-up: withdraw 50ml from 500ml bag 0.9% Saline + 20mmol KCl, replace with 50ml 50% glucose. If after 12 hours, with plasma Sodium stable or increasing Can change to 0.45% Saline in 5% Dextrose + KCl 20mmol in 500ml (Bag 2b). If after 12 hours, but plasma Sodium is low or falling Corrected sodium level should be rising as blood glucose falls during treatment. Do notchange to 0.45% Saline in 5% Dextrose + KCl 20mmol in 500ml (Bag 2b) Instead, continue 0.9% Saline in 5% Dextrose + KCl 20mmol in 500ml Bag(2a)(see above) Corrected Na = Na ([Glucose] - 5.5) On-line sodium calculator Some believe low Corrected Na relates to risk of cerebral oedema. If blood glucose falls <8mmol/L, add glucose to IV fluids as follows (don't reduce insulin infusion): If within first 12 hours Use 0.9% saline 10% glucose +20mmols KCL (Bag 3a) If after 12 hours, with plasma Sodium stable or increasing Change to 0.45% saline10% glucose (Bag 3b) If after 12 hours, but plasma Sodium is low or falling Do not change to Bag 3b, continue with Bag 3a. If blood glucose <4mmol/L, give bolus 2ml/kg 10% Dextrose and increase dextrose in IV fluids: Do not stop insulin, although may temporarily be reduced for 1 hour. Once ph >7.3 or HCO3 >15, consider reducing insulin infusion rate to 0.05 units/kg/hour rather than adding glucose to IV fluids if glucose <14mmol/L. If a massive diuresis continues, fluid input may need to be increased. Changing from IV to Subcutaneous Insulin Once glucose <14mmol/L, ph>7.30, HCO3 >15, blood ketones <1.0mmol/L and patient well, not vomiting and able to tolerate food, consider switching to subcutaneous insulin (urinary ketones may not have cleared completely). For insulin type, timing and dose, see your local protocol for newly diagnosed diabetic (Guideline 11022). Continue IV insulin for 10mins after starting first subcutaneous insulin analogue to avoid rebound hyperglycaemia. Additional Notes Bicarbonate: Stop! Rarely, if ever, necessary. Continuing acidosis means insufficient resuscitation, or insulin infusion problems, check lines and remake insulin infusion. Bicarbonate should only be considered if profoundly acidotic (ph < 6.9) and shocked, with circulatory failure. Its only purpose is to improve cardiac contractility. ALWAYS DISCUSS WITH THE CONSULTANT IN CHARGE, ALSO discuss with CATS team if they are involved. Anticoagulant prophylaxis There is significant risk of femoral vein thrombosis in young and very sick children with DKA who have femoral lines inserted. Consider anticoagulation with Fragmin 100units/kg once daily or other similar drug e.g. Enoxaparin. Children who are significantly hyperosmolar might also need anticoagulant prophylaxis (discuss with local consultant). 8

9 Discharge Plan Discharge Weight... Insulin doses on going home... Education offered... If recurrent DKA, discuss with diabetes consultant re. Psychology referral... Appointments made... If this is a newly diagnosed patient, see the New Diabetic ICP. 9

10 Results Flow Sheet: Aim to check bloods at the time intervals shown(* lab samples) Time from start Date & time Bag of fluid Insulin rate Lab (L) or Gas (G) or Ward meter (W) Venous (V) or Cap (C) or Arterial (A) Hourly Cap Glucose Blood ketone s ph pco 2 Exces s Base HCO 3 Na K Urea Creatinine 0 Baseline* 1hours 2hours* 3hours 4 hours 5hours 6hours* 7hours 8hours 9hours 10hours* 11hours 12 hours 13 hours 14 hours* 10

11 15 hours 16 hours 17 hours 18 hours* 19 hours 20 hours 21hours 22 hours* 23 hours 24hours 25 hours 26 hours* 27 hours 28 hours 29 hours 30 hours* Other results FBC: OTHER: CRP: 11

12 Date/ Time Title Name Multidisciplinary Notes Signature 12

13 Date/ Time Title Name Multidisciplinary Notes Signature 13

14 Date/ Time Title Name Multidisciplinary Notes Signature 14

15 Date/ Time Title Name Multidisciplinary Notes Signature 15

16 Date/ Time Title Name Multidisciplinary Notes Signature 16

17 Date/ Time Title Name Multidisciplinary Notes Signature 17

18 Date/ Time Title Name Multidisciplinary Notes Signature 18

19 Date/ Time Title Name Multidisciplinary Notes Signature 19

20 Date/ Time Title Name Multidisciplinary Notes Signature 20

21 PAGE 1 PAEDIATRIC DIABETIC KETOACIDOSIS INTRAVENOUS FLUID CHART Hospital No: DOB: First Name: Last Name: Date/Time: Weight: kg Allergies: Run Fluids at: ml/hours Dr s signature Dr s Name Start with Sodium Chloride 0.9% + 20mmol Potassium (KCI) in 500ml and continue this strength of Sodium Chloride for at least 12 hours. o When BG falls <14mmol/L, use Sodium Chloride 0.9%, Glucose 5% + 20mmol KCL in 500ml (Bag 2a) o If BG returns >14mmol/L, do not change fluid; discuss with Paediatrician. o If BG falls <8mmol/L, change to Sodium Chloride 0.9%, Glucose 10% + 20mmol KCL in 500ml (Bag 3a) o If BG returns >8mmol/L, do not change fluid discuss with Paediatrician. After 12 hours, if plasma sodium is stable or increasing, change to 0.45% Sodium Chloride with or without glucose, according to BG level + 20mmol KCI in 500ml. If plasma sodium is falling, continue with 0.9% Sodium Chloride with or without glucose, depending on BG level +20mmol KCL in 500ml. If BG falls <4mmol/L, call Paediatrician to inject an IV bolus of 10% Glucose 2ml/kg. Make up and clearly label and colour code bags 1 and 2a and the insulin prior to commencing treatment, as soon as bag 2a is commenced make up Bag 3a, bags 1 2a and 3a will be required for at least 12 hours, this may change after 12 hours depending on sodium results Bag Ref Intravenous Fluid Bags 1, 2a, 3a are to be used for at least 12 hours refer to DKA ICP Doctor s Signature/ Name Infusion Batch No Drug Batch No Administration Time/Date Time Signatures Started Stopped 1 Sodium Chloride 0.9% + Potassium (KCL) 20mmol in 500ml 1 Sodium Chloride 0.9% + Potassium (KCL) 20mmol in 500ml 2a Sodium Chloride 0.9% / Glucose 5% + Potassium (KCL) 20mmol in 500ml 2a Sodium Chloride 0.9% / Glucose 5% + Potassium (KCL) 20mmol in 500ml PAGE 2 \\Vfs1-rq \UserData\ialucking\My Documents\IAN\MEHT\INTRANET\Clinical Pages\Sharon Lim - Careers Support\NEW DKA ICP \DKA_ICP_EoEMEHTNov2013.docx

22 Bag Ref 3a PAEDIATRIC DIABETIC KETOACIDOSIS INTRAVENOUS FLUID CHART Intravenous Fluid To make up bag 3a withdraw 50ml from 500ml bag of 0.9% Saline in 5% Dextrose, replace with 50ml 50% glucose and add 20mmol KCL. Sodium Chloride 0.9% / Glucose 10% + Potassium (KCL) 20mmol in Doctor s Signature/ Name Infusion Batch No Drug Batch No Administration Time/Date Time Signatures Started Stopped 500ml 3a Sodium Chloride 0.9% / Glucose 10% + Potassium (KCL) 20mmol in 500ml Bags 1, 2b, 3b are for use after 12 hours refer to DKA ICP 2b 2b 3b 3b Sodium Chloride 0.45% / Glucose 5% + Potassium (KCL) 20mmol in 500ml Sodium Chloride 0.45% / Glucose 5% + Potassium (KCL) 20mmol in 500ml To make up bag 3b withdraw 50ml from 500ml bag of 0.45% Saline in 5%Dextrose, replace with 50ml 50% glucose and add 20mmol KCL. Sodium Chloride 0.45% / Glucose 10% + Potassium (KCL) 20mmol in 500ml Sodium Chloride 0.45% / Glucose 10% + Potassium (KCL) 20mmol in 500ml INSULIN BY SYRINGE PUMP: Delay Insulin till one hour after start of IV fluids. Pre filled Soluble insulin syringes with 50 units of soluble insulin in 50mls of 0.9% Sodium Chloride are available from pharmacy (in Phoenix 3 fridge) Start with 0.1 units/kg/hour = mls/hour. Dr s signature If BG remains <8mmol/L despite 10% glucose infusion, reduce insulin to 0.05 units/kg/hour = mls/hour. Dr s signature Time Soluble Human Insulin 0.1 units/kg/hour Time Soluble Human Insulin 0.05 units/kg/hour \\Vfs1-rq \UserData\ialucking\My Documents\IAN\MEHT\INTRANET\Clinical Pages\Sharon Lim - Careers Support\NEW DKA ICP \DKA_ICP_EoEMEHTNov2013.docx