DRUG ALLERGIES WT: KG

Transcription

1 DRUG AND TREATMENT Acute Diabetic Ketoacidosis Condition/Status ***(NOTE)*** For purpose of this DKA Regimen, DKA is considered clear only when the CO2 is GREATER than 18 meq/l and the anion gap is LESS than 12 mmol/l Patient Status Inpatient Patient Status: Inpatient, Level of Care: Intensive Care (8) Place in Observation Patient Status: Outpatient- Refer for Observation Status, Level of Care: Intensive Care (8) Diet Diet Order. Nursing Orders Notify Provider Notify ordering physician if Blood glucose LESS than 90 mg/dl while Acute Phase DKA orders are active, Blood glucose decreases by GREATER than 100 mg/dl per hour while on insulin infusion, Comments: Potassium level LESS than 2.3 meq/dl or GREATER than 6 meq/dl Phosphorus level LESS than 0.5 mg/dl Magnesium level LESS than 1 mg/dl Ionized Calcium level LESS than 3.4 mg/dl Urine output LESS than 0.5 ml/kg/hour Sodium level LESS than 130 meq/dl or GREATER than 155 meq/dl Serum Osmolality decreases GREATER than 12 mosm/kg over 4 hours Development of pulmonary edema (i.e. rales), headache or confusion Diabetic Ketoacidosis Reference Materials Communication Order Monitor potassium, magnesium, phosphorus, and ionized calcium levels while on an insulin infusion and replace as per SUB Acute DKA Electrolyte Replacement or as ordered Plan Progression Orderable Initiate POST ACUTE DKA phase and discontinue ACUTE DKA phase ONLY when the anion gap is LESS than 12 mmol/l and CO2 is GREATER than 18mEq/L and when the patient can attempt PO intake. Comments: Continue IV fluid orders until patient tolerates greater than 50% of first meal or otherwise ordered by physician. Continue Insulin infusion until 1 hour AFTER long acting insulin is administered and/or home insulin infusion pump is restarted or if patient to remain. Blood Glucose Monitor POC Q1H Comments: Check finger stick blood glucose every hour while on insulin infusion. Obtain lab glucose if finger stick blood glucose does NOT agree with clinical assessment.*******************************************************************when finger stick blood glucose is LESS than 250 mg/dl: Creatinine LESS than or EQUAL to 2 mg/dl -- Change IV fluids to D5 1/2 NS with 20 KCl Creatinine GREATER than 2 mg/dl -- Change IV fluids to D5 1/2 NS******************************************************************* Medications ***(NOTE)*** Cancel all prior IV fluid and insulin orders. Insulin (Regular) 100 units/ns 100mL (IVS)* NS (Insulin) Initial Multiplier: 0.03 BG Target Range: 140 mg/dl-180 mg/dl IV iv Titrate per algorithm Comments: Insulin Infusion Guidelines (DKA)Target Blood Glucose Range mg/dl Initial Infusion Rate: Initial Rate= Start Insulin infusion at 0.14 units/kg per hour Page 1 of 5

2 DRUG AND TREATMENT when potassium level is 3.2 meq/l or GREATER: - Flush tubing with 20mL of Insulin Infusion PRIOR to starting infusion - Administer via an infusion device piggybacked into IV fluids Rate in units/hour = (BG-60) x 0.03: - BG = Current Blood Glucose = Multiplier Hourly Dose Adjustments: If BG is within target range, do not change multiplier BUT do recalculate dose. Adjust multiplier as follows: If BG is GREATER than 180 mg/dl, increase the multiplier by 0.01If BG is LESS than 140 mg/dl reduce multiplier by 0.01For BG GREATER than 400 mg/dl, use 400 as Maximum BG for Calculation. If the calculated rate is LESS than 1 unit/hour, continue patient on insulin infusion at 1 unit/hour and adjust rate hourly as above. If BG is within target range, do not change multiplier but do recalculate dose. Insulin dose MUST be calculated hourly even if multiplier does not changexxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxx xxxxxxxxxxxxxxxxxxxxxxxxxxxdo NOT stop insulin infusion until anion gap is LESS than 12 mmol/l and CO2 is GREATER than 18 meq/l AND a long acting subcutaneous insulin (i.e. Levemir, Lantus, NPH, Novolog Mix 70/30) is administered OR Insulin Pump is resumed.xxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxx xxxxxxxxxxxxxxxxxxxxxxxxxxxxxhypoglycemia Treatment For Blood Sugar LESS than 120 mg/dl: administer D50W as per order details insulin regular (human) IV drip 100 unit SUB Acute DKA IV Fluid Regimen (SUB)* ***Reminder: Order SUB Acute DKA IV Fluid Regimen (SUB) on a separate form*** Notify Provider (BMCB) Notify Provider (BMCD) Notify Provider (BMCN) Call Physician for any abnormal lab results to obtain orders for electrolyte replacement Notify Provider (BMCS) SUB Acute DKA Electrolyte Replacement (SUB)* ***Reminder: Order SUB Acute DKA Electrolyte Replacement (SUB) on a separate form*** D50W (Insulin Infusion Orders) 50 ml IV PUSH syringe PRN, PRN Low Blood Sugar Comments: For Blood Sugar LESS than 120 mg/dl while on insulin infusion:1. Give Dextrose 50% 50mL 2. If Serum Creatinine is LESS than or EQUAL to 2 mg/dl Change IV Fluids to D10 ½ Normal Saline at 250 ml/hour and notify Pharmacy STAT3. If Serum Creatinine is GREATER than 2 mg/dl Change IV Fluids to D10 ½ Normal Saline at 250 ml/hour and notify Pharmacy STAT4. Recheck finger stick blood glucose in 30 minutes Repeat Dextrose 50% 50 ml IV every 30 minutes as needed to keep finger stick blood glucose GREATER than or EQUAL to 120 mg/dl Page 2 of 5

3 DRUG AND TREATMENT Laboratory CHEM 7 Magnesium Level Phosphorus Ionized Calcium Level Consults Consult Diabetes-Adult Soon, Teach Diabetic Ketoacidosis Consult Dietitian Other - See Special Instructions, Diabetic Ketoacidosis Consult Pharmacy Other - See Special Instructions, DKA: Discontinue all prior IV fluid and insulin orders Post-Acute Diabetic Ketoacidosis Non Categorized ***(NOTE)*** Recommend this phase to be placed in PLANNED state-to be initiated by nurse when patient meets defined parameters in Plan Progression Orderable. Diet Patient to be Initiated on a Diet ***(NOTE)*** For patients with anion gap LESS than 12 mmol/l and CO2 GREATER than 18 meq/l and patients that CAN attempt oral intake, choose diet order below: Diet Order 1800 kcal (DEF)* 1500 kcal 2000 kcal 2200 kcal 2400 kcal Patient to be kept ***(NOTE)*** For patients with anion gap LESS than 12 mmol/l and CO2 GREATER than 18 meq/l and patient who will remain, select BOTH Communication and order. Communication Order Change IV fluid rate to 150 ml/hour in patients who will remain. Continue Insulin infusion per Acute Phase algorithm. Diet Order. Nursing Orders Page 3 of 5

4 DRUG AND TREATMENT Plan Progression Orderable Initiate POST ACUTE DKA phase and discontinue ACUTE DKA phase ONLY when the anion gap is LESS than 12 mmol/l and CO2 is GREATER than 18mEq/L. Comments: Continue IV fluid orders until patient tolerates greater than 50% of first meal or otherwise ordered by physician. Continue Insulin infusion until 1 hour AFTER long acting insulin is administered and/or home insulin infusion pump is restarted or if patient to remain. Blood Glucose Monitor POC AC&BEDTIME Medications GEN Correction Insulin (Sliding Scale) (SUB)* ***Reminder: Order GEN Correction Insulin (Sliding Scale) (SUB) on a separate form*** Basal Insulins insulin detemir (Levemir) unit inj SUBCUT BEDTIME (DEF)* Comments: First dose NOW. Do NOT hold when patient is. If fingerstick blood glucose is less unit inj SUBCUT DAILY, Start: 0900 Comments: First dose NOW. Do NOT hold when patient is. If fingerstick blood glucose is less unit inj SUBCUT Q12H Comments: First dose NOW. Do NOT hold when patient is. If fingerstick blood glucose is less insulin glargine (Lantus) unit inj SUBCUT BEDTIME (DEF)* unit inj SUBCUT DAILY unit inj SUBCUT Q12H Insulin isophane (insulin NPH human) unit inj SUBCUT BIDAC (DEF)* unit inj SUBCUT BEDTIME&AM unit inj SUBCUT BEDTIME Insulin aspart-insulin aspart protamine (NovoLog Mix 70/30) unit inj SUBCUT BIDAC Comments: First dose NOW. HOLD if patient is and call physician for other insulin orders Page 4 of 5

5 DRUG AND TREATMENT Consults Consult Physician (BMCB) Consult Physician (BMCD) Consult Physician (BMCS) Page 5 of 5