DRUG AND TREATMENT *****ALSO ORDER SUB ACUTE DKA IV FLUIDS REGIMEN & SUB ACUTE ELECTROLYTE REPLACEMENT on separate forms ***** Condition/Status 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(note)* Patient Status Patient Status: Inpatient, Level of Care Intensive Care (8), Requested Location: MSICU Diet NPO Nursing Orders Notify Provider Notify ordering 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, -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 -Normalized 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 (see end of orders) Communication Order Monitor potassium, magnesium, phosphorus, and normalized 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. Comments: Continue IV fluid orders until patient tolerates greater than 50% of first meal or otherwise ordered by. 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 NPO. Page 1 of 7
DRUG AND TREATMENT 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 Cancel all prior IV fluid and insulin orders.(note)* Insulin (Regular) 100 units/ns 100mL (IVS)* NS (Insulin) Initial Multiplier: 0.03 140 mg/dl-180 mg/dl IV Titrate per algorithim Comments: Initial Rate in units/hour = (BG-60) x 0.03 Adjust multiplier as follows: If BG is greater than 180 mg/dl, increase the multiplier by 0.01. If BG is less than 140 mg/dl reduce multiplier by 0.01. If BG is within target range, do not change multiplier but do recalculate dose *Flush tubing with 20mL of Insulin Infusion PRIOR to starting infusion. Administer via an infusion device piggybacked into IV fluids For BG Greater Than 400 mg/dl, use 400 as Maximum BG for Calculation. Insulin dose MUST be calculated hourly even if multiplier does not change. 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. Do 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. Notify Provider Call attending for any abnormal lab results to obtain orders for electrolyte replacement (DEF)* Call Endocrinologist for any abnormal lab results to obtain orders for electrolyte replacement Page 2 of 7
DRUG AND TREATMENT 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 STAT 3. 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 Laboratory CHEM 7 Timed Study Priority, Q5H Int Magnesium Level Timed Study Priority, Q5H Int Phosphorus Timed Study Priority, Q5H Int Ionized Calcium Level. Timed Study Priority, Q5H Int 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 Page 3 of 7
DRUG AND TREATMENT Post Acute Diabetic Ketoacidosis Diet Patient to be Initiated on a Diet 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:(note)* Diet Order 1800 kcal (DEF)* 1500 kcal 2000 kcal 2200 kcal 2400 kcal Patient to be kept NPO For patients with anion gap LESS than 12 mmol/l and CO2 GREATER than 18 meq/l and patient who will remain NPO, select BOTH Communication and NPO order(note)* Communication Order Change IV fluid rate to 150 ml/hour in patients who will remain NPO. Continue Insulin infusion per Acute Phase algorithm. NPO Nursing Orders 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. 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 NPO. Blood Glucose Monitor POC AC&BEDTIME Medications ***Reminder : Order GEN Correction Insulin (Sliding Scale) on separate form*** Continued.. Page 4 of 7
DRUG AND TREATMENT Basal Insulins Levemir unit inj SUBCUT BEDTIME (DEF)* Comments: Do NOT hold when patient is NPO. If unit inj SUBCUT DAILY, Start: 0900. Comments: Do NOT hold when patient is NPO. If unit inj SUBCUT Q12H Comments: Do NOT hold when patient is NPO. If fingerstick blood glucose is less Lantus unit inj SUBCUT BEDTIME (DEF)* Comments: Do NOT hold if patient is NPO. If unit inj SUBCUT DAILY, Start: 0900 Comments: Do NOT hold if patient is NPO. If unit inj SUBCUT Q12H Comments: Do NOT hold if patient is NPO. If fingerstick blood glucose is less insulin NPH human unit inj SUBCUT BIDAC (DEF)* unit inj SUBCUT BEDTIME&AM unit inj SUBCUT BEDTIME NovoLog Mix 70/30 unit inj SUBCUT BIDAC Comments: HOLD if patient is NPO and call for other insulin orders Consults Consult Physician Endocrinologist, For management of all home insulin pumps. (Not available at BMCN) Page 5 of 7
DRUG AND TREATMENT MED Diabetes Ketoacidosis Reference Text: Target Range: 140-180 mg/dl Note: Target Range refers to Blood Glucose, NOT BG - 60 calculation 1. Regular Insulin 100 units/100 ml NS. Concentration=1 unit/ml 2. Refer to dosing nomogram for calculation assistance 3. Initial multiplier = 0.03. To be used for the second hour of insulin drip. 4. Obtain hourly finger stick blood glucose 5. IF BG is more than 180 mg/dl:, increase multiplier by 0.01 6. If BG is less than 140 mg/dl, reduce multiplier by 0.01 7. If BG is more than 400 mg/dl, use 400 maximum BG value for calculation Do NOT initiate Insulin drip unless K+ is 3.2 meq/l or greater (see # 12) Inform if initiation of insulin drip is delayed for any reason When BG less than 250 mg/dl, change IV fluids according to the SUB Acute DKA IV Fluid Regimen Do NOT stop insulin drip unless criteria (anion gap is LESS than 12 mmol/l and CO2 is GREATER than 18 meq/l and patient can attempt PO) is met or approved by If BG is less than 120 mg/dl while on insulin drip, see D50W orderable for treatment Page 6 of 7
DRUG AND TREATMENT Insulin Infusion Guidelines (DKA) Target Blood Glucose Range 140-180 mg/dl Initial Rate= Start Insulin infusion at 0.14 units/kg per hour 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 Hourly Dose Adjustments: BG = Current Blood Glucose 0.03 = Multiplier 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 0.01. If BG is less than 140 mg/dl reduce multiplier by 0.01. For 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 change. *************************************************************************** Do 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. *************************************************************************** Hypoglycemia Treatment For Blood Sugar Less than 120 mg/dl: administer D50W as per order details Page 7 of 7