Patient Care Orders Treatment of Diabetic Ketoacidosis ** For Adults greater than 18 years** page 1 of 4 Orders: Initial or tick where applicable. Changes/deletions to be initialed by prescriber Diabetic Ketoacidosis (DKA) is an abnormal diabetic metabolic state characterized by hyperglycemia, dehydration, anion gap, metabolic gap, ketonemia. Clinical parameters: serum glucose > 14 mmol/L; serum pH < 7.30; presence of serum ketones; anion gap > 10 mmol/L.
FIRST 60 MINUTES Confirm DKA and level of severity : **Patients with severe DKA should be stabilized and transferred to a hospital with an ICU Table I – diagnostic criteria and severity of DKA – adapted from ADA guidelines Mild Moderate Severe ** Plasma glucose (mmol/L) > 13.9 >13.9 >13.9 Arterial pH 7.25-7.30 7.00-7.24 12 >12 Sensorium Alert Alert/drowsy Stupor/coma
1:1 nursing x 8 hrs then reassess Cardiac monitoring for duration of protocol treatment Measure body weight in kilograms: _________ kg Order ABGs, venous blood gases, serum glucose, serum ketones, urinalysis & electrolytes CBC Creatinine Urea HbA1c urine culture blood culture ECG other ____________________________________________ Fluid replacement: MD to establish extent of dehydration, calculate total fluid deficit. Give initial N/S at a rate of 15-20ml/kg/hr x 1h, then reduce to 5-15 ml/kg/hr based on estimated fluid requirements. Goal: replace ½ the estimated fluid loses over 8 hours and the remaining ½ over 16 hours plus replacing ongoing losses.
Start 2 IV’s IV #1 N/S @ ___________ x 1 hr Record accurate ins/outs on DKA flow sheet Foley catheter
Date:
Physician's Signature:
______
Your signature indicates that bulleted items are authorized orders unless crossed out.
Patient Care Orders Treatment of Diabetic Ketoacidosis ** For Adults greater than 18 years** page 2 of 4 Orders: Initial or tick where applicable. Changes/deletions to be initialed by prescriber
Initial potassium replacement: 1.
If initial serum K > 5.2 mmol/L, or if ongoing urinary output not yet established, do not administer KCL in IV N/S 2. If initial serum K is between 3.4-5.2 mmol/L, and urine output established, add 40 meq/L KCL to IV N/S 3. If initial serum K 3.3 mmol/L, then resume insulin infusion ***** recheck serum K in 1 hour and follow ongoing potassium replacement on page 3***** 4.
IV #1 N/S @ _________ ml/hr x 8 hr, then reduce to __________ ml/hr x 16 hrs then reassess Add __________meq/L KCL to each litre of IV N/S recheck serum K in 1 hr Hold insulin infusion when K 7.05 Check AGBs and electrolytes q 1h until bicarbonate infusion discontinued Date: Physician's Signature: Your signature indicates that bulleted items are authorized orders unless crossed out.
______
Patient Care Orders Treatment of Diabetic Ketoacidosis ** For Adults greater than 18 years** page 3 of 4 Orders: Initial or tick where applicable. Changes/deletions to be initialed by prescriber
FIRST 24 HOURS Once DKA diagnosis confirmed: Order serum glucose and venous blood gases q1h until pH > 7.30 and then order lab/meter correlation (when results acceptable by lab), switch to glucoscans q1h until glucose < 12 mmol/L, then q2h Order lytes q 2h x 8h then as ordered Monitor vitals q 1h x 8h then as ordered Monitor neurologic status q 1h if altered status on admission and MD to reassess Fluid intake/output q 1h x 24h and then as ordered When blood glucose≤ 12mmol/L, change IV # 1 to 5% dextrose in normal saline @___________ml/hr Ongoing potassium replacement: treatment aim is serum potassium between 4-5 mmol/L. 1. 2. 3.
If serum K is between 3.4-5.2 mmol/L, and urine output established, add 40 meq/L KCL to IV N/S When serum K >4.5 mmol/L and < 5 mmol/L, reduce KCL to 20 meq/L to IV N/S If serum K rises during treatment > 5.2 mmol/L, hold KCL and reassess in 2 hours, giving just N/S alone
Add __________meq/L KCL in 5% dextrose in normal saline (IV #1) Insulin Infusion: Once glucose level is
