First Name:

Insulin Prescription Chart D Adult Diabetic Ketoacidosis (DKA) Age 19 yrs and over This chart should be used in conjunction with the DKA guidelines

Surname:

(Use addressograph)

Sample only - not for clinical use

Hospital No.

NHS no.

Consultant

Ward

Cross reference this chart on the main inpatient drug chart Date

DOB.

Hospital

Check allergy status on main drug chart

This chart is designed so that prescriptions and relevant observations can be recorded together.

DOCTOR: All prescriptions for insulin and fluids must be signed and dated. NURSE: All entries must be signed and dated. THIS CHART IS FOR THE MANAGEMENT OF DIABETIC KETOACIDOSIS (DKA) IN ADULTS ONLY (Aged 19 years and older). It is used to aid the management of diabetes ketoacidosis during the first 24 hours.

The DKA summary guideline is on the reverse of the chart. Please refer to this as indicated. Once the metabolic disturbance has been corrected, patients must have their diabetes treatment prescribed on the appropriate insulin prescription chart.

1. DIAGNOSIS OF DKA (all 3 criteria must be present) Capillary Blood Glucose (CBG) > 11mmol/L or known diabetes.

mmol/L

Capillary ketones ≥ 3mmol/L or urinary ketones + + or more.

mmol/L

Venous bicarbonate < 15mmol/L and/or venous pH < 7.3.

mmol/L

2. IMMEDIATE TREATMENT: 1L sodium chloride 0.9% intravenous infusion and fixed rate IV insulin infusion. (see Section 2 on reverse of chart for details) START IN EMERGENCY DEPARTMENT / ASSESSMENT UNIT OR THEIR CURRENT LOCATION ASAP

3. CRITICAL CARE REVIEW:

Document cause of DKA

Transfer to Acute Medicine unless any criteria for critical care review are met.

……..……………………………………………

(see Section 3 on reverse of chart for details)

Contact Diabetes Specialist Registrar ASAP Bleep no 4710 (tick when completed)

4. INVESTIGATIONS Baseline investigations are as detailed in Section 4, on reverse of the chart. If indicated, detail results of investigations below and on the results chart on page 5. Date & Time

Date & Time

CXR

Urine dip

Date & Time

Date & Time

ECG

Registered by Medicines Risk Management Group th

12 October 2006

Reviewed & re-registered July 2014

Pregnancy test

Next Review Due

Pharmacy Ref No.

July 2016

06/012 v4

Print Unit Ref no. WPG595

Weight (actual): …………..kg Date: ..……….

5. FIXED RATE INTRAVENOUS INSULIN PRESCRIPTION  

Draw up 50 units human soluble (Actrapid ®) insulin in 49.5mL sodium chloride 0.9% to give 1 unit /mL solution (pre-made solution available from pharmacy). Use a non-return device to administer. Commence fixed rate IV insulin at 0.1 unit / kg / hour based on actual or estimated weight. The table below can be used to assist in dose calculation.

Weight in kg

Insulin dose per hour (unit)

Weight in kg

Insulin dose per hour (unit)

Weight in kg

Insulin dose per hour (unit)

50-59

5

90-99

9

130-139

13

60-69

6

100-109

10

140-149

14

70-79

7

110-119

11

≥ 150

15

80-89  

Weight (estimate): …….….kg Date: …………

8

120-129

For any dose higher than 15units/hr Consult Diabetes Team.

12

For treatment targets and monitoring see Section 8 on reverse of chart. If blood glucose falls below 4mmol/L see Page 5 for hypoglycaemia guidance. In the event of hypoglycaemia reduce rate of IV insulin infusion by 25% Intravenous insulin infusion rate (units/hour)

Date

Time

Prescriber signature

PRINT name and contact number

Starting rate Change 1 Change 2

INSULIN INFUSION RECORD Nursing staff must keep this record Insulin Batch Number

Date

Time Infusion started

Started by

Checked by

Time infusion stopped

Sample only - not for clinical use REGULAR SUBCUTANEOUS LONG ACTING INSULIN PRESCRIPTION If patient normally takes basal insulin e.g. Lantus® (insulin glargine), Levemir® (insulin detemir) or Tresiba® (insulin degludec), Humulin I®, Insulatard® , Insuman basal it should be continued at the usual dose and time(s). Prescribe this in the box below even if the patient is not eating or drinking. When the patient transfers back to their usual subcutaneous insulin regimen the prescription must be cancelled here and transferred to the adult subcutaneous insulin prescription chart. For patients with newly diagnosed type 1 diabetes, please seek advice about initiation of subcutaneous insulin from the diabetes team.

ADMINISTRATION

ENTER TIME(S)

INSULIN

Dose 1

Change 1

Type Units Signature

Date

Units

Units Date

Dose Sign

Sign

Type Signature

Date

Units Sign

Dose Sign

2

6 & 7. INTRAVENOUS FLUID PRESCRIPTION AND POTASSIUM REPLACEMENT For suggested prescribing regimen see Sections 6 and 7 on reverse of chart Prescribe infusion to include strengths of solutions and any drugs or electrolytes. Infusion rate should be prescribed as mL per hour. When capillary blood glucose 15mmol / L. Blood Ketones to fall by at least 0.5mmol / L / Hour Until < 0.6mmol / L. Blood Glucose to fall by at least 3mmol / L / Hour Until ≤ 14mmol / L.

RESOLUTION OF DKA

Defined as: Blood ketones < 0.6mmol / L (or urinary ketones < 2) and bicarbonate > 15mmol/L; and the pH > 7.3.

Insulin Infusion - Day 1 Date

Time

Capillary blood glucose (mmol / L)

Rate

(units / hr) of insulin

Initials

Insulin Infusion - Day 2 Urinary / Blood Ketones

Date

Time

Capillary blood glucose (mmol / L)

Sample only - not for clinical use

Rate

(units / hr) of insulin

Initials

Urinary / Blood Ketones

SERIAL RESULT CHART See Section 8 on reverse of chart for frequency of laboratory monitoring. Date Time (from start) Time (actual) Lab glucose Na K Urea Creatinine eGFR HCO3 pH

0 min

1hr

2hr

4hr

6hr

12hr

24hr

Sample only - not for clinical use How to manage hypoglycaemia in an adult patient with DKA? • Hypoglycaemia is defined as Capillary Blood Glucose (CBG) less than 4mmol/L. • This algorithm exclusively applies to patients with DKA currently being treated with a •

fixed rate IV insulin infusion. For all other patients experiencing hypoglycaemia please see LTHT guidelines ‘The Hospital Management of Hypoglycaemia in Adults with Diabetes Mellitus’ and the associated algorithm.

If CBG is less than 4mmol/L:

STOP IV insulin infusion The patient is unconscious/ disorientated/ aggressive/ having seizures

The patient is conscious and alert Ensure 10% glucose IV is being infused at 125ml/hr Check the patency of IV line and the correct functioning of IV pump Re-test CBG after 15 minutes.

Check airway, breathing and circulation and request urgent medical review Give 150ml of 10% glucose IV over 15mins (rate 600ml/hr) If unable to quickly secure IV access give 1mg IM glucagon*. Test CBG every 15 minutes (until CBG greater than 4mmol/L)

Is CBG now greater than 4mmol/L?

No

Yes

Ensure 10% glucose IV is being infused at 125ml/hr. Restart fixed rate IV insulin infusion at a rate which is 25% lower than previous. Continue to follow DKA treatment protocol. Contact diabetes specialist team for urgent review in event of hypoglycaemia in DKA.

If CBG remains less than 4mmol/L and patient still unwell: 150ml of IV 10% glucose over 15 mins can be repeated up to 3 times, dependent on clinical response. Ensure venous glucose is sent to lab If CBG remains less than 4mmol/L, seek diabetes specialist advice, and consider other causes of hypoglycaemia.

CBG is now greater than 4mmol/L (*NB Give once only. Certain patients may respond poorly to glucagon i.e. those who are malnourished, severe liver disease, glucocorticoid deficiency)

LTHT MANAGEMENT OF DIABETIC KETOACIDOSIS IN ADULTS (19 YEARS OLD AND OVER) Use in conjunction with the SJUH care pathway for DKA in adults and insulin prescription, administration and monitoring chart.

1. DIAGNOSIS (all three):

2. IMMEDIATE TREATMENT : DO NOT DELAY STARTING TREATMENT



Raised blood glucose > 11mmol/L (or known diabetes).

1.

Insert intravenous cannula.

2.



Capillary ketones > 3 mmol/L (or ketones ≥ 2+ in urine).

1L sodium chloride 0.9% infusion over 1 hour if systolic BP > 90. (If systolic BP < 90 give repeated boluses of 500mL sodium chloride 0.9% over 10 - 15 minutes, max 2L). If BP remains low call critical care.



Venous pH < 7.3 or venous bicarbonate < 15 mmol/L.

3.

Start IV insulin infusion: 50 units human soluble (ACTRAPID ) insulin in 49.5 mL sodium chloride 0.9% to give a 1 unit/mL solution (pre-made solution available from pharmacy) via syringe driver at 0.1 units / kg / hour (estimated or actual body weight).

4.

Call diabetes specialist team (Bleep 4710)

3. CRITICAL CARE REVIEW:        

Venous bicarbonate < 5mmol/L or pH < 7.1 Drowsy (GCS 3 mmol / L / hour until < 14 mmol / L.  Capillary ketones fall of at least 0.5 mmol / L / hour until < 0.6 mmol / L.  Venous bicarbonate rise of > 3 mmol / L / hour until > 15mmol / L. NOT IMPROVING? CHECK:  IV pump operation, insulin addition, patency of cannula, patient weight.  Re-assess for concomitant illness. Consider lactic acidosis.  If CBG not falling CONSIDER increase rate of insulin infusion by 1 unit / hour, every hour. Re-assess regularly. ALWAYS THINK ABOUT  Cause of DKA, and treat cause if indicated.  Thromboprophylaxis.  Cerebral oedema, especially in young people (increasingly drowsy / irritable).  Senior review if not improving as expected.

9. AFTER RECOVERY 

Transfer to subcutaneous insulin when patient well, able to eat and drink normally and venous pH > 7.3 or blood ketones < 0.6 mmol / L.  In this case, start patient back on their normal subcutaneous insulin, coinciding cessation of IV insulin with rapid acting subcutaneous insulin and a meal.  If patient has newly diagnosed diabetes, refer to diabetes specialist team to initiate subcutaneous insulin. If metabolic parameters have resolved but patient not eating and drinking, transfer to variable rate IV insulin infusion.