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INITIAL CARE
ENSURE:
- Secure airway and adequate ventilation/oxygenation
MONITOR:
- Orthostatic hypotension (If not hypotensive)
GOALS OF TREATMENT - Continuous EKG monitoring
- Replace volume deficit* - Urine output
- Frequent Vital signs
- Correct ketosis and acidosis with continuous insulin PLACE:
- Replace electrolyte deficits* - Adequate IV access (may require 3 ports)
- Replace free water deficit* - Foley catheter
CALCULATE:
- Prevent hypoglycemia - Anion Gap
- Determine inciting condition for the DKA - Serum Osmolality
- Free Water Deficit
- Correct hyperglycemia (secondary goal)
- When DKA resolved: begin appropriate SQ insulin before
- Corrected Serum Sodium
LABS:
PROCEED TO
stopping Insulin drip - Basic metabolic panel, Serum phosphate level, hepatic enzymes, A1C
- beta-HCG. Urine (for women of child bearing age)
MANAGEMENT
- CBC w/differential
- Cardiac enzymes
- Serum ketones/acetone/Beta-hydroxybutyrate
- PT/PTT
- Venous/Arterial blood gas
- UA/Urine micro/Urine culture
CALCULATIONS ORDER:
- Anion Gap (AG) [<12-16]: - EKG
AG = [Na+] – [Cl- + HCO3-] - CXR
- Serum Osmolality [275-295 mOsm/L]: - Venous thromboembolism prophylaxis: Heparin 5,000 units SQ BID or TID (unless contraindicated)
= 2 X Serum Na+ (mEq/L) + [Glucose (mg/dL)/18] + [BUN (mg/dL)/2.8] CONSIDER, as indicated:
- Free Water Deficit: - Further Infectious work up
= Dosing Factor X wt (Kg) X [(Serum Na+/140) – 1] - Amylase/Lipase to rule out pancreatitis
{Dosing Factor = 0.6 (Male) and 0.5 (Female)} - Head CT/LP if encephalopathic
- Corrected Serum Sodium: – Consider Central access
Corrected Na+ = Serum Na+ mEq/L + (1.6 mEq/L for each 100 mg/dL
glucose > 100 mg/dL)
* Patients with ESRD/Anuria may not require volume and K+ repletion.
IV Fluids Potassium Insulin
*Wt < 60 kg may require Replacement - Fingersticks (FS BG) q 1 hour until BG
smaller volume < 250 mg/dl, stable and no change > 10
– Refer to table below
% for 3 hours, then FS BG q 2 hour
Determine Volume - Serum Chemistry every 4 hours
Status
Ketoacidosis/ AG persists & FS BG 70 to 150 mg/dL Ketoacidosis/ AG persists & FS BG < 70 mg/dL
For Discontinuation of Drip in PM: For Discontinuation of Drip in PM: - OOB, d/c foley and unneeded intravenous lines
- Pre- dinner administer both glargine - Pre- dinner administer 1/3 NPH dose - If eating reliably can discontinue IV dextrose
and aspart dose according to pre-meal and aspart dose according to pre-meal - If not volume or free water depleted discontinue
aspart order set aspart order set IV fluids