DKA Treatment Guidelines

Mercy Hospital and Medical Center APRIL 2012
Diabetic Ketoacidosis Treatment Guidelines
Monitor
TEST FREQUENCY
Blood glucose monitoring POC Q1 hour
Vital signs (Pulse, heart rate, respirations) Q1 hour
Chem 12 Stat once
Monitor intake / output Q1 hour
Chem 7 Q2 hours (if stable, and corrected CO2 >15,
then q4 hours
Phosphorous level Stat, if abnormal, then q4 hours
CBC w/ auto differential Stat, prn
Magnesium level Stat, prn
Arterial blood gas Stat, prn
Urinalysis w/ microscopic Stat, prn
EKG Stat, prn
Chest X-ray
Blood culture, if febrile
Urine culture, if febrile
OTHER testing, as clinically indicated
Diet Orders
NPO
NPO with ice chips and sips of water
Fluids and Electrolytes
□ Initiate 0.9NS IL IV @ 15mL/kg/hr for 1-2 hours and then 7.5mL/kg/hr
□ Call physician for IVF orders for hemodialysis (or heart failure patients)
IVF Options
□ 0.9% NS 1L at ____ mL/hour
□ 0.45% NS 1L at ____mL/hour
□ 0.9% NS with 20mEq/L at ____ mL/hour
□ 0.9% NS with 40mEq/L at ____ mL/hour
□ 0.45% NS with 20mEq/L at ____ mL/hour
□ 0.45% NS with 40mEq/L at ____ mL/hour
□ D5W / 0.45% NS 1L at ____ mL/hour
□ D5W / 0.45% NS 1L with 20mEq/L at ____ mL/hour
□ D5W / 0.45% NS 1L with 40mEq/L at ____ mL/hour
□ D10W / 0.45% NS 1L at ____ mL/hour
□ Other _________________________ at ____ mL/hour

MEDICATIONS:
pH < 7.0
For pH 6.9 - 7: Sodium Bicarbonate 50mEq IV in 0.45% NS 250mL IV over 1 hr
For pH < 6.9: Sodium Bicarbonate 100mEq IV in 0.45% NS 500mL IV over 2 hr
Initial Potassium Replacement
Potassium < 3.3
Peripheral access:
KCl 40mEq in 500mL over 4 hours
KPhos 30 mmol in 500 mL over 4 hours (consider if phos is 3.3, Start Insulin drip
Regular insulin IV Bolus
Regular insulin 0.1 units/kg (IBW) IV x1
Regular insulin ___units/kg (IBW) IV x1
Regular insulin 100 units / 0.9% NS 100 mL continuous IV infusion
Initiate drip at 0.1 units/kg/hour (IBW) IV
Initiate drip at ___units/kg/hour (IBW) IV

Mercy Hospital and Medical Center
DKA Management Algorithm
(Nursing and Physician Guidance Document)
Nursing Management of Insulin Infusion
When initiating insulin infusion, prime tubing by running 30mL through infusion
tubing before connecting to patient
Use Ideal Body Weight (IBW) for dosing
If K+ < 3.3 at the time of insulin administration, promptly notify physician
Initiate insulin drip at 0.1 units/kg/hour (or other dose written by physician)
Monitor glucose q1 hour. Titrate insulin drip using the below table
TABLE 1: Insulin Drip Titration (for use after insulin drip initiation)
Glucose (mg/dL) Insulin Drip (units/hr)
Increase drip by 4 units/hr
>500
(or 25 %, which ever increase is less)
251-500
151-250
101-150
71-100
Do not adjust rate if blood glucose is
decreasing by 50-75 mg/dL/hr
If blood glucose is NOT decreasing by 50-
75 mg/dL/hr, then increase the drip rate by
2 units/hr
When the plasma glucose reaches 250
mg/dl in DKA, decrease the insulin infusion
rate to 0.05 - 0.1 unit/kg/h (or 3–6 units/h)
IV fluids should contain D5W if glucose is

Diabetic Ketoacidosis Management
Physician Guideline
Initial Plan of Care
Determine hydration status
Initiate 0.9 % Normal Saline at 15 mL/kg/hour for 1-2 hours and then 7.5
mL/kg/hour
Consider less aggressive fluid replacement in heart failure or chronic renal failure
patients.
Potassium should be repleted if K + < 5. See Potassium Replacement section
Patient must have BUN and serum creatinine first.
Patient must have urine output > 30mL/hour to initiate any potassium in the first
two hours of DKA management.
When K > 3.3, Start Insulin drip
Using ideal body weight, initiate insulin
Consider a regular Insulin 0.1 units/kg (IBW) IV bolus x1
Then, start the insulin drip: regular insulin 100 units / 0.9% NS 100 mL
continuous IV infusion at 0.1 units/kg/hour (IBW)
Following serial, q1hour blood glucose values, titrate insulin drip,
hydration status and potassium repletion. See below guideline table.
Nursing will titrate the insulin drip based on the below instructions
Chem 7 is ordered q2hours in order to follow sodium and potassium closely.
o Change IVF, as needed.
o Potassium:
If K < 3.3, replete with KCL (or KPhos) IVPB given over 4+ hours
If K > 3.4, add KCl to maintenance IV fluids, until K > 5.
o Phosphate: Consider total potassium replacement (KCl + K Phos), when
ordering Potassium phosphate (recommend 2/3 KCl, 1/3 K Phos)
TABLE 2: Physician DKA Management (for use after insulin drip initiation)
Glucose (mg/dL) Insulin Drip (units/hr)
>500
251-500
151-250
Increase drip by 4 units/hr
(or 25 %, which ever increase is less)
Do not adjust rate if blood glucose
is decreasing by 50-75 mg/dL/hr
If blood glucose is NOT
decreasing by 50-75 mg/dL/hr,
then increase the drip rate by 2
units/hr
When the plasma glucose
reaches 250 mg/dl in DKA,
decrease the insulin infusion rate
to 0.05 - 0.1 unit/kg/h (or 3–6
units/h).
IV fluids (IVF)
Recommendations:
Na >135: 0.45NS
Na 135: 0.45NS
Na 135: D5W-0.45NS
Na 5: none
K 4.1 - 5: add 20 mEq/L
K 3.3 - 4: add 40 mEq/L
K 5: none
K 4.1 - 5: add 20 mEq/L
K 3.3 - 4: add 40 mEq/L
K 5: none
K 4.1 - 5: add 20 mEq/L
K 3.3 - 4: add 40 mEq/L
K

101-150
71-100
135: D5-0.45NS
Na135: D5-0.45NS
Na 5: none
K 4.1 - 5: add 20 mEq/L
K 3.3 - 4: add 40 mEq/L
K 5: none
K 4.1 - 5: add 20 mEq/L
K 3.3 - 4: add 40 mEq/L
K 5: none
K 4.1 - 5: add 20 mEq/L
K 3.3 - 4: add 40 mEq/L
K