Diabetic Ketoacidosis (D.K.

A) Beaumont Hospital Protocol

DIAGNOSIS:
1. 2. 3. Plasma Glucose > 13 mmol/L Plus: pH < 7.30 or Venous Bicarbonate < 17 mmol/L Plus: Ketone positive (urine or capillary)

*These patients have high mortality rates. Treatment should be initiated without delay.

(This is Not a prescription; prescribe on patients Drug Kardex) Insulin I.V.Fluids Potassium (K+) Monitoring
1). 1L 0.9% NACL Stat (no KCL) 2). 1L 0.9% NACL over 1 hr 3). 1L 0.9% NACL over 2 hrs 4). 1L 0.9% NACL over 4 hrs 5). 1L 0/9% NACL over 6-8 hours and repeat as per fluid status * Average fluid deficit of 6-10L Correct plasma sodium for hyperglycaemia Corrected sodium = (Plasma sodium) + (Glucose 4) If corrected sodium >152 mmol/L use 0.45% NACL as fluid replacement (discuss with endocrine registrar) Caution in the elderly due to fluid overload, may need admission to ICU / HDU 1). STAT dose of 6-10 units of IV Actrapid 2). Commence IV insulin infusion infusion at 6 units / hr Regime: 50 mls 0.9% NACL with 50 units Actrapid in a 50 ml syringe driver, (1 ml = 1 unit Actrapid) 3). Check CBG / plasma glucose hourly until on GKI 4). If no fall in CBG after 2 hours, check infusion and IV line. If both okay, then double infusion rate. If CBG does not fall on higher infusion rate, contact Endocrine Registrar / Medical Registrar on call. 5). Once CBG < 12mmol/L stop insulin infusion and switch to GKI:500mls of 10% dextrose +10 mmol KCL + 10 units of Actrapid over 5 hours and adjust as per GKI protocol 1). Check U&E and ECG - If serum K+ > 5.5 mmol/L, hold K+ replacement until next U&E. - If serum K+ < 5.5 mmol/L, add 20 mmol/L KCL to 2nd bag of NACL 2). Rpt U&E as per flow sheet 3). Adjust serum K+ as follows: K+ (mmol/L) KCL mmol <3 / ECG changes 40 - 60 34 30 - 40 45 20 >5 0 4). May need central line to allow K+ replacement. 1). Repeat U&E, glucose & venous bicarbonate at 2, 4, 6, 8 and 12 hours (serial ABG not required) 2). Perform a 12-lead ECG and place on telemetry. 3). If there is suspicion of sepsis, do MSU, blood cultures and CXR. 4). If BP / urine output is low, insert urinary catheter and monitor urine output hourly 5). If vomiting / drowsy / absent bowel sounds, insert Wide-bore NG 6). Na Bicarbonate therapy is rarely indicated and can worsen prognosis. Consider treatment if pH < 6.9 but discuss first with Endocrinology Consultant / Registrar or ICU / HDU Consultant / Registrar. If necessary transfer to ICU / HDU. 7). Prophylactic dose of low molecular weight heparin 8). Complete FLOW SHEET for ALL patients

0.9% Saline should be continued in addition to GKI if patient remains hypovolaemic / salt depleted Once patient is hungry, acidosis resolved and bowel sounds present, switch patient to subcutaneous insulin and stop GKI hr after 1st dose of regular insulin, give both a long and short acting insulin with first meal. Consult Endocrine Registrar directly (Bleep 132) as soon as possible ALL patients should also be referred to the Diabetes Nurse Specialist (on NDS system / Bleep 846) Approved by Insulin Prescription Committee 2009