-H&P, performed.
-Patient meets diagnostic criteria for DKA.
–DKA Protocol.
*DKA 2/2 1) Noncompliance w insulin/diet, 2) Infection, 3) MI (Get EKG)
*BUN/Cr elevation due to dehydration
*WBC due to DKA, dehydration, r/o infection
*Abd. pain due to DKA vs Gastroenteritis or Gastritis or PUD or Pancreatitis or Cholecystitis or Diverticulitis or UTI
Initial workup
Labs: CMP (glucose, BUN, Creatinine, electrolytes), CBC with diff, ABG/VBG, UA, ECG, AG, A1C, lipase, urine and serum ketones. CXR and BCx as needed. Trend troponins as needed.
CHF?:___
ESRD?:___
Pt in shock?:___
Treatment
Admit to ICU
NPO except for meds
Strict I/Os
Morphine 2 mg IV q 2-4 hr PRN pain
Prn Zofran for N/V
Orthostatic vitals
O2 to keep SpO2 >92%
IV Fluids, Potassium replacement, and Insulin therapy.
Bicarb if needed.
Monitoring
-BMP (for electrolytes, glucose, BUN, Cr.), Ketones, and venous pH q2-4hrs. No need to get ABG for monitoring, venous pH from VBG is enough.
-Accuchecks (capillary BS) every 1 hour
-Will Keep serum glucose between 150 and 200 mg/dL until resolution of DKA. Will do that by infusing D5 1/2 NS when the blood sugars are between 150 and 200.
-If Glu<100, use D10 at 50 ml/hr while on insulin drip
-Continue to monitor for s/s of infection
-CBC w/ diff, BMP, and ECG in AM
Disposition:
Pending DKA resolution.
Bridging insulin & feeding pt: When DKA resolves and the patient is able to eat, start insulin glargine SC. D/C Insulin drip 2 hr after the SC insulin glargine. In addition to the basal insulin, order pre-meal insulin boluses AC TID.
-Patient meets diagnostic criteria for DKA.
–DKA Protocol.
*DKA 2/2 1) Noncompliance w insulin/diet, 2) Infection, 3) MI (Get EKG)
*BUN/Cr elevation due to dehydration
*WBC due to DKA, dehydration, r/o infection
*Abd. pain due to DKA vs Gastroenteritis or Gastritis or PUD or Pancreatitis or Cholecystitis or Diverticulitis or UTI
Initial workup
Labs: CMP (glucose, BUN, Creatinine, electrolytes), CBC with diff, ABG/VBG, UA, ECG, AG, A1C, lipase, urine and serum ketones. CXR and BCx as needed. Trend troponins as needed.
CHF?:___
ESRD?:___
Pt in shock?:___
Treatment
Admit to ICU
NPO except for meds
Strict I/Os
Morphine 2 mg IV q 2-4 hr PRN pain
Prn Zofran for N/V
Orthostatic vitals
O2 to keep SpO2 >92%
IV Fluids, Potassium replacement, and Insulin therapy.
Bicarb if needed.
Monitoring
-BMP (for electrolytes, glucose, BUN, Cr.), Ketones, and venous pH q2-4hrs. No need to get ABG for monitoring, venous pH from VBG is enough.
-Accuchecks (capillary BS) every 1 hour
-Will Keep serum glucose between 150 and 200 mg/dL until resolution of DKA. Will do that by infusing D5 1/2 NS when the blood sugars are between 150 and 200.
-If Glu<100, use D10 at 50 ml/hr while on insulin drip
-Continue to monitor for s/s of infection
-CBC w/ diff, BMP, and ECG in AM
Disposition:
Pending DKA resolution.
Bridging insulin & feeding pt: When DKA resolves and the patient is able to eat, start insulin glargine SC. D/C Insulin drip 2 hr after the SC insulin glargine. In addition to the basal insulin, order pre-meal insulin boluses AC TID.
—-//—-
Amylase may be increased even if there is no pancreatitis.
Related Articles
- Fluid Replacement in DKA
- Potassium Replacement in DKA
- Insulin Therapy in DKA
- Bridging and Feeding the Patient after DKA
DKA Pearls
- Insulin deficiency is the main precipitating factor. So these patients need insulin.
Reference
Diabetes Metab Syndr Obes. 2014; 7: 255–264. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4085289/
Am Fam Physician. 2013 Mar 1;87(5):337-346. https://www.ncbi.nlm.nih.gov/pubmed/23547550