STEP BY STEP MANAGEMENT OF DKA

1
STEP BY STEPMANAGEMENT OF DKA

• See details in the DKA protocol guidelines
• Dr. D. Alvarez
• Up-dated 5-10

2
(DKA) General

• DKA is a life-threatening, preventable
  complication of diabetes
• Characteristics
• Inadequate insulin action,
• Hyperglycemia gtBS gt 200 gt HYPEROSMOTIC STATE
  (Polyuria)
• Dehydration gt pre-renal azothemia
• Electrolyte loss gt K, Na, Ph, Mg and Glucos
• Metabolic acidosis, and
• ketosis.

3
INITIAL PROCES

• Call from ED requesting bed
• Resident / Supervisor (if applicable) obtains
  information on patients condition, on the phone
  or going to the ED as activity in the unit
  warrants.
• Form to be taken to the ED to start
  documentation
• 30 sec assessment-
• Laboratory flow sheet
• DKA Flow sheet
• System by System flow sheet
• Information needed
• Base line patients chronic condition
• control status last HbA1c,
• last diabetic clinic visit with assessment,
  current dose of insulin, time last dose.
• HPI, duration of symptoms. Triggering factors,
  Interventions.

4
ED Course

• 3. Note time of arrival to the ED.
• ED assessment (fill up 30 sec assessment
• labs (start laboratory flow sheets) and therapy
• Get Ht, Wt and SA ( m2) to start doing
  calculations.
• 4. Communicate with PICU Attending and inform on
  patients condition to Nurses and Supervisor (if
  applicable)

5
Physiological Problems that will need to be
address.

• Address Severity of
• DKA /Acidemia

CO2 Ph (V) Clinical
Normal 20-28 7.35 7.45 Normal Base line
Mild 16-20 7.25 7.35 Oriented, alert but Fatigued
Moderate 10-15 7.15 lt 7.25 Kussmaul Resp. Oriented, Sleepy but arousable.
Severe lt10 lt 7.15 Kussmaul Or Depressed Resp./Sleep/ alter Mentalgt Coma.
6
Physiological Problems that will need to be
address.

• Address Severity of
• 2. Hyperglycemia / Heperosmolarity
• Can request to be measure directly in the lab OR
• Calculate it by formula
• Osm 2 x Na glucose/18 BUN /2.8
• Normal Osmolarity 300

7

• Address Severity of
• 3. Dehydration

Mild Moderate Severe
Infant 5-7 10-15 15-20
Younger Child 3-5 7-10 15
Older Child -Adolesc 3 7 10
8

• Address Severity of
• 4. Electrolyte Imbalance
• Na correct serum sodium level as per formula
• Add 1.6 for each 100 mg/dl of glucose over 100
• Example if Na 130 and BS of 800
• Corrected Na will be 1.6 x 700 11.2
• 130 11.2 141 (this is the true Na, still the
  total body sodium is low)
• K even though the serum K may be initially high,
  the total body sodium is always low.
• Ph and Calcium abnormalities as well

9
MANAGEMENT
10
Fluid Replacement Calculations

• Start filling up DKA flow sheet
• Check how much and what kind of fluids patient
  received in ED. (usually patient should had
  received NS, 20 to 40 cc/kg boluses)
• Check if patient passed urine and how much and
  calculated Fluid Balance
• Example if patient received 1 Liter of NS and
  passed 1 liter of urine because hyperosmolarity
  the balance is ZERO.

11
Fluid Replacement Calculations (CONTINUES)

• 3. Calculate patients maintenance fluids
  (requirements) Wt. base OR per SA(m2)
• Wt base 100 ml/kg for the first 10 kg
• 50 ml/kg for the next 10 kg
• 20 ml/kg for the rest.
  kg.
• Per SA (m2) 1500 mL/M2
• 4. Calculate deficit for ideal (pre-illness) wt.
• Example Pt. is 22.2 kg. Maintenance is 1540 mL

12
Fluid Replacement Calculations (CONTINUES)

• 4. Calculate deficit per ideal (pre-illness wt)
• Example
• Pt. current (dehydrated) wt is 20 kg
• Pt. is assess to be 10 dehydrated.
• Ideal wt is 22.2 kg
• (20 kg is 90 gtgtgt 100 100 x 20 / 90)
• Deficit will be 22.2 20 2.2 Liters

13
Fluid Replacement Calculations (CONTINUES)

• 4. To calculate IV rate ml/hr
• Add Maintenance ½ of deficit ()
• 1540 1.1 2640 mL in 24 hrs
• - IV rate of 2640/24 hr 110 cc/hr.
• () correction should be given in 48 hrs.
• 5. IV solution selection use standard solution
  pre-mixed by pharmacy
• There are 3 standard solutions. To select them go
  togt
• IV solution (16) gt then select IV
  solution (peds) (7) gtgt from Solution for DKA
• - 0.45 NS with 20 mEq KCl and 15 mM of KPh /
  Liter
• - D5 0.45 NS with 20 mEq KCl and 15 mM of KPh
  / Liter
• - D 10 0.45 NS with 20 mEq KCl and 15 mM of KPh
  / Liter

14
Ordering Standards DKA Solutions

• In the Order entry gtSelect 23 (IV Solutions)
• Pediatric Common IV Solutions-Order options gt
  Select 7 (IV sol (Ped).
• If Patient has severe hyperosmolarity (Osm gt350),
  hyponatremia and hyperkalemia (K gt 5.8)
• keep running Isotonic solution till repeat BMP
  and document that K is decreasing before ordering
  K containing solutions
• If needed can piggi-bag (PB) Examples
• - NS at 100 mL/h PB with ½ NS 80 ml/hr for a
  total rate of 180 mL/hr
• - NS at 100 ml/hr PB with D5 ½ NS 80 ml/hr for
  a total rate of 180 mL/hr
• IV Maintenance Solution for DKA Management
  (Potassium, Phosphate, Potassium Chloride) gt
  Select 5, 6, 7, Or 8
• 15 mmol kPO4 / 20 mEq KCl in NaCl 0.45 1000
  mL
• 15 mmol kPO4 / 20 mEq KCl in D5 NaCl 0.45 1000
  mL
• 15 mmol kPO4 / 20 mEq KCl in D10 NaCl 0.45 1000
  mL
• 15 mmol kPO4 / 20 mEq KCl in D5 NaCl 0.9 1000
  mL

15
(No Transcript)
16
Insulin drip

• Dose 0.05 to 0.1 Units /kg/hr. Choice will
  depend on
• the severity of the acidosis. If severe, start
  with 0.1 U/kg/hr (may need to go higher if
  patient not responding)
• The patients sensitivity to Insulin, according
  to age and individual response.
• Solution Concentration select standard solutions
  given on Misys
• RUN IT IN A SEPARATE IV LINE.

17
Insulin drip order Using standard Solution
Concentration

• Order entry Select 22 IV Drip
• Pediatric IV Drip Order Options
• Select 6 Insulin, Human, Regular
• Pediatric Dose select according to guidelines,
  computer will calculate IV rate according to
  entered Wt.

18
Insulin drip order (cont.) Using standard
Solution Concentration

• BE SURE THAT THE CORRECT WT WAS ENTER BEFORE
  ORDER IS WRITTEN
• 1.- 25 Units/100 mL NS _at_ 0.05 Unit/kg/hr
• 2.- 25 Units/100 mL NS _at_ 0.075 Unit/kg/hr
• 3.- 25 Units/100 mL NS _at_ 0.1 Unit/kg/hr
• 4.- 25 Units/100 mL NS _at_ ____ Unit/kg/hr
• WRITE INDICATIONS as well (DKA)
• RUN IT IN A SEPARATE IV LINE.

19
(No Transcript)
20
FOLLOW - UP

• Cardio-respiratory monitoring and Neuro checks
• Neuro checks observe for changes of metal status
  as signs of dehydration and or complications of
  DKA Cerebral edema, strokes
• Respiratory Observe for changes/ type of
  respiration as sign of acidosis (Kussmaul
  respirations) and /or respiratory depression 2nd
  to CNS depression as an imminent CNS
  complication.
• CV Observe for signs of dehydration and / or
  electrolyte abnormalities, I.e. Hyper
  /hypokalemia.

21
FOLLOW - UP

• 2. Fluid Balance
• The goals of fluid therapy are
• Initial fluid resuscitation is aim to replenish
  intravascular volume to reverse lactic acidosis.
• Slow rehydration (48 hr) and slow decrease in
  osmolarity to prevent risk of cerebral edema.
• Divide the 24 Fluid deficit by 3 to anticipate
  /estimated the positive 8 hour balance to achieve
• Example Calculated fluid correction deficit in
  24 hrs is 1500 mL.
• 1500/3 500 mL (Need to have a Positive balance
  of 500 every 8hrs)
• Daily Wt will be the best objective way to assess
  rehydration

22
FOLLOW - UP

• 3. Acid-Base-Balance
• VBG and electrolytes including Ca and Ph every
  2-3 hours until a steady improving trend, then it
  can be done Q 4-6 hours till all normal.
• 4. FS Q1H as long patient is on insulin drip
• Aim to have a slow decrease of BS /Osmolarity,
  may need to add glucose containing solution and
  /or use NS for a longer period of time at the
  beginning of rehydration.
• If started with high BS Osmolarity, change to
  D5 /SS when the FS falls lt 250 and adjust IV
  solutions to keep FS between 100 -150
• At the beginning and until the acidosis is
  corrected, control BS with IV solutions with or
  without Dext. using the 2 bag system

23
2 bag solutions

• Acidosis improving
• No changes in Insulin drip, except for
  temporarily hold if low FS (lt 80) until corrected
  with Glucose solutions.
• Adjust IV solution rates to keep FS Between 150
  (increase Dextrose Sol if lt 100 or decrease if
  close to 200)

• Acidosis Resolved
• Patient is ready to have the insulin drip switch
  to SC (dose to be given by Endocrinologist) and
  start Diabetic Diet.
• If FS is low can decrease Insulin drip instead of
  increase Glucose in the IV solution.
• After the first dose of SC given and Pt. Ate. D/c
  insulin drip after 1 hr.

D5 Or D10 0.45 NS with K(Same)
0.45 Or D5 NS with K(same)
Piggy-bag
Adjust rate.
Patient
Calculated rate Main deficit / mL/hr
24
Switching Insulin from drip to SC

• Get SC dose of insulin from Endocrinologist
• Order Diet as per Endo recommendations, usually
• If lt 5 yo is 3 meals and 3 snack
• If gt 5 yo 3 meals and 2 snacks
• Order initial Insulin dose as per
  endocrinologist. (see separate slide guidelines
  on how to write order)
• NPH dose is usually started in AM before
  breakfast.
• Lantus is usually given PM
• Humalog coverage for Glucose and/or carbohydrate
  caloric count.
• D/C insulin drip 1 hours after SC dose given
• D/C glucose in IV fluids as soon as patient
  starts eating meal
• Decrease IV fluid rate to calculated Replacement
  Rate only.
• Change schedule of FS to 7 times /day as per
  diabetic protocol. (see guideline orders)

25
(No Transcript)
26
Ordering insulin in relation to Carbohydrate
caloric count 7/08

• Order entry
• write Humalog
• Select (1) ____Units SC Now Select Expand (on the
  low right corner
• Select (5) Route ___
• Choose 78... gt Select Expand (button right
  corner button)
• Select 7( --- x perday), and 28 (Schedule at)
• Write 5 x perdaySchedule at (enter)
• Frequency.5xdaySchedule Time Options
• (1)
• (2)
• (3)
• (4)
• (5)

27
Ordering insulin in relation to Carbohydrate
caloric count gt 7/08 (Continue)

• For each selected click expand as follow
• (1) breakfast (chose option D-During),
• (2) lunch (chose option D-During),
• (3) select 1- time write 1500 for afternoon
  snack
• (4) Super (chose option D-During),
• (5) select 1 - time write 2100. for eve
  snack
• 10. Under instructions Select 27 Other ___
  write the amount of insulin as per example
• Example
• 15 minutes before meal and snack check BS and
  administer (x) Units of Humalog for each (x )
  grams of carbohydrate and (x ) Unit for each ( x
  ) mg/dl glucose level above the patient target
  (X) mg/dl. NOTIFY MD TO WRITE ORDER FOR THE
  AMOUNT OF INSULINE CALCULATED.

28
Ordering SC insulin coverage using Sliding Scale

• 1 to 7 is the same as per carbohydrate count.
• 8. Write 3 x (if No coverege for snacks) Or 5 if
  coverage coverage for snacks perdaySchedule at
  (enter)
• 9. Frequency.3 xdaySchedule Time Options
• (1)
• (2)
• (3)
• For each selected click expand as
  follow
• (1) breakfast (chose
  option D-During),
• (2) lunch (chose option
  D-During),
• ( ) select 1- time
  write 1500 for afternoon snack
• (3) Super (chose option
  D-During),
• (5) select 1 - time
  write 2100. for eve snack
• 10. Under instructions Select 26 Other ___
  write the amount of insulin as per example
• Example Check BS 15 min before meals and give
  the following coverage
• Breakfast Give (X) Units if FS is lt 100, Give
  (X) Units if FS is gt101lt 200 Give (X) Units if
  FS is gt201 and lt 300 Give (X) Units if FS is gt
  300.
• Lunch Give ( X ) Units if FS is lt 100, Give (X)
  Units if FS is gt101lt 300 Give (X) Units if FS is
  gt 300.
• Dinner Give ( X ) Units if FS is lt 100, Give (X)
  Units if FS is gt101lt 300 Give (X) Units if FS is
  gt 201 but lt 300 Give (X) Units if FS is gt 300

29
Dextrostics (FS) monitoring when pt. in on SC
insulin. 7 (times per day)

• Order entry dextrosticks
• (Fingersticks Glucose by Nursing)
• 2. Expand
• 3. Choose 7 ( _ X per day)
• 4. Write 7 (times per day)
• 5. In instructions field please Write
• As per diabetic protocol, using Glucometer

30
Complication of DKABEWARE
31
CNS

• Cerebral Edema gt high mortality
• Multifactor cause.
• Typically develops within the first 24 hrs of
  treatment of DKA
• Symptoms and signs include
• headache, confusion, slurred speech,
• bradycardia, hypertension, and
• signs of increased intracranial pressure
  sluggish pupils, decrease mental status
• Things to avoid
• Rapid rehydration (aim rehydration in 48 hrs)
  Initial NS bolus should to given to improve
  hemodynamical status ONLY i.e,
• improve perfusion,
• treat hypotension and
• keep good urine output
• Tachycardia takes time to improve (it has many
  factors, including high adrenergic stress
  release)
• Avoid Hypotonic Fluids
• Rapid changes in osmolarity, (aim / goal to
  decrease Blood sugar no more than100 mg/dl/hr)-
  May need to add dextrose solutions early to
  prevent it

32
CNS Complications

• Cerebral Edema gt high mortality
• Treatment is aim to decrease intracranial
  pressure.
• Prompt administration IV Mannitol (0.251 g/kg)
  is the best option
• Tracheal intubation to mechanically
  hyperventilate and surgical decompression with
  ventriculostomy are less successful at preventing
  mortality or severe disability.
• Intracranial imaging to exclude other
  pathologies, such as cerebral infarction or
  thrombosis, should be obtained but not at the
  expense of timely therapeutic interventions.
• 2. Other less common complications of DKA include
  thrombosis, a particular concern in children who
  require a central venous catheter for access

33
Electrolytes

• Hyperkalemia/hypokalemia high risk for
  arrythmias
• Continuous cardiac monitoring
• EKG
• Hypophosphatemia
• Hypocalcemia, special if using Phosphate
  supplement.

34
Other less common complications of DKA

• Pulmonary edema
• Renal failure
• Pancreatitis
• Rhabdomyolysis and
• Infection, such as aspiration pneumonia, sepsis,
  and mucormycosis

35
Case Exercise-Example on Initial Management

• Pt. 15 yo HF, know IDDM since 10 yo, poorly
  controlled (HbA1C 15), admitted in severe DKA
• Lethargic
• VS T 98 F, HR 150, RR 30, BP 130/75 O2Sat 96
• Wt. 50 kg
• Poor perfusion
• Labs VBG Ph 7.0 /CO2 7 / Bic 8, BE 20
• BMP Na133/K5.2/Cl98/5/AG 15/BS 800 / BUN 20/ Cr
  1.2, Ca 9