DKA Adult ICU Powerplan

Key Points for ED to ICU DKA power plan

• In addition to NS fluids and maintenance the regular insulin drip will either already be infusing from ED or needs to be initiated. • Regular insulin drip should be initiated at 0.1 units/kg/hr based on patient's weight with a

max initial rate of 15 units/hr.• Regular insulin drip will be titrated in units/hr. • Dedicated line for IV insulin drip.

• Physician will select initial NS boluses • Always check with physician and ED nurse to find out the number of boluses that patient has

received prior to coming to unit.

• When fasting blood sugar (FABS) is less than or equal to 250mg/dl per protocol the nurse will change the initial saline maintenance fluids to a dextrose maintenance fluid based on the CBG level.

• NS fluids will be discontinued per the nurse at that time when dextrose is begun.

• The goal fingerstick or serum BG is 150-250 mg/dL.

• Maximum recommended rate for nursing is 15 units/hr. Notify prescriber for rates > 15 unit/hr.

DKA Powerplan Orders:

DKA Powerplan Orders:

DKA Powerplan Orders:

DKA Powerplan Orders:

DKA Powerplan Orders:

• Patient with DKA will be admitted as a direct admit or through the ED

• DKA Adult Powerplan should be initiated

• Physician will select initial NS boluses • Always check with physician and ED nurse to find out the number of boluses

that patient has received prior to coming to unit.

• Physician will select the patient’s maintenance fluids based on the corrected serum sodium (Na)

Initial steps when admitting a DKA patient:

• In addition to NS fluids and maintenance the regular insulin drip will either already be infusing from ED or needs to be initiated. • Regular insulin drip should be initiated at 0.1 units/kg/hr based on patient's

weight with a max initial rate of 15 units/hr.

• Regular insulin drip will be titrated in units/hr.

• Dedicated line for IV insulin drip.

• Electrolyte Replacements as needed will be given based on lab values which should be monitored closely every 4 hours.

Initial steps when admitting a DKA patient:

• When fasting blood sugar (FABS) is less than or equal to 250mg/dl per protocol the nurse will change the initial saline maintenance fluids to a dextrose maintenance fluid based on the CBG level.

• NS fluids will be discontinued per the nurse at that time when dextrose is begun.

• Order information will be located within the powerplan and on MAR by hovering over the text.

Transitioning of Maintenance Fluids:

Example of hovering over continuous infusions on the MAR:

How to initiate or discontinue IV fluids in a powerplan:

To select order or discontinue IVF go into the power orders and select the DKA powerplan. Next, click the light bulb to open the plan. This will allow Dextrose fluids to be orders and also discontinue the NS fluids once transitioning to Dextrose fluids.

Right click to cancel or DC and order in the plan.

Click the box to order the IV fluids.

• The Nurse-Driven Insulin Infusion and IV Fluid Titration guidelines should be used to adjust regular insulin drip and dextrose maintenance fluids.

• *** Remember it is important to titrate your Dextrose first before adjusting regular insulin drip. Insulin drip should not be turned off unless severe hypoglycemia. DKA patients need insulin to correct the acidosis.

The Nurse-Drive Insulin Infusion and IV Fluid Titration can also be found by right clicking and selecting Reference Manual…

Electrolyte Replacements:

• Electrolyte replacements for the DKA should be given per the “DKA” Adult Replacement Subphase. This is different from the ICU electrolyte replacement subphase.

• Use of the subphase is built within the DKA powerplan and replacements are ordered the same way.

• Physician should be notified if electrolyte deficiency does not correct after two rounds of electrolyte replacement in 24 hours.

DKA Electrolyte Replacements:

KEY POINTS:

• BG should drop by about 50 mg/dl per hour but never more than 100mg/dl per hour. This can cause intracellular swelling.

• Serum K+ should be high enough to support IV insulin. • Remember that when initiating IV regular insulin this will decrease your potassium

levels even more but remember the potassium is pseudo-high due to electrolyte shifts. As the acidosis is corrected serum potassium levels will decrease. It is critical to monitor your potassium levels to avoid over or under correction.

• Don’t forget the other electrolytes: Mg & Phos. Remember K needs Mg!

• CBG’s must be checked q1hr and BMP’s q4hrs.

• With each BMP the “Anion Gap” should be calculated.• Anion Gap= Na-Cl-CO2• Notify the provider when the serum CO2 is > or =18 (MICU likes 20) AND the anion

gap <12mEq/L x2 lab draws. Both of these values are required prior to transitioning to subq regimen.

• The nurse will be ordering and discontinuing fluids per protocol.

Key Points Continued• Remember D51/2 NS with 20 meq KCL can be ordered instead of

D51/2 NS but this order must be placed by the physician.

• Remember IV fluids and electrolytes should run concurrently.

• Dedicated IV line for insulin gtt.

• Make sure weight is accurate

• Consider one arm for infusions and one arm from labs.

Transition to Subcutaneous Insulin:

• MD is to assess whether patient is clinically stable to be transitioned from the insulin gtt to subq insulin. Insulin gtt should not be discontinued until the following parameters have been met:• Anion Gap <12mEq/L AND serum bicarbonate >18 mEq/L x 2

• Blood glucose <200 mg/dL

• pH >7.3

• Patient is tolerating PO intake• If tolerating PO intake first basal dose of subq insulin ordered by physician can be

administered.

• Diet tray should be at bedside and dextrose maintenance fluids should be discontinued

• Insulin gtt to remain on x1 hr after administration of basal dose insulin; recheck cbg and stop insulin gtt. Notify MD of CBG results.

Key Points:

• During the transition phase the patients must also be able to tolerate PO intake. • Zofran IV for nausea.

• Physician has ordered a diet.• Ex: Bariatric Clear liquid, Full liquid, or Clear liquid tray

• Do not transition until food arrives.

Case Scenario:

You admit a DKA from the ED. The ED nurse says that the patient has been given 2 liters of NS and they have not begun the regular insulin drip yet. Patient arrives to you unit. The DKA Adult Powerplan has been initiated. What would you do?• Key points to assess;•What is the patients BG• You have called for the regular insulin IV drip (is the ED nurse bringing it)•Was any IV regular insulin bolus given.•Ask what the patients electrolytes are and what other labs have been sent.

(ABG, CMP, LA, BC, UA & Cx, possible ECG)•What was the initial anion gap?• Peripheral IV functional and you need 2 and 3 is more desirable •What are the VS?

Case Scenario:1. Your patient’s is 550. Your patients weight is 75kg. Your serum potassium is 5.5.

What is your initial regular insulin rate?Answer: Your initial dosing of regular insulin IV would begin at 0.1units/kg/hr based on their dosing weight. So the regular insulin would begin at 7.5 units/hr. No K needed at this point. Would you let them order Kayexalate?

2. You assess the patient’s BG an hour later and it is 445? What are your next steps?

Answer: Based on the Nurse-Driven Insulin Infusion and IV Fluid Titration Protocol you would decrease your insulin drip to 5.5 units/hr. And recheck in 1 hour.

3. After several hours, your BPM comes back and your labs are K 4, Mg 1.8, Phos 3.3? CBG is 300 What are your next steps?

Answer: Using your DKA electrolyte replacement protocol you should replace your K, Mg and Phos. Also you should calculate your anion gap to see if your acidosis is correcting. K would be 20 meq, Mg would be 2 gm, and Phos would be 1 pack TID for 24 hours.

4. The next BG is 249. What is your next step?Answer: Using the protocol you can initiate your D5 ½ NS at 150ml/hr. You will have to go into the powerplan and order the D51/2 NS. What if your BG was 252? Call doctor and discuss plan of starting D51/2NS. It would probably be wise to go ahead and transition to the D51/2NS.

Case Scenario:

6. The 2 hours later your BG is 130. What is your next step?Answer: Increase your D51/2NS to 200 ml/hr

7. Then 1 hour later your BG is 120. What is your next step?Answer: Increase your D51/2NS to 250ml/hr

8. Then 1 hour later your BG is 140. Insulin drip is at 5.5 units/hr. What is your next step?

Answer: Decrease regular insulin to 4.5 units/hr.

9. What if your insulin drip was at 1 unit/hr & BG 140?Answer: You would change your D51/2NS to D10 at 150ml/hr.

Case Scenario:

10. Your repeat BMP shows an anion gap of 8? What is your next step?Answer: Repeat 2nd BMP to ensure gap is closed. What CO2 are you looking for? >= to 18 (MICU likes 20)

11. Your GAP is closed x2 BMPS and Your CO2 is 20. What is your next step?Answer: Call MD and let them know that the gap is closed and CBG is 180. Assess if the patient can tolerate PO intake. A diet should be ordered for the patient. SQ basal insulin should be ordered.

12. How do your transition your patient from IV regular insulin to SQ basal insulin dose?

Answer: Turn off Dextrose IV Fluids, have trey at the bedside, Administer ordered insulin dose SQ and allow patient to eat. After 1 hour turn your insulin drip off and recheck CBG.