Dka Algorithm

Use Of A Computer-based Insulin Infusion Algorithm To Treat Diabetic Ketoacidosis In The Emergency Department

Diabetes Technology & Therapeutics Authors Jagdeesh Ullal,1 Raymie McFarland,2 Margaret Bachand,3 Joseph Aloi4 Abstract Background Efforts at improving quality metrics in diabetes focus on minimizing adverse events and avoiding re-admissions to the hospital. Our experience with Glucommander (Glytec, Greenville, SC), a cloud-based insulin management software system, suggested that its use in the emergency department (ED) would be useful in treating patients with mild diabetic ketoacidosis (DKA). Materials and Methods Thirty-five patients seen in the ED with hyperglycemic crises and diagnosed with DKA during one calendar year were reviewed. A retrospective chart review was performed on patients who were placed on Glucommander for DKA management. We excluded patients with significant acidosis or concomitant medical illnesses. Results Initial average capillary glucose level was 487 + 68mg/dL, average time to target glucose was 5 h 11min, and rate of hypoglycemia (blood glucose level < 70mg/dL) was less than 0.3%. Sixteen patients treated with the protocol were discharged from the ED directly, and 19 were admitted. Patients were maintained for an average of 14 + 1 h on the Glucommander protocol. There was a significantly higher anion gap (P = 0.002) and lower serum bicarbonate level (P= 0.006) in the admitted group. We found very low evidence of re-admission (6%) within 30 days of discharge from the ED for DKA patients. No significant glucose-related adverse events were noted. Conclusions Use of Glucommander for guiding the insulin treatment of mild DKA in the ED can decrease admissions to the hospital for DKA by 45%. Low rates of hypoglycemia make this an option to improve efficiency of utilization of inpatient hospital beds. The cost savings for nonadmissions were estimate Continue reading >>

Management Of Diabetic Ketoacidosis

Diabetic ketoacidosis is an emergency medical condition that can be life-threatening if not treated properly. The incidence of this condition may be increasing, and a 1 to 2 percent mortality rate has stubbornly persisted since the 1970s. Diabetic ketoacidosis occurs most often in patients with type 1 diabetes (formerly called insulin-dependent diabetes mellitus); however, its occurrence in patients with type 2 diabetes (formerly called non–insulin-dependent diabetes mellitus), particularly obese black patients, is not as rare as was once thought. The management of patients with diabetic ketoacidosis includes obtaining a thorough but rapid history and performing a physical examination in an attempt to identify possible precipitating factors. The major treatment of this condition is initial rehydration (using isotonic saline) with subsequent potassium replacement and low-dose insulin therapy. The use of bicarbonate is not recommended in most patients. Cerebral edema, one of the most dire complications of diabetic ketoacidosis, occurs more commonly in children and adolescents than in adults. Continuous follow-up of patients using treatment algorithms and flow sheets can help to minimize adverse outcomes. Preventive measures include patient education and instructions for the patient to contact the physician early during an illness. Diabetic ketoacidosis is a triad of hyperglycemia, ketonemia and acidemia, each of which may be caused by other conditions (Figure 1).1 Although diabetic ketoacidosis most often occurs in patients with type 1 diabetes (formerly called insulin-dependent diabetes mellitus), more recent studies suggest that it can sometimes be the presenting condition in obese black patients with newly diagnosed type 2 diabetes (formerly called non–insulin-depe Continue reading >>

What Is The Nursing Intervention For Diabetic Ketoacidosis?

My response will be geared towards the emergent presentation amd treatment. 90+ % of the time the blood sugar will be above 500 on your glucometer. Do not let this fool You! Even if it's over 2000 (my highest treated fingerstick glucose was 2042 which wasn't even this patients personal highest) you don't need to worry about administering insulin for about 1–2 hour. You first need great IV access. Being a soon to be ICU admit, I tried my best to give them at least an 18 g and a 20 g preferably not in the AC but access is better than an inconvenient location. These patients are dehydrated so get ready to administer 2 up to 4 liters of fluid. Truthfully Lactated ringers is coming en vogue as NS can worsen the acidosis by raising the chloride levels. With labs pending (electrolytes are the important labs and either an ABG or a VBG… yes a venous gas gives equally treatable results and causes much less pain). If the potassium is above the recommended value you will be able to start an insulin drip and in case you are too in the moment to remember — giving IV insulin will tank a potassium within 30 min or less so replace potassium before administering insulin in this situation!! There are a few options for insulin replacement, some use a computerized algorithm while other base insulin dosage on patient weight ( kg x .01 units/kg/hr is one example) with hourly glucose checks. While administering insulin, if they begin having seizures you will need to give IV glucose, yes it's counter intuitive but it's necessary. Regardless, go with your facilities recommendations. Ensure quality oxygenation/ventilation because the body will do its best to correct the condition itself but sometimes the patient must be intubated. All this to say this- the goal of treatment is to: hydrate, Continue reading >>

Use Of A Computer-based Insulin Infusion Algorithm To Treat Diabetic Ketoacidosis In The Emergency Department

Abstract Background: Efforts at improving quality metrics in diabetes focus on minimizing adverse events and avoiding re-admissions to the hospital. Our experience with Glucommander™ (Glytec, Greenville, SC), a cloud-based insulin management software system, suggested that its use in the emergency department (ED) would be useful in treating patients with mild diabetic ketoacidosis (DKA). Materials and methods: Thirty-five patients seen in the ED with hyperglycemic crises and diagnosed with DKA during one calendar year were reviewed. A retrospective chart review was performed on patients who were placed on Glucommander™ for DKA management. We excluded patients with significant acidosis or concomitant medical illnesses. Results: Initial average capillary glucose level was 487 ± 68 mg/dL, average time to target glucose was 5 h 11 min, and rate of hypoglycemia (blood glucose level <70 mg/dL) was less than 0.3%. Sixteen patients treated with the protocol were discharged from the ED directly, and 19 were admitted. Patients were maintained for an average of 14 ± 1 h on the Glucommander™ protocol. There was a significantly higher anion gap (P = 0.002) and lower serum bicarbonate level (P = 0.006) in the admitted group. We found very low evidence of re-admission (6%) within 30 days of discharge from the ED for DKA patients. No significant glucose-related adverse events were noted. Conclusions: Use of Glucommander™ for guiding the insulin treatment of mild DKA in the ED can decrease admissions to the hospital for DKA by 45%. Low rates of hypoglycemia make this an option to improve efficiency of utilization of inpatient hospital beds. The cost savings for nonadmissions were estimated at $78,000 over the 12 months of the study. Our results suggest that Glucommander™ is Continue reading >>

Updated Feb 2017 J Clayton

NUH Management of Diabetic Ketoacidosis in Adults (18 years old & over) (Please see the Paediatric guidelines for patients under 18 years) If in doubt, call someone more senior. KETOACIDOSIS CAN KILL. Use in conjunction with the NUH pathway of care for DKA in adults (insulin prescription, administration and monitoring chart). 1. DIAGNOSIS All three required 1. Raised blood glucose>11mmol /L or known diabetes 2. Capillary ketones > 3 mmol/L (or Ketones >2+ in urine) 3. Venous pH < 7.35 or venous bicarb < 15mmol/L 2. ESSENTIAL INVESTIGATIONS Arterial puncture NOT routinely needed ï‚· U+E, creatinine, blood glucose ï‚· Venous blood gas for bicarbonate, potassium and pH (analyse on machine on B3, ED, HDU, ITU) ï‚· ECG/CXR/MSU/blood cultures/pregnancy test depending on clinical suspicion Raised WCC and serum amylase are common in DKA and do not usually suggest pancreatitis. 4. IMMEDIATE TREATMENT START IN EMERGENCY DEPT / ASSESSMENT UNIT OR THEIR CURRENT LOCATION. DELAY IN STARTING TREATMENT MAY BE FATAL. 1. Insert venflon 2. 1L 0.9% sodium chloride infusion over 1hr if systolic BP>90 (If systolic BP<90 give repeated boluses of 500ml 0.9% sodium chloride over 10-15 minutes) 3. Start IV insulin infusion: 50 units human soluble (ACTRAPIDÂ®) insulin added to 49.5 mls 0.9% sodium chloride to give a 1 unit/ml solution via syringe driver at 0.1 units/ kg / hr (estimated or actual weight) 3. SEVERITY (Venous bicarbonate or pH) >14 mmol/l or pH >7.3 Mild 10-14 mmol/l or pH 7.1-7.3 Moderate < 10 mmol/l or pH <7.1 Severe 5. TRANSFER NO PATIENT WITH DKA SHOULD BE TRANSFERRED BETWEEN HOSPITALS URGENT CRITICAL CARE/HDU REVIEW if any of: Venous bicarbonate < 10 mmol/l or pH<7.1, drowsy (P or U on AVPU), fluid balance problems, pregnancy, co morbidities, sats<94% on 40% O2, p Continue reading >>

Episode 63 – Pediatric Dka

Pediatric DKA was identified as one of key diagnoses that we need to get better at managing in a massive national needs assessment conducted by the fine folks at TREKK – Translating Emergency Knowledge for Kids – one of EM Cases’ partners who’s mission is to improve the care of children in non-pediatric emergency departments across the country. You might be wondering – why was DKA singled out in this needs assessment? It turns out that kids who present to the ED in DKA without a known history of diabetes, can sometimes be tricky to diagnose, as they often present with vague symptoms. When a child does have a known history of diabetes, and the diagnosis of DKA is obvious, the challenge turns to managing severe, life-threatening DKA, so that we avoid the many potential complications of the DKA itself as well as the complications of treatment – cerebral edema being the big bad one. The approach to these patients has evolved over the years, even since I started practicing, from bolusing insulin and super aggressive fluid resuscitation to more gentle fluid management and delayed insulin drips, as examples. There are subtleties and controversies in the management of DKA when it comes to fluid management, correcting serum potassium and acidosis, preventing cerebral edema, as well as airway management for the really sick kids. In this episode we‘ll be asking our guest pediatric emergency medicine experts Dr. Sarah Reid, who you may remember from her powerhouse performance on our recent episodes on pediatric fever and sepsis, and Dr. Sarah Curtis, not only a pediatric emergency physician, but a prominent pediatric emergency researcher in Canada, about the key historical and examination pearls to help pick up this sometimes elusive diagnosis, what the value of serum Continue reading >>

University Of Zagreb

SCHOOL OF MEDICINE Mohammad Imran Khan Malik A review of the efficacy of the Milwaukee protocol in the treatment of ketoacidosis in pediatric Intensive Care Unit patients at Rebro hospital between 2009-2014. GRADUATE THESIS Zagreb, 2014 UNIVERSITY OF ZAGREB SCHOOL OF MEDICINE Mohammad Imran Khan Malik A review of the efficacy of the Milwaukee protocol in the treatment of ketoacidosis in pediatric Intensive Care Unit patients at Rebro hospital between 2009-2014. GRADUATE THESIS Zagreb, 2014 This graduation paper has been completed at the Department of Paediatrics at the University Hospital Centre Zagreb (Rebro hospital) under the supervision of Dr. sc. Mario Ä†uk and was submitted for evaluation during the academic year 2013 /2014. LIST OF TABLES Table 1: DKA laboratory diagnosis criteria Table 2: Classification of DKA. Modified from Kliegman et al. Nelson Textbook of Pediatrics, 2011. Table 3: Table 3: Summary of key data of patients admitted to pediatric ICU at Rebro hospital. LIST OF FIGURES Figure 1: DKA pathogenesis. Figure 2: Ketone bodies: showing formation of negatively charged conjugate bases of the ketoacids. The conjugate bases cause the increased anion gap in DKA metabolic acidosis. Figure 3: Algorithm of key steps in DKA pathophysiology. Colour coded to highlight the two areas that treatment should target: metabolic acidosis and hyperglycemia. Figure 4: True sodium level calculations for glucose levels above 100mg/dL (5.6mmol/L). Figure 5: Goals of DKA management Figure 6: Diabetic ketoacidosis treatment: Milwaukee protocol. Modified from Kliegman et al. Nelson Textbook of Paediatrics. 2011 p.1979 Figure 7: DKA incidence between 1 st January 2009 â€“ 30 th June 2014. LIST OF ABBREVIATIONS DKA ..............Diabetic Ketoacidosis CE...................C Continue reading >>

Diabetic Ketoacidosis In Pregnancy

Diagnosis of DKA: ï¿½ Initial STAT labs include â€¢ CBC with diff â€¢ Serum electrolytes â€¢ BUN â€¢ Creatinine â€¢ Glucose â€¢ Arterial blood gases â€¢ Bicarbonate â€¢ Urinalysis â€¢ Lactate â€¢ Serum ketones â€¢ Calculation of the Anion Gap ï¿½ serum anion gap = serum sodium â€“ (serum chloride + bicarbonate) â€¢ Electrocardiogram Treatment Protocol for Diabetic Ketoacidosis Reviewed 5/2/2017 2 Updated 05/02/17 DKA Diagnostic Criteria: ï¿½ Blood glucose >250 mg/dl ï¿½ Arterial pH <7.3 ï¿½ Bicarbonate â‰¤18 mEq/l ï¿½ Anion Gap Acidosis ï¿½ Moderate ketonuria or ketonemia 1. Start IV fluids (1 L of 0.9% NaCl per hr initially) 2. If serum K+ is <3.3 mEq/L hold insulin ï¿½ Give 40 mEq/h until K â‰¥ 3.3 mEq/L 3. Initiate DKA Order Set Phase I (*In PREGNANCY utilize OB DKA order set) 4. Start insulin 0.14 units/kg/hr IV infusion (calculate dose) RN will titrate per DKA protocol Insulin Potassium Bicarbonate IVF Look for the Cause - Infection/Inflammation (PNA, UTI, pancreatitis, cholecystitis) - Ischemia/Infarction (myocardial, cerebral, gut) - Intoxication (EtOH, drugs) - Iatrogenic (drugs, lack of insulin) - Insulin deficiency - Pregnancy DKA/HHS Pathway Phase 1 (Adult) Approved by Diabetes Steering Committee, MMC, 2015, Revised DKA Workgroup 1_2016 Initiate and continue insulin gtt until serum glucose reaches 250 mg/dl. RN will titrate per protocol to achieve target. When sugar < 250 mg/dl proceed to DKA Phase II *In PREGNANCY when sugar <200 proceed to OB DKA Phase II *PREGNANCY ï¿½ Utilize OB DKA order set Phase 1 ï¿½ When glucose reaches 200mg/dL, Initiate OB DKA Phase 2 ï¿½ Glucose goals 100-150mg/dL OB DKA Phase 2 Determine hydration status Hypovolemic shock Mild hypotensio Continue reading >>

Smh Dka Protocol

Insulin Drip protocol for DKA Purpose: Quick/Safe management of the patient in DKA Method: Evidence based approach using a standardized protocol. Outcomes: Patient will have complete recovery from DKA episode and be discharged in a safe and timely manner. History at SMH The DKA protocol has been used in the: Renal, Diabetic, Wound Unit (7wt) for 2 years ICU for 1 year ECC for 6 months It was developed by a team lead by Dr. Antunes, Pharmacy, the Certified Diabetic Educator on 7wt and the Clinical Manager on 7wt . The Protocol is evidence based.* Procedure When your patient comes into the ECC the ECC MD may have already initiated the ECC DKA Protocol. When the patient reaches 7wt/ICU it will be discontinued and converted to the inpatient DKA protocol . To continue the protocol just add â€ DKA Protocolâ€ to your orders, the patient will be on algorithm 2 from the ECC. If you are initiating then please specify which algorithm to start the protocol on 1 or 2. Once the patient is stabilized we will need orders for long acting insulin , short acting sliding scale insulin and a diet order. We like to keep patient on clear liquids until we can get blood sugar and CO2 in a safe range. Once the patients glucose , CO2 and potassium are within range the long acting insulin can be given and the drip discontinued within 4-8 hours. Criteria for Placement on 7WT Patient must be stable CO2 must be 8 or greater Potassium must be 3.0. If this is the only factor keeping the patient from 7wt please call communicator on the floor. Patient must be on remote telemetry if potassium less than 3.0 or greater than 6. MD Notification Any acute change in condition If urine output less than 30 ml/hr Creatinine greater than 2.0 Potassium less than 3.0 or greater than 6 If hypoglycemia not resolv Continue reading >>

Diabetes Complications in Dogs and Cats: Diabetes Ketoacidosis (DKA)

Tiny Tips – Approach To Diabetic Ketoacidosis

Don’t Know Anything about Diabetic Ketoacidosis (DKA)? In Canada, 5 000 – 10 000 patients are admitted to the hospital with diabetic ketoacidosis (DKA) each year.1 Most of these patients will initially present to the Emergency Department. The initial assessment and management of these patients in the ED is crucial, as 50% of DKA deaths occur in the first 48-72hrs.2 Managing DKA can be overwhelming for learners; interpreting blood gases, thinking about electrolyte and fluid replacement, managing blood glucose levels, and determining the underlying precipitant. Simply remembering ‘DKA’ will help to take you from Step One – assessment and symptoms – through to management. Symptoms Diuresis (polyuria), Dizziness, Dehydration, Delirium, Drinking (polydipsia) Kussmaul respirations (deep, fast respirations that attempt to correct for metabolic acidosis) Abdominal pain and vomiting Diagnosis Diabetic: capillary blood glucose >14mmol/L Ketotic: beta-hydroxybutyrate >3mmol/L or ketonuria (3+) Acidotic: pH <7.3 and HCO3– <15mmol/L Algorithm created using available resources.2–4 This article was copyedited by Michael Bravo (@bravbro). References Continue reading >>

#25: Master Hyperglycemia And Dka

Master the management of hyperglycemia, DKA, and learn to avoid common pitfalls. This episode is packed with clinical pearls from repeat guest, Endocrinologist, Dr. Jeffrey Colburn. Recommend a guest or topic and give feedback at [email protected] Rate us on iTunes. Clinical Pearls: Type 1 diabetes (DM1) occurs by autoimmune destruction of beta cells occurs at any age Typically lean body type and normal lipid profiles Type 2 diabetes (DM2) Typically obese and insulin resistant Eventually fat deposition in pancreas destroys insulin production 15-20 years after onset of DM2 leading to absolute insulin deficiency Triad of DKA = hyperglycemia, ketonemia, acidemia DKA occurs w/total lack of insulin leads to inability to utilize glucose (hyperglycemia) Simulated starvation occurs Counter regulatory hormones kick in Free fatty acids are broken down for fuel Keto acids are made as a by product (ketonemia) Acidemia occurs DKA can occur in DM2 if overwhelming infection, or infarction (MI or CVA) Even just a little bit of insulin can keep patient out of DKA! Dehydration is a cardinal issue in DKA from osmotic diuresis Often 6-8 liters depleted! Sick day rules for Type 1 diabetes Early contact with healthcare team Reduce, but do not discontinue insulin during the illness (see #8) Check frequent fingersticks Use antipyretics to manage fever Push the fluids Educate family members about signs/symptoms of DKA If sick, then drop basal insulin by 20% whether SQ or basal rate on insulin pump Keep mealtime insulin dose the same, but skip if not eating Ketones Beta hydroxybutyrate is the predominant ketone in DKA Urine ketones measure acetoacetate (strongly) and acetone (weakly) NOT beta hydroxybutyrate Serum ketones measure acetoacetate and acetone NOT beta hydroxybutyrate Thus, che Continue reading >>

Diabetic Ketoacidosis Mortality Prediction Model (dka Mpm) Score

Note: This calculator is not externally validated and should be used with caution. It is not intended to routinely disposition patients. The APACHE II Score may be a better mortality predictor. Use in patients with DKA. Continue reading >>

Diabetic Ketoacidosis

Treatment Approach The main goals of treatment are: Restoration of volume deficits Resolution of hyperglycemia and ketosis/acidosis Correction of electrolyte abnormalities (potassium level should be >3.3 mEq/L before initiation of insulin therapy; use of insulin in a patient with hypokalemia may lead to respiratory paralysis, cardiac arrhythmias, and death) Treatment of the precipitating events and prevention of complications. It must be emphasized that successful treatment requires frequent monitoring of clinical and laboratory parameters to achieve resolution criteria. A treatment protocol and a flow sheet for recording the treatment stages and laboratory data should be maintained. [1] [38] [39] [40] Initial and supportive treatment The majority of patients present to the emergency department, where treatment should be initiated. There are several important steps that should be followed in early management: Fluid therapy should be started immediately after initial laboratory evaluations. Infusion of isotonic solution of 0.9% sodium chloride at a rate of 1 to 1.5 L/hour should be used for the first hour of fluid therapy. Indications for admission to the intensive care unit (ICU) are hemodynamic instability or cardiogenic shock, altered mental status, respiratory insufficiency, severe acidosis, and hyperosmolar state with coma. The diagnosis of hemodynamic instability should made by observing for hypotension and clinical signs of poor tissue perfusion, including oliguria, cyanosis, cool extremities, and altered mental state. After admission to ICU, central venous and arterial lines are required, with continuous percutaneous oximetry. Oxygenation and airway protection are critical. Intubation and mechanical ventilation are commonly required, with constant monitoring of r Continue reading >>

Diabetic Ketoacidosis Treatment & Management

Approach Considerations Managing diabetic ketoacidosis (DKA) in an intensive care unit during the first 24-48 hours always is advisable. When treating patients with DKA, the following points must be considered and closely monitored: It is essential to maintain extreme vigilance for any concomitant process, such as infection, cerebrovascular accident, myocardial infarction, sepsis, or deep venous thrombosis. It is important to pay close attention to the correction of fluid and electrolyte loss during the first hour of treatment. This always should be followed by gradual correction of hyperglycemia and acidosis. Correction of fluid loss makes the clinical picture clearer and may be sufficient to correct acidosis. The presence of even mild signs of dehydration indicates that at least 3 L of fluid has already been lost. Patients usually are not discharged from the hospital unless they have been able to switch back to their daily insulin regimen without a recurrence of ketosis. When the condition is stable, pH exceeds 7.3, and bicarbonate is greater than 18 mEq/L, the patient is allowed to eat a meal preceded by a subcutaneous (SC) dose of regular insulin. Insulin infusion can be discontinued 30 minutes later. If the patient is still nauseated and cannot eat, dextrose infusion should be continued and regular or ultra–short-acting insulin should be administered SC every 4 hours, according to blood glucose level, while trying to maintain blood glucose values at 100-180 mg/dL. The 2011 JBDS guideline recommends the intravenous infusion of insulin at a weight-based fixed rate until ketosis has subsided. Should blood glucose fall below 14 mmol/L (250 mg/dL), 10% glucose should be added to allow for the continuation of fixed-rate insulin infusion. [19, 20] In established patient Continue reading >>

A Unified Hyperglycemia And Diabetic Ketoacidosis (dka) Insulin Infusion Protocol Based On An Excel Algorithm

Abstract: Objective – An insulin infusion protocol (IIP) was instituted in medical and surgical ICUs for post-cardiac surgery stress hyperglycemia (SH), diabetes hyperglycemia (DH), and DKA. Prior to 2014, Saint Louis University Hospital (SLUH) used a proportionate delivery protocol which required hourly Insulin Infusin Rate (IIR) recalculation based on BG change. A separate protocol was followed for diabetic ketoacidosis (DKA). A unified ICU protocol was designed in 2013 and implemented in 2014 for treatment of DH, DKA, and post-cardiothoracic surgery SH to meet SCIP criteria. The protocol utilized conventional diabetes management techniques, i.e. 1) body weight based, 2) designed with the concept of basal plus correction factor, 3) pre-calculated insulin doses , 4) maximum IIR at higher BG and 6) progressively decreasing IIR as BG approaches designated target range (DTR) to limit hypoglycemia Method - The IIP was assessed during one month for all patients in ICUs. The IIP was developed in Excel and our project is IRB exempt. The IIR is higher at BG >160mg/dL (0.5units/ kg/24 hour, defined as “Phase 1” to lower hyperglycemia), and decreases progressively as BG decline. There is an abrupt decrease in the IIR at a threshold BG of 160mg/dL, (rate 0.3units/kg/ 24hours defined as “Phase 2”, maintenance rate) to sustain BG between a DTR, 120 mg/dL-180 mg/dL. An acceptable target range (ATR) is considered between 100mg/dL-200mg/dL. A correction factor for BG >120mg/dL is added to the IIR by estimating Total Daily Dose (TDD) of insulin. IIR is pre-calculated and stored in the electronic medical record system (EPIC) in weight based columns from 40kg through 150kg with increments of 10 kg. Nurses titrate IIR hourly based only on the current BG. When BG has been in targ Continue reading >>