602-563 6/7/2000 3:41 PM Page 1
UNIT NUMBER
PT. NAME
UCSF Medical Center
BIRTHDATE
ADULT DIABETIC KETOACIDOSIS (DKA)
AND HYPEROSMOLAR COMA
MANAGEMENT ORDERS
(For Use In Critical Care Units Only) LOCATION DATE
Date _____________Time _______________
ALLERGIES _________________________________________ HT (cm) _____________ WT (kg) ____________
“√” in box activates order
1. See Critical Care Admission Orders for additional orders/medications
2. DIET: NPO
3. INITIAL LABORATORY WORK (if not done in Emergency Department):
A. CBC, Na, K, Cl, CO2, Glucose, BUN, Creatinine, Ca, PO4, Mg, Serum Ketones, Serum Osmolality,
urinalysis, ABG
Other _______________________________________________________________________________
4. SUBSEQUENT LABORATORY ORDERS – RUN ALL LABS STAT.
A. Check blood glucose (BG) q1 hour with glucose meter. If BG >500 send to lab.
Do not use fingertip for blood sample if patient is hypotensive or in shock.
B. Na, K, Cl, CO2 q2h x 3, then q4 hour
Other ______________________________________________
5. IV FLUIDS (See Fluid Management and Electrolyte Management #1 on back of sheet). Monitor I/O’s q2 hour.
Bolus: ____________________
NS at __________ cc/hour Additive: KCl _________ meq/liter
1/2 NS at _________ cc/hour Other: ______________________
6. INITIAL INSULIN DOSE
A. IV Insulin Bolus: give 0.1 units/kg IV push (if not done in ED)
B. Insulin Infusion
Mix Standard Insulin Solution (Mix 25 units of regular human insulin in 250 cc NS;
Standard Concentration is 1 unit/10 cc). Flush first 50 cc through tubing before connecting to patient.
C. Begin Insulin Infusion at 5 units/hour. (Using standard concentration, 5 units/hour = 50 cc/hour).
7. ADJUSTMENT OF INSULIN INFUSION RATE
A. When BG >200 mg/dl, adjust Insulin Infusion rate as follows:
1. If BG has decreased by 50-200 mg/dl in a one hour period keep the insulin drip rate the same.
2. CALL HOUSE OFFICER IF BG has decreased by <50 mg/dl or >200 mg/dl in a one hour period.
(Aim to correct BG by 100 mg/dl per hour. See General Guidelines on back)
B. When BG <200 mg/dl, call House Officer and:
1. Change IV solution to: D5 1/2 NS at _______ cc/hour + KCl _____ meq/liter
2. Change insulin infusion to _______ units/hour (See General Guidelines on back)
3. Check BS q1 hour.
4. Adjust Insulin Infusion rate as follows:
BG <80 mg/dl STOP insulin infusion and Call House Officer; see #8 below
*Do not restart insulin infusion until BG ≥100 mg/dl*
BG 80-120 Decrease drip by 0.5 unit/hour
BG 121-180 No change in drip rate
BG 181-250 Increase drip by 0.5 unit/hour
BG >250 Bolus 5 units regular insulin and increase drip by 0.5 unit/hour
8. For a BG <80 mg/dl or >400 mg/dl, call House Officer.
602-563 (6/00) MEDICAL RECORD COPY
• BG <80 mg/dl but >60 mg/dl, stop insulin infusion. Check BG q15 minutes.
• BG ≤60 mg/dl, stop insulin infusion; give 50 cc D50 IV push; check BG q15 minutes and repeat treatment
until BG >100 mg/dl.
• When BG ≥100 mg/dl, call House Officer for new insulin infusion rate.
• BG >400 mg/dl, call House Officer to reassess insulin infusion rate
9. Call House Officer for urine output <30 cc/hour.
10. When converting to subcutaneous (SQ) insulin, give prescribed SQ dose 30 minutes prior to discontinuing insulin infusion.
Then use SQ Insulin Order Sheet 602-562
602-563 6/7/2000 3:41 PM Page 2
ADULT DIABETIC KETOACIDOSIS (DKA) AND HYPEROSMOLAR COMA
MANAGEMENT ORDERS
(For Use In Critical Care Units Only)
DIAGNOSTIC CRITERIA
DKA HYPEROSMOLAR COMA
Serum HCO3 low ( < 15 meq/l) Normal or slightly low
pH < 7.3 > 7.3
BG < 800 mg/dl & can be normal Often > 800 mg/dl
Serum Ketones > 5 mmol/l < 5 mmol/l
Urine Ketones large small
Na correction: 2.4 X (plasma glucose - 100)/100 (Am. J. Med. 1999;106:399)
Anion Gap: Na - Cl - CO2 (nl 8-20)
(Use measured Na)
Calculated Osmolality: 2 (Na + K) + glucose/20 (coma: calculated osmolality exceeds ~ 340)
FLUID MANAGEMENT
Assume about 10% dehydration (100 ml/kg). Give 1 liter/hour for 4 hours and then 250-500 cc/hour for the next 2-4 hours;
then 100-250 cc/hour. Correct fluid deficit over 36-48 hours. Give NS initially; give 1/2 NS if corrected Na is >150 meq/l. Change to
D5 NS or D5 1/2 NS when BG <200 mg/dl.
ELECTROLYTE MANAGEMENT
1. Potassium:
Serum K+ KCl Maximum KCl administration rate:
<3.5 meq/l give 40 meq Central line: 20 meq/hour
3.5-5.5 meq/l give 20 meq Peripheral line: 10 meq/hour
>5.5 meq/l no replacement necessary
2. Bicarbonate:
Generally replacement not recommended. May administer ONLY if pH <7.0; give 50 meq Na bicarbonate in 1/2 NS with KCl 20
meq/l over 1 hour. The non-gap acidosis that occurs in the recovery phase generally does not require management.
3. Phosphate:
Generally replacement not recommended despite anticipated fall during Days 1 and 2.
May administer ONLY if serum PO4 <1 mg/dl.
Use sodium phosphate (3 mmol P/cc; 4 meq Na/cc)
Give 0.3-0.6 mmol P/kg/day. Give phosphate ordered in millimoles over 6 hours. Do not use if patient has hypercalcemia or
renal failure. Monitor Ca, PO4, and Na.
4. Magnesium:
Administer ONLY if serum Mg <1.8 mg/dl or if patient has tetany; give 5 g Mg sulfate in 500 cc 1/2 NS over 5 hours
(100 cc/hour).
GENERAL GUIDELINES FOR ADJUSTING INSULIN INFUSION RATE:
1. When BG >200 mg/dl:
If BG has decreased by <50 mg/dl in the one hour period, increase the insulin drip rate 50-100%, depending on the degree of
insulin resistance.
If BG has decreased by >200 mg/dl in the one hour period, decrease the insulin drip rate by 50%.
2. When BG <200 mg/dl:
Usually, starting the insulin infusion rate at approximately 2-4 units/hour is adequate. Generally, the insulin infusion rate should be
1 unit/hour for every 100 cc/hour of D5 1/2 NS (e.g., if D5 1/2 NS is set at 200 cc/hour, then the insulin infusion rate should be 2
units/hour).
