1. STEP BY STEP MANAGEMENT OF DKA See details in the DKA protocol guidelines Dr. D. Alvarez February 2008

2. INITIAL PROCES 1.Call from ED requesting bed 2.Resident / Supervisor (if applicable) obtains information on patients condition, on the phone or going to the ED as activity in the unit warrants. Information needed: Base line patient’s chronic condition -control status: last HbA1c, -last diabetic clinic visit with assessment, current dose of insulin, time last dose.

3. INITIAL PROCES (continue) 3. Describe current event. –ED 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 patient’s condition to Nurses and Supervisor (if applicable)

4. Physiological Problems that will need to be address. Address Severity of: 1.DKA /Acidemia : CO2PH (V)Clinical Normal 20-287.35 – 7.45 Normal Base line Mild 16-207.25 – 7.35 Oriented, alert but Fatigued Moderate10-157.15 < 7.25 Kussmaul Resp. Oriented, Sleepy but arousable. Severe<10< 7.15 Kussmaul Or Depressed Resp./Sleep/ alter Mental>Coma.

5. 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

6. Address Severity of: 3. Dehydration: Mild Moderate Severe Infant5-7 %10-15%15-20 % Younger Child 3-5 %7-10%15% Older Child - Adolesc 3 %7 %10%

7. 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

8. MANAGEMENT

9. Fluid Replacement Calculations 1.Check how much and what kind of fluids patient received in ED. (usually patient should had received NS, 20 to 40 cc/kg boluses) 2.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.

10. Fluid Replacement Calculations (CONTINUES) 3. Calculate patient’s 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

11. 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% >>> 100 % =100 x 20 / 90) Deficit will be 22.2 – 20 = 2.2 Liters

12. 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 to> IV solution (16) > then select “IV solution (peds)” (7) >> 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

13. Ordering Standards DKA Solutions 1.In the Order entry >Select # 18 (IV Solutions) 2.Pediatric Common IV Solutions-Order options > Select # 7 (IV sol (Ped)…. 3.IV Maintenance Solution for DKA Management (Potassium, Phosphate, Potassium Chloride) > 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. Insulin drip 1.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 The patient’s sensitivity to Insulin, according to age and individual response. 2.Solution Concentration: select standard solutions as per “Insulin drip guideline”. 3.RUN IT IN A SEPARATE IV LINE.

16. Insulin drip order Using standard Solution Concentration 1.Order entry: write insulin 2.Procedure option for insulin Select # 12 “Insulin, Regular IV drip” 3.Pediatric Dose: select according to guidelines, computer will calculate IV rate according to entered Wt. Children > 25 kg –50 Units/100 mL NS @ 0.05 Unit/kg/hr –50 Units/100 mL NS @ 0.075 Unit/kg/hr –50 Units/100 mL NS @ 0.1 Unit/kg/hr –50 Units/100 mL NS @ ----Unit/kg/hr Children < 25 kg –50 Units/500 mL NS @ 0.05 Unit/kg/hr –50 Units/500 mL NS @ 0.075 Unit/kg/hr –50 Units/500 mL NS @ 0.1 Unit/kg/hr –50 Units/500 mL NS @ ---- Unit/kg/hr 4.Write / Copy the calculated rate (ml/hr) in the instruction fields and 5.WRITE INDICATIONS as well (DKA) 6.RUN IT IN A SEPARATE IV LINE.

18. FOLLOW - UP 1.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 2 nd to CNS depression as an imminent CNS complication. CV: Observe for signs of dehydration and / or electrolyte abnormalities, I.e. Hyper /hypokalemia.

19. FOLLOW - UP 2. Fluid Balance a)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. Daily Wt will be the best objective way to assess rehydration

20. FOLLOW - UP 3. Acid-Base-Balance –VVG and electrolytes including Ca and Ph every 2-3 hours until a steady improving trend, then it can be done Q 4hours 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. -Keep BS between 150 – 250 before changing IV solutions -At the beginning and until the acidosis is corrected, control BS with IV solutions with or without Dext. using the “2 bag system”

21. “2 bag solutions” Acidosis improving –No changes in Insulin drip, except for temporarily hold if low FS (< 80) until corrected with Glucose solutions. –Adjust IV solution rates to keep FS Between ~150 ( increase Dextrose Sol if < 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) Patient Piggy- bag Adjust rate. Calculated rate: Main + deficit / mL/hr

22. Switching Insulin from drip to SC Get SC dose of insulin from Endocrinologist Order Diet as per Endo recommendations, usually: –If < 5 yo is 3 meals and 3 snack –If > 5 yo 3 meals and 2 snacks Order initial dose as instructed, –NPH dose is usually started in AM before breakfast. –Lantus is given PM D/C insulin drip 1 hours after SC dose given D/C glucose in IV fluids after tolerating breakfast and BS is within normal level. Decrease IV fluid rate to replacement rate only. Change schedule of FS to 7 times /day as per diabetic protocol. (see guideline orders)

23. Dextrostics (FS) monitoring when pt. in on SC insulin. 7 (times per day ) 1.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

24. Guidelines for ordering sliding scale Humalog insulin coverage. 1.Order entry 2.write “Humalog” 3.Select (1) ____Units SC Now 4.Select Expand (on the low right corner > see diagram) 5.Select (5) Route ___ 6.Choose #76 ( subcutaneous) 7.Select (3) When... > 8.Select # 34 prn___ type: “according to instructions” 9.Instructions: write endocrinologist recommendations. Write your sliding scale as per endocrinology consult Example: Check BS 15 minutes before breakfast if glucose less 50 mg/dl 0U 51-100 5U 101-150 8U 151-200 10U 201-300 12U 301-400 14U >400 16U

25. Ordering insulin in relation to Carbohydrate caloric count 1.Order entry 2.write “Humalog” 3.Select (1) ____Units SC Now 4.Select Expand (on the low right corner > see diagram) 5.Select (5) Route ___ 6.Choose #76 ( subcutaneous) 7.Select (3) When... > 8.Select # 34 prn___ type: “according to instructions” 9.Instructions: write encocrinologist recommendations. Example: 15 minutes before meal and snack administer (1) U of Humalog for each (15) gr of carbohydrate and (1) U for each (50) mg/dl glucose level above the patient target (X) mg/dl

27. 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