Diabetic ketoacidosis Hyperosmolar state

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Diabetic ketoacidosis (DKA)

Hyperosmolar state (HHS)

1. Hyperglycemia (BG>250 mg/dL) 2. Metabolic acidosis (pH<7.35)

3. Positive ketone in urine or blood

1. Hyperglycemia (BG>600 mg/dL)

3. pH 7.3

**

electrolyte (K)

2. Hyperosmolarity (effective osmole>320 mOsm/L)

effective osmole 2(serum Na + K)+ (glucose/18)

acidosis

1
- vital signs, consciousness,
fluid status, urine output
- lab
* Blood glucose
* Serum electrolyte
* BUN/Cr
* Serum ketone, urine ketone
* EKG
electrolyte
* ABG tachypnea
serum HCO3 <10 mEq/L
* Lab precipitating cause
infection screening, CXR
- Serial CBG 1 hr
- diabetic flow chart

- K add IV fluid EKG - IV insulin

- insulin IV infusion
serum K
* bolus RI 10-20 unit (0.15 unit/kg)
- EKG peaked T K;
intravenous
flat T U wave hold insulin
* RI 500 unit + NSS 1,000 mL
K 40 mEq/hr serum K 3.3
50 mL (
- serum K (mEq/L)
RI 100 unit + NSS 100 mL
* K <3.3: hold insulin K 40
20 mL)
mEq IV fluid 1,000 mL infusion
continuous infusion 10 unit/hr
serum K 3.3 insulin
- CBG 1 hour
* K 3.3-5.5: K 20-30 mEq
IV fluid 1,000 mL infusion
keep serum K 4-5 mEq/L
* K > 5.5: K check
**
serum K 2 hr
24
- K add IV fluid
DKA = 6-9 L, HHS = 9-12 L

2 1/2 8
- K infusion > 10mEq/hr
1/2 16
monitor EKG

- hypo K PO4 < 1 mg/dL

potassium phosphate KCL
PO4 10-20 mEq/hr
- IV fluid
* shock low serum Na
NSS
* high normal serum Na
NSS/2
- hyperglycemia serum Na

serum Na 1.6 mEq 100 mg/dL
glucose serum Na

- IV fluid 1.0 L/hr

- hemodynamic

- NaHCO3 pH
* pH < 6.9: NaHCO3 100
mmol + NSS 400 mL IV infusion
rate 200 mL/hr
* pH 6.9-7.0: NaHCO3 50
mmol + NSS 200 mL IV infusion
rate 200 mL/hr
* pH > 7.0: HCO3
- HCO3 2 hr
pH > 7.0

new onset DM cerebral edema 24 alteration of consciousness, suddenly headache, seizure, papilledema,
ophthalmoplegia mannitol 1 mg/kg intravenous infusion

electrolyte (K)

acidosis

2
- vital signs, consciousness,
fluid status, urine output
- electrolyte, pH, anion gap
- Serial CBG 1 hr

- IV fluid 0.5-1 L/hr

- IV fluid serum Na

- hemodynamic

- serum K 4-5
- insulin IV infusion
mEq/L KCl IV fluid
* CBG < 250 mg/dL 1/10
Serum K
Add KCl
rate RI infusion
(mEq/L) (mEq IV fluid 1,000 mL) 1-2 unit/hr (
3.0
30
RI 10 unit + NSS 100 mL 20 mL)
3.0 - 4.0
20
5% D/N/2 rate maintenance
4.0 - 5.0
15
keep CBG 100-250 mg/dL
5.0 - 6.0
10
* CBG (not decline)
> 6.0
No
50-70 mg/dL rate RI
- K add IV fluid
infusion

- NaHCO3
- pH, anion gap
[ anion gap = Na - (Cl+HCO3)
< 12 mEq/L ]

3
- vital signs, consciousness, - IV fluid
DKA HHS
fluid status, urine output
- electrolyte, pH, anion gap
* 24 hr
2-6 hr
DKA = 6-9 L, HHS = 9-12 L

* 2
- Serial CBG 1 hr
# 1/2 8 hr
insulin SC 6 hr
( 2 hr 1.5- 2 L
rate IV 8 hr )
# 1/2 16 hr
# rate IV 2
rate
( rate IV )
- IV fluid
serum Na

- serum K 4-5
- insulin IV infusion 2
mEq/L
- insulin IV infusion
- 2
* pH 7.3
add K (
* Serum HCO3 > 18 mEq/L
add IV fluid
* Normal anion gap
) rate maintenance
insulin IV infusion SC
insulin IV infusion SC
1/2 hr

- NaHCO3
- pH, anion gap
[ anion gap = Na - (Cl+HCO3)
< 12 mEq/L ]

rate IV 3 DKA fluid 6 L 8 hr 3 L 16 hr 3 L, 3 80 mL/hr

rate maintenance
- rate IV 3 8 3 L 2 L 1 2 1 L 6 hr =166 mL/hr 80 mL/hr rate 80 mL/hr
- rate IV 9 24 3 L 16 hr = 187 mL/hr 80 mL/hr rate 100 mL/hr

 (hour)
/
Physical signs
Consciousness
Blood pressure
Heart rate
Respiratory rate
Urine output
Laboratory
Blood glucose
Urine/Blood ketone
BUN/Cr
Na
K
CI
HCO3
Blood pH.
Anion Gap
Serum Osmolality
Treatment
IV fluid type
IV fluid amount
Insulin rate
KCL

1st

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DIABETIC COMA FlOW SHEET

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