7 Tangdom of Sau Rrabia Ministry of Defense General stati Command Medical Senice General Directorate ‘Armed Forces Hospital, Southern Region Department: Hospital Wide Policy No: AFHSR-COP 033 Tile Protocol for Management of Patients with DKA (Diabetic ketoacidosis) Inflation Date; 1-08-2017 Replaces New | Effective Date: 1-09-2017 | Revision Date. 1-09-2020 Edition. 1" Edition Standard Reference JCI & CBAHI 1, PURPOSE: 1.1. To standardize and improve the patient care provided in accordance with evidence based information 2, RESPONSIBILITIES: 2.1 Clinical Director. Head of ER, and all medical doctors. 3, SCOPE: 3.1 All Armed Forces Hospital, Southern Region Medical, nursing and allied healthcare staff 4, DEFINITION: 4.1 To identify and update proper management of DKA 5. PROCEDURE: 5.1. Diagnostic criteria: (All 3 of the following must be present) 5.1.1 BS>11 mmol, 51.2 Venous pH <7.3 andlor bicarbonate <15 mmol/L 51.3. Capillary ketones >3 mmol/L or urine ketones ++ or more 5.2 Assessment of Severity of DKA: DKA Z z Mild ~ Moderate Severe ‘Arterial pH (iaavas7 aime e700 724: <7.00 Serum bicarbonate (£E4/l) 15:18 Oto <15 10 >10 > Alert Alert/drowsy | Stupor/coma | 5.3. Initial Clinical Assessment: 5.3.1 Respiratory rate. temperature: blood pressure; pulse: oxygen saturation 53.2 Glasgow Coma Scale 53.3 Full clinical examination 54 Initial Investigations: 5.4.1. Capillary blood glucose (BG) 5.4.2 Urine ketones Protoceltor Management of Patents wih OKA (Diabet Ketoasisis) Page tot,5.43 544 5.45 5.46 SAT 5.48 5.49 Venous plasma glucose Urea and electrolytes Venous blood gases (VBG) Full blood count (CBC) ECG Chest cardiograph, urinalysis and culture, blood cultures as needed Identify and treat precipitating factors 5.5 Resolution of DKA is defined by: 551 552 563 Venous pH over 7.3 or anion gap <12 mEq/L Venous bicarbonate 2 18 mmol/L BS < 11 mmol 5.6 IV Fluids Management: 561 If systolic BP (SBP) <90 mmHg 5.6.2. Give 500 mi of 0.9% NaCl solution over 15 minutes 5.6.2.1 Repeat if SBP remains <90 mmHg 5.6.3 Once SBP above 90 mmHg follow fluid replacement as below 56.4 If systolic BP 2 90 mmHg 565 515 years: the recommended rate of fluid replacement (0.9% NaCl) is 15 mUkg/hr fot the first hour then, 5 mi/kg/hr 566 >15 years: Give 5.6 6.10.9% NaCl 1L over 1% hour 5.6.6.20.9% NaC! 1L over next 2 hours. 5.6.6 30.9% NaCl 1L over next 4 hours 5.6.6.40.9% Na Gl 1L over 6 hours 56.7 If BS <14 mmol/L, change to 5% Dextrose with 0.45% Na Cl at 100-150 mifhr: If extra fluid is needed, use NaCl 0.9% 568 if the BP remains <90 mmHg, reconsider other causes of hypotension and consider involving the ICU/eritical care team. A plasma expander can be considered in this situation 5.6.9. A slower infusion rate should be considered in: young people (<18 years (risk of cerebral edema), elderly, pregnant heart or kidney failure, other serious co- morbidities 5.6.10 Fluids should be replaced cautiously (monitor BP, cardiac and pulmonary auscultation), check the inputs and the outputs (diuresis) 56.11 Re-assessment of cardiovascular status at 12 hours is mandatory, further fluid may be required Protocol ter Managers of Paberts with OKA (Oabet Ketoscxos Page 204557 Insulin Management: 5.7.1. Start continuous fixed rate of intravenous insulin infusion (IVI) 5.7.2 Put 50 units human soluble insulin made up to 50 mi with 0.9% NaCI solution 5.7.3. Infuse at a fixed rate of 0.1 unitikgikr (i.e. 7 mU/hr if weight is 70 kg) 57.4 Only give a stat dose f IV insulin bolus (0.1 unit/kg) if there is a delay in setting up a fixed rate IVI 57.5 Check BS hourly 5.7.5.1 If BS is not faling by at least 3 mol/L/hr. check the insulin infusion pump 's working and connected and increase insulin infusion rate by 1 to 2 Unitfhr increments hourly until the glucose falls at this rate 5.76 If BS <14 mmol/L, the rate of insulin infusion should be decreased. If the rate of IVIl required 2 required 2 7UWhr, decrease by 30%. If the rate of IVI <7Ul, see algorithm, Algorithm: rate of IVI if BS <14 mmol/l. Units/hr Off 05 1 15 B 3 4 577 Transfer to subcutaneous insulin if patient is able to eat, drink and passing urine 5.7.8 Ensure subcutaneous insulin is started at least 1 hour before IV insulin is discontinued 579 Give subcutaneous fast acting insulin and a meal and discontinue IV insulin one hour later (see conversion to subcutaneous insulin 5.7.10 Give intermediate or long acting insulin (NPH, Lantus, etc.) 8 to 10 UI with the short acting insulin Conversion to subcutaneous insulin 5.7.11 Restarting subcutaneous insulin for patients already established on insulin, 57.111 Previous regimen should generally be re-started. The insulin infusion should not be stopped until some form of background basal insulin has been given. Check glucose levels regularly (every 4 to 6 hours) 57.12 Calculating subcutaneous insulin dose in insulin-naive patients: The Total Dose Daily (TOD) of insulin can be calculated by multiplying the patients weight (in kg) Prtacoifor Managemen of Patents wih OKA (Diabetic Ketoaodos) Paget, ____|ee by 0.5 units. Use 0.75 units/kg for those thought to be more insulin resistant ie teens, obese. Give 50% of total dose in the form of long acting insulin and divide remaining dose equally pre-breakfast, pre-lunch and pre-evening meal NB: In patients new to insulin therapy dose requirements may decrease within a few days as the insulin resistance associated with DKA resolves. Close supervision from the specialist diabetes team and the diabetic educator is required 58 Potassium Management: 5.8.1 Add potassium as per protocol below hourly in 100 mi in a burette 5.82 Take this as a part of hourly fluid replacement 5.8.2.1 NB: maximum concentration of IV KCl is 20 mEq in 100 ml fof peripheral vein administration and 40 mEq/L in 100 ml for central vein administration 583. If serum K $3 mmol/L, hold insulin and give KC! 30-40 mEqihr until >3 mmol/L 58.4 IfserumK 3.1 to 3.9 mmol/L, give KC! 20 mEqinour 585 If K 25 mmol/L, do not give KCI but check K every 2 hours Potassium replacement cautions: 5.8.6 If potassium is infused rapidly or in high dose intravenous, it may cause cardiac arrest. Intravenous potassium must NEVER be administered undiluted 5.8.7 ECG monitoring is required when the infusion rate is greater than 20 mEqihr 58.88 tis preferable to replace potassium in a separate line 5.9. Bicarbonate Management: 59.1 IfpH>6.9, noHCO3 5.9.2 If pH $6.9: NaHCO3 (50 mmol) dilute in 200 mi H20 infuse at 200 mi/hr. Repeat every 2 hours until pH > 6 9, monitor K+ level 59.3 Take this a part of fluid replacement 5.10.1 Consider urinary catheterization if incontinent or anuric (i.e not passed urine by 60 minutes) 5.10.2 Consider nasogastric tube if patient obtunded or if persistently vomiting 5.10.3 If oxygen saturation falling perform arterial blood gases and request repeat chest 5.10 Re-assess patient, monitor vital signs: radiograph | 5.10.4 Accurate fluid balance chart, minimum urine output 0.5 mi/kg/hr 5.10.5 Continuous cardiac monitoring in those with severe DKA Proacolr Managemen of Patents wih OKA (Diabet Ketoaedosi Page sot5. | ———5.10.6 Discuss low molecular weight heparin in patients with high risk of thrombosis. 5.10.7 Continue IV fluids if not eating and drinking 5.10.8 Re-assess for complications of treatment e.g. fluid overload, cerebral edema 5.11 Review metabolic parameters: 5.11.1 Measure BS hourly (note: if meter reads “HI”, venous blood should be sent to the laboratory hourly) 5.11.2 Measure VBG for pH and bicarbonate and serum potassium at 60 minutes and 2 hourly thereafter til the resolution of DKA 5.11.3 Assess the appropriateness of potassium replacement and check it 2 hourly 5.114 Do not rely on urinary ketone clearance to indicate resolution of DKA, because these will be present when DKA has resolved. 6, ATTACHMENTS: None 7. REFERENCE: | 8. APPROVAL: Prepared by: ———T Signaiyger ALF Date — brow ar Bre ge — Clinical Director. Medicine _ cant ada Ww Reviewed by: — Dr. Reda Refale Chairman, Evidence Based Medicine Reviewed by: Col Dr Faisal Al Banah Director of Diabetic Cente Reviewed by: | Dr Jawad Khaled | Head of Ambulance & Emergency Reviewed by: | Dr. Abdullah Haram | Director of Pharmacy Reviewed by: Ms. Samirah Asi |_COIBPS Director ‘Approved by: | Ms: Krshnavelie Chetty Director of Nursin ‘Approved by: Dr Yanya Al Qahtani Medical Director Approved by: Brig. Gen, Abdullah Al Ghamdi | Hospital Director Protocol fr Management of Patents with OKA (Disbetic Ketosedors) Page Sof