Management of Adult Diabetic Ketoacidosis (DKA)/ Hyperosmolar Hyperglycemic Syndrome (HHS)
Make Sure the following Initial Labs are Ordered: FS q1hr BMP, Mg, Phos HbA1c Beta Hydroxy Lactic Acid UA/UC ABG EKG, CXR EKG Nursing Instructions: Notify MD when FS <200 Blood Cx/CPK/Trop if needed
Make sure the following are ordered Q2 hours:
Volume Depleted Step 1. Intravenous Fluids -BOLUS 1L NS -Repeat as necessary -NS Continuous at 250cc/hr
BMP, Mg. Phos Venous BG Beta-Hydroxy
Check IVC for Volume Status
Volume Corrected
If Sodium <140: Begin NS@250-500 If Sodium >140: Change to .45%NS@250-500
Step 2. Potassium -Replete with a goal of: 4-5 mEq/L
<3.3 mEq/L
Do Not Start Insulin Drip Until >3.3 mEq/L Insulin without Fluids = Vascular Collapse
>3.3 mEq/L Step 3 Insulin A) 0.1units/kg Regular Insulin IVP B) Infusion of 0.1 units/kg of Regular Insulin (100units/100ml 0.9%NaCl) Reassess/Repeat cycle with every SMA/Glucose result
If Serum Glucose does not fall by 10% (50-70 mg/dL within the first hour) double the current dose and ensure adequate hydration
Step 4. Bicarbonate -If pH ≥ 6.9: Do NOT administer HCO3 -If pH < 6.9 Administer 50 mEq NaHCO3 IVP ONCE
Step 2. Phosphate If Serum Phosphate <1 mg/dL: Administer 20mEq Potassium Phosphate over 2 hours IVPB ONCE. No
Glucose < 200 mg/dL (DKA) Or < 300 mg/dL (HHS) ? Yes Add Dextrose to IVF Either: A) D5W/½ Ns at 150-250mL/hr B) D5W/NS at 150-250 mL/hr
Useful Calculations: -- Anion Gap = ([Na+] + [K+]) − ([Cl-] + [HCO3−]) -- Correcting Anion Gap for Hypoalbuminemia = Anion gap +2.5 mEq/L for every 1g/dL decline in plasma albumin -- Corrected Serum Sodium = 1.6 mEq/L for every 100 mg/dL increase in serum glucose -- Serum Osm = (2 x (Na + K)) + (BUN / 2.8) + (glucose / 18) -- Free Water Deficit = (0.6 x TBW) x [1- (140 / Na+)]
Titrate Insulin to 0.02-0.05 units/kg/hr to a goal of: 150-200 mg/dL in DKA 200-300 mg/dL in HHS If stable (<10% change) for 3 hours, then change FS to q2hr No
Anion Gap Closed OR Beta Hydroxy < 2mmol/L AND Tolerating PO? Yes Switch to SQ Insulin Protocol “Insulin transition IVCD to SQ” 2hr after Long acting Insulin SQ OR 1hr after Short Acting Insulin SQ Discontinue Insulin Infusion
DKA Diagnostic Criteria Blood Glucose > 250 mg/dL (may present with lower levels) Arterial pH: <7.3 Serum HCO3: <18 Beta hydroxybutyrate Elevated Anion Gap >12 meq/L (Corrected for Albumin) Mental Status: Alert/ Drowsy *Note: At least 50% of Anion Gap must be explained by Beta hydroxybuterate (1mmol:1mEq)
*Common Precipitating factors: Infection, Pt Dioscontinues Insulin therapy, Pancreatitis, MI, CVA, Medications (Corticosteroids/Thiazides)
HHS Diagnostic Criteria Blood Glucose > 600 mg/dL Arterial pH: >7.3 Serum HCO3: >18 Beta hydroxybutyrate < 2 Variable Anion Gap Mental Status: Stupor/Coma *Common Precipitating factors: Inadequate Hydration, Infection, Inadequate Insulin therapy, Pancreatitis, MI, CVA, Medications (Corticosteroids/Thiazides)
Goals of Treatment Volume Correction Replacing Free Water Deficit Preventing Hypoglycemia Identifying Co-morbid precipitating factors When condition Resolves: Restart SQ Insulin *In DKA additional goals include: Replacing electrolyte Deficit Correcting Acidosis