EDH - ED Care Maps

Question 1

DKA - Triggers:

Answer 1

1. Infection
2. Pregnancy
3. MI
4. CVA
5. Alcohol

Question 2

DKA - Early Mx (< 1 hr):

Answer 2

1. IV access
2. Bloods - VBG, FBC, U&E, glucose, CMP, CRP, lipase, HBA1C, lipogram, CE
3. ECG
4. CXR
5. U-Cath
6. Fluids:
7. MRL 1L over 1st hr
8. Followed by 500 ml/hr
9. Insulin:
10. Actrapid 200U in 200 mls N/S
11. Start @ 0.1 U/kg/hr
12. Continue long acting insulin
13. K replacement:
14. K < 3.5 - don’t start insulin - add KH2PO4 40 mmol to MRL & run @ 500 ml/hr
15. K > 3.5 - start insulin
16. ABx - if infection
17. NGT - obtunded pt

Question 3

DKA - Early Monitoring (1-6 hrs):

Answer 3

1. Fluids:
2. Continue MRL @ 500 mls/hr
3. When GR < 14 - Start 10% dextrose @ 125 mls/hr + MRL @ 375 mls/ hr
4. U-cath > 0.5 ml/kg/hr
5. Rpt VBG @ 2 & 6 hrs - goals:
6. HCO3 increase by 3/mmol/L/hr
7. pH > 7.3 @ 6 hrs
8. Insulin:
9. Continue @ 0.1U/kg/hr
10. 2hrly GR - goal - decrease by 3 mmol/L/hr
11. Clexane 40 mg S/C
12. K replacement:
13. K < 3.5 - add 40 mmol KH2PO4 to MRL & run @ 500 ml/hr - check K 2 hrly
14. K 3.5 - 5.5 - add 20 mmol KH2PO4 to MRL
15. K > 5.5 - no K, check K 2 hrly
16. Check K 2 hrly - goal: 4 - 5.5

Question 4

DKA - Ongoing Rx (6-12 hrs)

Answer 4

1. Maintain fluid input (250 - 500 ml/hr) according to output (> 0.5 ml/kg/hr)
2. ID & Rx precipitant (CAP, UTI, MI)

Question 5

DKA - Rx Adjustment - urine output < 0.5 ml/kg/hr:

Answer 5

1. Increase fluid rate by 100 mls/hr

2. Reassess in 2 hrs

Question 6

DKA - Rx Adjustment - HCO3 rising < 3 mmol/L/hr:

Answer 6

1. Increase insulin by 1 U/hr until target achieved

Question 7

DKA - Rx Adjustment - GR drop < 3 mmol/L/hr:

Answer 7

1. Increase insulin by 1 U/hr until target achieved

Question 8

DKA - Rx Adjustment - GR < 14:

Answer 8

1. Start 10% dextrose @ 125 mls/hr

2. Decrease MRL to 375 mls/hr

Question 9

DKA - D/C goals @ 24 hrs:

Answer 9

1. pH > 7.30
2. HCO3 > 18
3. No ketones in urine
4. K: 3.5 - 5.5
5. GR: 3 - 8

Question 10

DKA - Restarting insulin pts on insulin - if using basal bolus regime:

Answer 10

1. Continue basal bolus regimen

2. Continue infusion for at least 30 - 60 min following that

Question 11

DKA - starting new patients on insulin - if using twice daily fixed regime:

Answer 11

1. Calculate TDD: 0.5 - 0.75 U/kg/d
2. Give 2/3 morning
3. Give 1/3 night

Question 12

DKA - starting new patients on insulin - if using basal bolus insulin regimen:

Answer 12

1. Calculate TDD: 0.5 - 0.75 U/kg/d
2. Give 50% in evening as long acting
3. Divide 50% as short acting: pre-breakfast, pre-lunch, pre-evening

Question 13

DKA - how to calculate AG?

Answer 13

1. AG = (Na + K) - (Cl + HCO3)

2. Normal = 10 - 12

Question 14

DKA - if Na > 155:

Answer 14

1. Use 0.45% saline