Diabetes Care Flow Chart — Diabetic Ketoacidosis, ED and Diabetic Ketosis without Acidosis, Inpatient

Diabetes Care Flow Chart — Diabetic Ketoacidosis, ED and Diabetic Ketosis without Acidosis, Inpatient

Diabetes Care Flow Chart: DKA, Diabetic Ketosis, Routine Diabetic Care

DKA
Diabetic Ketosis
"Regular" Diabetic
 
 
 
 
 
 
 
 
 
 
 
 
  • Bicarb < 5
  • Kussmaul’s breathing
  • Altered mental status
  • Very difficult to arouse
  • Critical electrolytes
  • BG < 200
  • Bicarb < 15
  • Ketones present
  • BG 200-300
  • Bicarb < 15
  • Ketones present
  • BG ≥ 300
  • Bicarb < 15
  • Ketones present
  • Bicarb ≥ 15*
  • Ketones ≥ 1.0
  • Bicarb > 15*
  • Ketones < 1.0
 
 
 
 
 
 
 
 
 
 
 
 
Patient should go to the PICU. Call 5S Charge RN if above issues are in the report.

Insulin Infusion:
0.1 u/kg/hr

AND

1-2x maintenance IV fluids:
ALL D10%

Fluids should contain KCL and KPhos

Insulin Infusion:
0.1 u/kg/hr

AND

1-2x maintenance IV fluids:
Half D10% and
half NSS

Both bags of fluids should contain KCL and KPhos

Insulin Infusion:
0.1 u/kg/hr

AND

1-2x maintenance IV fluids:
ALL NORMAL SALINE

Fluids should contain KCL and KPhos
  • NO Insulin Infusion:
  • Ketone dose of insulin, usually 10% of total daily dose of insulin
  • Drink/IV fluids:
    1 oz per age in years PER HOUR, max 16 oz/hr
    e.g. 10 y/o drinks 10 oz/hr
  • Re-check BG/ketones in 2 hours
  • Type of fluids depends on what the BG is:
    BG < 200 = sugar containing fluids + ketone dose
    BG 200 = sugar-free fluids + ketone dose
  • Transition to Regular Rules if BOHB < 1 or urine ketones < small
  • At the time of transition out of ketosis, if the patient wants to eat, it is okay to dose for ICR and ISF within 3 hours of the previous insulin dose. If patient is not eating at this time, resume regular day rules.
  • Pre-meal, bedtime, 2 a.m., BG checks
  • If you corrected a high BG overnight, re-check BG
    3 hrs after correction dose given
  • Only check for ketones if BG > 300
  • Cover carbs and high BGs per sliding scale.
    If applicable, confirm correct scale is being used for that specific meal.
 
 
 
 
 
 
  • For all patients in DKA:
    • Full CRM monitor
    • VS & neuro assessment q1h
    • POC BG q1h, POC BOHB q2h
    • BMP/mag/phos q2h
    • NPO
    • Frequent PIV assessments
Goal in treating DKA:
Lower BG by 50-100 mg/dL per hour
*OK to transition to sick day or regular day rules if
Bicarb is < 15 AND ketones are < 2
Patients are permitted to have Lantus® while they are on insulin infusions.
Insulin Chart
When transitioning a child from insulin infusions to sick day rules/regular diabetic, cover carbs AND BG (or ketones if ketone dose is higher); allow to eat for 20 minutes THEN turn off infusions.