Diabetesscenariosforjuniordoctors.co.uk

DIABETIC KETOACIDOSIS INTRAVENOUS INSULIN CHART
ONLY TO BE USED FOR THE MANAGEMENT OF DKA IN ADULTS
‘INSULIN’ SHOULD ALSO BE DOCUMENTED ON THE MAIN CHART Please read the prescribing and administration notes overleaf before completing this chart.
Further details are available in the Trust Guideline: DKA Management 2010, available on the Intranet.
1. Replacement of circulating volume and potassium:
Prescribe concurrent intravenous fluids with potassium on appropriate fluid chart
– see 1a. & 1b. overleaf
Once glucose is less than 14mmol/L prescribe concurrent intravenous glucose on the
appropriate fluid chart – see 1c. overleaf
2a. Intravenous Insulin Prescription:
Signature
Insulin prescription – see 1a overleaf
Prescribed
50 Units of ACTRAPID in 49.5ml of 0.9% Sodium Chloride
50 Units of ACTRAPID in 49.5ml of 0.9% Sodium Chloride
If the patient is on regular Detemir (Levemir) or Glargine (Lantus) insulin, please
continue. Prescribe this on the regular insulin prescription chart
2b. Initial Fixed-rate Intravenous Insulin Infusions (IVII) Rate:
Signature
(0.1 Units/kg/hour)
Continue as long as blood ketones falling by at least 0.5 mmol/L/hr & bicarbonate rising by at least 3mmol/L/hr 2c. Adjusting intravenous Insulin Infusions (IVII) rate
If blood ketones not falling by at least 0.5 mmol/L/hr or bicarbonate Continue fixed rate insulin infusion until ketones less than 0.3 mmol/L, venous pH over 7.3 and/or venous
bicarbonate over 18 mmol/L.
Monitoring blood glucose and insulin infusion rate: (Check blood glucose hourly till stable, then
two-hourly)
Title: Diabetic Ketoacidosis Intravenous Insulin Chart Approved by: Records Management Committee July 2010 Management of Diabetic Keto-Acidosis
Patient name: .
NHS no: .
Hospital no: .
Definition
Blood glucose over 11 mmol/L or known diabetes mellitus Ketonaemia 3 mmol/L and over or significant ketonuria (2+ or more on standard urine sticks) Serum bicarbonate < 15 mmol/L and/or venous pH < 7.3.
Assessment of severity
The presence of one or more of the following may indicate severe DKA and admission to a Level 2/HDU environment, insertion of a
central line and immediate senior review should be considered:
• GCS less than 12 or abnormal AVPU scale • Oxygen saturation below 92% on air (assuming normal baseline • Hypokalaemia on admission (under 3.5mmol/L) • Anion gap above16 [Anion Gap = (Na+ + K+) – (Cl- + HCO3-) ] Monitoring
• Capillary glucose and blood ketones should be measured hourly
• Venous blood gas for pH, bicarbonate and potassium at 60 mins and 2 hour and 2 hourly thereafter
• Accurate fluid balance chart, with minimum urine output 0.5ml/kg/hr. Catheterise if no urine output after 60 mins
1a. Intravenous fluids
On average these patients are at least 100ml/kg fluid-deplete i.e a 70kg man may be up to 7 litres in deficit
The initial fluid regimen should be 0.9% (Normal) saline and this should be infused quickly.
0.9% sodium chloride with potassium chloride 0.9% sodium chloride with potassium chloride 0.9% sodium chloride with potassium chloride 0.9% sodium chloride with potassium chloride 0.9% sodium chloride with potassium chloride Re-assessment of cardiovascular status at 12 hours is mandatory, further fluid may be required
1b. Potassium replacement
Potassium level (mmol/L)
Potassium replacement
Senior review as addition potassium needs to be given 1c. Glucose replacement
Once glucose falls to <14 mmol/L add a glucose infusion to run concurrently with the intravenous insulin. The rate of glucose
infusion remains constant. Normal saline should continue as fluid replacement, if necessary. (Fluids MUST be prescribed & batch
no. MUST be recorded on a fluid chart)
500ml 10% glucose at 125ml/hr via a pump.
Regimen if concerns about fluid overload: 500ml 20% glucose at 62.5ml/hr via a pump.
2a. Intravenous Insulin Prescription
2b. Intravenous Insulin Rate
If patient’s weight is unknown, then estimate weight, but weight at earliest opportunity if blood ketones not falling by at least 0.5 mmol/L/hr or bicarbonate not rising by at least 3. Stopping fixed rate intravenous insulin
DKA has resolved when blood ketones < 0.3mmol/L, venous pH >7.3 and/or venous bicarbonate > 18mmol/L • If the patient is eating and drinking give fast acting or mixed subcutaneous insulin at the next meal and take IV insulin down • If patient not eating and drinking switch to routine intravenous insulin chart, note that this will mean a decrease in the insulin Title: Diabetic Ketoacidosis Intravenous Insulin Chart Approved by: Records Management Committee July 2010

Source: http://diabetesscenariosforjuniordoctors.co.uk/sites/peninsulamedicalschool/files/blank_chart/Scenario%201%20-%20blank%20insulin%20chart.pdf