#Episode_5
✅ Management (Algorithm) of DKA and HHS
#Order
▪️Imp: DKA
▪️Cond: Emergent
▪️Diet: NPO
▪️Act: CBR
▪️IV line
▪️CVS q4h
▪️CM & POM
▪️ECG
▪️Foley Fix and I/O chart
▪️Check CBC, Na, K, Mg, P, Ca, Cr, BUN, VBG, BS, Trop, U/A Stat.
+
▫️ESR, CRP, U/C, B/C ×2, Amylase, Lipase, LFTs, Bilirubin, CXR
*براساس شرایط بیمار
▪️Check Na, K, P, Mg, VBG, BUN, Cr, serum ketone q 2-4h
تا استیبل‌شدن بیمار
▪️BS Glucometer q1h
تا استیبل‌شدن بیمار
▪️IV Fluid 0.9% N.S 1L/h
🔹Replete ECF volume and free water deficits:
▪️For patients with signs of shock, administer several liters as rapidly as possible.
▫️IV isotonic fluid (lactated ringers or 0.9% N.S) 20-30cc/kg bolus during the first hour, and repeated if neede(e.g 2-3 L during first 2-3h)
▪️For patients with hypovolemia but without shock and without signs of cardiac or kidney compromise.
▫️IV isotonic fluid (15-20 mg/kg) or 1L/h for the first few hours.(max <50mg/kg in first 4h)
▪️For patients with mild hypovolemia
▫️individualize
🔹After the second or third hour and when volume deficit is corrected, optimal fluid replacement depends upon the state of hydration, serum electrolyte, and the urine output. based on the corrected serum Na
▫️In hyperglycemia; for each 100 mg/dL serum glucose exceeds 100 mg/dL, add 2 mEq to plasma Na.
▪️If corrected Na ≥135
▫️IV fluid one-half isotonic saline (0.45%) at 250 to 500 mL/hour.
▪️If corrected Na<135
▫️isotonic saline should be continued at a rate of 250 to 500 mL/hour until hyponatremia resolved.
▪️if serum glucose declines to <250
*Change to D5or10W with H.S
▫️Add 2 vials Dextrose 50% to the one liter of H.S(0.45%N.S) and at a rate of 150-250 ml/h
*هر ویال دکستروز ۵۰درصد به حجم ۵۰ میلی لیتر، حاوی ۲۵گرم قند میباشد
🔹Replete potassium (K+) deficits:
▫️provided urine output is adequate (approximately > 50 mL/hour)
▫️ویال های KCl در بیمارستان: 15% و حجم 10cc هستند که هر ویال آن 20mEq پتاسیم دارد. پس هر ۱ سی سی از محلول ۱۵ درصد، حاوی 2mEq پتاسیم میباشد.
▪️If K<3.5
▫️Delay initiation of insulin until K>3.5
▫️IV KCl, (KCl; 10 to 20 mEq/hour, which usually requires:
10 to 20 mEq KCL + 1 liter of IV fluid"->10-20 mEq/L.
*Infusion rate of final fluid: 1L/h(equal 20 mEq/h)
▪️If K 3.5 to 5
▫️IV KCl (10 to 20 mEq) is added to each liter of IV fluid; maintain serum K between 4 to 5.
▪️If K>5
▫️Do not give potassium until K<5
▫️check serum K q2h
▫️administer potassium chloride as needed to maintain serum K between 4 and 5.
🔹Give insulin(based on the K level)
*start insulin immediately in all patients with DKA who have a K ≥3.5.
*Decline in serum glucose should not exceed 90-120 mg/dL/h
▪️If K <3.5
▫️do not give insulin until K>3.5
▫️replete K+ and fluid deficit first.
▪️If K ≥3.5 (DKA severity)
◽️Moderate to severe DKA:
IV short-acting (eg. regular): 0.1 U/Kg bolus then 0.1 U/kg/h infusion
◽️Uncomplicated DKA:
S.C rapid- acting(eg. Aspart): 0.1/kg bolus then 0.1 U/Kg q1h
▫️If serum glucose does not fall by at least 50 to 70 mg/dL in the first hour, double the rate of insulin infusion.
▪️When serum glucose is <250
▫️add 5 to 10 percent dextrose to the IV fluid,
▫️decrease the insulin infusion rate to 0.05 units/kg per hour.
▫️Serum glucose should be maintained between 150 and 200 mg/dL until resolution of DKA
▪️Continue insulin infusion until ketoacidosis is resolved, serum glucose is below 200 and S.C insulin is begun.
🔹Bicarbonate and phosphate (rarely indicated)
▫️ویال های سدیم بیکربنات در بیمارستان: 8.4% و حجم 50cc هستند که هر ویال آن 50mEq بیکربنات دارد. پس هر یک سی سی از محلول ۸.۴٪، حاوی 1mEq بیکربنات است.
▪️If the arterial pH is <7.0
▫️100 mEq of sodium bicarbonate in 400 mL sterile water over 2 hours
▫️if potassium is <5.0 mEq/L, add 20 mEq KCl.
▫️Monitor pH, HCO3 q2h
▫️Bicarbonate administration may be repeated as needed to raise pH to >7.0.
▪️If serum phosphate is <1 mg/dL
▫️sodium phosphate 20 to 30 mEq can be added to 1 L of IV fluid
OR
▫️1 vial glycophos (20cc) can be added to 1L of IV fluid.
*هر ویال از glycophosبه حجم 20 سی سی، حدود 20mEq فسفر دارد. پس هر یک سی سی از آن دارای 1mEq فسفر میباشد.