Unique Plan Description: DKA HHS
Plan Selection Display: DKA HHS
PlanType: Medical                                 
Version: 3          
Begin Effective Date: 2023-07-25 15:33:00
End Effective Date: 2100-12-31 00:00:00
Last Updated Date: 2024-06-26 09:08:39
Available at all facilities: Yes

DKA HHS
Diet
	NPO
		T;N
Laboratory
STAT, one time
	Blood Gases Arterial (ABG) - MH/WH/JE
		T;N, Stat, spec type = Blood
			Comment: IF NOT DONE IN ED
	Blood Gases Arterial (ABG) - FH
		T;N, Stat, spec type = Blood
			Comment: IF NOT DONE IN ED
	Blood Gases VENOUS (VBG)
		T;N, Stat, spec type = Blood
			Comment: IF NOT DONE IN ED
		T;N+240, Stat, spec type = Blood
	CBC with Diff
		T;N, Stat, spec type = Blood
			Comment: IF NOT DONE IN ED
	CMP
		T;N, Stat, spec type = Blood
			Comment: IF NOT DONE IN ED
	Magnesium Level
		T;N, Stat, spec type = Blood
			Comment: IF NOT DONE IN ED
	Phosphorus
		T;N, Stat, spec type = Blood
			Comment: IF NOT DONE IN ED
	UA (Culture if Positive)
		T;N, Stat, Stat, spec type = Urine
			Comment: IF NOT DONE IN ED
	Beta-Hydroxybutyrate (Inpatient)
		T;N, Stat, spec type = Blood
			Comment: IF NOT DONE IN ED
Timed Lab
	Basic Metabolic Panel
		T;N+240, Timed, Q4H, 24, hr, spec type = Blood
		T;N+1680, Timed, Q6H, 24, hr, spec type = Blood
	Magnesium Level
		T+1;0400, Routine, Q24H, 2, Day(s), spec type = Blood
	Phosphorus
		T+1;0400, Routine, Q24H, 2, Day(s), spec type = Blood
IV Solutions

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		Sodium Bicarb Replacement(NOTE)*
	Sodium Bicarbonate 200 mEq/SWFI 1000 mL
		800 mL, IV, Once, Routine, 250 ml/hr
			Comment: If pH<6.9 (goal pH>7.0) regardless of Na+If SBP<95 (goal SBP>95 then contact provider to adjust rate)Post sodium bicarbonate infusion, if VBG indications pH <7.0 notify provider
		200 mEq, EVERY BAG
	Sodium Bicarbonate 200 mEq/NS 0.45% 1000 mL
		800 mL, IV, Routine, 250 ml/hr
			Comment: If pH<6.9 (goal pH>7.0) regardless of Na+If SBP<95 (goal SBP>95 then contact provider to adjust rate)Post sodium bicarbonate infusion, if VBG indications pH <7.0 notify provider
		200 mEq, EVERY BAG
		Patient Corrected Sodium <135(based on Katz Correction Factor)(NOTE)*
		Patient Corrected Sodium > 135 (based on Katz Correction Factor)(NOTE)*
		Lactactated Ringer Option(NOTE)*
		If patient's potassium is less than 3.3 - DO NOT START insulin until the potassium is corrected to greater than 3.3(NOTE)*
		Any previous insulin and/or oral diabetic medication orders should be discontinued when starting insulin drip(NOTE)*
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	insulin regular 100 units/NS 100 mL Premix
		100 mL, IV, Routine, T;N, Total Volume = 100
			Comment: Initial rate: 4 unit(s)/hrMax Rate: 25 units/hrGlucose <60mg/dL, STOP insulin infusion; START DKA HHS Hypoglycemia protocol. Check every 30 minutes. Restart at 50% prior rate once the glucose is >120. Make sure there is D5% in IV fluid, if not add D5% to existing IV fluids. Glucose 60 - 119mg/dL, STOP insulin infusion. Check every 30 minutes. Restart at 50% prior rate once the glucose is >119mg/dL. Make sure there is D5% in IV fluid, if not add D5% to existing IV fluids.Glucose 120-249mg/dL = Therapeutic Range - No ChangesGlucose <250 ensure a D5 fluid is running and decrease fluid rate to 125 mL/hr. Infusion goal is to decrease blood glucose by ~60mg/dL/hr until glucose is 120-250mg/dL. Glucose >=250mg/dL  goal is to decrease ~60mg/dL per hour; If glucose has decreased by >70mg/dl from the last glucose check, decrease insulin rate by 50%, and check glucose in 30 minutes. If glucose has decreased 50 - 70mg/dL from the last check, continue current rate. If glucose has decreased <50mg/dL,or is greater than previous BG from last check, double the current rate, and check glucose in 30 minutes
		100 units, EVERY BAG, 4 units/hr
Medications
	insulin regular for IV injection
		0.1 units/kg, Solution-Injection, IV Push, Once, STAT
			Comment: if blood sugar is greater than 300 and IF NO BOLUS GIVEN IN ED
	Dextrose 50%
		50 mL, Injection, IV Push, Q15MIN, PRN low blood sugar, STAT
			Comment: If glucose <60mg/dL: Repeat the blood glucose in 15 minutes. May repeat dextrose as often as needed if blood sugar still less than 60 mg/dL.
	glucagon
		1 mg, Injection, IV Push, Q15MIN, PRN low blood sugar
			Comment: If glucose < 60 mg/dL and if dextrose 50% not available or inadequate response to IV dextrose 50%.  May give SQ or IM if patient does not have IV access. Notify provider if given with corresponding POC glucose recheck value
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		K+ Replacement for DKA is higher than normal as long as adequate urine output is maintained.  DKA patients present with normal K+, but this is largely due to insulin deficiency and hyperosmolarity.(NOTE)*
	potassium chloride IVPB - Peripheral line
		40 mEq, Injection-Premix, IVPB, Q4H, PRN for see comment, 125 ml/hr, duration: 3 Dose(s)/Time(s)
			Comment: In NS 500 mL. for potassium <3.3; K+ goal = 5.0 - 5.3 mmol/LNotify MD prior to starting a 3rd dose of electrolytes for abnormal lab values
	potassium chloride IVPB (FH)
		40 mEq, Injection-Premix, IVPB, Q4H, PRN for see comment, duration: 3 Day(s)
			Comment: For potassium <3.3; K+ goal = 5.0 - 5.3 mmol/L Notify MD prior to starting a 3rd dose of electrolytes for abnormal lab values
	potassium chloride IVPB - Peripheral line
		20 mEq, Injection-Premix, IVPB, Q4H, PRN for see comment, 125 ml/hr, duration: 3 Dose(s)/Time(s)
			Comment: In NS 250 mL for potassium 3.3 - 5.0; K+ goal = K+ goal = 5.0 - 5.3 mmol/LNotify MD prior to starting a 3rd dose of electrolytes for abnormal lab values
	potassium chloride IVPB (FH)
		20 mEq, Injection-Premix, IVPB, Q4H, PRN for see comment, duration: 3 Day(s)
			Comment: For potassium 3.3 - 5.0; K+ goal = K+ goal = 5.0 - 5.3 mmol/L Notify MD prior to starting a 3rd dose of electrolytes for abnormal lab values
	magnesium sulfate IVPB
		2 gm, Injection-Premix, IVPB, Q12H, PRN for see comment, duration: 3 Dose(s)/Time(s)
			Comment: For Mg 1.0-1.6; Mg++  goal = 1.7 - 2.5 mg/dL  Recheck Mg++ in 4 hours; administer again if necessary Notify MD prior to starting a 3rd dose of electrolytes for abnormal lab values
		4 gm, INT, IVPB, Once, PRN see comment
			Comment: For Mg < 1.0; Mg++  goal = 1.7 - 2.5 mg/dL  Contact provider after administration
	potassium phosphate-sodium phosphate 250 mg-280 mg-160 mg oral powder for reconstitution
		2 packet(s), Suspension, By Mouth, Once, PRN see comment, duration: 2 Day(s)
			Comment: Use oral if possible; For phosphorus level 1.1-2.0; Phosphorus goal = 2.4 - 4.7 mg/dL   Notify MD prior to starting a 2nd dose of electrolytes for abnormal lab values
	potassium phosphate IVPB
		30 mmol, INT, IVPB, Once, PRN, see comment, 2 Day(s), Infuse Over 5 hr
			Comment: For phosphorus level <= 1.0; Phosphorus goal = 2.4 - 4.7 mg/dL   Use oral if possibleNotify MD upon administration
		15 mmol, INT, IVPB, Once, PRN, see comment, 2 Day(s), Infuse Over 5 hr
			Comment: For phosphorus level 1.1-2.0; Phosphorus goal = 2.4 - 4.7 mg/dL   Use oral if possible Notify MD prior to starting a 2nd dose of electrolytes for abnormal lab values
Patient Care
	Glucose POC - RN
		Q1H
	IV Insulin Parameters
		T;N
			Comment: If enteral &/or parenteral nutrition support is stopped or held TURN OFF INSULIN infusion and notify physician
		T;N
			Comment: When the glucose is less than or equal to 250, and if the patient is not on any dextrose containing IV or TPN, add D5% to the current IV and decrease rate to 125 mL/hr.
	DKA HHS Hypoglycemia Treatment Parameters
		T;N
			Comment: If glucose <60: stop insulin infusion STAT, give 50ml D 50% IV STAT, and notify MD STAT. Repeat the blood glucose in 15 minutes. May repeat 50ml bolus of D50% as often as needed if blood sugar still less than 60, and no response from MD.
	Notify MD
		If IV dextrose source, tube feeding, TPN, or PO diet stopped for any reason, TURN OFF INSULIN infusion and notify physician. For instructions (Caloric intake necessary to prevent hypoglycemia)
	Notify MD of Lab results
		T;N+360, if glucose is not less than 350 after 6 hours on the DKA HHS treatment protocol.
	Notify MD
		T;N+90, for instructions if IV insulin infusion rate is greater than 10 units/hr.
		When Glucose POC consistently less than 200 and Anion Gap < 12(DKA) or Normal Osmolality and Normal Mental Status (HHS), contact provider for long acting insulin orders. Once long acting insulin is given, Stop Insulin Infusion after 2 hours
	Discontinue Medication
		Patient's home insulin pump
	Peripheral Lock-Insert
		Patient to have 2 IV sites, if not done in ED
	Notify MD
		if patient remains hypotensive for IVF and rate.
Consults/Follow-up
	Consult Endocrinologist
		Reason for Referral: Admitted with DKA
	Pharmacy Consult
		Please discontinue any previous insulin and or oral diabetic medication orders when starting insulin drip

Sodium Chloride 0.45% Option
IV Solutions
	Sodium Chloride 0.45%
		1,000 mL, IV, 1 Dose(s)/Time(s), 1,000 ml/hr, 1 hr
			Comment: for SBP < 95 and NS 1000mL not already completed in ED
		1,000 mL, IV, T;N+60, 1 Dose(s)/Time(s), 500 ml/hr
			Comment: for SBP < 95; Notify provider when SBP consistently > 95 to decrease rate.
		1,000 mL, IV, T;N+180, 1 Dose(s)/Time(s), 250 ml/hr
			Comment: for SBP>95
		1,000 mL, IV, T;N+420, 125 ml/hr
			Comment: For SBP>95
	Dextrose 5% with 0.45% NaCl
		1,000 mL, IV, 125 ml/hr
			Comment: Initiate and replace IV fluids when glucose < or = to 250, and patient not on any IV or TPN

Lactated Ringer Option
	Lactated Ringers Injection
		1,000 mL, IV, 1 Dose(s)/Time(s), 1,000 ml/hr, 1 hr
			Comment: for SBP < 95 and NS 1000mL not already completed in ED
		1,000 mL, IV, T;N+60, 1 Dose(s)/Time(s), 500 ml/hr
			Comment: for SBP < 95; Notify provider when SBP consistently > 95 to decrease rate.
		1,000 mL, IV, T;N+180, 1 Dose(s)/Time(s), 250 ml/hr
			Comment: for SBP>95
		1,000 mL, IV, T;N+420, 125 ml/hr
			Comment: For SBP>95
	Dextrose 5% in Lactated Ringers
		1,000 mL, IV, 125 ml/hr
			Comment: Initiate and replace IV fluids when glucose < or = to 250, and patient not on any IV or TPN

Sodium Chloride 0.9% Option
	Sodium Chloride 0.9%
		1,000 mL, IV, 1 Dose(s)/Time(s), 1,000 ml/hr, 1 hr
			Comment: for SBP < 95 and not already completed in ED; Stat Sodium Level when complete.
		1,000 mL, IV, T;N+60, 1 Dose(s)/Time(s), 500 ml/hr
			Comment: for SBP < 95; Notify provider when SBP consistently > 95 to decrease rate.
		1,000 mL, IV, T;N+180, 1 Dose(s)/Time(s), 250 ml/hr
			Comment: for SBP>95
		1,000 mL, IV, T;N+420, 125 ml/hr
			Comment: For SBP>95
	Dextrose 5% with 0.9% NaCl
		1,000 mL, IV, 125 ml/hr
			Comment: Initiate and replace IV fluids when glucose < or = to 250, and patient not on any IV or TPN

*Report Legend:
DEF - This order sentence is the default for the selected order
GOAL - This component is a goal
IND - This component is an indicator
INT - This component is an intervention
IVS - This component is an IV Set
NOTE - This component is a note
Rx - This component is a prescription
SUB - This component is a sub phase