Protocal for the Treatment of Diabetic Ketoacidosis and Hyperosmolar Hyperglycemic Non-Ketotic Coma

 

IV fluid

Insulin

Potassium

Bicarbonate

1

Hypovolemic shock for Plasma expander

Cardiovasular

instability or aged:CVP or Swan-Ganz monitoring

2

injection 0.1 u/kg regular insulin as iv bolus first

3

[K]<3.5 meq/l, give K40meq per Min of iv fluid,if 3.5<[K]<5.0 meq/l and no peak T wave in EKG,give K20-30 meq per liter of iv fluid

4

88 meq NaCO3 in infusion 30 mins every 2 hours if pH<<6.9 but no NaHCO3 when pH>7.0

5

Usisng nomal saline unless [Na]>150meq/l when half saline is suitable;infusion 1 liter for the first hour then0.5 liter every hour for 4 hours, then100-250 ml/hour

6

Using infusion pump RI 25u in 250ml N/S (lu/10ml), flush 50ml through line before connecting to patient

7

supply K as 2/3 KCI and 1/3 K2HPO4-KH2PO4 buffer to avoid hyperchloremic acidosis and to correct phosphate depletion

 

10

be careful in using half-saline in very youngpatientand avoid too rapid infusion rate to avoid complicated brain edema

11

BG(mg/dl) insulin(u/h)

   <80           0

  81-100       0.5

 101-140       1.0

 141-180       1.5

 181-220       2.0

 221-260       2.5

 261-300       3.0

 301-340       4.0

   >340        6.0

12

if urine output is good, give K 20 meq per liter of iv fluid to keep K at 4-5 meq/l

 

13

Switching into 5% dextrose in half saline if plasma glucose falls below 150mg/dl

14

if patient is confused or unable to eat:5% dextrose in half saline100 ml/hour and infuse insulin as adjusted by series of glucose

15

if patient is eating well:    NPH 15-20 u before breakfast and NPH 5-15u before dinner, however,previous doses of insulin should be taken into consideration

 

1.Check ABG, sugar, Na, K, Cl.urine ketone every 2 hours before sugar falls below 200 mg/dl; then check sugar, Na, K, every 4 hours and urine ketone every 12 hours until clinical condition stabilized.

2.Obtain body fluid and send for bacteria culture of any suspicion but not routinely use antibiotics unless showing clinically obvious toxic signs:WBC count>20000/mm3 and or toxic granules (+) or left-shifted leukocytosis.

3.check CPK when just arrived ER, if elevated check serum myoglobulin and

urine myoglobulin, serum phosphate.

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