Unique Plan Description: DKA HHS Protocol (MFH) [EBM]
Plan Selection Display: DKA HHS Protocol (MFH) [EBM]
PlanType: Medical                                 
Version: 1          
Begin Effective Date: 2020-04-28 14:11:00
End Effective Date: 2100-12-31 00:00:00
Last Updated Date: 2022-01-27 13:09:06
Available at all facilities: No

DKA HHS Protocol (MFH) [EBM]
Laboratory
	Glucose POC - RN
		T;N, Q1H
	CBC with Diff
		Stat, spec type = Blood
			Comment: IF NOT DONE IN ED
	CMP
		Stat, spec type = Blood
			Comment: IF NOT DONE IN ED
	Magnesium Level
		Stat, spec type = Blood
			Comment: IF NOT DONE IN ED
		T;N+720, Timed, Q12H, spec type = Blood
	Phosphorus
		T;N+720, Timed, Q12H, spec type = Blood
	BMP
		T;N+120, Q2H-Sch 6 hr, spec type = Blood
		T;N+480, Timed, Q4H 8 hr, spec type = Blood
		T;N+960, Timed, Q8H, spec type = Blood
	Blood Gases Arterial (ABG) - MH/WH/JE
		Nurse Collect, T+1;0500, Routine, Q24H, spec type = Blood
			Comment: DKA Protocol: Check with nursing before drawing
	Blood Gases Arterial (ABG) - FH
		Nurse Collect, T+1;0500, Routine, Q24H, spec type = Blood
	Blood Gases VENOUS (VBG)
		T+1;0500, Routine, Q24H, spec type = Blood
	UA (Culture if Positive)
		Stat, Stat, spec type = Urine
		T;N+240, Routine, Routine, spec type = Urine
	Beta-Hydroxybutyrate (Inpatient)
		Nurse Collect, spec type = Blood
			Comment: DKA HHS Protocol [EBM]
IV Solutions
		Patient sodium low (<145) and potassium level >4.0(NOTE)*
	Sodium Chloride 0.9%
		1,000 mL, IV, 250 ml/hr
			Comment: if sodium still < 145, potassium > 4.0 and glucose >=250.  If glucose < 250, start Dextrose 5% with 0.9% NaCl at 250ml/hr
		1,000 mL, IV, 500 ml/hr
			Comment: if sodium still < 145, potassium > 4.0 and glucose >=250.  If glucose < 250, start Dextrose 5% with 0.9% NaCl at 250ml/hr
		Patient sodium low (<145) and potassium level 3.1-4.0(NOTE)*
	Sodium Chloride 0.9% with KCl 20mEq
		1,000 mL, IV, 250 ml/hr
			Comment: if sodium still < 145, potassium 3.1-4.0 and glucose >=250.  If glucose < 250, start Dextrose 5% with 0.9% NaCl with KCl 20mEq at 250ml/hr
		Patient sodium low (<145) and potassium level <3.0(NOTE)*
	Sodium Chloride 0.9% with KCl 40mEq
		1,000 mL, IV, 250 ml/hr
			Comment: hr if sodium still < 145, potassium < 3.0 and glucose >=250.  If glucose < 250, start Dextrose 5% with 0.9% NaCl with KCl 40mEq at 250ml/hr
		Patient sodium low (>145) and potassium level >4(NOTE)*
	Sodium Chloride 0.45%
		1,000 mL, IV, 250 ml/hr
			Comment: if sodium > 145, potassium >4.0 and glucose >=250.  If glucose < 250, start Dextrose 5% with 0.45% NaCl at 250ml/hr
		Patient sodium low (>145) and potassium level <3.0(NOTE)*
	Sodium Chloride 0.45% with KCl 40 mEq
		1,000 mL, IV, Routine, 250 ml/hr
			Comment: if sodium still > 145, potassium < 3.0 and glucose >=250.  If glucose < 250, start Dextrose 5% with 0.45% NaCl with KCl 40mEq at 250ml/hr
		40 mEq, EVERY BAG
		Patient sodium low (>145) and potassium level 3.1-4.0(NOTE)*
	Sodium Chloride 0.45% with KCl 20 mEq
		1,000 mL, IV, Routine, 250 ml/hr
			Comment: if sodium still > 145, potassium 3.1-4.0 and glucose >=250.  If glucose < 250, start Dextrose 5% with 0.45% NaCl with KCl 20mEq at 250ml/hr
		20 mEq, EVERY BAG
		DESTROSE CONTAINING FLUIDS:(NOTE)*
	Dextrose 5% in Water
		1,000 mL, IV, 250 ml/hr
			Comment: if glucose < 250 and sodium < 145, potassium > 4.0
	Dextrose 5% with 0.9% NaCl w/KCl 20 mEq
		1,000 mL, IV, 250 ml/hr
			Comment: if glucose < 250 and sodium still < 145, potassium 3.1-4.0
	Dextrose 5% with 0.45% NaCl
		1,000 mL, IV, 250 ml/hr
			Comment: if glucose < 250 and  sodium > 145, potassium >4.0
	Dextrose 5% with 0.45% NaCl w/KCl 20 mEq
		1,000 mL, IV, 250 ml/hr
			Comment: if glucose < 250 and sodium still > 145, potassium 3.1-4.0
	Dextrose 5% with 0.45% NaCl w/KCl 40 mEq
		1,000 mL, IV, 250 ml/hr
			Comment: if glucose < 250 and sodium still > 145, potassium < 3.0
Medications
	insulin regular 100 units/NS 100 mL Premix
		100 mL, IV, Routine, T;N, Total Volume = 100
			Comment: Initial rate of 0.1units/kg/hr (max of 3 units/hr), When glucose is <250mg/dL ensure a D5% fluid is running.1.  If the glucose decreases >60mg/dl from the last glucose check, decrease insulin rate by 50%, and check     glucose in 30 minutes. 2.  For glucose <60, stop infusion, contact provider and follow DKA HHS Hypoglycemia protocol. Restart at 50% of    previous rate once the glucose is >120. Make sure there is D5% in IV fluid, if not add D5% to existing IV fluids. 3.  For glucose 60-120, HOLD infusion, Restart at 50% of previous rate once the glucose is >120, check POC BG    every 30 min4.  120-180 No change to infusion.  Make sure there is D5% in IV fluid, if not add D5% to existing IV fluids.5.  181-250 increase infusion by 0.5units/hr 6.  250-399 and is greater than or equal to the previous glucose, bolus with 5 units insulin and increase infusion by     0.5 unit/hr. 7.  >=400 and is less than previous glucose, bolus with 10 units insulin and increase infusion by 1unit/hr
		100 units, EVERY BAG, 0.1 unit/kg/hr
			Comment: INITIAL Infusion Rate: glucose 200-249mg/dl: 4 units/hr; 250-299mg/dl: 6 units/hr; 300-399md/dl: 8 units/hr; > 400mg/dl: 10 units/hr.  Titrate to a target glucose of 140-200.  MAXIMUM rate of 40 units/hr.  Call physician for direction if unable to reach goal range.  DO NOT enter as a basic infusion in pump1. If glucose is < 60, HOLD DRIP and give 1 amp 50% glucose and check POC glucose every 30 minutes until >   100mg/dl and then re-initiate drip at 50% previous rate2. If glucose is 60-80, HOLD DRIP and check POC glucose every 30 minutes until > 100mg/dl and then re-initiate   drip at 50% previous rate3. If glucose is 81-100 mg/dl    a. Previous glucose 60-80, decrease rate by 1 unit/hr    b. Previous glucose 81-139, decrease rate by 0.5units/hr    c. Previous glucose 140-250, decrease rate by 1 unit/hr    d. Previous glucose 251-300, decrease rate by 1.5units/hr    e. Previous glucose >300, decrease rate by 2 units/hr4. If glucose is 101-139 mg/dl    a. Previous glucose <101, NO CHANGE    b. Previous glucose 101-200, decrease rate by 0.5units/hr    c. Previous glucose > 200, decrease rate by 1unit/hr5. If glucose is 140-200 mg/dl    a. Previous glucose < 101, increase rate by 1 unit/hr    b. Previous glucose 101-250, NO CHANGE    c. Previous glucose > 250, decrease rate by 2 units/hr6. If glucose 201-250 mg/dl    a. When Blood Glucose is < 250 mg/dl, update IV fluid to dextrose containing fluid.  If no fluids on patient       profile,     start D5%-Normal Saline 0.9% at 50mL/hr.    b. Previous glucose < 139, increase rate by 2 units/hr    c. Previous glucose 140-300, increase rate by 1 unit/hr    d. Previous glucose >300, NO CHANGE7. If glucose 251-300 mg/dl    a. Previous glucose < 101, increase rate by 2.5 units/hr    b. Previous glucose 101-139, increase rate by 1.5 units/hr    c. Previous glucose 140-250, increase rate by 1 unit/hr    d. Previous glucose 251-300, increase rate by 1.5units/hr    e. Previous glucose 301-400, increase rate by 2 units/hr    f. Previous glucose > 400, NO CHANGE8. If glucose 301-400 mg/dl    a. Increase rate by 3 units/hr9. If glucose > 400 mg/dl    a. Increase rate by 4 units/hr
	insulin regular 100 units/NS 100 mL IV
		100 mL, IV, Routine, T;N+960, Total Volume = 100
			Comment: Initial rate of 0.1units/kg/hr (max of 3 units/hr), When glucose is <250mg/dL ensure a D5% fluid is running.1.  If the glucose decreases >60mg/dl from the last glucose check, decrease insulin rate by 50%, and check     glucose in 30 minutes. 2.  For glucose <60, stop infusion, contact provider and follow DKA HHS Hypoglycemia protocol. Restart at 50% of    previous rate once the glucose is >120. Make sure there is D5% in IV fluid, if not add D5% to existing IV fluids. 3.  For glucose 60-120, HOLD infusion, Restart at 50% of previous rate once the glucose is >120, check POC BG    every 30 min4.  120-180 No change to infusion.  Make sure there is D5% in IV fluid, if not add D5% to existing IV fluids.5.  181-250 increase infusion by 0.5units/hr 6.  250-399 and is greater than or equal to the previous glucose, bolus with 5 units insulin and increase infusion by     0.5 unit/hr. 7.  >=400 and is less than previous glucose, bolus with 10 units insulin and increase infusion by 1unit/hr
		100 units, EVERY BAG, 0.1 unit/kg/hr
Hypoglycemia
	Dextrose 50%
		25 mL, Injection, IV Push, Q15MIN, PRN low blood sugar, STAT
			Comment: For glucose < 70, May repeat as needed if blood sugar still less than 100.
		50 mL, Injection, IV Push, Q15MIN, PRN low blood sugar, STAT
			Comment: For glucose < 50, May repeat as needed if blood sugar still less than 100.
	glucagon
		1 mg, Injection, SUBCUTANEOUS, Q15MIN, PRN for low blood sugar, STAT
			Comment: :For glucose < 70, May repeat as needed if blood sugar still less than 100.
Potassium Supplement
	potassium chloride Oral
		20 mEq, Tablet-Extended-Release, By Mouth, DAILY, PRN see comment
			Comment: If potassium level 3.0-4.0 and Oral desired
		40 mEq, Tablet-Extended-Release, By Mouth, DAILY, PRN see comment
			Comment: If potassium level 2.5-3.0 and Oral desired.  Insure K+ containing fluids are running
	potassium chloride IVPB (FH)
		40 mEq, Injection-Premix, IVPB, Q4H, PRN see comment
			Comment: For potassium <3.0. Enter order for stat potassium level after infusion complete. For potassium < 2.0, contact provider. Contact provider prior to starting a 3rd dose of replacement.
		20 mEq, Injection-Premix, IVPB, Q4H, PRN see comment
			Comment: For potassium 3.0-4.0. Enter order for stat potassium level after infusion complete. Contact provider prior to starting a 3rd dose of replacement.
Phosphorous
	potassium phosphate-sodium phosphate 250 mg-280 mg-160 mg oral powder for reconstitution
		2 packet(s), Suspension, By Mouth, Once, PRN see comment
			Comment: For phosphorus level 1.1-2.0 and oral desired.  Contact provider prior to starting a 3rd dose of replacement.
	sodium phosphate IVPB
		30 mmol, INT, IVPB, Once, PRN, see comment, Infuse Over 4 hr
			Comment: For phosphorus level <= 1.0.  Contact provider for low level and prior to starting a 3rd dose of replacement
	potassium phosphate IVPB
		30 mmol, INT, IVPB, Once, PRN, see comment, Infuse Over 4 hr
			Comment: For phosphorus level <= 1.0  Contact provider for low level and prior to starting a 3rd dose of replacement
		15 mmol, INT, IVPB, Once, PRN, see comment, Infuse Over 2 hr
			Comment: For phosphorus level 1.1-2.0.  Watch for hypocalcemia.  Contact provider prior to starting a 3rd dose of replacement.
Magnesium
	magnesium sulfate IVPB
		2 gm, INT, IVPB, Q4H, PRN see comment
			Comment: For Mg 1-1.6.  Recheck level in 4 hours.  Contact provider prior to starting a 3rd dose of replacement.
		4 gm, INT, IVPB, Q4H, PRN see comment
			Comment: For Mg < 1.0.  Recheck level in 4 hours.  Contact provider for low level and prior to starting a 3rd dose of replacement.
Patient Care

	Notify MD
		If Blood Glucose not within goal range for 4 consecutive hours.
		If Blood Glucose less than 60mg/dl for 2 consecutive measurements
	Intake and Output
		
	Notify MD
		If IV dextrose source, TPN, or PO diet stopped for any reason, TURN OFF INSULIN infusion and notify physician.
		Once blood sugar < 250mg/dL to add dextrose to IV fluid once blood sugar < 250 mg/dl.  If no fluids ordered start D5% Normal Saline 0.9% at 50mL/hr
	Discontinue Medication
		T;N, Pt. started on insulin infusion...Discontinue all previous blood glucose monitoring orders
	Notify MD
		When BG is at goal, pH > 7.3, and HCO3 > 18 mEq/L, Contact provider to discontinue protocol and switch to sliding scale insulin protocol and order diet.
Consults/Follow-up
	Pharmacy Consult
		T;N, Pt. started on insulin infusion...Discontinue all previous insulin orders

*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