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    ●   History   and    physical   ●   Basic   metabolic  panel,   calcium,    phosphorus   and magnesium   every   4   hours   ●   Capillary    blood   glucose   every   hour    ●   Urine   ketones 2   ●   Ionized   calcium   ●   Diagnostic   imaging   as   clinically   indicated    Note:   Interventions 3 for    Serum    bicarbonate   than   16    breaths    per    minute?   less   than   15   mE /L   or    res irator    rate   reater      Yes   ●   Arterial    blood   gas   ●   Capillary    blood   glucose   every   WORKUP/   ASSESSMENT   Assess 4 the   following: ●   Hydration   status   ●   Electrolyte   status   ●   Blood   Glucose   ●   Acidosis   ●   Calculate   anion   a     Yes   ●   Consult   Endocrinology service   ●   See   Page   2   for    DKA/HHS Management    No   Continue   work  p   for    further    treatment   or    alternative   diagnosis   Page   1   of    6   Hyperglycemic   Emergency   Management   (DKA/HHS 1 )   -   Adult   This    practice   algorithm   has   been    specifically   developed     for     MD    Anderson   using    a   multidisciplinary   approach   and    taking    into   consideration   circumstances    particular    to    MD    Anderson,   including    the    following:    MD    Anderson ’  s    specific    patient     population;    MD    Anderson ’  s    services   and     structure;   and     MD    Anderson ’  s   clinical    information.    Moreover,   this   algorithm   is   not    intended    to   replace   the   independent    medical    or     professional     judgment    ofp   hysicians   or    other    health   care    providers.   PATIENT   PRESENTATION   of    hyperglycemic   emergency 5 ?   Patient   with   history   of     polydipsia,   nausea/    No   Continue   to   monitor    hourly   capillary    blood   glucose   as    per     protocol   (See   Appendix   A   and   B)   1 Diabetic   ketoacidosis   (DKA)   and   hyperosmolar    hyperglycemic   state   (HHS)   2 If    urine   ketones   are    positive,   send   serum    beta-hydroxybutyrate,   and   start   treatment    pending   results   3 Interventions:   ●   Strict   input   and   output   hourly   for    a   total   of    4   hours   and   notify    physician   if    urine   output  is less   than   0.5   mL/kg/hour    ●   If     pH   is   less   than   7   or    if    serum    bicarbonate   is   less   than  10  mEq/L,   notify    physician   4 Continue   to   look    for    the   underlying   cause   of    events   5 DKA   diagnostic   criteria:    blood   glucose   greater    than   250   mg/dL,   arterial    pH   less   than   7.3,    bicarbonate   less   than  15  mEq/L,   and   moderate   ketonuria   or    ketonemia   HHS   diagnostic   criteria:    blood   glucose   greater    than   600   mg/dL,   arterial    pH   greater    than7.3,    bicarbonate   greater    than  15  mEq/L,   and   minimal   ketonuria   and   ketonemia    TREATMENT   Hydration   INTERVENTION   3.3   mEq/L   Potassium   3.3-5.5   mEq/L   Potassium   greater      orrecte   so um   initiation   of    insulin 3   Potassium   and   Calculate correcte less   than   147   mEq/L   Corrected   sodium reater    than   or    equa   to     m q   Additional   fluids   of    0.9%   sodium   chloride   t an   .   m q   Give   regular    insulin   0.15   units/kg   IV    bolus 5 and   start   regular    insulin   0.1   units/kg/hour    IV   infusion 3   Greater than   7.14   6.9   -   7.14     Treat   with   sodium    bicarbonate   (as    per    ICU   team   management)   Consider    sodium    bicarbonate   (as    per    ICU   team   management)   Recheck blood   gas   hourly   for     pH   and   icarbonate   until    pH   reaches   7.2   or    higher    IV   over    1   hour,   then   initiate   continuous infusion   to   replete   volume   status   Additional   fluids   of    0.45%   sodium   chloride   otass um   ess   t an   ●   Recheck     potassium   and   electrolytes   every   4   hours   ●   See   Page  3  for    Insulin   Titration    No   need   to   give   sodium    bicarbonate   Once    potassium   greater    than   3.3   mEq/L,   give   regular    insulin   0.15   units/kg   IV    bolus 5  and   start   regular    insulin   0.1   units/kg/hour    IV   infusion 3,6   ●   ot y   team   ●   Stop   all   sources   of     potassium   administration   and   treat   hyperkalemia   as   clinically   indicated   ●   Give   regular    insulin   0.15   units/kg   IV    bolus 5 and   start   regular    insulin   0.1   units/kg/hour    IV   infusion 3   ●   Repeat   serum    potassium   every   2   hours   until   less   than   5.5   mEq/L   Replete   and   recheck     potassium    per    electrolyte   replacement 4  protocol.   If     protocol   contraindicated   or not   ordered,   notify    physician.   When    blood   glucose   is   less   than or    equal   to   250   mg/dL,   change   IVF   to   D   5   0.45%   sodium   chloride   to   infuse   at   current   rate   Department   of    Clinical   Effectiveness   V2 Approved    by   the   Executive   Committee   of    the   Medical   Staff    on   12/12/2017   Page   2   of    6   Hyperglycemic   Emergency   Management   (DKA/HHS)   -   Adult   This    practice   algorithm   has   been    specifically   developed     for     MD    Anderson   using    a   multidisciplinary   approach   and    taking    into   consideration   circumstances    particular    to    MD    Anderson,   including    the    following:    MD    Anderson ’  s    specific    patient     population;    MD    Anderson ’  s    services   and     structure;   and     MD    Anderson ’  s   clinical    information.    Moreover,   this   algorithm   is   not    intended    to   replace   the   independent    medical    or     professional     judgment    ofp   hysicians   or    other    health   care    providers.   DKA/HHS   Management   0.9%   sodium   chloride   1   liter     pH   Less   than   6.9   1 Consider    reduction   for     patients   with   heart   failure,   end-stage   liver    or    renal   disease,   or    greater    than   65   years   old   2 Calculation   for    corrected   sodium   =   0.016   x   (measured   glucose   –   100)    plus   measured    Na   3 Prime   all   insulin   tubing   with   25   units   of    insulin   from    bag   and   do   not   use   a   manifold   4 Refer    to   the   Critical   Care   Adult   PRN   Electrolyte   Replacement   Orders   via   CVC    protocol   5 For    insulin   management   with   regular    insulin    bolus:   usual   dose   10-15   units   for     patients   70   to   100   kg   6 Consider    reducing   insulin   dose   for     patients   with   end-stage   liver    or    renal   disease    ●    Notify   Endocrinology service   ●   Endocrinology   to   dose long-acting   insulin   ●   nsu n   g arg ne   .   un ts g   ●   Consider    reducing   dose   in    patients   with   end   stage   liver    failure     ●   nsu n   g arg ne   .   un ts g   ●   Consider    reducing   dose   in    patients with   end   stage   liver    failure   ●   nsu n   g arg ne   .   un ts g   ●   Consider    reducing   dose   in    patients with   end   stage   liver    failure   Discontinue   insulin   infusion   2   hours   after long-acting   insulin   administration   Blood   glucose   250   mg/dL?   less   than   or    e ual   to   ●    Notify   ICU/EC   Team   and   change   IVF   to   D 5   0.45%   sodium   chloride to   infuse   at   current   rate   ●   Decrease   insulin   infusion   rate    by   half    ●   Titrate   insulin   infusion    per    Appendix   B    No   See   Management   below   Lon   Actin     Insulin   eGFR    less   than   or    age   greater    60   mL/minute/1.73   m 2   than   70   years?   BMI   less   than   30     o   BMI   30   or    greater    or taking   more   than   1   unit/kg/day   insulin   dose   at home   Yes   Page   3   of    6   Hyperglycemic   Emergency   Management   (DKA/HHS)   -   Adult   This    practice   algorithm   has   been    specifically   developed     for     MD    Anderson   using    a   multidisciplinary   approach   and    taking    into   consideration   circumstances    particular    to    MD    Anderson,   including    the    following:    MD    Anderson ’  s    specific    patient     population;    MD    Anderson ’  s    services   and     structure;   and     MD    Anderson ’  s   clinical    information.    Moreover,   this   algorithm   is   not    intended    to   replace   the   independent    medical    or     professional     judgment    ofp   hysicians   or    other    health   care    providers.   INSULIN   TITRATION   Yes   Insulin   Titration 1   Continue   to   monitor    capillary    blood   glucose   every   hour    and   titrate   insulin   infusion    per    Appendix   A   LONG   ACTING   INSULIN   MANAGEMENT   150-250   mg/dL   eGFR    =   estimated   glomerular    filtration   rate   1 Prime   all   insulin   tubing   with   25   units   of    insulin   from    bag   and   do   not   use   a   manifold   Department   of    Clinical   Effectiveness   V2 Approved    by   the   Executive   Committee   of    the   Medical   Staff    on   12/12/2017      Glucose   Level   Intervention   Recheck    Glucose   Less   than   70   mg/dL   ●   Stop   infusion,   notify    physician,   and   give   D   50 W   25   mL   IV    push   ●   Restart   infusion   at   half    the    previous   rate   when   glucose   is   greater than   180   mg/dL   on   1   measurement   1   hour    70-90   mg/dL   ●   Stop   infusion   ●   Restart   infusion   at   half    the    previous   rate   when   glucose   is   greater than   180   mg/dL   on   1   measurement   1   hour    91-120   mg/dL   Decrease   infusion   rate    by   half    the   current   rate   1   hour    121-140   mg/dL   Decrease   infusion   rate    by   1   unit/hour    1   hour    141-180   mg/dL   ●    No   change   ●   If    no   changes   are   needed   for   3 consecutive   measurements, decrease   monitoring   to   every   2   hours   1   hour    181-200   mg/dL   ●   If    glucose   increasing,   increase   infusion   rate    by   1   unit/hour    ●   If    glucose   decreasing   or    the   same,   continue   current   rate   1   hour    201-250   mg/dL   ●   If    glucose   increasing,   increase   infusion   rate    by   1.5   units/hour    ●   If    glucose   decreasing   or    the   same,   continue   current   rate   1   hour    251-300   mg/dL   ●   If    glucose   increasing,   increase   infusion   rate    by   2   units/hour    ●   If    glucose   decreasing   or    the   same,   continue   current   rate   1   hour    301-350   mg/dL   ●   If    glucose   increasing,   give   regular    insulin   10   units   IV    push and   increase   infusion   rate    by   2   units/hour    ●   If    glucose   decreasing   or    the   same,   continue   current   rate   1   hour    Greater than   350   mg/dL   ●   If    glucose   increasing,   give   regular    insulin   15   units   IV    push and   increase   infusion   rate    by   2   units/hour    ●   If    glucose   decreasing   or    the   same,   continue   current   rate   1   hour    Decrease   greater   than 100   mg/dL   at   one   Decrease   infusion   rate    by   half    the   current   rate   1   hour    APPENDIX   B:   Blood   Glucose   and   Insulin   Drip   Titration   for   Blood   Glucose   Less   Than   or   Equal   to   250   mg/dL   1.   Decrease   insulin   continuous   IV   infusion   rate    by   half    of    current   dose   (if    not   already   done)   2.   Once    blood   glucose   is   less   than   or    equal   to   250   mg/dL,   start   insulin   drip   titration   Page   4   of    6   Hyperglycemic   Emergency   Management   (DKA/HHS)   -   Adult   This    practice   algorithm   has   been    specifically   developed     for     MD    Anderson   using    a   multidisciplinary   approach   and    taking    into   consideration   circumstances    particular    to    MD    Anderson,   including    the    following:    MD    Anderson ’  s    specific    patient     population;    MD    Anderson ’  s    services   and     structure;   and     MD    Anderson ’  s   clinical    information.    Moreover,   this   algorithm   is   not    intended    to   replace   the   independent    medical    or     professional     judgment    ofp   hysicians   or    other    health   care    providers.   APPENDIX A:   Glucose   Insulin   Drip   Management for   Blood   Glucose   Greater   Than   250   mg/dL   Glucose   Level   Intervention   Recheck    Glucose   ●   Decreased    by   less   than   50   mg/dL   or   increased    by any   amount   ●   And   remains   greater    than   250   mg/dL   Double   infusion   rate   1   hour     post   change   Decreased    by   50-100   mg/dL and   remains   greater    than   250   mg/dL   Continue   current   rate   1   hour     post   change   Decreased   greater    than   100   mg/dL   and   remains greater    than   250   mg/dL   Decrease   rate    by   half    1   hour     post   change     Once    blood   glucose   is   less   than   or    equal   to   250   mg/dL:   ●   Decrease   insulin   infusion   rate    by   half    and   ●    Notify   ICU/EC   team   to   change   IV   fluids   to   D   5   0.45%   sodium   chloride and   activate   Appendix   B   Insulin   Drip   Management   Orders   Department   of    Clinical   Effectiveness   V2   Approved    by   the   Executive   Committee   of    the   Medical   Staff    on   12/12/2017  
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