Protocols – Page 2 – GSAA

Indications for Inpatient Echocardiograms

CVA/TIA

Per KP Stroke Clinical Practice Reference, “Echocardiography, both Transthoracic Echocardiogram (TTE) and Transesophageal Echocardiogram (TEE), is generally NOT recommended in the routine evaluation of TIA or stroke as the yield for finding a lesion which would alter therapy is very low

TTE (and TEE if TTE is unrevealing) should only be done for:

Patients with cryptogenic stroke and history of previous cardiac problems / abnormal EKG.
Young patients (age < 60) without other obvious etiology.”

Atrial Fibrillation/flutter

An echo is indicated for a new diagnosis of atrial fibrillation. This can be done as an outpatient unless there is a significant murmur or if the patient has new congestive heart failure.

If a prior echo exists, then repeating an echo is not necessary unless there is a new murmur or CHF.

Syncope

An inpatient echo should be done if there is a new murmur on exam. Otherwise, this can be done as an outpatient. If a prior echo exists without significant valvular disease (in the past 5 years), then a repeat echo is not needed.

CHF

Inpatient echocardiogram is indicated for patient with a new diagnosis of CHF. If the patient has had a prior echocardiogram documenting HFrEF, inpatient echocardiogram is not needed, and the patient should follow-up with his/her cardiologist. Patients with known HFpEF do not need repeated echocardiograms.

Endocarditis

Echocardiogram is indicated for bacteremia with a microbe known to be a common cause of endocarditis. Echocardiogram is not indicated for transient bacteremia with a pathogen not typically associated with endocarditis.

Insulin:

At first Lantus 0.3 units/kg x 1 (or start home dose insulin) and lispro 0.3 units /kg x 1

Then: Lispro 0.2 units/kg q4h.

Glucose monitored every 2 hours.

Protocol ends when sugars are less than 250. AG monitored to make sure it is decreasing. May still be elevated at the end of the protocol.

Fluids:

LR: 2 L then 500 mL/hr to complete total of 5 L.

D5-1/2NS with or without K: 150 mL/hr

Both fluids will run together. LR will stop when hits total of 5 L or when glucose is <250

D5 continues until 6 hours after last high dose lispro from protocol was given.

If the patient has CHF or renal failure, you will need to adjust these fluids. It is the same type of adjustment you would consider if they were on an insulin gtt.

Electrolyte Replacements:

We can use the K and Mg replacement protocols that the ICU uses. Also consider changing the D5 to including KCl.

End of protocol:

You will get a call from nursing staff that the patient’s glucose is less than 250. At this point, you will need to stop the insulin. Initiate sliding scale qAcHs. Discontinue everything in the protocol except the D5 gtt. If given lantus, start the patient’s long acting insulin 24 hours after lantus was given.

Of note, the AG may be still be elevated, so just because they are off the protocol doesn’t mean they can go home. You will need to follow this until the AG is less than 12.

Who is eligible:

Those with mild to moderate DKA which is defined as pH >=7.0 via ABG or VBG and bicarb >= 10. Someone who is alert or drowsy (not comatose).

Exclusion criteria:

Severe DKA (coma, pH < 7, bicarb < 10)

Anyone who needs ICU for any other reason.

Pregnancy

Patient weighing more than 133 kg (orderset has max 40 units per dose)

Can the patient go to CDA?

No, while the patients typically remain on protocol for 8 hours, it typically takes them just over 24 hours before they AG returns back to normal with patients typically staying another day before discharge. There is no significant time difference between SQ and IV insulin if you are wondering.

Category: Protocols

TTE Indications

DKA Subcutaneous Protocol