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.