Patients have either new onset Diabetes or well established type 1 Diabetes patients who ran out of insulin or had some other precipitating factor usually an infection like UTI, cellulitis etc.
ER:
Routine Labs, CXR, EKG. Leukocytosis, Pseudohyponatremia and Hyperkalemia can be seen. If K is less than 3.3, replace Potassium first before starting insulin drip.
UA to rule out UTI as precipitating factor
IV Fluids-NS @100-150ml/hr. ER may give one or two liters of IV fluid boluses before handing over the patient to the hospitalist for admission.
NPO if they are vomiting.
IV Insulin Boluses followed by Insulin drip.
Many have slight hyperkalemia but don’t treat mild hyperkalemia as it comes down along with blood sugar when Insulin drip is started.
Usually, patient with DKA goes to ICU unless it is very mild
Check ABG if suspecting severe metabolic acidosis and might require IV Bicarbonate is patient is severely acidotic.
Check for Ketones in urine with Dipstick, Check for Serum Ketones.
Hospitalist:
IV antibiotics if UTI is present
Check HBA1C
BMP q 2-4hrs
Finger stick Glucose testing every 1hr
Initially give NS or 1/2 NS along with insulin drip, they may need several liters of IV fluids.
Once Blood sugar is less than 250, Decrease Insulin drip rate but Continue IV insulin drip and change fluids to D5NS or D51/2NS.
Once HCO3 and Anion gap improve, start Diet and Long Acting Insulin. Continue Insulin drip for 1-2hrs after giving long acting SQ Insulin –>At this point, Patient is transferred out of ICU if patient had been in ICU.
Diabetic diet, Adult Diabetic Educator consult.
Endocrine consult especially if patient is diagnosed newly with Diabetes. They will start diabetic medications and / or insulin if HBA1C is very high and will follow the patient closely as out-patient. Insulin is started as Bolus insulin once or twice a day with long acting insulin like Levemir or Lantus and Prandial insulin with each meal with short acting insulin like Aspart.
Continue to monitor blood sugars QAC [with each meal]and HS [before sleep]. Adjust insulin dose based on blood sugar levels.
NON KETOTIC HYPEROSMOLAR SYNDROME (NKHS)
ER:
Routine labs
IV Fluids boluses
oxygen
Insulin Bolus-small dose
Hospitalist:
Frequent BMP and Finger stick glucose initially
UA
Endocrine Consult
HBA1C
Amylase, Lipase
Serum Ketones
Diabetic diet
Diabetic Education
Calculate Total Body Water Deficit and replace
Sodium Correction to be around 8-12 per 24hrs
May need Insulin drip
Check Mg, P, ABG if acidosis on BMP
Insulin Sliding Scales: Very Low, Low, Moderate, High dose
Reasonable Approach would be:
150-200——2 Units of Insulin Novolog
201-250——4 Units
251-300——6 Units
301-350——8 Units
>350 RN calls MD.
The choice of scale depends on the patient and also on institution.
