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DKA/HHNK

Critical   (487 Views | 6 Replies)

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Hello all, 

I work in a medical ICU in a primarily cardiac hospital. It is rare we see patients in HHNK but it does happen. Most recently, a patient was admitted at 4 am and not initiated on fluids until day shift arrived at 7 am. Of course there is a knowledge gap that will be addressed, but I am just wondering if other hospitals have a DKA or HHNK protocol or policy place, and if it is something we should be looking to initiate in our ICU so this does not happen again. 

 

Thanks 🙂

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Dodongo has 7 years experience as a APRN, NP.

2 Followers; 793 Posts; 11,479 Profile Views

Holy moly.  Who was the admitting provider??  That is an enormous gap in their base knowledge.  Aggressive correction of dehydration is critical, then insulin should be given.  And after urine output has been established, potassium (and phos) replacement should begin.  Pretty standard.  We have an insulin drip protocol, but the treatment of DKA/HHNK falls on the providers, not the nurses.  

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kataraang has 4 years experience as a BSN and specializes in critical care ICU.

129 Posts; 2,454 Profile Views

Wow. That patient should have been started on fluids the second they rolled through that door. We have a DKA/HHS protocol in place. It's really useful.

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myoglobin has 12 years experience as a ASN, BSN, MSN and specializes in ICU, trauma, neuro.

657 Posts; 4,551 Profile Views

Here are a few of the issues that might affect having a protocol for DKA/HHS.

a.  In some hospitals these are (ICU only) patients while at others (such as where I worked in Indianapolis, Methodist. They were PCU).  Implementing hourly accuchecks, managing the insulin drip, IV fluids, and frequent BMP along with electrolyte replacement can be very challenging in a PCU situation where you may have three or four other patients.  

b.  In my opinion managing the drip requires nuance and nurses should be given maximum flexibility working in concert with expert providers.  For example when someone drops from 400 to 250 in an hour our "new" protocol would have automatically cut the drip rate (of insulin) by 50%. However, "our old" protocol would have actually called for an increase in the insulin rate because the drop wasn't at least 50% of the total blood glucose.  Thus, following the "old" protocol might lead to a situation where the next hourly glucose resulted in a result of 60 less than optimal.  Also some practitioners will allow patients to eat (usually very ill advised while on an insulin drip in my opinion both due to dangers of nausea/vomiting and increased difficulty in managing fluids/electrolytes and glucose) while others will specify different anion gap levels and blood glucose levels where they want to add D-5/0.5 NS.    Also, I frequently encounter these conditions (more HHS than DKA) in combination with chronic renal failure, and advanced heart failure which further complicates management since aggressive hydration could lead to intubation, worsened heart failure and other less than optimal outcomes (and should obviously only be managed in the ICU).  Also, there are sometimes other challenging situations. For example, I recently had a client who presented with a blood glucose of 550, anion gap of 18, but his/her initial potassium was only 2.8!  Obviously starting an insulin drip before correcting the electrolytes (at least partially) could lead to less than optimal outcomes. 

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Dodongo has 7 years experience as a APRN, NP.

2 Followers; 793 Posts; 11,479 Profile Views

17 hours ago, myoglobin said:

Here are a few of the issues that might affect having a protocol for DKA/HHS.

a.  In some hospitals these are (ICU only) patients while at others (such as where I worked in Indianapolis, Methodist. They were PCU).  Implementing hourly accuchecks, managing the insulin drip, IV fluids, and frequent BMP along with electrolyte replacement can be very challenging in a PCU situation where you may have three or four other patients.  

b.  In my opinion managing the drip requires nuance and nurses should be given maximum flexibility working in concert with expert providers.  For example when someone drops from 400 to 250 in an hour our "new" protocol would have automatically cut the drip rate (of insulin) by 50%. However, "our old" protocol would have actually called for an increase in the insulin rate because the drop wasn't at least 50% of the total blood glucose.  Thus, following the "old" protocol might lead to a situation where the next hourly glucose resulted in a result of 60 less than optimal.  Also some practitioners will allow patients to eat (usually very ill advised while on an insulin drip in my opinion both due to dangers of nausea/vomiting and increased difficulty in managing fluids/electrolytes and glucose) while others will specify different anion gap levels and blood glucose levels where they want to add D-5/0.5 NS.    Also, I frequently encounter these conditions (more HHS than DKA) in combination with chronic renal failure, and advanced heart failure which further complicates management since aggressive hydration could lead to intubation, worsened heart failure and other less than optimal outcomes (and should obviously only be managed in the ICU).  Also, there are sometimes other challenging situations. For example, I recently had a client who presented with a blood glucose of 550, anion gap of 18, but his/her initial potassium was only 2.8!  Obviously starting an insulin drip before correcting the electrolytes (at least partially) could lead to less than optimal outcomes. 

This is why we do not have a protocol for this.  The treatment algorithm is pretty straight forward, but there are always nuances and exceptions that need to be managed by a medical provider.  

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23 Posts; 2,455 Profile Views

This is why I was wondering if a protocol worked in other institutions, because of those kinds of nuances. I'll just be doing some reeducating.  Thanks 🙂

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839 Posts; 14,197 Profile Views

We have a protocol in place and it works great for us. There are of course, times when there is deviation from the protocol but ours is pretty thorough in addressing most situations (like potassium variances and quick drops in glucose levels). 

We have one physician who will always, ALWAYS put a diet order in 🙄 We (the RNs) will only give ice chips no matter what the diet order says. 

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