Page 223 - Critical Care Notes

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CAUTION: Hypoglycemia among critically ill patients increases the risk of
death. There should be a well-devised plan for transitioning the patient from an
IV insulin infusion to subcutaneous insulin.
■ IV insulin infusion protocols and algorithms differ by hospitals. Examples
include:
■ Atlanta Medical Center protocol:
• http://www.hospitalmedicine.org/ResourceRoomRedesign/pdf/Atlanta.pdf
■ Yale University protocol:
• http://www.hospitalmedicine.org/AM/Template.cfm?Section=Home&
Template=/CM/ContentDisplay.cfm&ContentID=11492
■ University of Washington algorithm:
• http://www.uthsc.edu/endocrinology/documents/Protocols/UWMC_
Insulin_Infusion_Protocol.pdf
■ Computer-based systems: Glucommander, GlucoStabilizer, proportional
integral derivative algorithm
Institution-specific care:

Diabetic Ketoacidosis (DKA)
DKA is a life-threatening metabolic complication caused by an absence or inad-
equate amount of insulin. Affecting those mostly with type 1 diabetes but not
uncommon in type 2 diabetes, it is marked by three concurrent abnormalities:
severe hyperglycemia (300–1,000 dL), dehydration, and electrolyte loss
(ketonemia, ketonuria, and metabolic acidosis [bicarbonate level <15 mEq/L
and pH <7.30]).
Pathophysiology

DKA can be initiated by trauma or conditions such as new-onset diabetes, heart
failure, pancreatitis, infection, illness, surgery, or stress. The most common
causes are infections including urinary tract infections and pneumonia. The
body under stress → ↓ in the amount of insulin → ↓ of glucose entering cells and
↑ glucose production by the liver → hyperglycemia → liver attempting to remove
+
+
excess glucose by excreting glucose with water, Na , and K → polyuria →
dehydration.
ENDO