Name: ABC Date of Dx: 16.6.21 RBS: 29 pH / HCO3-: 7.

0/13 BW: 60kg

SD: SDXXXXXXXX Time: 12.00am Blood Ketone: 4 BE: -4.8 Na / Serum Osm: 140/ 288

Date / Time 12.00am 1.00am 2.00am 3.00am 4.00am REMARKS

BG / RBS (if HI) DXT 27 26 23 20 19

RBS (29)
Blood Ketone 4 - - - 3
pH / HCO3- 7.0/13 7.12/13.5 - - 7.2/13.8
Insulin Rate (U/Hr) 6U 6U 6U 6U 6U

K+ (mmol/L) 4.3 4.3 4.2 4.2 3.5

K+ in IVD (g) - - - - 1g/kcl in NS Only put when you add in KCI in drip, aim 4-5. If no KCL added put -
drip
Cl- / Anion Gap 101/30.3 100/ 101/ 100/ 99/ Calculate the anion gap

Vol fluid resus (ml) 1L/1H 1L/2H 1L/2H 1L/4H 1L/4H This is the DKA fluid regimen
(NS) (NS) (NS) (NS) (NS)
Maintenance drip 6pt/NS 6pt/NS 6pt/NS 6pt/NS 6pt/NS If patient was given 6 pt NS , adjusted accordingly
regimen (pint)
NS Volume (ml/Hr) 1000 500 500 250 250 This case is 1L in 1 H for DKA regimen.
+125 +125 +125 +125 +125 But maintenance is also NS, so 3000/24
total : total : total : total : total :
1125 625 625 375 375
D5% / D10% Volume - - - - - Only if D5 and D 10 added
(ml/Hr)
Volume Output Hrly (ml) 500 700 900 950 110 Urine output , measure hourly (in case you forgot the total CBD, you can
500 200 200 50 0 put the total output on the right corner and then minus the previous
(700-500) (900-700) 150 total)- only write out the highlighted one, no need show calculation
Cumulative I/O (ml) 425 425 325 225 Important as we need to know the hydration status.
(+625) (+1050) (+1475) (+1800) (+2025) Right upper corner is i/o hourly ( so just add on previous accumulative
with current i/o)
Next Review 1am 2am 3am 4am 5am
1/ DIAGNOSIS (TAKE RBS, VBG, Serum ketone, Serum Osmolality, RP +/- septic workout if indicated)
ph<7.3, DXT>11.0, ketone>3

2/ Make sure there is CBD and 3 line (but In ED normally 2 branulla line: pls make sure there are function all the time: for insulin, for DKA regimen, for maintenance)

3/ Fixed scale formula: 0.1U/KG/H

- this patient 60kg thus start 6U

4/ K+ reading take from VBG run stat in ED or if got formal report then traced from formal report

5/ repeat VBG, RP post 1L/bolus , then update to check whether need another bolus. If not normally, RP, VBG, Ketone 4 hourly or as sp requested (in DKA), if in HHS add on
serum osmolality 4 hourly

6/ Anion Gap calculation ((Na + K) - (Cl +hco3)) : find from the VBG paper run stat in Ed or from RP formal report and VBG formal report which ever available
- Na: 140 K 4.3 Cl 101 hco3 13 therefore: 30.3

7/ Aim:
drop in sugar 3-5mmol hourly; not more than 5, afraid of cerebral oedema. If you noted more than 5 mmol, change the maintenance fluid used / half then insulin dose if
acidosis resolving
drop in ketone 0.5mmol/L/hour
increase in pH>3mmol/L/hour

8/ If Dxt<15, change to D5% (change the fluid maintenance according to dxt)

9/ Insulin purpose is for persistent acidosis/ketosis, if acidosis not yet resolved, don’t half the dosage yet. Play around with the fluid first.

** if in ED, ketone machine at the VBG room in resus opp storeroom of resus** get the ketone strip from MA room. **

Thanks. Feel free to comment if anything wrong.