doubt...misshyd , samy anyone ? - funny3

[ArchivalUser]

In ccs primum in the case of DKA i wanted to give first insulin shot bolus and then continuous , but when i order conti it say you already order and i can not place the order for continuous order ..is this the limitation of software ? also i could not do the same for normal saline ( bolus form ) in severly hypotensive patient ?

[ArchivalUser]

order one time advance the clock and then order continour after that.

there is no bolus in the software, either one time or continous.

[ArchivalUser]

Well you can order one time bolus then advance the clock then order continuous. Now if you order in the same time frame software will not allow you to order same drug again. make sure you previous order is executed then only you can order same drug again in continuous. Execution will only be done if you advance the clock.

This is true for aspirin/clopidogrel

Hope this helps
BUmba

[ArchivalUser]

you do not want to order continuous until you get the bmp result back with increased anion gap which confirms DKA.
In the beginning of the case, we order both glucometer glucose and bmp in initial orders. The glucometer reading comes in 2 minutes and at that time we do not know if there is DKA...we will only know there is hyperglycemia in that case, so give insulin one time bolus now. Now, you must advance clock by 30 minutes to reach BMP... BMP comes in 30 minutes and if there is increased anion gap, the DKA will be established . Only at that time, you will enter insulin continuous.

THAT MEANS YOU SHOULD NOT ENTER INSULIN CONTINUOUS DRIP UNTIL YOU HAVE CONFIRMATION OF DKA . THIS CONFIRMATION YOU WILL NOT GET UNTIL BMP IS BACK WHICH WILL TAKE 30 MINUTES.
BOLUS INSULIN ON THE OTHER HAND WILL GIVEN SOON AFTER YOU SEE VERY HIGH SUGAR ON GLUCOMETER READING THAT COMES BACK AFTER 2 MINUTES OF START OF CASE

( this is very best explained in Dr.Red ccs workshop...check the DKA case video he explained solves all questions here http://usmlestep3blog.com/usmle-step-3-ccs-workshop/

[ArchivalUser]

with due respect to Dr.red


When we see very high in accucheck we don't know whether its DKA/HONK..we have to give IV regular insulin to the patient either as IV bolus or infusion.

In my opinion you can start either IV bolus/infusion ..your target is to start 0.3-0.8 (commonly 0.5 U) U /kg bw /hour. Whether the patient has acidosis or not that wont decide the amount of insulin. Whether you give bolus or infusion the amount/hr is the same.

The acidosis counts mainly when to stop the IV insulin.

Again regarding stop of IV insulin & overlap of subcut insulin ....traditionally it says you start overlap when only complete correction of acidosis is done. But Harrison says you can start the overlap when near correction is done i.e if a patient had anion gap of 29 to start with decrease to 15 you cna start overlap as most of the correction os already done. Although there are two opinions on this coz MKSAP 15 recommends complete correction. So bit debatable here.

Hope I didnt confuse you....if you have more questions on DKA please print here

Bumba

[ArchivalUser]

Bumba, an important correction... it is important to know this point very well i think...... DKA happens at lower glucose levels when compared to HONK. You can have DKA at a blood glucose of 400 or 300 ...if you start insulin infusion there at 300 and patient has no DKA , patient gets hypoglycemic soon enough and dies!
In order to prevent hypoglycemia, if sugar is less than 300 you must start insulin infusion only with a back up d5 drip in DKA cases.

In HONK sugars usually very high, mostly > 800 to 1000mg%...at that level you can start infusion right away but in lesser sugars wait until you get the BMP back

So HONK and DKA occur at a different blood sugar levels...so protocol needs you to see sma7 to check anion gap before you jump in and start a insulin drip in an uncontrolled DM with sugar of 400 or 500.

[ArchivalUser]

Ya DKA occurs a lower sugar level .. that not my point.....my point amount of insulin per hour ..either as bolus or infusion...if you give same amount in infusion will patient go into hypoglycemia....my point is y patient will go into hypoglycemia if same amount given infusion rather than bolus...so y we have wait for bmp to start infusion.

coz the amount we r giving in bolus y cant cant we give same amount in infusion. y to avoid infusion ....

do u mean bolus cant cause hypoglycemia if given ...in infusion u can control rate by checking accucheck every 15 mins initially if u have risk of hypoglycemia....

plz explain if we start 0.5 u /hr in infusion rather than bolus y it can cause more hypoglycemia.

I can't find this explanation...does insulin will reduce blood glucose faster in infusion than in bolus???

Bumba

[ArchivalUser]

Bumba...if you go to an ER in any american hospital, they never start an infusion drip for insulin when sugars are on lower side 300 to 600 if there is no evidence of DKA....that is the first point.

The point is that insulin given in different routes : IV , SUB Q ....sub q takes longer time because of the absorption kinetics. IV acts definitely faster and has potential to bring down the sugars faster ...that is the second point

ER in any hospital can only accommodate certain people. When it is not necessary people do not start invasive measures like starting IV insulin when things can be controlled by a Sub Q shot...takes up more physician and ER time, waste of resources, more invasive to patient and IV has its risks too ...this the third point ( check dr.red CCS demos on these)


If a patient comes to ER and you do not know what is going on and if sugars are in 300 to 600 range, give a sub q insulin and HOLD ON until BMP comes back. If BMP comes back and if there is no evidence of anion gap acidosis, diagnosis is UNCONTROLLED DM not DKA. Such uncontrolled DM must be discharged home from ER on po medications and sub q insulin.
If BMP comes back with increased gap acidosis, the diagnosis is DKA and next step is starting IV insulin ( please watch Dr.Red CCS Workshpop carefully, all these are clear in it). Now, if you started IV insulin drip on first screen 2 minutes after patient came to ER when accucheck first showed 300 to 400 sugar and if BMP did not suggest DKA ...you DID an invasive, harmful measure on a patient who did not need an IV drip ...could be a failure on the case for invading a patient when you donot need to!! ...that is the fourth and most important point.

That is why stick to ER protocols , if you can not find them use Dr.Red protocols for CCS they are the closest to American ER protocols.

[ArchivalUser]

so u mean bolus is only S/C..that means if any patient comes >600 blood sugar or accucheck shows very high we dont give Insulin IV bolus ?????

well in certain cases we do use IV bolus insulin in emergency depends on presentation of patient followed by IV infusion.

So if you find accucheck very high ...then no acidosis in bmp & ABG you wont give IV infusion you will give s/c????

Please read Harrison's Internal principles Vol II page 2284

harrison says start Iv bolus 0.1/U per kg followed by infusion 0.5 u/kg per hour.......confirm acidosis & continue treatment until anion gap is corrected.

This is not my opinion.

Bumba

[ArchivalUser]

Bumba, we did not discuss > 600 sugars here...we discussed DKA case and DKA case often has lower side sugars similar to those seen with uncontrolled DM , not similar to those in HONK

And what Harrison said is the treatment for DKA not for simple uncontrolled DM... you are missing the whole point of navigating the software here... the point is we do not know that there is a DKA or just an uncontrolled DM when sugars are on lower side until BMP comes back.

I just clarified these how things are done in the emergency room , check with any emergency physician that is close to you if they ever start insulin infusion until BMP comes back when sugars are in lower range say 300 to 500