Smith, Adam A. dob 07/01/1959        45 & 6/12 y/o           01-01-05

000-0000                 000-0000 

Hospital MR #          Clinic MR #            

John Alexander, MD               


Mercy Folsom Hospital, Med Surg Ward

983-7460, Fax 983-7548,



Starting to type ketoacidosis offers the following hospital ICU orders upon reaching “keto”.  Other examples are at the bottom of this page.


Suggested hospital orders for DKA & non-ketonic hyperosmolar syndrome (prepared 11-23-2003)


1             Initially use NS at 1 L/hr × 1-5 L to restore volume; thereafter, half NS or NS at 250-500 mL/hr; Base on cardiovascular parameters (e.g., heart rate, blood pressure) and urine output

2             Acidosis: Use bicarbonate if pH < 7.1, shock, coma, or severe hyperkalemia is present:

a                if acidosis, please do:
  1 ampule of NaHCO3 (44 mEq)
  Check ABG after 1 hr: if pH > 7.1, stop

b                obtain the following and if abnormal, repeat in 4 hrs

i                   ABG's

ii                 Bicarbonate

iii               Anion gap

3             Regular insulin:

a                  Bolus: 0.1 U/kg

b                  IV drip: start at 0.1 U/kg (if HHNS rather than DKA, 1-2 U/hr)

c                obtain RBS q hourly (Expected rate of fall, 100 mg/dL/hr; Initial goal: 200-300 mg/dL (to avoid hypoglycemia)

d                If Blood glucose still elevated or falling slowly: Increase insulin IV by 50-100% per hr (peak effect of regular insulin is at about 3 hours.)

4             If Blood glucose < 250 mg/nutrition outline

a                Start IV dextrose infusion

b                Start SC regular insulin

c                Discontinue IV insulin 2 hr after giving SC insulin

d                Begin clear liquid diet and progress as tolerated

5             obtain Electrolyte panel (Hyperkalemia may be initially present but Hypokalemia during insulin therapy should be anticipated)

a                obtain Serum K+, Ca, Mg, phosphate

b                obtain serum K+ q 2 hrs while awake and q 4 hrs otherwise for first 24 hrs

c                12 lead ECG

d                Record Urine output Q 2 hrs (should be at least >30 mL/hr)

6             consider prophylactic low dose heparin q 12 hr, cpk


look for other conditions

osmolality formula: The serum osmolality may be calculated by adding Na+ and K+, multiplying by 2, adding glucose (mg/dL) divided by 18, and adding BUN divided by 2.8 (ie, 2 [Na+ + K+] + [mg/dL of glucose/18] + [BUN/2.8]).          

fluids before insulin to avoid further intravascular dehydration

target blood glucose level at 250-300 mg/dL


John Alexander, MD           01-01-05 Saturday 12:38 AM 



Example #2:

jl” becomes joint line

“knee” offers ACL, PCL, MCL, LCL, Apley's grind all wnl; no effusion, heat nor LOM

“hepat” offers labs for hepatitis, Hep A IgM, HepBsAg, hepatitis C Ab & anti-hepatitis B core IgG, iron, ferritin, ceruloplasmin.

“diarrhea” offers stool C&S, giardia Ag, stool for wbc exam.

“card” offers CR: cta & percussion; RSR w/o murmur, gallop, click or altered 2nd sound

etc., etc.