PROTOCOL FOR MANAGEMENT OF ADULT PATIENTS WITH DKA^*

Complete initial evaluation. Check capillary glucose and serum/urine ketones to confirm hyperglycemia and ketonemia/ketonuria. Obtain blood for metabolic profile. Check blood glucose by finger stick every hr. Until it is 200 mg/dl. Get an ECG. Start IV fluids: 1.0 L of 0.9% NaCl per hour.^†

IV route

Administer 0.9% NaCl (1.0 L/hr)

Hemodynamic monitoring/pressors

Determine hydration status

Severe Hypovolemia

Mild dehydration

Cardiogenic shock

End

0.9% NaCl (250-500 ml/hr) depending on hydration state

0.45% NaCl (250-500 ml/hr) depending on hydration state

When serum glucose reaches 200 mg/dl change to 5% dextrose with 0.45% NaCl at 150-250 ml/hr

Check electrolytes, BUN, venous pH, creatinine and glucose every 2 - 4 hrs until stable. After resolution of DKA and when patient is able to eat, initiate SC multidose insulin regimen. To transfer from IV to SC, continue IV insulin infusion for 1 - 2 hr after SC insulin begun to ensure adequate plasma insulin levels. In insulin naïve patients, start at 0.5 U/kg to 0.8 U/kg body weight per dy and adjust insulin as needed. Look for precipitating cause(s).

100 mmol in 400 ml H₂O + 20 mEq KCl infuse for 2 hours

No HCO₃^-

Repeat every 2 hours until pH 7.
Monitor serum K⁺ every 2 hrs.

0.14 U/kg Bwt/hr as IV continuous insulin infusion

If serum glucose does not fall by at least 10% in first hour, give 0.14 U/kg as IV bolus, then continue previous Rx

When serum glucose reaches 200 mg/dl, reduce regular insulin infusion to 0.02 - 0.05 U/kg/hr IV, or give rapid-acting insulin at 0.1 U/kg SC every 2 hrs. Keep serum glucose between 150 and 200 mg/dl until resolution of DKA

Hold insulin and give 20 - 30 mEq/hr
Until K⁺ >3.3 mEq/L

Give 20 - 30 mEq K⁺ in each liter of IV fluid to keep serum K⁺ between 4-5 mEq/L

Do not give K⁺, but check serum K⁺ every 2 hrs.

^*DKA diagnostic criteria: Blood glucose >250 mg/dl, arterial pH <7.3, bicarbonate <15, mEq/l, and moderate ketonuria or ketonemia.

^‡Serum Na⁺ should be corrected for hyperglycemia (for each 200 mg/dl glucose, add 1.6 mEq to sodium value for corrected serum value)

BUN, Blood urea nitrogen; DKA, diabetic ketoacidosis; ECG, electrocardiogram; IV, intravenous; Rx, prescription; SC, subcutaneous.

IV fluids

Bicarbonate

Insulin

Potassium

pH 6.9

pH <6.9

Establish adequate renal function (urine output ~50 ml/hr)

K⁺ <3.3 mEq/L

K⁺ = 3.3-5.2 mEq/L

K⁺ >5.2 mEq/L

Evaluate corrected serum Na⁺:^‡

Serum Na⁺ high

Serum Na⁺ normal

Serum Na⁺ low