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Table 23-2

Management of Diabetic Ketoacidosis

  1. Confirm diagnosis (plasma glucose, positive serum ketones, metabolic acidosis).
  2. Admit to hospital; intensive-care setting may be necessary for frequent monitoring or if pH <7.00 or unconscious.
  3. Assess: Serum electrolytes (K+, Na+, Mg2+, Cl-, bicarbonate, phosphate) Acid-base status—pH, HCO3-, PCO2, β-hydroxybutyrate renal function (creatinine, urine output)
  4. Replace fluids: 2-3 L of 0.9% saline over first 1-3 h (10-15 mL/kg per hour); subsequently, 0.45% saline at 150-300 mL/h; change to 5% glucose and 0.45% saline at 100-200 mL/h when plasma glucose reaches 14 mmol/L (250 mg/dL).
  5. Administer short-acting insulin: IV (0.1 units/kg) or IM (0.3 units/kg), then 0.1 units/kg per hour by continuous IV infusion; increase two- to threefold if no response by 2-4 h. If initial serum potassium is <3.3 meq/L, do not administer insulin until the potassium is corrected to >3.3 meq/L. If the initial serum potassium is >5.2 meq/L, do not supplement K+ until the potassium is corrected.
  6. Assess pt: What precipitated the episode (noncompliance, infection, trauma, infarction, cocaine)? Initiate appropriate workup for precipitating event (cultures, chest x-ray, ECG).
  7. Measure capillary glucose every 1-2 h; measure electrolytes (especially K+, bicarbonate, phosphate) and anion gap every 4 h for first 24 h.
  8. Monitor blood pressure, pulse, respirations, mental status, fluid intake and output every 1-4 h.
  9. Replace K+: 10 meq/h when plasma K+<5.0-5.2 meq/L, ECG normal, urine flow and normal creatinine documented; administer 40-80 meq/h when plasma K+<3.5 meq/L or if bicarbonate is given. If initial serum potassium is >5.2 mmol/L (5.2 meq/L), do not supplement K+ until the potassium is corrected.
  10. Continue above until pt is stable, glucose goal is 150-250 mg/dL, and acidosis is resolved. Insulin infusion may be decreased to 0.05-0.1 units/kg per hour.
  11. Administer intermediate or long-acting insulin as soon as pt is eating. Allow for overlap in insulin infusion and SC insulin injection.

Source: Adapted from M Sperling, in Therapy for Diabetes Mellitus and Related Disorders, American Diabetes Association, Alexandria, VA, 1998; and AE Kitabchi et al: Diabetes Care 29:2739, 2006.