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Table 25-2

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 (10-20 mL/kg per hour); subsequently, 0.45% saline at 250-500 mL/h; change to 5% glucose and 0.45% saline at 150-250 mL/h when plasma glucose reaches 250 mg/dL (13.9 mmol/L).
  5. Administer short-acting regular insulin: IV (0.1 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 the initial serum potassium is <3.3 mmol/L (3.3 meq/L), do not administer insulin until the potassium is corrected.
  6. Assess pt: What precipitated the episode (noncompliance, infection, trauma, pregnancy, infarction, cocaine)? Initiate appropriate workup for precipitating event (cultures, CXR, 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 (or 20-30 meq/L of infusion fluid), 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. See text about bicarbonate or phosphate supplementation.
  11. Continue above until pt is stable, glucose goal is 8.3-11.1 mmol/L (150-200 mg/dL), and acidosis is resolved. Insulin infusion may be decreased to 0.02-0.1 units/kg per hour.
  12. Administer long-acting insulin as soon as pt is eating. Allow for a 2-4 h overlap in insulin infusion and SC long-acting insulin injection.

Source: Adapted from Sperling M: Therapy for Diabetes Mellitus and Related Disorders. American Diabetes Association, Alexandria, VA, 1998; and Nyenwe EA, Kitabchi AE: Metabolism 65:507, 2016.