Management of Diabetic Ketoacidosis

Objectives
Management of DKA:
1) Fluids
2) Insulin
3) Electrolyte replacement

Management: Fluids
Glucose osmotic diuresis causes dehydration
Give between 4-6 liters, then reassess (caution in
CHF)
Fluids help decrease the blood glucose levels

Always start with NS

Bolus and then steady rate (i.e. 150cc/hr)

Switch to 0.45% NS when corrected sodium

within normal limits
Add 1.6 mEq to sodium for every 100 glucose is above 100.

Switch to D5 1/2NS when glucose between 200-250

Management: Insulin
IV insulin dripbolus approx 10 units (or .1unit/kg), then
initiate drip at 0.1 unit/kg/hr
Avoid bolus if K<3.3
Replete K before starting drip
Insulin drive s potassium into the cells so if potassium starts off very
low can make hypokalemia life threatening.

Switch to SC insulin when anion gap closed signifying

acidosis cleared.
SC insulin must overlap with insulin drip over 2
hours.
Use patients outpatient insulin dose OR
In insulin-naive patients, a multi-dose insulin regimen should be
started at a dose of 0.5 to 0.8 U/kg per day, including bolus and basal
insulin until an optimal dose is established OR
Calculate 24 hour insulin requirements and use 50% as long acting
Once the AG closes, can feed the patient. Remember to add sliding scale
insulin (preferably lispro) with meals in addition to basal SC insulin dose.

Management: Electrolyte Replacement

Bicarbonate:
If pH<6.9 (controversial) or K>6 with ECG changes

Potassium:
If potassium <5.3
20-60 meq/L of NS given when K <5.3 with severe acidosis

Phosphate:
If phos <1, especially if muscle weakness
When needed 20-30mEQ/L of potassium phosphate can be added to
replacement fluids

Overall Management
Be sure to check q1hour glucose checks and q2-4hrs
bmp to monitor anion gap and acidosis

CASE
A 24 year old female with past medical history of diabetes
mellitus I is brought to the ER by her mother with
complaints of fatigue and increased thirst and urination. Of
note patient states she ran out of her insulin last week.
She also has had a runny nose and cough for the past
week. She noticed her glucose levels have been running
very high and got concerned.
On Exam:
BP 101/72; heart rate: 113; respirations: 32; Temperature: 36.8 C; pulse
oximetry: 100% on room air.
General: No apparent distress, AA and Ox3.
HEENT: dry mucous membranes
CV: tachycardic, normal s1, s2. No murmurs
Lung: CTAB
Abdomen: +bs, non distended, slight tenderness to deep palpation, no
HSM no rebound or guarding
Ext: no cyanosis, clubbing or edema

 What labs do you want to order?

CMP
Complete blood count with differential
Urinalysis and urine ketones by dipstick
Arterial blood gas

Lab Results:
EKG sinus tachycardia
BMP:
Na: 124
K: 5.0
Cl: 95
CO2: 11
BUN: 38
Cr: 1.8
Glucose 450
AST:40
ALT:41
Alk phos:67
Arterial blood gas:
pH 6.9, CO2 9, bicarb 10
WBC 13K, Hb14.4 mg/dL, and Hct 43.5%.
75% neutrophils
UA +glucose, +protein, -leuko esterase, -nitrite NO KETONES

 Serum ketones test ordered is positive for betahydroxybutyrate

 What would you do next?

 Bolus 10 units insulin, then start insulin drip

Bolus with normal saline, then start maintence
Blood cultures, chest x-ray to rule out other sources of
infection
Empiric antibiotics?
Bicarbonate?

 Q2 hour BMP checks:

After 6 hours:

Na: 139
K: 2.5
Cl: 108
Co2: 13
BUN 28
Creatinine 1.4
Glucose 280

ABG:
pH 7.2, CO2 of 18 and a bicarb of 12

 What do you do next?

 Switch to 0.45% saline with potassium supplements

Repeat BMP in 4 hours:

Na: 142
K: 4.5
Cl: 110
Co2: 15
BUN 38
Creatinine 1.2
Glucose 230

 Start on d5 NS with K supplements

Continue insulin drip

 Repeat BMP in 4 hours:

Na: 140
K: 4.0
Cl: 110
Co2: 23
BUN 28
Creatinine 1.1
Glucose 105

 Continue insulin drip

Start patient on home regimen of SQ insulin or calculate
last 24 hour total dose and give 50% in form of long
acting (i.e lantus)

 2 hours later

 Stop drip (after 2 hours of starting the SQ insulin)!!

Feed patient!
If anion gap remains closed after meal can transfer to
floor.

Key Points
Close monitoring is crucial with glucose checks and bmps
as electrolytes respond quickly and management
depends on these numbers
Early fluid resuscitation is important
Insulin gtt must overlap SQ insulin for 2 hours prior to
discontinuation of the drip