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Diabetic Ketoacidosis Management in AdultsAka: DKA Management

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  1. See Also
    1. Diabetic Ketoacidosis
    2. Diabetic Ketoacidosis Management in Children
  2. Management: Phase 1 - Fluids in Adults (Emergent)
    1. Stabilize shock and Coma states first!
    2. Correct Volume Deficit
      1. Initial
        1. Give 1 liter NS bolus over first 45 minutes
        2. Repeat fluid bolus until shock corrected
      2. Next
        1. Protocol 1 (standard protocol)
          1. Replace first 50% volume deficit in first 8 hours
            1. Use Normal Saline or Lactated Ringers
          2. Replace remaining 50% deficit over next 16 hours
            1. Use D5 1/2 NS at 150-250 ml per hour
        2. Protocol 2
          1. NS at 10 cc/kg/hr (+/- 5 cc/kg/hr)
            1. Until Serum Glucose <250 mg/dl
          2. Then D5 1/2NS with 20 kcl
            1. Give 150-250 cc/hour
        3. Protocol 3 (new protocol)
          1. Protocol uses 0.675% saline
          2. Administer 2.5 x maintenance rate
            1. Continue for 24 hours or until no acidosis
          3. Then administer 1 to 1.5 x maintenance rate
          4. Efficacy in children (compared with Protocol 1)
            1. Reduces fluid rate
              1. May decrease risk of cerebral edema
            2. Resulted in cost savings >$1000/patient
            3. Faster acidosis resolution
            4. Felner (2001) Pediatrics 108:735
    3. Precautions
      1. Do not drop Serum Osmolality (calc) >3 mOsms/hour
        1. Risk of cerebral edema
      2. Slow replacement if Fluid Overload risk
        1. Congestive Heart Failure
        2. Chronic Renal Insufficiency
        3. Myocardial Infarction
      3. Follow Intake and output closely
  3. Management: Phase 2 - Acidosis, electrolytes in Adults
    1. Potassium Replacement
      1. Precautions
        1. Hypokalemia must be corrected prior to Insulin
        2. Hold Insulin until potassium >3.3 meq/L in adults
      2. Prerequisites
        1. Electrocardiogram without signs of Hyperkalemia
        2. Adequate urine output
      3. Administration: Adults
        1. Serum Potassium <3.3 meq/L
          1. Do not administer Insulin until potassium >3.3
          2. Give KCl 40 meq/hour IV until corrects
            1. Requires hourly recheck of Serum Potassium
            2. This is maximum IV potassium rate!
            3. Requires cardiac monitoring
        2. Serum Potassium 3.3 to 5.0 meq/L
          1. Standard replacement: 20-30 meq per liter
        3. Serum Potassium >5.0 meq/L
          1. Do not administer any potassium
          2. Monitor every 2 hours until <5.0
    2. Phosphate Replacement
      1. Indications
        1. Serum Phosphorus < 0.5-1.0 mg/dl (Severe Depletion)
        2. Controversial - May not be required
        3. Consider if cardiopulmonary adverse affects
      2. Contraindications
        1. Renal Insufficiency
      3. Administration
        1. Determine Potassium Replacement as above
        2. Replace part of potassium with potassium phosphate
          1. Potassium Phosphate: Replace one third potassium
          2. Potassium Chloride: Replace two thirds potassium
    3. Magnesium Replacement
      1. Indications
        1. Symptomatic Hypomagnesemia (Magnesium <1 meq/L)
      2. Administration
        1. MgSO4 50%: 2.5-5.0 ml (20-40 meq) IM
    4. Sodium Bicarbonate Replacement
      1. Indications
        1. ABG pH < 6.9 to 7.0 after initial hour of hydration
        2. Other contributing factors
          1. Shock or Coma
          2. Severe Hyperkalemia
      2. Administration
        1. See Sodium Bicarbonate in Severe Metabolic Acidosis
  4. Management: Phase 3 - Blood Glucose Control
    1. Precautions
      1. Hypokalemia must be corrected prior to Insulin
    2. Adult Insulin protocol
      1. IV Insulin administration
        1. Initial
          1. Give IV bolus of 0.15 units/kg
          2. Start 0.1 units/kg/hour Insulin Drip
        2. Maintenance
          1. Anticipate Serum Glucose drop of 50-70 mg/dl/hour
            1. If inadequate drop, then increase drip
              1. Increase Insulin Infusion rate by 50-100%
              2. Continue at increased rate until adequate
          2. When Serum Glucose <200-250 mg/dl
            1. Keep Serum Glucose at 150 to 200 mg/dl
            2. Decrease rate by 50% (to 0.05 units/kg) or
            3. Discontinue Insulin Drip and start SC dosing
      2. IM or SC Insulin administration
        1. See Hourly Subcutaneous Insulin Lispro
    3. Glucose monitoring
      1. Glucose monitoring every 30 minutes to 1 hour
      2. Target glucose decrease 50-70 mg/dl/h
    4. Dextrose Administration
      1. Add 5% Dextrose to fluids when glucose < 250 mg/dl
  5. References
    1. Chiasson (2003) CMAJ 168:859
    2. Orland in Stine (1994) Emergency Med, p. 204-5
    3. Kitabchi (2001) Diabetes Care 24:131
    4. Trachtenbarg (2005) Am Fam Physician 71(9):1705
    5. Trence (2001) Endocrinol Metab Clin North Am 30:817

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