II. Management: Phase 1 - Fluids in Adults (Emergent)

  1. Stabilize shock and Coma states first!
  2. Disconnect Insulin Pump
    1. Removes the risk of uncalculated additional Insulin admininistered from pump (risk of Hypoglycemia)
    2. Clearly, pump is not working properly if the patient is presenting in Diabetic Ketoacidosis
    3. Remove needle from insertion site and observe for needle or tubing problem, or insertion site infection
  3. Correct Volume Deficit
    1. Initial
      1. Physiologic crystalloids are preferred (e.g. Lactated Ringers, Plasmalyte) over Normal Saline
        1. Hyperchloremic Metabolic Acidosis is a risk factor for Renal Failure and requiring acute Dialysis
      2. Initial Fluid Replacement of 10-20 ml/kg (patients typically with total deficit 6-10 Liters)
      3. Give first liter LR bolus over first 45 minutes
      4. Repeat 5-10 ml/kg fluid bolus until shock corrected
        1. Use Inferior Vena Cava Ultrasound for Volume Status
        2. Give fluid additional fluid boluses of 5-10 ml/kg until IVC no longer collapsed
    2. Next
      1. Evaluate Corrected Serum Sodium for Hyperglycemia
      2. Adjust protocol below for Hypernatremia (to use 1/2 NS)
    3. Next
      1. Replace first 50% volume deficit in first 8 hours
        1. Rate: 150 to 250 ml/hour or 10 cc/kg/hour (+/- 5cc/kg/hour) depending on hydration status
        2. Lactated Ringers is preferred over Normal Saline
      2. Replace remaining 50% deficit over next 16 hours
        1. Rate: 150 to 250 ml/hour or 10 cc/kg/hour (+/- 5cc/kg/hour) depending on hydration status
        2. Use fluids without dextrose (1/2NS) until Serum Glucose <250 mg/dl, then use D5 1/2NS
          1. Could also continue NS until Serum Glucose <200-250 mg/dl, then transition to D5 1/2 NS
      3. Potassium and other electrolyte replacement
        1. See below
  4. Precautions
    1. Do not drop Serum Osmolality (calc) >3 mOsms/hour
      1. Risk of cerebral edema (major cause of mortality in DKA, especially in children)
      2. Serum Sodium and Calculated Serum Osmolality needs to be monitored closely
    2. Slow replacement if Fluid Overload risk (and consider close hemodynamic monitoring)
      1. Congestive Heart Failure
      2. Chronic Renal Insufficiency
      3. Myocardial Infarction
    3. Monitor volume status
      1. Consider Inferior Vena Cava Ultrasound for Volume Status
      2. Follow Intake and output closely
      3. Urine output is unreliable as a marker of volume status and perfusion
        1. Osmotic diuresis results from Hyperglycemia and severe Metabolic Acidosis

III. Management: Phase 2 - Acidosis, electrolytes in Adults

  1. Potassium Replacement
    1. Precautions
      1. Hypokalemia must be corrected prior to Insulin
        1. Hold Insulin until Potassium >3.3 meq/L in adults
      2. Total body Potassium is depleted in DKA (diuresis, Vomiting)
      3. Insulin and hydration will further lower Serum Potassium
        1. Metabolic Acidosis correction drives Potassium back into cells
        2. IV hydration results in additional Potassium wasting in urine
    2. Prerequisites
      1. Electrocardiogram without signs of Hyperkalemia
      2. Adequate urine output (at least 50 ml/hour)
    3. Administration: Adults
      1. Serum Potassium <3.3 meq/L
        1. Do not administer Insulin until Potassium >3.3 meq/L
        2. If Potassium < 2.0, consider Central Line for faster Potassium Replacement
          1. May also use more than one large bore peripheral IV site
        3. Give KCl 20-30 meq/hour IV until corrects
          1. Requires hourly recheck of Serum Potassium
          2. Potassium at 40 meq/h is maximum IV Potassium rate!
          3. Additional Potassium may be given orally (if patient can tolerate)
          4. Requires cardiac monitoring
      2. Serum Potassium 3.3 to 5.2 meq/L
        1. Standard replacement: 10 meq/hour
          1. Adjust Potassium 20-40 meq per liter of IV fluids depending on IV fluid rate
          2. If IV fluid rate is 250 ml/h, then may use up to 40 meq/L Potassium = 10 meq/hour
          3. If IV fluid rate is 500 ml/h, then may use up to 20 meq/L Potassium = 10 meq/hour
        2. Maintain Serum Potassium at 4 to 5 meq/L
        3. Recheck Serum Potassium every 2 hours
      3. Serum Potassium >5.2 meq/L
        1. Do not administer any Potassium
        2. Monitor every 2 hours until Potassium <5.0 meq/L
        3. For severe Hyperkalemia Management, delay Insulin until initial fluid boluses are completed
          1. Starting Insulin too soon will result in hemodynamic compromise
  2. Phosphate Replacement
    1. Indications
      1. Serum Phosphorus < 0.5-1.0 mg/dl (Severe Depletion)
      2. Controversial - May not be required
        1. Phosphate is a key component of ATP (as well as DNA and 2,3-DPG)
        2. Hypophosphatemia (phosphate <1mg/dl) may further exacerbate organ dysfunction
      3. Patient may experience Muscle Weakness resulting in decreased respiratory drive
      4. 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 <1.2 mg/dl)
    2. Administration
      1. Magnesium Sulfate 1 gram IM or IV over 1 hour
  4. Sodium Bicarbonate Replacement
    1. Indications
      1. ABG pH < 6.9 after initial hour of hydration
        1. Although recommended by ADA, specific pH cutoff for bicarbonate is controversial
      2. Other indications per expert opinion
        1. Cardiac Arrest
        2. Severe Hyperkalemia with arrhythmia
        3. Shock with fluid refractory Hypotension
    2. Precautions
      1. Risk of intracellular Potassium shift and further worsening of Hypokalemia
      2. Potential risk of worsening cerebral edema
      3. Risk of decreasing peripheral tissue oygen delivery (due to shift in oxygen dissociation curve)
      4. Lack of evidence that Sodium Bicarbonate improves outcomes in pH <7.0 or 7.1
        1. Green (1998) Ann Emerg Med 31(1): 41-8 [PubMed]
        2. Viallon (1999) Crit Care Med 27(12): 2690-3 [PubMed]
    3. Administration
      1. See Sodium Bicarbonate in Severe Metabolic Acidosis
      2. Dilute 100 mEq NaHCO3 and 20 mEq Potassium Citrate in 400 ml Sterile Water
      3. Recheck serum Sodium Bicarbonate and Serum Potassium every 2 hours
      4. Infuse at 200 ml/hour until pH>6.9

IV. Management: Phase 3 - Blood Glucose Control

  1. Precautions
    1. Hydration with Crystalloid (e.g. LR, NS, Plasmalyte) 1-2 Liters precedes starting Insulin
    2. Hypokalemia must be corrected prior to Insulin (Potassium must be >3.3 meq/L)
      1. See Potassium management as above
      2. Even if Potassium in normal range (3.3 to 5.2 meq/L), administer Potassium 10 meq/hour with Insulin
    3. Insulin's initial role in DKA is not to lower Serum Glucose
      1. Insulin's initial role is to stop ketogenesis, thereby decreasing the Anion Gap and correcting the acidosis
  2. Adult Insulin protocol
    1. Initial: Preferred Insulin starting regimen (no bolus)
      1. Bolus: None
      2. Continuous infusion: 0.1 units/kg/hour or 0.14 units/kg/hour Insulin
        1. Infuse the IV line with Insulin first to avoid delay in patient getting Insulin
    2. Alternative Initial Bolus regimen (with bolus)
      1. Bolus: 0.1 units/kg IV and then
      2. Continuous infusion: 0.1 units/kg/hour Insulin
      3. Risk of Hypoglycemia and no benefit in Glucose control over no-bolus regimen
        1. Goyola (2010) J Emerg Med 38(4): 422-7 [PubMed]
        2. Kitabchi (2008) Diabetes Care 31(11): 2081-5 [PubMed]
    3. Maintenance and titration
      1. Anticipate Serum Glucose drop of 10% in first hour
      2. Anticipate Serum Glucose drop of 50-70 mg/dl/hour
      3. Protocol 1: If inadequate drop, then increase drip
        1. Give 0.14 units/kg IV bolus and continue prior rate or increase Insulin Infusion rate by 50-100%
        2. Continue at increased rate until adequate
      4. Protocol 2: Alternative
        1. Leave Insulin Drip at same rate as long as Metabolic Acidosis and Anion Gap are improving
    4. Tapering
      1. Targets (when to start tapering)
        1. Anion Gap normalizes (e.g. 12 or less)
        2. Serum Glucose <200 mg/dl
        3. pH>7.3 and serum bicarbonate >18 mEq/L
          1. May be unreliable as Normal Saline is acidotic
          2. pH may remain suppressed due to Normal Saline (does not occur with LR)
      2. Approach
        1. Keep Serum Glucose at 150 to 200 mg/dl
        2. Add dextrose to Intravenous Fluids
        3. Decrease rate by 50% (to 0.05 units/kg)
        4. Start subcutaneous Insulin and overlap intravenous Insulin Drip for 1-2 hours prior to shutting off
      3. References
        1. Orman and Weingart in Herbert (2015) EM:Rap 15(1): 14-6
    5. Alternative regimen: IM or SC Insulin administration
      1. See Hourly Subcutaneous Insulin Lispro
  3. Glucose monitoring
    1. Glucose monitoring every 1 hour (consider every 30 minutes as Glucose approaches target of 250 mg/dl)
    2. Target Glucose decrease 50-70 mg/dl/hour
  4. Dextrose Administration
    1. Add 5% Dextrose to fluids when Glucose <200 mg/dl (see fluid management above)
  5. Initiate subcutaneous Insulin Dosing
    1. Known diabetic
      1. Restart prior program and readjust Insulin
    2. New patient: Determine Insulin requirements
      1. Regular 0.5 to 0.8 units per kg/day divided in 2-3 daily doses

V. Management: Respiratory Failure

  1. Avoid Intubation if possible
    1. Peri-intubation apnea is poorly tolerated by the patient with severe Metabolic Acidosis (Cardiac Arrest risk)
    2. High Respiratory Rate must be matched to allow facilitate acidosis correction (otherwise Metabolic Acidosis will worsen)
  2. If intubation is unavoidable
    1. Record Respiratory Rate prior to intubation
    2. RSI with Rocuronium (avoid Succinylcholine due to Hyperkalemia)
    3. Use Intubation Preoxygenation
    4. Leave patient on Bipap, Ventilator SIMV or Bag Valve Mask until time to insert Laryngoscope
    5. Set Ventilator rate to preintubation Respiratory Rate (typically 30-40 breaths/min in severe DKA)
  3. Post-intubation precautions: Breath Stacking (Auto-PEEP)
    1. Breath stacking (auto-PEEP) occurs with high Ventilator rates
    2. Monitor repeat VBG or ABG
    3. Check plateau pressure at time of inspiratory pause
      1. Plateau pressure >30 mmHg should prompt disconnecting vent to allow for a full expiration
      2. Decrease Respiratory Rate if breath stacking occurs

VI. Management: Home Disposition from Emergency Department

  1. Most patients with significant DKA are admitted to Intensive Care Unit on Insulin Drip
  2. Indications
    1. Alert mental status AND
    2. Taking oral fluids AND
    3. Mild Diabetic Ketoacidosis that is corrected in Emergency Department
      1. Anion Gap <17 AND
      2. Serum Bicarbonate >18-20 AND
      3. Serum Glucose <250 mg/dl

VII. Labs: Monitoring every 2-4 hours until stable

  1. Serum electrolytes (esp. Serum Potassium)
  2. Serum Creatinine
  3. Blood Urea Nitrogen
  4. Serum Glucose (checked every 1 hour as above)

VIII. Resources

  1. FpNotebook DKA Adult Management Flowsheet
    1. endoDkaAdult.pdf

IX. References

  1. Orland in Stine (1994) Emergency Med, p. 204-5
  2. Orman and Willis in Herbert (2017) EM:Rap 17(9): 19-20
  3. Orman and Willis in Herbert (2017) EM:Rap 17(11): 13-5
  4. Swaminathan in Majoewsky (2013) EM:Rap 13(5): 9-10
  5. Chiasson (2003) CMAJ 168:859-66 [PubMed]
  6. Kitabchi (2001) Diabetes Care 24:131-53 [PubMed]
  7. Kitabchi (2009) Diabetes Care 32(7): 1335-43 [PubMed]
  8. Trachtenbarg (2005) Am Fam Physician 71(9): 1705-22 [PubMed]
  9. Trence (2001) Endocrinol Metab Clin North Am 30:817-31 [PubMed]

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