II. 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. Evaluation
      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. Use Normal Saline or Lactated Ringers
      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
  3. 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. Follow Intake and output closely

III. 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 (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. 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: 20-30 meq per liter of IV fluids
        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 <5.0
  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
      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
      2. Other contributing factors
        1. Shock or Coma
        2. Severe Hyperkalemia
    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 NS 1-2 Liters precedes starting Insulin
    2. Hypokalemia must be corrected prior to Insulin (Potassium must be >3.3 meq/L)
    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. IV Insulin administration
      1. Initial: Preferred Insulin starting regimen (no bolus)
        1. Bolus: None
        2. Continuous infusion: 0.14 units/kg/hour 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. 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. 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
    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/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. Monitoring: Labs every 2-4 hours until stable

  1. Serum electrolytes
  2. Serum Creatinine
  3. Blood Urea Nitrogen
  4. Serum Glucose (checked every 30 min to hour as above)

VI. Resources

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

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