Diabetic ketoacidosis

Background

-Hyperosmolality and insulin deficiency causes hyperkalemia; as reverses K+ goes back into cell

-Most pts 3-6L depleted

-Look for precipitating causes:

Insulin non-compliance
Infection
Ischemia
Intra-abd process
1. (Lipase/amylase not specific in pts w/ DKA)
Iatrogenic (steroids)
Etoh/drug abuse�

Workup

PRECIPITANT
- (Fever is rare even in the presence of infection due to�

peripheral vasoconstriction 2/2 hypovolemia

CBC
Chem 10
Urine acetone/b-OH
- If urine ketones + then obtain serum ketones
Plasma osmolality�
hCG
UA
ECG
?VBG
?CXR

�

Treatment

Initial

Mild (ketosis): gap <12

Mod: gap 12-18

Severe: gap >18

1) Labs:

Glucose check Q1hr
Chem 10 Q4hr
Corrected Na+
- Add 1.6mEq for each glucose 100mg/dl >100)�

2) IV Fluids

If severe hypovolemia: 1L NS / hr for up to 3 hr
If mild dehydration then evaluate corrected Na+
- If hypernatremic: 1/2NS @ 250-500ml/hr
- If hyponatremic: NS @ 250-500ml/hr�
When BS < 200 switch to D5½NS�@ 150-200 ml/hr�(+/- KCl)
Bolus NS as needed for unstable VS

3) Insulin

Check K+ prior to insulin Tx!
- If K < 3.3 do not administer insulin
IV Route
- IV gtt 0.14 U/kg/hr =10 U/hr in 70kg pt
  - Bolus dose unnecessary
- If BS does not decrease by 50-70/hr then double infusion rate qhr until achieved�
- When BS <200, reduce to 0.02-0.05 U/kg/hr IV OR give subQ 0.1 U/kg q2hr
  - Maintain BS between 150 and 200 until resolution of DKA�
SubQ route (appropriate only for mild DKA)
- Insulin lispro or aspart 0.3 U/kg initially
  - 0.2 U/kg one hr later
    - 0.2 U/kg q2hr thereafter
- If BS does not decrease by 50-70/hr then double dose qhr until achieved�

4) Potassium (initial)

>5.5: don't give, but recheck q2hr
3.3-5.5: give 30 meq/hr in each liter bag
- 1/2NS is preferred b/c adding 30meq to NS = hypertonic soln
<3.3: hold insulin and give 30 meq/hr until K >3.3

6) Bicarb

if pH <6.9: 100 meq NaHCO3 in 400mL H2O @ 200 mL/hr
- Dose as needed until pH > 7.00�

7) Phosphate

Repletion is controversial
- Has not been shown to be beneficial
- Hypophosphatemia following insulin tx usually asymptomatic�
- Repletion is associated with hypoCa and hypoMg�
Consider repletion (KPO4 20-30 meq/L)�if:
- Phosphate <1.0
- Cardiac dysfunction
- Respiratory dysfunction�
- Evidence of hemolysis or rhabdo�

When gap closes and patient able to eat:

Begin multidose insulin regimen
Continue IV infusion for 1-2 hr after SC insulin tx is begun

Complications

Cerebral Edema
- Almost all affected pts are <20yrs
Noncardiogenic pulmonary edema�

SLIDING SCALE

200- 250- 4u sq

251- 300- 6

301- 350- 8

351- 400- 10

> 400- call MD

[/f/DKA.jpg DKA Algorithm]

Source

Adapted from Chavira, Rosen, Mistry, Ip, Donaldson, Pani, UpToDate