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 dripbolus 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 patient’s 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 ½ 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 ½ 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