Diabetic Ketoacidosis (DKA) Clinical Pathway – Emergency Department, ICU and Inpatient – Initial Management of DKA

Diabetic Ketoacidosis (DKA) Clinical Pathway – Emergency Department, ICU and Inpatient

Initial Management of DKA

Fluid and Electrolyte Management

General Concepts for Rehydration
  • Volume depletion from osmotic diuresis
  • PE and VS underestimate deficits
  • Assume 5-10% dehydration
  • Frequent PE assessment and careful I/O are important
Initial Fluid Resuscitation
  • Initial resuscitation is 20mL/kg of NS over 1 hr
  • Improve circulatory volume
  • Consider additional 10-20 mL/kg NS bolus as indicated by VS, PE
Maintenance Fluids and Electrolytes
  • Begin NS at 1.5 times maintenance after bolus until BMP results available
    • If glucose required prior to electrolyte results, use D10 0.45%NS
    • Provide dextrose based on BG as below
      • e.g., BG 200-299, use Half D10 0.45%NS + Half 0.9%NS
  • Urinary replacement is not necessary
  • Maintenance Calculation, mL/hr, use weight in kg:
    • 4 mL/kg for the first 10 kg
    • + 2 mL/kg for the next 10 kg
    • + 1 mL/kg for each kg over 20 kg
  • Electrolyte Replacement
    • Elevated chloride, concern for a hyperchloremic metabolic acidosis
      • Consider switching fluids to 0.45% NS, review with endocrine
    • Serum K KCL Ordered Amount of KPhos
      Use potassium acetate if KPhos is not available
      < 4 30 mEq 30 mEq, 20.4 mM
      4-5.4 20 mEq 20 mEq, 13.6 mM
      5.5-6 10 mEq 10 mEq, 6.8 mM
      > 6 None None
    • Electrolyte Abnormalities in DKA
Glucose
  • Aim to lower glucose 50-100 mg/dL per hr
  • Begin 2 bag system:
    • One bag D10 NS, one bag NS (no dextrose)
    • Dextrose provided based on BG
    • Electrolytes content based on K+ level
    • Rate 1.5 maintenance
  • Glucose Concentration in IVF
    • Blood Glucose Dextrose
      < 200 All D10 0.9% NaCl
      200-299 Half D10 0.9% NaCl
      Half 0.9% NaCl
      > 300 All 0.9% NaCl

Insulin

Insulin
  • Reverses the acidosis
  • Stop insulin pump during DKA treatment
  • Initiate regular insulin at rate of 0.1 u/kg/hr after initial NS bolus completed
  • Do not use IV insulin bolus; may increases risk of cerebral edema
  • Rarely, the rate of the infusion may need to be adjusted
  • Delayed/No IV access
    • Consult Endocrinology
    • 0.15 units/kg IM or SQ rapid-acting insulin (Humalog/Novolog/Apidra) q2hr
  • Lantus dose may be given while on insulin infusion