Management of Adult Patients with DKA

 resolution: pH >7.3, bicarbonate >18 mmol/L, blood glucose <200 mg/dL,

and normalization of anion gap, beta hydroxybutyrate closure

INITIAL CARE

ENSURE:

- Secure airway and adequate ventilation/oxygenation

MONITOR:

- Orthostatic hypotension (If not hypotensive)

- Continuous EKG monitoring

- Urine output

- Frequent Vital signs

PLACE:

- Adequate IV access (may require 3 ports)

- Foley catheter

CALCULATE:

- Anion Gap

- Serum Osmolality

- Free Water Deficit

- Corrected Serum Sodium

LABS:

- Basic metabolic panel, Serum phosphate level, hepatic enzymes, A1C

- beta-HCG. Urine (for women of child bearing age)

- CBC w/differential

- Cardiac enzymes

- Serum ketones/acetone/Beta-hydroxybutyrate

- PT/PTT

- Venous/Arterial blood gas

- UA/Urine micro/Urine culture

ORDER:

- EKG

- CXR

- Venous thromboembolism prophylaxis: Heparin 5,000 units SQ BID or TID (unless contraindicated)

CONSIDER, as indicated:

- Further Infectious work up

- Amylase/Lipase to rule out pancreatitis

- Head CT/LP if encephalopathic

– Consider Central access

Definition: Metabolic anion-gap acidosis due to elevated serum ketones

Diagnostic Criteria:

- Blood glucose > 250 mg/dL

- Arterial pH <7.3

- Serum Bicarbonate < 18 mEq/L

- Anion Gap > 10

- Ketonuria and/or ketonemia

CALCULATIONS

- Anion Gap (AG) [<12-16]:

AG = [Na+] – [Cl- + HCO3

-]

- Serum Osmolality [275-295 mOsm/L]:

= 2 X Serum Na+ (mEq/L) + [Glucose (mg/dL)/18] + [BUN (mg/dL)/2.8]

- Free Water Deficit:

= Dosing Factor X wt (Kg) X [(Serum Na+/140) – 1]

{Dosing Factor = 0.6 (Male) and 0.5 (Female)}

- Corrected Serum Sodium:

Corrected Na+ = Serum Na+ mEq/L + (1.6 mEq/L for each 100 mg/dL

glucose > 100 mg/dL)

Insulin

- Glucagon

- Cortisol

- Catecholamines

- Growth Hormone

GOALS OF TREATMENT

- Replace volume deficit*

- Correct ketosis and acidosis with continuous insulin

- Replace electrolyte deficits*

- Replace free water deficit*

- Prevent hypoglycemia

- Determine inciting condition for the DKA

- Correct hyperglycemia (secondary goal)

- When DKA resolved: begin appropriate SQ insulin before

stopping Insulin drip

PATHOPHYSIOLOGY

Acidemia

Osmotic

Diuresis

Volume Depletion

Free Water

Depletion

Hypokalemia

1) Ketonemia

2) Hyperglycemia

PROCEED TO

MANAGEMENT

* Patients with ESRD/Anuria may not require volume and K+ repletion.

- Clinical judgment always supersedes pathway recommendations

- Review all medications, fluids/elctrolytes and procedures for specific

contraindications

IV Fluids

*Wt < 60 kg may require smaller volume

Determine Volume Status

Potassium Replacement

– Refer to table below

Insulin

• Fingersticks (FS BG) q 1 hour until BG

< 250 mg/dl, stable and no change > 10

% for 3 hours, then FS BG q 2 hour

• Serum Chemistry every 4 hours

Severe Hypovolemia

Bolus 1 Liter of 0.9% NS or LR over 15 - 20 mins

- Start initial infusion 0.9% NS @ 250 - 500 mL/h until volume depletion is mild

Mild Volume Depletion

Evaluate Corrected Serum Sodium Level

Corrected Serum [Na⁺] < 140

Regular Insulin: 0.15 Units/Kg as IV Bolus; Then IV infusion @ 0.1 Units/Kg/hr (100 Units/100 mL NS)

- If Serum Glucose does

0.45% NaCl @ 100-250 mL/h                  0.9% NaCl @ 100-250 mL/h

not fall by 50 -70 mg/dL in the next hour: double Insulin Infusion

every hour until Glucose Falls by 50-70 mg/dL

Serum Glucose Reaches 250 mg/dL

• Add Dextrose (D₅½NS or D₅NS*) to IVF @ 150 –

250 mL/h to maintain serum glucose 150 – 200 mg/dL and continue insulin at same rate

• Titrate insulin to a minimum 0.1 Units/kg/hr and glucose goal between 150 – 200 mg/dL until ketosis and anion gap resolves.
• If patient can tolerate PO, encourage consistent carbohydrate diet

* Use D5NS if corrected [Na⁺] 140 or remains volume depleted

Ketoacidosis/ AG persists & FS BG 70 to 150 mg/dL      Ketoacidosis/ AG persists & FS BG < 70 mg/dL

Ketoacidosis/ AG persists & FS BG 70 to 150 mg/dL:

• Start D₁₀W or D₁₀NS @ 150 - 250 mL/h and/or consider reducing insulin rate by ½.
• Keep Serum glucose between 150 – 200 mg/dL
• If cannot maintain glucose > 150 mg/dL despite D10 and diet then titrate insulin down to a minimum of 0.5 unit/hr

PROCEED TO PAGE 3

POTASSIUM REPLACEMENT

(Serum Chemistry q 2-4 hours) [Excludes ESRD/Anuria]

Ketoacidosis/ AG persists & FS BG < 70 mg/dL:

• Hold insulin X 15 min & Bolus 1 AMP D50 IVP
• Recheck FS BG if < 70, retreat w/ 1 AMP D50 IVP and repeat FS BG
• Once FS BG > 70 mg/dL, restart Insulin @ ½ prior infusion rate
• Start D₁₀W or D₁₀NS (If volume depleted)@ 150 - 250 mL/h
• Keep Serum glucose between 150 – 200 mg/dL
• If cannot maintain glucose > 150 mg/dL despite D10 and diet then titrate insulin down to a minimum of 0.5 unit/hr

Serum K+1	Total Replacement Dose2,3 (consider lower dose for renal insufficiency)	Maximum Rate of Infusion
< 3 mEq/L	HOLD INSULIN	Peripheral Line: 10 mEq/hour Central Line: 20 mEq/hour∆ ∆ may be exceeded in an adult ICU, ED, OR, PACU or designated patient care units
	40 - 80 mEq
3.1 – 3.4 mEq/L	40 - 60 mEq
3.5 – 3.9 mEq/L	20 - 40 mEq
4 – 5 mEq/L4	Add KCl 20 mEq to each liter of IVF
> 5.5 mEq/L*	No Potassium Replacement

*Check Serum K+ every 2 hours

¹ If acidemic, serum K+ may underestimate potassium deficiency

² Please refer to Adult Potassium Replacement Policy: http://www.crlonline.com/crlsql/servlet/crlonline

- Can use oral KCl if patient is tolerating enteral

³ Refer to Phosphate policy for replacement http://www.crlonline.com/crlsql/servlet/crlonline

⁴IF patient acidemic requires potassium repletion