Authors: V. Dimov, M.D., Cleveland Clinic; R. Akhtar, M.D.
Reviewer: S. Randhawa, M.D.
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Dr. Tahir from Case Western Reserve University (St. Vincent/St. Luke) discusses DKA management (click the "play" button to listen to the MP3 file).
CBC, BMP and arterial blood gas (ABG) analysis in diabetic ketoacidosis (DKA) (click to enlarge the images).
Blood glucose levels and response to insulin drip (click to enlarge the images).
Medications during the hospital stay (click to enlarge the images).
Intravenous fluids (IVF): correct the 6-8 L fluid deficit which typically occurs in DKA.
Fluid of choice: Normal saline (NaCl 0.9%). You can calculate corrected sodium by using this formula: Corrected Sodium = Measured sodium + 0.016 * (Serum glucose - 100).
IV bolus followed by 250-500 cc/hr aiming for positive balance of 6-8 L.
Add D5W or D5 1/2NS when blood glucose falls below 250 mg/dL.
Objective: to correct acidosis (bicarbonate level > 16) and/or to normalize the anion gap. Method: IV, no bolus necessary. If you decide to give an insulin bolus, the dose is 10-15 U.
Rate of infusion is 0.1 U/Kg/hr.
Stop IV insulin drip and switch to SQ insulin only when the above parameters are reached (bicarbonate greater than 16 mEq/L, normal anion gap).
Use a generous sliding scale (eg. 5-10 U for the first step) with overlap with IV for 2-3 hours. Continue frequent Accuchecks for the next 4-6 hrs. You can start NPH insulin immediately.
Start replacing potassium at high normal levels (5.0 mEq/L for our lab).
Replace phosphate if necessary (dangers: respiratory depression; cardiac arrythmias are rare).
Give bicarbonate if pH is less than 7.2 (bicarbonate is not usually needed). Target glucose drop: 70-100 mg/dl/hr. If more precipitous, then peril of cerebral edema. You can give simultaneous D5W or D5 1/2 NS to avoid this. If blood glucose drop is not sufficient, you can double insulin rate (at lower levels) or increase the rate significantly without doubling (at higher levels).
Diabetic Ketoacidosis. American Family Physician, May 1, 2005.
Diabetic Ketoacidosis. eMedicine.
Hyperosmolar Hyperglycemic State. American Family Physician, May 1, 2005.
Corrected Sodium for Glucose. MDCalc.com.
Cases: Inpatient Diabetes Management. NYU Internal Medicine Blog.