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BIMC Adult DKA Protocol 2012
BIMC Adult DKA Protocol 2012
Protocol:
A. Once enrolled, all patients should get
1. An assessment for shock status
a. If in shock SBP<90 or MAP<65, intravenous fluid (IVF) resuscitation 20cc/kg wide open
b. If not in shock, IVF NS 1L over 1st hour, then 1L over 1-2hr, and another 1L over 1-2hrs
for goal IVF NS 4L by 5-9 hours
2. Initiation of an insulin drip accordingly for moderate-severe vs. mild DKA
a. moderate-severe: bolus 0.1U/kg and maintenance drip at 0.1 U/kg/hr
b. mild: no bolus and maintenance rate 0.14U/kg/hr
3. Checks of fingerstick glucose (FSG) hourly
4. Check of basic metabolic panel (BMP) every 4 hours
5. Check of initial CBC
6. Correction of potassium and magnesium as follows:
a. K 5.5: observe
b. 4.5 K < 5.5: IV potassium repletion
c. 3.3 K < 4.5: IV and PO potassium repletion
d. K < 3.3: IV and PO potassium repletion + add 40meq of KCL to NS infusion
7. A urinalysis and blood cultures before antibiotics (if indicated)
* volume expansion is key & must occur simultaneously, see Volume Resuscitation
Acute Phase
250 mg/dL
<250 mg/dL
Did glucose
by 75-100
over last hour?
no
Assess acidosis:
AG 12 (or known baseline)
* If next SMA not done, assume still acidotic
yes
yes
1.
IV insulin
by 1 unit/hr
Check
glucose
Keep IV insulin
at current rate
2.
3.
IV insulin to
current rate
Start D5NS (or
D5NS) at 150ml/hr
Keep glucose 150-250
until Acidosis resolves
Transition Phase
no
Enter
Transition Phase
Start
Maintain IV insulin
& D5 at current rate
until can eat
Check glucose
q1-hour
yes
Feed & Provide SQ insulin
Option #1:
Start home dose of long acting insulin and
meal coverage
Option #2:
Start 0.5-0.8U/kg as daily dose for insulin nave
(50% long acting; 50% subdivided in 3 for
with-meal short acting insulin)
After 1-2 hours: Discontinue IV insulin & D5 infusions
Laboratory Work-Up
Initially (time=0)
Repetition Frequency
Absolute
Blood glucose (fingerstick)
Complete metabolic panel (SMA20
and magnesium)
VBG for pH (mild vs severe DKA)
CBC
Urinalysis, EKG, CXR (DKA trigger)
Lactate (other cause of AG)
Serum/urine ketones
Recommended
HbA1C
Every 1 hour
Every 4 hours (SMA10 with
magnesium and phosphorus)
Volume Resuscitation
Patients in shock
SBP<90 or MAP<65
Electrolyte Repletion
Potassium (Patients are most often total body K+ depleted)
K+ 5.5
observe
IV Potassium repletion
Consider adding 20meq of KCL to NS infusion
IV Potassium repletion
Consider adding 40meq of KCL to NS infusion
IV/PO Potassium repletion
Consider adding 40meq of KCL to NS infusion
Hold insulin and give 20-30meq/hr until >3.3**