BIMC Adult DKA Protocol, Page 1 of 5 BIMC ADULT DIABETIC KETOACIDOSIS (DKA) PROTOCOL Aim: To establish a protocol for

adults with diabetic ketoacidosis. Rationale: Diabetic ketoacidosis is one of the most serious acute complications of diabetes. Therapy is time sensitive and should be instituted as soon as possible. Having a unified protocol will allow for rapid identification of DKA and early initiation of treatment in the emergency department (ED) which can be continued until resolution of acidosis in the ED or once the patient is admitted to the hospital. Eligibility: Adults (age18) with DKA are characterized by the triad of hyperglycemia, an anion gap metabolic acidosis and ketonemia/ketouria. If adult patients meet the DKA criteria, they should be enrolled in the DKA protocol and categorized into either mild versus moderate-severe DKA. DKA Criteria 1. FS 250 2. AG 12 3. Ketonemia/ketouria DKA Severity Mild: Venous pH 7.25 Moderate-Severe: Venous pH < 7.25 When patients come from the ED into the hospital and the protocol has already been initiated, the protocol should be followed to completion. Please complete documentation on ER flow sheet. Goals: 1. 2. 3. 4. 5. Glucose level less than 250mg/dL Anion gap (AG) less than or equal to 12 Volume resuscitation Electrolyte management Patient off continuous insulin infusion and back on home regimen or appropriate alternative

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)

BIMC Adult DKA Protocol, Page 2 of 5 8. A chest x-ray (if indicated) 9. Blood pressure, heart rate and oxygen saturation monitoring per ED/ICU protocol 10. Supplemental oxygen or mechanical ventilation (if required) B. If glucose still greater than 250: 1. If FSG decreased by 75-100 over last hour, maintain current insulin infusion rate 2. If FSG decreased by less that 75-100 over last hour, increase insulin drip by 1 unit per hour 3. Continue to check FSG hourly and BMP every four hours C. If glucose less than/equal to 250, but anion gap is greater than 12: 1. Decrease insulin drip to current rate 2. Initiate D5 NS at 150cc/hr 3. Titrate D5 NS to keep glucose 150-250 mg/dL until acidosis resolves (anion gap 12) 4. Continue to check FSG hourly and BMP every four hours D. If glucose less than/equal to 250 and anion gap is less than/equal to 12: 1. Test to see that patient can tolerate food If patient is able to tolerate food: 2. Administer subcutaneous long-acting insulin in one of following doses: a. home dose of long acting insulin and meal coverage b. 0.5-0.8U/kg as daily dose for insulin nave50% long acting & 50% divided in 3 doses for with-meal short acting insulin (for example: 70kg man to get 0.7*70U/day = 49U/day ~25U Lantus and ~25U/3 = ~8U regular insulin before meals) 3. Discontinue both insulin infusion and D5 NS infusion 1-2 hours after administration of long-acting insulin If patient is UNABLE to tolerate food: 4. Continue insulin drip 5. Continue IVF D5 NS fluid 6. Goal FSG 120-180 E. If hypoglycemic (FSG150) 1. If FSG <70 a. Administer 1 ampule of D50 b. Hold insulin drip for 15min and recheck FSG c. If FSG >100, re-start insulin drip reduced rate ( rate) d. Goal FSG > 150 2. If FSG 70-150 a. If patient is still has acidosis (AG >12): i. Switch IVF from D5 NS to D10 NS and start at 150ml/hr ii. Hold insulin drip for 15min and recheck FSG iii. If FSG >100, re-start insulin drip reduced rate ( rate) iv. Goal FSG > 150 b. If patient no longer has acidosis (AG 12): i. Increase IVF D5 NS rate by 50-150ml/hr ii. Hold insulin drip for 15min and recheck FSG iii. If FSG >100, re-start insulin drip reduced rate ( rate) iv. Goal FSG > 150

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* volume expansion is key & must occur simultaneously, see Volume Resuscitation

Adult Diabetic Ketoacidosis Treatment Algorithm

Acute Phase

Check glucose 250 mg/dL <250 mg/dL

Severe (VBG pH<7.25) Bolus 0.1U/kg Insulin and start drip at 0.1U/kg/hr Mild (VBG pH7.25) Insulin drip 0.14U/kg/hr

Did glucose by 75-100 over last hour? no yes

1. IV insulin by 1 unit/hr Keep IV insulin at current rate
(If on D5, may need )

Assess acidosis: AG 12 (or known baseline)

* If next SMA not done, assume still acidotic

yes
IV insulin to current rate Start D5NS (or D5NS) at 150ml/hr Keep glucose 150-250 until Acidosis resolves

no

2.

3.

Enter Transition Phase

Transition Phase
Is patient able to eat? test a few bites of food no Maintain IV insulin & D5 at current rate until can eat Check glucose q1-hour yes Feed & Provide SQ insulin

Start

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

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Laboratory Work-Up
Initially (time=0) 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 Repetition Frequency Every 1 hour Every 4 hours (SMA10 with magnesium and phosphorus)

Every 4 hours until normal

Volume Resuscitation
Patients in shock SBP<90 or MAP<65

20cc/kg NS wide open Consider addition of vasopressors Evaluate for cause other than hypovolemia
1L NS over 1st hour then 1L NS over 1-2 hours then 1L NS over 1-2 hours then 1L NS over 2-4 hours Should have 4L in by 5-9 hours
* may need to be adjusted for patients with ESRD or CHF

Patients not in shock*

Electrolyte Repletion
Potassium (Patients are most often total body K+ depleted)
K+ 5.5 4.5 K+ < 5.5
3.3 K+ < 4.5 K+ < 3.3 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**

**only if able to recheck K within 1hr in ICU or ER setting via VBG/ABG

Magnesium & Phosphorus: Aggressively replete (goal Mg>1.6, Ph>2.5)