Metabolic emergency Management priorities for DKA treatment: Diabet ic Ket oacidosis M an agem en t

usually in patients with

Patient with Volume resuscitation
type 1 diabetes with ABBREVIATIONS:
confirmed DKA Electrolytes (K and Na)
hyperglycemia, ADA: American Diabetes Association
metabolic acidosis, Glucose
BUN : blood urea nitrogen
and ketosis Identify precipitant of DKA
DKA: diabetic ketoacidosis
HCO3: bicarbonate
K: potassium
KCl: potassium chloride
Start IV fluids with 0.9% NaCl 1 L/hour Na: sodium
NaCl: sodium chloride
Initiate corrective actions SC: subcutaneous

Estimate Restore volume Correct severe

hydration status with IV fluids acidosis (pH <6.9)
by clinical exam,
vital signs, and Estimate
laboratory
hydration status
studies
If pH <6.9, give HCO3 100
mEq in 400 mL of water with 20
mEq KCl (if adequate renal
Correct hyperglycemia: Correct/prevent function established) and
Severe Mild Cardiogenic
initiate insulin only after K deficit infuse for 2 hours
hypovolemia dehydration shock
fluid resuscitation and if
serum K >3.3

Use either IV or SC insulin

Continue 0.9% Evaluate Initiate hemodynamic

NaCl 1 L/hour corrected Hold insulin
monitoring/pressors Serum K
serum Na+ <3.3
Give K 20?30 mEq/hour
mEq/L
until K >3.3 mEq/L
Give IV regular Give SC rapid-acting
insulin: 0.1 insulin: 0.3 units/kg
units/kg IV bolus bolus and then 0.2
Normal or and then 0.1 units/kg every 2
Low
high units/kg/hr IV hours
infusion
Serum K Give K 20?30 mEq/L in
3.3?5.2 each L of IV fluid to keep
Initiate 0.9% Initiate mEq/L serum K at 4?5 mEq/L
NaCl 0.45% NaCl
250?500 250?500
mL/hour mL/hour If serum glucose does
depending depending not fall by 50?70 mg/dL
on hydration on hydration in first hour, double IV
status status rate or SC insulin bolus Do not give K, but
dose Serum K
check serum K every 2
>5.2 mEq/L
hours

When serum glucose reaches

200 mg/dL, change to 5% dextrose
with 0.45% NaCl at 150?250 mL/hour When serum glucose falls to
200 mg/dL, reduce regular
Check electrolytes, BUN, venous pH, insulin infusion to 0.02?0.05
creatinine, and glucose every 2?4 units/kg/hr IV or give
hours until stable rapid-acting insulin 0.1
units/kg SC every 2 hours

Maintain serum glucose 150?200

mg/dL until DKA is resolved

* ADA criteria for resolution of DKA:

After DKA is resolved* and patient is
- Serum bicarbonate level ?15 mEq/L
able to eat, transition to multidose SC
- Venous pH >7.3
regimen (basal and bolus)
- Calculated anion gap ?12 mEq/L

Continue IV insulin for 1?2 hours

after starting SC insulin

REFERENCES: Diabetes Care in the Hospital: Standards of Medical Care in Diabetes? 2022. American Diabetes Association, 2022. Copyright and all rights reserved.
Material from this publication has been modified with the permission of American Diabetes Association.
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