Initial diagnostic measures

First priority measures

· Rapid examination for airway, cardiovascular function, neurologic status, signs of infection

· Capillary blood glucose and urinary ketones

· Stat blood work: arterial gases, serum Na, K, Cl, HCO3^-, glucose, creatinine, BUN; CBC. Calculate serum osmolality and anion gap

· Stat ECG

· Start a flow sheet

Initial general medical data

· Chest film if indicated

· Cultures: blood, urine, sputum

Initial therapy

General

· NG tube if patient is unconscious or vomiting.

· Hemodynamic monitoring if there is suspicion of LV failure or cardiogenic shock.

· DVT prophylaxis, especially if patient is unconscious or severely volume-depleted.

Fluids

· 0.9% saline: 1 L in 30 min; then 1 L in next 1 hour; then 1 L in next 2 hours; then 2 L in next 8 hours

· Switch to 0.45% saline if osmolality increases during administration of saline, or if [serum Na + 0.016 • (serum glucose – 100)] > 145.

Insulin

· Check serum K. Hold insulin if K<3.3 mEq/L. Give KCl at 40 mEq/h, until K≥3.3 mEq/L.

· Load with 0.15 units/kg Regular, IV; then start infusion at 0.1 units/kg/h.

· Double rate of infusion if glucose does not fall by at least 50 mg/dl in 1 h. Double rate hourly, until glucose falls by at least 50 mg/dl/h.

Potassium

· Be sure patient is making urine.

· If K<3.3 mEq/L, hold insulin. Give 40 mEq K/h, until K≥3.3 mEq/L.

· If K between 3.3 and 4 mEq/L, give 25 mEq K/h.

· If K between 4 and 5 mEq/L, give 20 mEq K/h.

· If K rises above 5 mEq/L, stop giving K; check K level q2h.

· K infusion should be 2/3 as KCl, 1/3 as K phosphate.

· Adjust rate of K infusion to keep serum K between 4 and 5 mEq/L.

· Monitor ECG as guide to extracellular [K⁺]

Alkali

· If arterial pH>7.0, no need for bicarbonate

· For pH 6.9 ‑ 7.0, may give 44 mEq NaHCO3, with 10 ‑ 15 mEq K+, over 30 min

· For pH <6.9, give 88 mEq NaHCO3, with 25 mEq K+, over 45 min

· 30 min after each infusion of NaHCO₃, re-check pH, and re-evaluate need for more alkali

Phosphate

· Patients in DKA are usually phosphate depleted, but not hypophosphatemic on admission; serum phosphate usually falls during therapy

· Controlled studies have failed to show a beneficial effect of intravenous phosphate replacement on clinical outcome, in diabetic ketoacidosis.

· Do not give IV phosphate if patient is hyperphosphatemic, hypercalcemic, hypocalcemic, azotemic or oliguric

· Check P level initially and 8 hr. after starting insulin

· If [P] <1 mg/dL, may give neutral K phosphate, 10 ‑ 20 millimoles per liter of IV fluids

· Do not add phosphate to solutions containing calcium

· Monitor serum Ca, P and creatinine q12 h, while giving IV phosphate

· Safest way to replete phosphate is orally, after patient can take oral feedings

Continued management

Check capillary glucose hourly

· When glucose down to 250 mg/dL:

o Switch to fluids containing 5% or 10% dextrose, until patient can eat

o Patient will develop a non-anion-gap acidosis, during the treatment. Continue insulin infusion at therapeutic rate of at least 5 units/hr, until the acidosis has cleared (i.e. [HCO3‑] >18 mEq/L). Give dextrose-containing fluids as needed to avoid hypoglycemia

o After acidosis has cleared, continue insulin infusion at maintenance rate of 0.5 ‑ 2 units/hr, until patient can eat

o Keep giving IV K⁺ at about 3 ‑ 5 mEq/hr, until patient begins eating

When acidosis has cleared and patient can eat, start NPH insulin

· Wait at least 1 hr after giving NPH insulin, before stopping the insulin infusion.

· Remember that a Type 1 diabetic patient will require NPH insulin twice daily

· Continue oral K⁺ and phosphate repletion for 5 to 7 days