II. Management: Phase 1 - Fluids in Adults (Emergent)
- Stabilize shock and Coma states first!
- Disconnect Insulin Pump
- Removes the risk of uncalculated additional Insulin admininistered from pump (risk of Hypoglycemia)
- Clearly, pump is not working properly if the patient is presenting in Diabetic Ketoacidosis
- Remove needle from insertion site and observe for needle or tubing problem, or insertion site infection
- Correct Volume Deficit
- Initial
- Physiologic crystalloids are preferred (e.g. Lactated Ringers, Plasmalyte) over Normal Saline
- Hyperchloremic Metabolic Acidosis is a risk factor for Renal Failure and requiring acute Dialysis
- Initial Fluid Replacement of 10-20 ml/kg (patients typically with total deficit 6-10 Liters)
- Give first liter LR bolus over first 45 to 60 minutes
- Repeat 5-10 ml/kg fluid bolus until shock corrected
- Use Inferior Vena Cava Ultrasound for Volume Status
- Give fluid additional fluid boluses of 5-10 ml/kg until IVC no longer collapsed
- Physiologic crystalloids are preferred (e.g. Lactated Ringers, Plasmalyte) over Normal Saline
- Next
- Evaluate Corrected Serum Sodium for Hyperglycemia
- Adjust protocol below for Hypernatremia (to use 1/2 NS)
- Next
- Replace first 50% volume deficit in first 8 hours
- Rate: 150 to 250 ml/hour or 10 cc/kg/hour (+/- 5cc/kg/hour) depending on hydration status
- Lactated Ringers is preferred over Normal Saline
- Replace remaining 50% deficit over next 16 hours
- Rate: 150 to 250 ml/hour or 10 cc/kg/hour (+/- 5cc/kg/hour) depending on hydration status
- Use fluids without dextrose (1/2NS) until Serum Glucose <250 mg/dl, then use D5 1/2NS
- Could also continue NS until Serum Glucose <200-250 mg/dl, then transition to D5 1/2 NS
- Potassium and other Electrolyte replacement
- See below
- Replace first 50% volume deficit in first 8 hours
- Initial
- Precautions
- Do not drop Serum Osmolality (calc) >3 mOsms/hour
- Risk of cerebral edema (major cause of mortality in DKA, especially in children)
- Serum Sodium and Calculated Serum Osmolality needs to be monitored closely
- Slow replacement if Fluid Overload risk (and consider close hemodynamic monitoring)
- Monitor volume status
- Consider Inferior Vena Cava Ultrasound for Volume Status
- Follow Intake and output closely
- Urine Output is unreliable as a marker of volume status and perfusion
- Osmotic diuresis results from Hyperglycemia and severe Metabolic Acidosis
- Do not drop Serum Osmolality (calc) >3 mOsms/hour
III. Management: Phase 2 - Acidosis, Electrolytes in Adults
-
Potassium Replacement
- Precautions
- Hypokalemia must be corrected prior to Insulin
- Hold Insulin until Serum Potassium >3.3 meq/L in adults
- Total body Potassium is depleted in DKA (diuresis, Vomiting)
- Insulin and hydration will further lower Serum Potassium
- Metabolic Acidosis correction drives Potassium back into cells
- IV hydration results in additional Potassium wasting in urine
- Hypokalemia must be corrected prior to Insulin
- Prerequisites
- Electrocardiogram without signs of Hyperkalemia
- Adequate Urine Output (at least 50 ml/hour)
- Administration: Adults
- Serum Potassium <3.3 meq/L
- Do not administer Insulin until Potassium >3.3 meq/L
- If Potassium < 2.0, consider Central Line for faster Potassium Replacement
- May also use more than one large bore peripheral IV site
- Give KCl 20-30 meq/hour IV until corrects
- Requires hourly recheck of Serum Potassium
- Potassium at 40 meq/h is maximum IV Potassium rate!
- Requires cardiac monitoring
- Additional Potassium may be given orally (if patient can tolerate)
- Consider oral Potassium via Nasogastric Tube if cannot tolerate oral
- Serum Potassium 3.3 to 5.2 meq/L
- Standard replacement: 10 meq/hour
- Maintain Serum Potassium at 4 to 5 meq/L
- Recheck Serum Potassium every 2 hours
- Serum Potassium >5.2 meq/L
- Do not administer any Potassium
- Monitor every 2 hours until Potassium <5.0 meq/L
- For severe Hyperkalemia Management, delay Insulin until initial fluid boluses are completed
- Starting Insulin too soon will result in hemodynamic compromise
- Serum Potassium <3.3 meq/L
- Precautions
-
Phosphate Replacement
- Indications
- Serum Phosphorus < 0.5-1.0 mg/dl (Severe Depletion)
- Controversial - May not be required
- Phosphate is a key component of ATP (as well as DNA and 2,3-DPG)
- Hypophosphatemia (phosphate <1mg/dl) may further exacerbate organ dysfunction
- Phosphorus Replacement may result in Hypocalcemia and Hypomagnesemia
- Symptomatic Hypophosphatemia
- Cardiopulmonary effects (e.g. Arrhythmia, cardiac dysfunction)
- Neurologic effects (e.g. Seizures, metabolic encephalopathy)
- Musculoskeletal effects (e.g. Rhabdomyolysis, Muscle Weakness causing Respiratory Failure)
- Contraindications
- Administration
- Indications
-
Magnesium Replacement
- Indications
- Moderate to Severe Hypomagnesemia (Magnesium <1.2 mg/dl)
- Symptomatic Hypomagnesemia
- Administration
- Magnesium Sulfate 1 gram IM or IV over 1 hour
- Indications
-
Sodium Bicarbonate Replacement
- Indications
- ABG pH < 6.9 after initial hour of hydration
- Although recommended by ADA, specific pH cutoff for bicarbonate is controversial
- Other indications per expert opinion
- Cardiac Arrest
- Severe Hyperkalemia with Arrhythmia
- Shock with fluid refractory Hypotension
- ABG pH < 6.9 after initial hour of hydration
- Precautions
- Risk of intracellular Potassium shift and further worsening of Hypokalemia
- Potential risk of worsening cerebral edema (esp. children)
- Risk of decreasing peripheral tissue oygen delivery (due to shift in oxygen dissociation curve)
- Lack of evidence that Sodium Bicarbonate improves outcomes in pH <7.0 or 7.1
- Administration
- See Sodium Bicarbonate in Severe Metabolic Acidosis
- Dilute 100 mEq NaHCO3 and 20 mEq Potassium Citrate in 400 ml Sterile Water
- Infuse at 200 ml/hour for 2 hours or until pH>6.9
- Recheck serum Sodium Bicarbonate and Serum Potassium every 2 hours
- Indications
IV. Management: Phase 3 - Blood Glucose Control
- Precautions
- Hydration with Crystalloid (e.g. LR, NS, Plasmalyte) 1-2 Liters precedes starting Insulin
- Hypokalemia must be corrected prior to Insulin (Potassium must be >3.3 meq/L)
- Insulin's initial role in DKA is not to lower Serum Glucose
- Insulin's initial role is to stop Ketogenesis, thereby decreasing the Anion Gap and correcting the acidosis
- Adult Insulin Initiation
- IV Initial Insulin: Preferred Insulin starting regimen (no bolus)
- Assumes no delays in starting Insulin Drip (consider bolus regimen if significant delay)
- Bolus: None
- IV Continuous infusion: 0.1 units/kg/hour or 0.14 units/kg/hour Insulin
- Infuse the IV line with Insulin first to avoid delay in patient getting Insulin
- Waste 10 ml of the Insulin Drip before attaching to patient to ensure line infused
- IV Alternative Initial Insulin Bolus regimen (with bolus)
- Bolus: 0.1 units/kg IV and then
- Continuous infusion: 0.1 units/kg/hour Insulin
- Risk of Hypoglycemia and no benefit in Glucose control over no-bolus regimen
- Alternative: Subcutaneous Insulin for DKA (SQUID protocol)
- See Hourly Subcutaneous Insulin
- SQ Insulin protocol appears to be safe, fast, effective with similar outcomes to IV Insulin
- Consider in hemodynamically stable, milder DKA (Ketones <6 mmol/L, serum bicarbonate >15 mEq/L)
- Griffey (2023) Acad Emerg Med +PMID: 36775281 [PubMed]
- IV Initial Insulin: Preferred Insulin starting regimen (no bolus)
- Adult Insulin Maintenance and Titration
- IV Insulin Maintenance and titration
- Targets
- Anticipate Serum Glucose drop of 10% in first hour
- Anticipate Serum Glucose drop of 50-70 mg/dl/hour
- Anticipate serum bicarbonate increase by 3 mEq/L (3 mmol/L) per hour
- Options if inadequate Glucose correction
- Option 1: Give 0.14 units/kg IV bolus and continue prior rate
- Option 2: Increase Insulin Infusion rate by 1 unit/hour and continue at increased rate until adequate
- Option 3: Leave Insulin Drip at same rate if Metabolic Acidosis and Anion Gap are improving
- Targets
- IV Insulin Tapering
- Targets (when to start tapering)
- Anion Gap normalizes (e.g. 12 or less)
- Correct Anion Gap for albumin
- Serum Albumin will be artificially high on presentation due to Dehydration, hemoconcentration
- Anion Gap increases up to 3 mmol for each gram increase in Serum Albumin
- Beta hydroxybutyrate normalization (e.g. <1 mmol/L)
- Serum Glucose <200 mg/dl (some guidelines use <300 mg/dl as target)
- pH>7.3 and serum bicarbonate >18 mEq/L
- May be unreliable as Normal Saline is acidotic
- pH may remain suppressed due to Normal Saline (does not occur with LR)
- Anion Gap normalizes (e.g. 12 or less)
- Approach
- Keep Serum Glucose at 150 to 200 mg/dl
- Add dextrose to Intravenous Fluids
- Decrease rate by 50% (to 0.05 units/kg)
- Start subcutaneous Insulin
- Overlap IV Insulin Infusion for 30 min with SQ Insulin, and for 60 min with Insulin Pumps
- Consided early Insulin Glargine initiation while still on Insulin Infusion
- Associated with faster DKA resolution
- Resume home dose or use 0.3 units/kg Insulin Glargine
- Thammakosol (2023) Diabetes Obes Metab 25(3):815-22 +PMID: 36479786 [PubMed]
- References
- Orman and Weingart in Herbert (2015) EM:Rap 15(1): 14-6
- Targets (when to start tapering)
- IV Insulin Maintenance and titration
- Glucose monitoring
- Dextrose Administration
- Add 5% Dextrose to fluids when Glucose <200 mg/dl (see fluid management above)
- Initiate subcutaneous Insulin Dosing (overlapping by 30-60 min with Insulin Infusion as above)
- Known diabetic
- Restart prior program if previously well controlled and readjust Insulin
- New patient or poorly controlled Diabetes: Determine Insulin requirements
- Total SQ Insulin: 0.5 to 0.8 units per kg/day
- Split total daily dose into basal and Bolus Insulin
- Basal insulin (Insulin Glargine): 50% of total Insulin
- Bolus Insulin (prandial Insulin): 50% of total Insulin divided into 2-3 daily premeal doses
- Known diabetic
V. Management: Respiratory Failure
- Avoid Intubation if possible
- Peri-intubation apnea is poorly tolerated by the patient with severe Metabolic Acidosis (Cardiac Arrest risk)
- High Respiratory Rate must be matched to allow facilitate acidosis correction (otherwise Metabolic Acidosis will worsen)
- If intubation is unavoidable
- Record Respiratory Rate prior to intubation
- RSI with Rocuronium (avoid Succinylcholine due to Hyperkalemia)
- Use Intubation Preoxygenation
- Leave patient on Bipap, Ventilator SIMV or Bag Valve Mask until time to insert Laryngoscope
- Set Ventilator rate to preintubation Respiratory Rate (typically 30-40 breaths/min in severe DKA)
- Post-intubation precautions: Breath Stacking (Auto-PEEP)
- Breath Stacking (Auto-PEEP) occurs with high Ventilator rates
- Monitor repeat VBG or ABG
- Check plateau pressure at time of inspiratory pause
- Plateau pressure >30 mmHg should prompt disconnecting vent to allow for a full expiration
- Decrease Respiratory Rate if Breath Stacking occurs
VI. Management
- Physiologic Targets for DKA Resolution
- Clinical improvement (normal alertness, taking oral fluids, hemodynamically stable) AND
- pH >7.3 and serum bicarbonate >=18 meq/L AND
- Normalization of beta hydroxybutyrate
- Blood Glucose <200 to 250 mg/dl
- Home Disposition from Emergency Department
- Most patients with significant DKA are admitted to Intensive Care Unit on Insulin Drip
- Indications
- Alert mental status AND
- Taking oral fluids AND
- Mild Diabetic Ketoacidosis that is corrected in Emergency Department
- Anion Gap <17 AND
- Serum Bicarbonate >18-20 AND
- Serum Glucose <250 mg/dl
VII. Labs: Monitoring every 2-4 hours until stable
- Telemetry
- Serum Electrolytes (esp. Serum Potassium, Serum Creatinine, Serum Sodium)
- Bedside Glucose (checked every 1 hour as above)
VIII. Resources
- FpNotebook DKA Adult Management Flowsheet
IX. References
- Kirschke (2020) Crit Dec Emerg Med 34(8): 3-7
- Orland in Stine (1994) Emergency Med, p. 204-5
- Orman and Willis in Herbert (2017) EM:Rap 17(9): 19-20
- Orman and Willis in Herbert (2017) EM:Rap 17(11): 13-5
- Swaminathan in Herbert (2013) EM:Rap 13(5): 9-10
- Swaminathan and Weingart in Herbert (2018) 18(7): 2-3
- Chiasson (2003) CMAJ 168:859-66 [PubMed]
- Kitabchi (2001) Diabetes Care 24:131-53 [PubMed]
- Kitabchi (2009) Diabetes Care 32(7): 1335-43 [PubMed]
- Trachtenbarg (2005) Am Fam Physician 71(9): 1705-22 [PubMed]
- Trence (2001) Endocrinol Metab Clin North Am 30:817-31 [PubMed]
- Veauthier (2024) Am Fam Physician 110(5): 476-86 [PubMed]