Diabetic ketoacidosis

Plus – supportive care + ICU admission

Back

1st line –

intravenous fluids

Severe volume depletion is indicated by the presence of orthostatic hypotension or supine hypotension, dry mucous membranes, and poor skin turgor. Extreme cases may be hemodynamically unstable.

The goal of initial fluid therapy is to restore tissue perfusion. The initial choice of fluid is isotonic saline infused at a rate of 1.0 to 1.5 L (or 15-20 mL/kg body weight) for the first hour. In patients with severe volume depletion or cardiogenic shock, isotonic fluid therapy and hemodynamic monitoring should continue in the intensive care unit until the patient becomes stable.

Electrolytes should be checked at least hourly (to monitor potassium levels) and BUN, venous pH, creatinine, and glucose should be checked every 2-4 hours until the resolution of DKA.

When plasma glucose reaches 200 mg/dL, fluid therapy should be changed to 5% dextrose with 0.45% NaCl at 150-250 mL/hour in order to avoid hypoglycemia.[1]

Back

Plus –

supportive care + ICU admission

Treatment recommended for ALL patients in selected patient group

Indications for intensive care unit (ICU) admission include hemodynamic instability or cardiogenic shock, altered mental status, respiratory insufficiency, and severe acidosis.

After admission to ICU, central venous and arterial lines are required as well as Swan-Ganz catheterization and continuous percutaneous oximetry.

Intubation and mechanical ventilation are commonly required, with constant monitoring of respiratory parameters.

How to insert a tracheal tube in an adult using a laryngoscope.

How to use bag-valve-mask apparatus to deliver ventilatory support to adults. Video demonstrates the two-person technique.

Nasogastric suctioning is always performed because of frequent ileus and danger of aspiration.[1]

Plus – intravenous insulin once serum potassium reaches 3.3 mEq/L

Back

Plus –

potassium therapy

Treatment recommended for ALL patients in selected patient group

Insulin therapy and correction of hyperosmolarity and acidemia decrease plasma concentration of potassium. For this reason, insulin therapy should be withheld until the serum potassium level reaches 3.3 mEq/L.

Likewise, if plasma potassium falls <3.3 mEq/L at any point of therapy, insulin should be discontinued.

The dose of potassium replacement is 20-30 mEq added to each liter of infusion fluid.[1]

Choices are potassium phosphate or potassium chloride. One third of the potassium replacement should be administered as potassium phosphate to avoid excessive chloride administration.

The serum potassium level should be monitored at least hourly and replacement adjusted accordingly.

Primary options

potassium phosphate: 20-30 mEq added to each liter of infusion fluid initially, adjust dose according to serum potassium level

potassium chloride: 20-30 mEq added to each liter of infusion fluid initially, adjust dose according to serum potassium level

Back

Plus –

intravenous insulin once serum potassium reaches 3.3 mEq/L

Treatment recommended for ALL patients in selected patient group

Insulin therapy should not be commenced until serum potassium reaches 3.3 mEq/L.

Patients should receive a continuous intravenous infusion of regular insulin after exclusion of hypokalemia (i.e., potassium level should be >3.3 mEq/L before initiation of insulin therapy). This is the standard of care in critically ill and mentally obtunded patients with DKA.[3] Two alternative low-dose regimens are recommended by the American Diabetes Association (ADA).[1] The first option is a continuous intravenous infusion of regular insulin at a dose of 0.14 units/kg/hour (approximately 10 units/hour in a 70 kg patient) with no initial bolus.[1] This is based on studies that show the use of low-dose regular insulin administered by intravenous infusion is sufficient for the treatment of DKA, provided the dose is >0.1 units/kg/hour. The alternative regimen involves an initial intravenous bolus dose of 0.1 units/kg followed by a continuous infusion at a dose of 0.1 units/kg/hour.[53] These low-dose insulin therapy protocols decrease plasma glucose concentration at a rate of 50-75 mg/dL/hour.[1]

If plasma glucose does not fall by at least 10% or 50 mg/dL in the first hour of insulin infusion, then a dose of 0.14 units/kg of regular insulin should be administered as an intravenous bolus and the continuous insulin infusion rate should be continued (either 0.1 units/kg/hour or 0.14 units/kg/hour depending on the regimen selected).[1][53] Insulin injection by a sliding scale is no longer recommended. When serum glucose reaches 200 mg/dL, the infusion can be reduced to 0.02 to 0.05 units/kg/hour, at which time dextrose may be added to the intravenous fluids.[1][53] The rate of insulin infusion (or the dextrose concentration) should then be adjusted to maintain a plasma glucose level of between 150-200 mg/dL.[1]

This regimen should be followed until all remaining criteria for resolution are met: serum bicarbonate >18 mEq/L, venous pH >7.3, and anion gap <10.[1]

Primary options

insulin regular: consult local protocols for dosing guidelines

Consider – vasopressors

Back

Consider –

vasopressors

Treatment recommended for SOME patients in selected patient group

In hemodynamically unstable patients, vasopressor therapy may also be required.[1][52]

Consult a specialist for guidance on suitable vasopressor regimens.

Back

Consider –

bicarbonate therapy

Treatment recommended for SOME patients in selected patient group

Bicarbonate therapy may be used in adult patients with pH <7 or a bicarbonate level <5 mEq/L, although data are limited.[1][64]

In adults with pH 6.9 to 7.0, 50 mmol sodium bicarbonate (1 ampule) in 200 mL sterile water with 10 mEq KCl may be administered over 1 hour until pH is >7.0.

In adults with pH <6.9, we recommend that 100 mmol sodium bicarbonate in 400 mL sterile water with 20 mEq KCl be administered at a rate of 200 mL/hour for 2 hours or until pH >7.0. Treatment should be repeated every 2 hours until pH >7.0. Bicarbonate therapy, like insulin therapy, lowers serum potassium; therefore, KCl is added to isotonic bicarbonate.[1][65]

Primary options

sodium bicarbonate: serum pH 6.9 to 7.0: 50 mmol intravenous infusion over 1 hour until pH >7.0; serum pH <6.9: 100 mmol intravenous infusion at a rate of 200 mL/hour for 2 hours or until pH >7.0

serum potassium 3.3 to 5.3 mEq/L

Back

Consider –

phosphate therapy

Treatment recommended for SOME patients in selected patient group

Routine replacement of phosphate is not recommended.

However, to avoid cardiac, respiratory, and skeletal muscle dysfunction, careful phosphate therapy may be indicated in patients with cardiac dysfunction (e.g., with signs of left ventricular dysfunction), symptomatic anemia, or respiratory depression (e.g., decreased oxygen saturation), and in those with confirmed hypophosphatemia (serum phosphate concentration <1.0 mg/dL).[1]

The dose is 20-30 mEq/L potassium phosphate added to replacement fluids.

Phosphate therapy above the recommended dose may result in severe hypocalcemia.[1][77][78]

Primary options

potassium phosphate: 20-30 mEq added to each liter of infusion fluid

Plus – supportive care + ICU admission

Back

1st line –

intravenous fluids

Severe volume depletion is indicated by the presence of orthostatic hypotension or supine hypotension, dry mucous membranes, and poor skin turgor. Extreme cases may be hemodynamically unstable.

The goal of initial fluid therapy is to restore tissue perfusion. The initial choice of fluid is isotonic saline infused at a rate of 1.0 to 1.5 L (or 15-20 mL/kg body weight) for the first hour. In patients with severe volume depletion (i.e., orthostatic or supine hypotension, dry mucous membranes, and poor skin turgor) or cardiogenic shock, isotonic fluid therapy and hemodynamic monitoring should continue in the intensive care unit until the patient becomes stable.

Electrolytes should be checked at least hourly (to monitor potassium levels) and BUN, venous pH, creatinine, and glucose should be checked every 2-4 hours until the resolution of DKA.

When plasma glucose reaches 200 mg/dL, fluid therapy should be changed to 5% dextrose with 0.45% NaCl at 150-250 mL/hour in order to avoid hypoglycemia.[1]

Back

Plus –

supportive care + ICU admission

Treatment recommended for ALL patients in selected patient group

Indications for intensive care unit (ICU) admission include hemodynamic instability or cardiogenic shock, altered mental status, respiratory insufficiency, and severe acidosis.

After admission to ICU, central venous and arterial lines are required as well as Swan-Ganz catheterization and continuous percutaneous oximetry.

Intubation and mechanical ventilation are commonly required, with constant monitoring of respiratory parameters.

How to insert a tracheal tube in an adult using a laryngoscope.

Plus – intravenous insulin

How to use bag-valve-mask apparatus to deliver ventilatory support to adults. Video demonstrates the two-person technique.

Nasogastric suctioning is always performed because of frequent ileus and danger of aspiration.

Back

Plus –

intravenous insulin

Treatment recommended for ALL patients in selected patient group

Patients should receive a continuous intravenous infusion of regular insulin after exclusion of hypokalemia (i.e., potassium level should be >3.3 mEq/L before initiation of insulin therapy). This is the standard of care in critically ill and mentally obtunded patients with DKA.[3] Two alternative low-dose regimens are recommended by the ADA.[1] The first option is a continuous intravenous infusion of regular insulin at a dose of 0.14 units/kg/hour (approximately 10 units/hour in a 70 kg patient) with no initial bolus.[1] This is based on studies that show the use of low-dose regular insulin administered by intravenous infusion is sufficient for the treatment of DKA, provided the dose is above 0.1 units/kg/hour. The alternative regimen involves an initial intravenous bolus dose of 0.1 units/kg followed by a continuous infusion at a dose of 0.1 units/kg/hour.[53] These low-dose insulin therapy protocols decrease plasma glucose concentration at a rate of 50 to 75 mg/dL/hour.[1]

If plasma glucose does not fall by at least 10% or 50 mg/dL in the first hour of insulin infusion, then a dose of 0.14 units/kg of regular insulin should be administered as an intravenous bolus and the continuous insulin infusion rate should be continued (either 0.1 units/kg/hour or 0.14 units/kg/hour depending on the regimen selected).[1][53] Insulin injection by a sliding scale is no longer recommended. When serum glucose reaches 200 mg/dL, the infusion can be reduced to 0.05 units/kg/hour, at which time dextrose may be added to the intravenous fluids.[1][53] The rate of insulin infusion (or the dextrose concentration) should then be adjusted to maintain a plasma glucose level of between 150-200 mg/dL.[1]

This regimen should be followed until all remaining criteria for resolution are met: serum bicarbonate >18 mEq/L, venous pH >7.3, and anion gap <10.[1]

If plasma potassium falls below 3.3 mEq/L at any point, insulin should be discontinued and potassium replaced intravenously. Insulin therapy can be restarted when the potassium level returns to 3.3 mEq/L.

Primary options

insulin regular: consult local protocols for dosing guidelines

Consider – vasopressors

Back

Plus –

potassium therapy

Treatment recommended for ALL patients in selected patient group

Insulin therapy and correction of hyperosmolarity and acidemia decrease the plasma concentration of potassium. Concurrent potassium replacement is recommended if the serum potassium is in the range 3.3 to 5.3 mEq/L, to prevent cardiac arrhythmias due to hypokalemia. The dose is 20-30 mEq added to each liter of infusion fluid. If potassium is <3.3 mEq/L at any point of therapy, insulin should be discontinued and potassium replaced intravenously.[1]

Choices are potassium phosphate or potassium chloride. One third of the potassium replacement should be administered as potassium phosphate to avoid excessive chloride administration.

The serum potassium level should be monitored at least hourly and replacement adjusted accordingly.

Primary options

potassium phosphate: 20-30 mEq added to each liter of infusion fluid initially, adjust dose according to serum potassium level

potassium chloride: 20-30 mEq added to each liter of infusion fluid initially, adjust dose according to serum potassium level

Back

Consider –

vasopressors

Treatment recommended for SOME patients in selected patient group

In hemodynamically unstable patients, vasopressor therapy may also be required.[1][52]

Consult a specialist for guidance on suitable vasopressor regimen.

Back

Consider –

bicarbonate therapy

Treatment recommended for SOME patients in selected patient group

Bicarbonate therapy may be used in adult patients with pH <7 or a bicarbonate level <5 mEq/L, although data are limited.[1][64]

In adults with pH 6.9 to 7.0, 50 mmol sodium bicarbonate (1 ampule) in 200 mL sterile water with 10 mEq KCl may be administered over 1 hour until pH is >7.0.

Primary options

sodium bicarbonate: serum pH 6.9 to 7.0: 50 mmol intravenous infusion over 1 hour until pH >7.0; serum pH <6.9: 100 mmol intravenous infusion at a rate of 200 mL/hour for 2 hours or until pH >7.0

serum potassium >5.3 mEq/L

Back

Consider –

phosphate therapy

Treatment recommended for SOME patients in selected patient group

Routine replacement of phosphate is not recommended.

The dose is 20-30 mEq/L potassium phosphate added to replacement fluids.

Phosphate therapy above the recommended dose may result in severe hypocalcemia.[1][77][78]

Primary options

potassium phosphate: 20-30 mEq added to each liter of infusion fluid

Plus – supportive care + ICU admission

Back

1st line –

intravenous fluids

Severe volume depletion is indicated by the presence of orthostatic hypotension or supine hypotension, dry mucous membranes, and poor skin turgor. Extreme cases may be hemodynamically unstable.

The goal of initial fluid therapy is to restore tissue perfusion. The initial choice of fluid is isotonic saline infused at a rate of 1.0 to 1.5 L (or 15-20 mL/kg body weight) for the first hour. In patients with severe volume depletion (i.e., orthostatic or supine hypotension, dry mucous membranes, and poor skin turgor) or cardiogenic shock, isotonic fluid therapy and hemodynamic monitoring should continue in the intensive care unit until the patient becomes stable.

Electrolytes should be checked at least hourly (to monitor potassium levels), and BUN, venous pH, creatinine, and glucose should be checked every 2-4 hours until the resolution of DKA.

When plasma glucose reaches 200 mg/dL, fluid therapy should be changed to 5% dextrose with 0.45% NaCl at 150-250 mL/hour in order to avoid hypoglycemia.[1]

Back

Plus –

supportive care + ICU admission

Treatment recommended for ALL patients in selected patient group

Indications for intensive care unit (ICU) admission include hemodynamic instability or cardiogenic shock, altered mental status, respiratory insufficiency, and severe acidosis.

After admission to ICU, central venous and arterial lines are required as well as Swan-Ganz catheterization and continuous percutaneous oximetry.

Intubation and mechanical ventilation are commonly required, with constant monitoring of respiratory parameters.

How to insert a tracheal tube in an adult using a laryngoscope.

Plus – intravenous insulin

How to use bag-valve-mask apparatus to deliver ventilatory support to adults. Video demonstrates the two-person technique.

Nasogastric suctioning is always performed because of frequent ileus and danger of aspiration.

Back

Plus –

intravenous insulin

Treatment recommended for ALL patients in selected patient group

Patients should receive a continuous intravenous infusion of regular insulin after exclusion of hypokalemia (i.e., potassium level should be >3.3 mEq/L before initiation of insulin therapy). This is the standard of care in critically ill and mentally obtunded patients with DKA.[3] Two alternative low-dose regimens are recommended by the ADA.[1] The first option is a continuous intravenous infusion of regular insulin at a dose of 0.14 units/kg/hour (approximately 10 units/hour in a 70 kg patient) with no initial bolus.[1] This is based on studies that show the use of low-dose regular insulin administered by intravenous infusion is sufficient for the treatment of DKA, provided the dose is above 0.1 units/kg/hour. The alternative regimen involves an initial intravenous bolus dose of 0.1 units/kg followed by a continuous infusion at a dose of 0.1 units/kg/hour.[53] These low-dose insulin therapy protocols decrease plasma glucose concentration at a rate of 50-75 mg/dL/hour.[1]

This regimen should be followed until all remaining criteria for resolution are met: serum bicarbonate >18 mEq/L, venous pH >7.3, and anion gap <10.[1]

Potassium replacement is not required, but potassium levels should be checked every 2 hours.

Primary options

insulin regular: consult local protocols for dosing guidelines

Consider – vasopressors

Back

Consider –

vasopressors

Treatment recommended for SOME patients in selected patient group

In hemodynamically unstable patients, vasopressor therapy may also be required.[1][52]

Consult a specialist for guidance on suitable vasopressor regimen.

Back

Consider –

bicarbonate therapy

Treatment recommended for SOME patients in selected patient group

Bicarbonate therapy may be used in adult patients with pH <7 or a bicarbonate level <5 mEq/L, although data are limited.[1][64]

In adults with pH 6.9 to 7.0, 50 mmol sodium bicarbonate (1 ampule) in 200 mL sterile water with 10 mEq KCl may be administered over 1 hour until pH is >7.0.

Primary options

sodium bicarbonate: serum pH 6.9 to 7.0: 50 mmol intravenous infusion over 1 hour until pH >7.0; serum pH <6.9: 100 mmol intravenous infusion over 2 hours or until pH >7.0

serum potassium <3.3 mEq/L

Back

Consider –

phosphate therapy

Treatment recommended for SOME patients in selected patient group

Routine replacement of phosphate is not recommended.

The dose is 20-30 mEq/L potassium phosphate added to replacement fluids.

Phosphate therapy above the recommended dose may result in severe hypocalcemia.[1][77][78]

Primary options

potassium phosphate: 20-30 mEq added to each liter of infusion fluid

mild to moderate volume depletion: hyponatremic

Back

1st line –

intravenous fluids

Mild to moderate volume depletion is indicated by the absence of orthostatic hypotension or supine hypotension, dry mucous membranes, and poor skin turgor. The goal is to gradually replace half of the fluid deficit over 12-24 hours, to prevent complications such as cerebral edema.

The initial choice of fluid is isotonic saline infused at a rate of 1.0 to 1.5 L (or 15-20 mL/kg body weight) for the first hour.

Following the initial fluid replacement, corrected serum sodium level should be evaluated (corrected sodium [mEq/L] = measured sodium [mEq/L] + 0.016 [glucose (mg/dL) - 100]). In patients found to be hyponatremic, 0.9% NaCl should be started at 250-500 mL/hour.

Electrolytes should be checked at least hourly (to monitor potassium levels), and BUN, venous pH, creatinine, and glucose should be checked every 2-4 hours until the resolution of DKA.

When plasma glucose reaches 200 mg/dL, fluid therapy should be changed to 5% dextrose with 0.45% NaCl at 150-250 mL/hour in order to avoid hypoglycemia.[1]

Back

Plus –

supportive care ± ICU admission

Treatment recommended for ALL patients in selected patient group

Indications for intensive care unit (ICU) admission include altered mental status, respiratory insufficiency, and severe acidosis.

After admission to ICU, central venous and arterial lines are required as well as Swan-Ganz catheterization and continuous percutaneous oximetry. Intubation and mechanical ventilation are commonly required, with constant monitoring of respiratory parameters. Nasogastric suctioning is always performed because of frequent ileus and danger of aspiration.

How to insert a tracheal tube in an adult using a laryngoscope.

How to use bag-valve-mask apparatus to deliver ventilatory support to adults. Video demonstrates the two-person technique.

Mild cases of DKA may be managed without ICU admission.[1]

Plus – insulin once serum potassium reaches 3.3 mEq/L

Back

Plus –

potassium therapy

Treatment recommended for ALL patients in selected patient group

Likewise, if plasma potassium falls <3.3 mEq/L at any point of therapy, insulin should be discontinued.

The dose is 20-30 mEq added to each liter of infusion fluid.[1]

Choices for potassium therapy are potassium phosphate or potassium chloride. One third of the potassium replacement should be administered as potassium phosphate to avoid excessive chloride administration.

Primary options

potassium phosphate: 20-30 mEq added to each liter of infusion fluid initially, adjust dose according to serum potassium level

potassium chloride: 20-30 mEq added to each liter of infusion fluid initially, adjust dose according to serum potassium level

Back

Plus –

insulin once serum potassium reaches 3.3 mEq/L

Treatment recommended for ALL patients in selected patient group

Insulin therapy should not be commenced until serum potassium reaches 3.3 mEq/L.

Patients should receive a continuous intravenous infusion of regular insulin after exclusion of hypokalemia (i.e., potassium level should be >3.3 mEq/L before initiation of insulin therapy). This is the standard of care in critically ill and mentally obtunded patients with DKA.[3] Two alternative low-dose regimens are recommended by the ADA.[1] The first option is a continuous intravenous infusion of regular insulin at a dose of 0.14 units/kg/hour (approximately 10 units/hour in a 70 kg patient) with no initial bolus.[1] This is based on studies that show the use of low-dose regular insulin administered by intravenous infusion is sufficient for the treatment of DKA, provided the dose is above 0.1 units/kg/hour. The alternative regimen involves an initial intravenous bolus dose of 0.1 units/kg followed by a continuous infusion at a dose of 0.1 units/kg/hour.[53] These low-dose insulin therapy protocols decrease plasma glucose concentration at a rate of 50-75 mg/dL/hour.[1]

Patients with mild to moderate DKA (plasma glucose >250 mg/dL, arterial pH 7.00-7.30, serum bicarbonate 10-18 mEq/L) that is not complicated by acute MI, congestive heart failure, end-stage renal or hepatic failure, steroid use, or pregnancy, may be given rapid-acting insulin subcutaneously as an alternative to intravenous regular insulin (with no significant difference in outcomes when using either approach alongside aggressive fluid management for mild or moderate DKA).[3][61][62][63] [ ] A suggested protocol would be an initial subcutaneous injection of rapid-acting insulin at a dose of 0.3 units/kg, followed 1 hour later by another subcutaneous injection of 0.2 units/kg. Thereafter, they should receive 0.2 units/kg every 2 hours until blood glucose becomes <250 mg/dL. At this point, the insulin dose should be decreased by half to 0.1 units/kg every 2 hours until the resolution of DKA.[59] Patients treated with subcutaneous insulin should receive adequate fluid replacement, frequent bedside blood glucose testing and appropriate treatment of underlying causes to avoid recurrent DKA.[3] Continuous intravenous infusion of regular insulin should remain the preferred route because of intravenous insulin's short half-life and easy titration. This is compared with the delayed onset of action and prolonged half-life of subcutaneously administered insulin. However, if there are prolonged waiting times for intensive care unit (ICU) admission or limited medical resources, the use of insulin analogs for the treatment of mild uncomplicated DKA episodes can be considered for outpatient, general floors, or emergency departments.

Patients with severe DKA (plasma glucose >250 mg/dL, arterial pH <7.00, serum bicarbonate <10 mEq/L), hypotension, anasarca (severe generalized edema), or associated severe critical illness should be managed with intravenous regular insulin in the ICU using the regimen described above.[1][59][58][60]

This regimen should be followed until all remaining criteria for resolution are met: serum bicarbonate >18 mEq/L, venous pH >7.3, and anion gap <10.[1]

Primary options

insulin regular: consult local protocols for dosing guidelines

Secondary options

insulin aspart: consult local protocols for dosing guidelines

insulin lispro: consult local protocols for dosing guidelines

Back

Consider –

bicarbonate therapy

Treatment recommended for SOME patients in selected patient group

Bicarbonate therapy may be used in adult patients with pH <7 or a bicarbonate level <5 mEq/L, although data are limited.[1][64]

In adults with pH 6.9 to 7.0, 50 mmol sodium bicarbonate (1 ampule) in 200 mL sterile water with 10 mEq KCl may be administered over 1 hour until pH is >7.0.

Primary options

sodium bicarbonate: serum pH 6.9 to 7.0: 50 mmol intravenous infusion over 1 hour until pH >7.0; serum pH <6.9: 100 mmol intravenous infusion at a rate of 200 mL/hour for 2 hours or until pH >7.0

serum potassium 3.3 to 5.3 mEq/L

Back

Consider –

phosphate therapy

Treatment recommended for SOME patients in selected patient group

Routine replacement of phosphate is not recommended.

The dose is 20-30 mEq/L potassium phosphate added to replacement fluids.

Phosphate therapy above the recommended dose may result in severe hypocalcemia.[1][77][78]

Primary options

potassium phosphate: 20-30 mEq added to each liter of infusion fluid

Back

1st line –

intravenous fluids

The initial choice of fluid is isotonic saline infused at a rate of 1.0 to 1.5 L (or 15-20 mL/kg body weight) for the first hour.

Electrolytes should be checked at least hourly (to monitor potassium levels), and BUN, venous pH, creatinine, and glucose should be checked every 2-4 hours until the resolution of DKA.

When plasma glucose reaches 200 mg/dL, fluid therapy should be changed to 5% dextrose with 0.45% NaCl at 150-250 mL/hour in order to avoid hypoglycemia.[1]

Back

Plus –

supportive care ± ICU admission

Treatment recommended for ALL patients in selected patient group

Indications for intensive care unit (ICU) admission include altered mental status, respiratory insufficiency, and severe acidosis.

How to insert a tracheal tube in an adult using a laryngoscope.

How to use bag-valve-mask apparatus to deliver ventilatory support to adults. Video demonstrates the two-person technique.

Mild cases of DKA may be managed without ICU admission.[1]

Back

Plus –

insulin

Treatment recommended for ALL patients in selected patient group

Patients should receive a continuous intravenous infusion of regular insulin after exclusion of hypokalemia (i.e., potassium level should be >3.3 mEq/L before initiation of insulin therapy). This is the standard of care in critically ill and mentally obtunded patients with DKA.[3] Two alternative low-dose regimens are recommended by the ADA.[1] The first option is a continuous intravenous infusion of regular insulin at a dose of 0.14 units/kg/hour (approximately 10 units/hour in a 70 kg patient) with no initial bolus.[1] This is based on studies that show the use of low-dose regular insulin administered by intravenous infusion is sufficient for the treatment of DKA, provided the dose is above 0.1 units/kg/hour. The alternative regimen involves an initial intravenous bolus dose of 0.1 units/kg followed by a continuous infusion at a dose of 0.1 units/kg/hour.[53] These low-dose insulin therapy protocols decrease plasma glucose concentration at a rate of 50-75 mg/dL/hour.[1]

Patients with mild to moderate DKA (plasma glucose >250 mg/dL, arterial pH 7.00 to 7.30, serum bicarbonate 10-18 mEq/L) that is not complicated by acute MI, congestive heart failure, end-stage renal or hepatic failure, steroid use, or pregnancy, may be given rapid-acting insulin subcutaneously as an alternative to intravenous regular insulin (with no significant difference in outcomes when using either approach alongside aggressive fluid management for mild or moderate DKA).[3][61][62][63] [ ] A suggested protocol would be an initial subcutaneous injection of rapid-acting insulin at a dose of 0.3 units/kg, followed 1 hour later by another subcutaneous injection of 0.2 units/kg. Thereafter, they should receive 0.2 units/kg every 2 hours until blood glucose becomes <250 mg/dL. At this point, the insulin dose should be decreased by half to 0.1 units/kg every 2 hours until the resolution of DKA.[59] Patients treated with subcutaneous insulin should receive adequate fluid replacement, frequent bedside blood glucose testing and appropriate treatment of underlying causes to avoid recurrent DKA.[3] Continuous intravenous infusion of regular insulin should, however, remain the preferred route because of intravenous insulin's short half-life and easy titration. This is compared with the delayed onset of action and prolonged half-life of subcutaneously administered insulin. However, if there are prolonged waiting times for intensive care unit (ICU) admission or limited medical resources, the use of insulin analogs for the treatment of mild or moderate uncomplicated DKA episodes can be considered for outpatients, in general floors, or in emergency departments.[3]

The intravenous or subcutaneous regimens should be followed until all remaining criteria for resolution are met: serum bicarbonate >18 mEq/L, venous pH >7.3, and anion gap <10.[1]

Primary options

insulin regular: consult local protocols for dosing guidelines

Secondary options

insulin aspart: consult local protocols for dosing guidelines

insulin lispro: consult local protocols for dosing guidelines

Back

Plus –

potassium therapy

Treatment recommended for ALL patients in selected patient group

Choices are potassium phosphate or potassium chloride. One third of the potassium replacement should be administered as potassium phosphate to avoid excessive chloride administration.

The serum potassium level should be monitored at least hourly and replacement adjusted accordingly.

Primary options

potassium phosphate: 20-30 mEq added to each liter of infusion fluid initially, adjust dose according to serum potassium level

potassium chloride: 20-30 mEq added to each liter of infusion fluid initially, adjust dose according to serum potassium level

Back

Consider –

bicarbonate therapy

Treatment recommended for SOME patients in selected patient group

Bicarbonate therapy may be used in adult patients with pH <7 or a bicarbonate level <5 mEq/L, although data are limited.[1][64]

In adults with pH 6.9 to 7.0, 50 mmol sodium bicarbonate (1 ampule) in 200 mL sterile water with 10 mEq KCl may be administered over 1 hour until pH is >7.0.

Primary options

sodium bicarbonate: serum pH 6.9 to 7.0: 50 mmol intravenous infusion over 1 hour until pH >7.0; serum pH <6.9: 100 mmol intravenous infusion at a rate of 200 mL/hour for 2 hours or until pH >7.0

serum potassium >5.3 mEq/L

Back

Consider –

phosphate therapy

Treatment recommended for SOME patients in selected patient group

Routine replacement of phosphate is not recommended.

The dose is 20-30 mEq/L potassium phosphate added to replacement fluids.

Phosphate therapy above the recommended dose may result in severe hypocalcemia.[1][77][78]

Primary options

potassium phosphate: 20-30 mEq added to each liter of infusion fluid

Back

1st line –

intravenous fluids

The initial choice of fluid is isotonic saline infused at a rate of 1.0 to 1.5 L (or 15-20 mL/kg body weight) for the first hour.

Potassium replacement is not required, but potassium levels should be checked every 2 hours.

Electrolytes, BUN, venous pH, creatinine, and glucose should be checked every 2-4 hours until the resolution of DKA.

When plasma glucose reaches 200 mg/dL, fluid therapy should be changed to 5% dextrose with 0.45% NaCl at 150-250 mL/hour in order to avoid hypoglycemia.[1]

Back

Plus –

supportive care ± ICU admission

Treatment recommended for ALL patients in selected patient group

Indications for intensive care unit (ICU) admission include altered mental status, respiratory insufficiency, and severe acidosis.

How to insert a tracheal tube in an adult using a laryngoscope.

How to use bag-valve-mask apparatus to deliver ventilatory support to adults. Video demonstrates the two-person technique.

Mild cases of diabetic ketoacidosis may be managed without ICU admission.[1]

Back

Plus –

insulin

Treatment recommended for ALL patients in selected patient group

Patients should receive a continuous intravenous infusion of regular insulin after exclusion of hypokalemia (i.e., potassium level should be >3.3 mEq/L before initiation of insulin therapy). This is the standard of care in critically ill and mentally obtunded patients with DKA.[3] Two alternative low-dose regimens are recommended by the ADA.[1] The first option is a continuous intravenous infusion of regular insulin at a dose of 0.14 units/kg/hour (approximately 10 units/hour in a 70 kg patient) with no initial bolus.[1] This is based on studies that show the use of low-dose regular insulin administered by intravenous infusion is sufficient for the treatment of DKA, provided the dose is above 0.1 units/kg/hour. The alternative regimen involves an initial intravenous bolus dose of 0.1 units/kg followed by a continuous infusion at a dose of 0.1 units/kg/hour.[53] These low-dose insulin therapy protocols decrease plasma glucose concentration at a rate of 50-75 mg/dL/hour.[1]

Patients with mild to moderate DKA (plasma glucose >250 mg/dL, arterial pH 7.00 to 7.30, serum bicarbonate 10-18 mEq/L) that is not complicated by acute MI, congestive heart failure, end-stage renal or hepatic failure, steroid use, or pregnancy, may be given rapid-acting insulin subcutaneously as an alternative to intravenous regular insulin (with no significant difference in outcomes when using either approach alongside aggressive fluid management for mild or moderate DKA).[3][61][62][63] [ ] A suggested protocol would be an initial subcutaneous injection of rapid-acting insulin at a dose of 0.3 units/kg, followed 1 hour later by another subcutaneous injection of 0.2 units/kg. Thereafter, they should receive 0.2 units/kg every 2 hours until blood glucose becomes <250 mg/dL. At this point, the insulin dose should be decreased by half to 0.1 units/kg every 2 hours until the resolution of DKA.[59] Patients treated with subcutaneous insulin should receive adequate fluid replacement, frequent bedside blood glucose testing and appropriate treatment of underlying causes to avoid recurrent DKA.[3] Continuous intravenous infusion of regular insulin should remain the preferred route because of intravenous insulin's short half-life and easy titration. This is compared with the delayed onset of action and prolonged half-life of subcutaneously administered insulin. However, if there are prolonged waiting times for intensive care unit (ICU) admission or with limited medical resources, the use of insulin analogs for the treatment of mild or moderate uncomplicated DKA episodes can be considered for outpatients, in general floors, or in emergency departments.[3]

The intravenous or subcutaneous regimens should be followed until all remaining criteria for resolution are met: serum bicarbonate >18 mEq/L, venous pH >7.3, and anion gap <10.[1]

Primary options

insulin regular: consult local protocols for dosing guidelines

Secondary options

insulin aspart: consult local protocols for dosing guidelines

insulin lispro: consult local protocols for dosing guidelines

Back

Consider –

bicarbonate therapy

Treatment recommended for SOME patients in selected patient group

Bicarbonate therapy may be used in adult patients with pH <7 or a bicarbonate level <5 mEq/L, although data are limited.[1][64]

In adults with pH 6.9 to 7.0, 50 mmol sodium bicarbonate (1 ampule) in 200 mL sterile water with 10 mEq KCl may be administered over 1 hour until pH is >7.0.

Primary options

sodium bicarbonate: serum pH 6.9 to 7.0: 50 mmol intravenous infusion over 1 hour until pH >7.0; serum pH <6.9: 100 mmol intravenous infusion at a rate of 200 mL/hour for 2 hours or until pH >7.0

serum potassium <3.3 mEq/L

Back

Consider –

phosphate therapy

Treatment recommended for SOME patients in selected patient group

Routine replacement of phosphate is not recommended.

The dose is 20-30 mEq/L potassium phosphate added to replacement fluids.

Phosphate therapy above the recommended dose may result in severe hypocalcemia.[1][77][78]

Primary options

potassium phosphate: 20-30 mEq added to each liter of infusion fluid

mild to moderate volume depletion: eunatremic or hypernatremic

Back

1st line –

intravenous fluids

The initial choice of fluid is isotonic saline infused at a rate of 1.0 to 1.5 L (or 15-20 mL/kg body weight) for the first hour.

Following the initial fluid replacement, corrected serum sodium level should be evaluated (corrected sodium [mEq/L] = measured sodium [mEq/L] + 0.016 [glucose (mg/dL) - 100]). In patients found to be hypernatremic or eunatremic, 0.45% NaCl at 250 to 500 mL/hour is recommended.

Electrolytes should be checked at least hourly (to monitor potassium levels), and BUN, venous pH, creatinine, and glucose should be checked every 2-4 hours until the resolution of DKA.

Back

Plus –

supportive care ± ICU admission

Treatment recommended for ALL patients in selected patient group

Indications for intensive care unit (ICU) admission include altered mental status, respiratory insufficiency, and severe acidosis.

How to insert a tracheal tube in an adult using a laryngoscope.

How to use bag-valve-mask apparatus to deliver ventilatory support to adults. Video demonstrates the two-person technique.

Mild cases of DKA may be managed without ICU admission.[1]

Plus – insulin once serum potassium reaches 3.3 mEq/L

Back

Plus –

potassium therapy

Treatment recommended for ALL patients in selected patient group

Likewise, if plasma potassium falls <3.3 mEq/L at any point of therapy, insulin should be discontinued.

The dose is 20-30 mEq added to each liter of infusion fluid.[1]

The serum potassium level should be monitored at least hourly and replacement adjusted accordingly.

Primary options

potassium phosphate: 20-30 mEq added to each liter of infusion fluid initially, adjust dose according to serum potassium level

potassium chloride: 20-30 mEq added to each liter of infusion fluid initially, adjust dose according to serum potassium level

Back

Plus –

insulin once serum potassium reaches 3.3 mEq/L

Treatment recommended for ALL patients in selected patient group

Insulin therapy should not be commenced until serum potassium reaches 3.3 mEq/L.

Patients should receive a continuous intravenous infusion of regular insulin after exclusion of hypokalemia (i.e., potassium level should be >3.3 mEq/L before initiation of insulin therapy). This is the standard of care in critically ill and mentally obtunded patients with DKA.[3] Two alternative low-dose regimens are recommended by the ADA.[1] The first option is a continuous intravenous infusion of regular insulin at a dose of 0.14 units/kg/hour (approximately 10 units/hour in a 70 kg patient) with no initial bolus.[1] This is based on studies that show the use of low-dose regular insulin administered by intravenous infusion is sufficient for the treatment of DKA, provided the dose is >0.1 units/kg/hour. The alternative regimen involves an initial intravenous bolus dose of 0.1 units/kg followed by a continuous infusion at a dose of 0.1 units/kg/hour.[53] These low-dose insulin therapy protocols decrease plasma glucose concentration at a rate of 50 to 75 mg/dL/hour.[1]

Patients with mild to moderate DKA (plasma glucose >250 mg/dL, arterial pH 7.00 to 7.30, serum bicarbonate 10-18 mEq/L) that is not complicated by acute MI, congestive heart failure, end-stage renal or hepatic failure, steroid use, or pregnancy, may be given rapid-acting insulin subcutaneously as an alternative to intravenous regular insulin (with no significant difference in outcomes when using either approach alongside aggressive fluid management for mild or moderate DKA).[3][61][62][63] [ ] A suggested protocol would be an initial subcutaneous injection of rapid-acting insulin at a dose of 0.3 units/kg, followed 1 hour later by another subcutaneous injection of 0.2 units/kg. Thereafter, they should receive 0.2 units/kg every 2 hours until blood glucose becomes <250 mg/dL. At this point, the insulin dose should be decreased by half to 0.1 units/kg every 2 hours until the resolution of DKA.[59] Patients treated with subcutaneous insulin should receive adequate fluid replacement, frequent bedside blood glucose testing and appropriate treatment of underlying causes to avoid recurrent DKA.[3] Continuous intravenous infusion of regular insulin should remain the preferred route because of intravenous insulin's short half-life and easy titration. This is compared with the delayed onset of action and prolonged half-life of subcutaneously administered insulin. However, if there are prolonged waiting times for intensive care unit (ICU) admission or limited medical resources, the use of insulin analogs for the treatment of mild or moderate uncomplicated DKA episodes can be considered for outpatient, general floors, or in emergency departments.[3]

This regimen should be followed until all remaining criteria for resolution are met: serum bicarbonate >18 mEq/L, venous pH >7.3, and anion gap <10.[1]

Primary options

insulin regular: consult local protocols for dosing guidelines

Secondary options

insulin aspart: consult local protocols for dosing guidelines

insulin lispro: consult local protocols for dosing guidelines

Back

Consider –

bicarbonate therapy

Treatment recommended for SOME patients in selected patient group

Bicarbonate therapy may be used in adult patients with pH <7 or a bicarbonate level <5 mEq/L, although data are limited.[1][64]

In adults with pH 6.9 to 7.0, 50 mmol sodium bicarbonate (1 ampule) in 200 mL sterile water with 10 mEq KCl may be administered over 1 hour until pH is >7.0.

Primary options

sodium bicarbonate: serum pH 6.9 to 7.0: 50 mmol intravenous infusion over 1 hour until pH >7.0; serum pH <6.9: 100 mmol intravenous infusion at a rate of 200 mL/hour for 2 hours or until pH >7.0

serum potassium 3.3 to 5.3 mEq/L

Back

Consider –

phosphate therapy

Treatment recommended for SOME patients in selected patient group

Routine replacement of phosphate is not recommended.

The dose is 20-30 mEq/L potassium phosphate added to replacement fluids.

Phosphate therapy above the recommended dose may result in severe hypocalcemia.[1][77][78]

Primary options

potassium phosphate: 20-30 mEq added to each liter of infusion fluid

Back

1st line –

intravenous fluids

Mild to moderate volume depletion is indicated by the absence of orthostatic hypotension or supine hypotension, dry mucous membranes, and poor skin turgor. The goal is to gradually replace half of the fluid deficit over 12 to 24 hours, to prevent complications such as cerebral edema.

The initial choice of fluid is isotonic saline infused at a rate of 1.0 to 1.5 L (or 15-20 mL/kg body weight) for the first hour.

Following the initial fluid replacement, corrected serum sodium level should be evaluated (corrected sodium [mEq/L] = measured sodium [mEq/L] + 0.016 [glucose (mg/dL) - 100]). In patients found to be hypernatremic or eunatremic, 0.45% NaCl at 250-500 mL/hour is recommended.

Electrolytes should be checked at least hourly (to monitor potassium levels), and BUN, venous pH, creatinine, and glucose should be checked every 2-4 hours until the resolution of DKA.

Back

Plus –

supportive care ± ICU admission

Treatment recommended for ALL patients in selected patient group

Indications for intensive care unit (ICU) admission include altered mental status, respiratory insufficiency, and severe acidosis.

How to insert a tracheal tube in an adult using a laryngoscope.

How to use bag-valve-mask apparatus to deliver ventilatory support to adults. Video demonstrates the two-person technique.

Mild cases of DKA may be managed without ICU admission.[1]

Back

Plus –

insulin

Treatment recommended for ALL patients in selected patient group

Patients should receive a continuous intravenous infusion of regular insulin after exclusion of hypokalemia (i.e., potassium level should be >3.3 mEq/L before initiation of insulin therapy). This is the standard of care in critically ill and mentally obtunded patients with DKA.[3] Two alternative low-dose regimens are recommended by the ADA.[1] The first option is a continuous intravenous infusion of regular insulin at a dose of 0.14 units/kg/hour (approximately 10 units/hour in a 70 kg patient) with no initial bolus.[1] This is based on studies that show the use of low-dose regular insulin administered by intravenous infusion is sufficient for the treatment of DKA, provided the dose is above 0.1 units/kg/hour. The alternative regimen involves an initial intravenous bolus dose of 0.1 units/kg followed by a continuous infusion at a dose of 0.1 units/kg/hour.[53] These low-dose insulin therapy protocols decrease plasma glucose concentration at a rate of 50-75 mg/dL/hour.[1]

Continuous intravenous infusion of regular insulin should, however, remain the preferred route because of intravenous insulin's short half-life and easy titration. This is compared with the delayed onset of action and prolonged half-life of subcutaneously administered insulin. However, if there are prolonged waiting times for intensive care unit (ICU) admission or limited medical resources, the use of insulin analogs for the treatment of mild or moderate uncomplicated DKA episodes can be considered for outpatients, general floors, or in emergency departments.[3]

The intravenous or subcutaneous regimens should be followed until all remaining criteria for resolution are met: serum bicarbonate >18 mEq/L, venous pH >7.3, and anion gap <10.[1]

Primary options

insulin regular: consult local protocols for dosing guidelines

Secondary options

insulin aspart: consult local protocols for dosing guidelines

insulin lispro: consult local protocols for dosing guidelines

Back

Plus –

potassium therapy

Treatment recommended for ALL patients in selected patient group

Choices are potassium phosphate or potassium chloride. One third of the potassium replacement should be administered as potassium phosphate to avoid excessive chloride administration.

The serum potassium level should be monitored at least hourly and replacement adjusted accordingly.

Primary options

potassium phosphate: 20-30 mEq added to each liter of infusion fluid initially, adjust dose according to serum potassium level

potassium chloride: 20-30 mEq added to each liter of infusion fluid initially, adjust dose according to serum potassium level

Back

Consider –

bicarbonate therapy

Treatment recommended for SOME patients in selected patient group

Bicarbonate therapy may be used in adult patients with pH <7 or a bicarbonate level <5 mEq/L, although data are limited.[1][64]

In adults with pH 6.9 to 7.0, 50 mmol sodium bicarbonate (1 ampule) in 200 mL sterile water with 10 mEq KCl may be administered over 1 hour until pH is >7.0.

Primary options

sodium bicarbonate: serum pH 6.9 to 7.0: 50 mmol intravenous infusion over 1 hour until pH >7.0; serum pH <6.9: 100 mmol intravenous infusion at a rate of 200 mL/hour for 2 hours or until pH >7.0

serum potassium >5.3 mEq/L

Back

Consider –

phosphate therapy

Treatment recommended for SOME patients in selected patient group

Routine replacement of phosphate is not recommended.

The dose is 20-30 mEq/L potassium phosphate added to replacement fluids.

Phosphate therapy above the recommended dose may result in severe hypocalcemia.[1][77][78]

Primary options

potassium phosphate: 20-30 mEq added to each liter of infusion fluid

Back

1st line –

intravenous fluids

The initial choice of fluid is isotonic saline infused at a rate of 1.0 to 1.5 L (or 15-20 mL/kg body weight) for the first hour.

Following the initial fluid replacement, corrected serum sodium level should be evaluated (corrected sodium [mEq/L] = measured sodium [mEq/L] + 0.016 [glucose (mg/dL) - 100]). In patients found to be hypernatremic or eunatremic, 0.45% NaCl at 250 to 500 mL/hour is recommended.

Potassium replacement is not required, but potassium levels should be checked every 2 hours.

Electrolytes, BUN, venous pH, creatinine, and glucose should be checked every 2-4 hours until the resolution of DKA.

Back

Plus –

supportive care ± ICU admission

Treatment recommended for ALL patients in selected patient group

Indications for intensive care unit (ICU) admission include altered mental status, respiratory insufficiency, and severe acidosis.

How to insert a tracheal tube in an adult using a laryngoscope.

How to use bag-valve-mask apparatus to deliver ventilatory support to adults. Video demonstrates the two-person technique.

Mild cases of DKA may be managed without ICU admission.[1]

Back

Plus –

insulin

Treatment recommended for ALL patients in selected patient group

Patients should receive a continuous intravenous infusion of regular insulin after exclusion of hypokalemia (i.e., potassium level should be >3.3 mEq/L before initiation of insulin therapy). This is the standard of care in critically ill and mentally obtunded patients with DKA.[3] Two alternative low-dose regimens are recommended by the ADA.[1] The first option is a continuous intravenous infusion of regular insulin at a dose of 0.14 units/kg/hour (approximately 10 units/hour in a 70 kg patient) with no initial bolus.[1] This is based on studies that show the use of low-dose regular insulin administered by intravenous infusion is sufficient for the treatment of DKA, provided the dose is above 0.1 units/kg/hour. The alternative regimen involves an initial intravenous bolus dose of 0.1 units/kg followed by a continuous infusion at a dose of 0.1 units/kg/hour.[53] These low-dose insulin therapy protocols decrease plasma glucose concentration at a rate of 50-75 mg/dL/hour.[1]

Patients with mild to moderate DKA (plasma glucose >250 mg/dL, arterial pH 7.00 to 7.30, serum bicarbonate 10-18 mEq/L) that is not complicated by acute MI, congestive heart failure, end-stage renal or hepatic failure, steroid use, or pregnancy, may be given rapid-acting insulin subcutaneously as an alternative to intravenous regular insulin (with no significant difference in outcomes when using either approach alongside aggressive fluid management for mild or moderate DKA).[3][61][62][63] [ ] A suggested protocol would be an initial subcutaneous injection of rapid-acting insulin at a dose of 0.3 units/kg, followed 1 hour later by another subcutaneous injection of 0.2 units/kg. Thereafter, they should receive 0.2 units/kg every 2 hours until blood glucose becomes <250 mg/dL. At this point, the insulin dose should be decreased by half to 0.1 units/kg every 2 hours until the resolution of DKA.[59] Patients treated with subcutaneous insulin should receive adequate fluid replacement, frequent bedside blood glucose testing and appropriate treatment of underlying causes to avoid recurrent DKA.[3] Continuous intravenous infusion of regular insulin should, however, remain the preferred route because of intravenous insulin's short half-life and easy titration. This is compared with the delayed onset of action and prolonged half-life of subcutaneously administered insulin. However, if there are increased waiting times for intensive care unit (ICU) admission or limited medical resources, the use of insulin analogs for the treatment of mild or moderate uncomplicated DKA episodes can be considered for outpatient, in general floors, or in emergency departments.[3]

The intravenous or subcutaneous regimens should be followed until all remaining criteria for resolution are met: serum bicarbonate >18 mEq/L, venous pH >7.3, and anion gap <10.[1]

Potassium replacement is not required, but potassium levels should be checked every 2 hours.

Primary options

insulin regular: consult local protocols for dosing guidelines

Secondary options

insulin aspart: consult local protocols for dosing guidelines

insulin lispro: consult local protocols for dosing guidelines

Back

Consider –

bicarbonate therapy

Treatment recommended for SOME patients in selected patient group

Bicarbonate therapy may be used in adult patients with pH <7 or a bicarbonate level <5 mEq/L, although data are limited.[1][64]

In adults with pH 6.9 to 7.0, 50 mmol sodium bicarbonate (1 ampule) in 200 mL sterile water with 10 mEq KCl may be administered over 1 hour until pH is >7.0.

Primary options

sodium bicarbonate: serum pH 6.9 to 7.0: 50 mmol intravenous infusion over 1 hour until pH >7.0; serum pH <6.9: 100 mmol intravenous infusion at a rate of 200 mL/hour for 2 hours or until pH >7.0