Diabetic Ketoacidosis

Diabetic Ketoacidosis

Euglycemic DKA management:

• insulin drip + dextrose containing fluids are started at the same time to prevent hypoglycemia. Follow the same DKA protocol as listed below otherwise.
• keep patient NPO until off the insulin drip
• q1h FSG, q4h BMP, ICU venous panel and lytes, replete as below
• use insulin drip calculator on Epic hourly to titrate insulin drip rate
• will be ready to transition off the insulin drip when bicarb >18, AG <12, and glucose <200
   
  DKA management:
• keep patient NPO until off the insulin drip
• q1h FSG, q4h BMP, ICU venous panel and lytes, replete as below
• use insulin drip calculator on Epic hourly to titrate insulin drip rate
• will be ready to transition off the insulin drip when bicarb >18, AG <12, and glucose <200   DKA PROTOCOL: FLUIDS: 2 L Normal saline (0.9% NaCl) in 1st hr Then 500 mL/hr x 2 Liters, followed by 250 (or 150) mL/hr (If high serum Na+, may use 0.45% Normal saline after volume resuscitated) Fluid Goal: replace ~50% of estimated TBW deficit over 8 hours. CHANGE to D5 ½ NS @ 150 mL/hr when glucose <250 mg/dL. If volume is an issue, use D10. REDUCE IVFs in CHF, end-stage liver or renal disease, >65 yrs old, hypoxemia.
   
  INSULIN: If K < 3.3 mEq/L, hold insulin until actively correcting K IV Insulin Bolus 0.1 Units/kg, then Insulin drip 0.1 Units/kg/hour. Check FS glucose every 1 hour. Initial Goal: ↓ Glucose by 50-75 / hour If glucose not decreasing by ≥ 50 mg/dL in 1st hourÆincrease/ double IV insulin rate. When glucose < 250 mg/dL, ADD D5 to IVF, 150 mL/hr & ↓ insulin drip to ≤ 0.05 U/kg/hour. Glucose goal = 150-200 mg/dL Goal: Clear ketoacidosis using insulin and avoid hypoglycemia. MD adjusts insulin drip rate. Can go as low as 0.5 Units/hour   POTASSIUM/ELECTROLYTES: If initial K+ <3.3, replete K+ immediately and hold insulin until actively correcting (risk of severe hypokalemia if give insulin first). Hold K+ repletion if pt has renal failure & urine output < 50cc/hr. Goal K = 4 – 5 mEq/L. K+ > 5 mEq/L: No additional K+
  K+ 4 – 5 mEq/L : Add 20 mEq KCl /L to fluids x 2 Liters OR IV + PO total ~40mEq
  K+ 3.3 – 4 mEq/L: Add 40 mEq KCl /L to fluids x 2 Liters OR IV + PO total ~60mEq
  K+ < 3.3 mEq/L: Give IV+ PO Potassium, total 60-80 mEq, check K+ level every 1-2hr

After initial repletion of K, follow K and replete as needed.
Mg++ <1.5 mg/dL: give 2 gms IV Magnesium Sulfate Phos < 1 mg/dL: give 0.24 mmol/kg Potassium Phosphate in 250cc fluid over 6 hours Bicarb, consider using bicarbonate ONLY if pH<7   LAB CHECKS: [] FSG every 1 hour [] At 2 hours after initial treatment: Chem 7 (K+) and pH (VBG) [] Every 4 hours until anion gap closed & lytes normal: Chem 7 (K+), Magnesium, Phosphorus   CONVERSION TO SUBCUTANEOUS (SC) INSULIN: when Anion gap < 12, HCO3- >18 mEq/L, Glucose < 200 mg/dL, and patient clinically stable / ready to eat.
New onset DM
1) Weight based
Total daily dose of insulin ~ 0.5 Units/kg per day
Basal (Glargine) = 0.25 Units/kg per day
Mealtime insulin (Aspart ) = 0.25 Units/kg/day ÷ 3 = mealtime insulin dose
First meal: order 50% of calculated mealtime insulin dose to be given only
after patient eats ≥ ½ meal.
Subsequent meals: depending on PO intake, give 20-100% dose of
mealtime insulin (can give immediately after eats).

2) Insulin Drip based: total insulin over last 6 hours x 4 = Total IV units/day
Caution: this method may overestimate the patient’s insulin needs.
Total IV units per day X 0.70 = Total Subcutaneous insulin
Total Subcut insulin ÷ 2 = Basal insulin dose
Total Subcut insulin ÷ 6 = Mealtime insulin dose. Use 1st meal rule.

Prior diagnosis of DM: start insulin as above OR restart home insulin basal/bolus insulin (if
patient was adherent, controlled, and with no major hypoglycemia).

Administer SC basal insulin (Glargine) Æ stop insulin drip 2 HOURS later.

Diet orders: Add modification ‘No Concentrated sweets’