DKA TREATMENT GUIDELINES

Dehydration (often profound) Hyperglycemia Diabetic ketoacidosis is a state of insulin deficiency, which results in the following: Dehydration (often profound) Hyperglycemia Anion-gap metabolic acidosis Electrolyte disturbances Hypokalemia (which may be masked in the presence of acidosis) Hypophosphatemia Hyponatremia and Pseudohyponatremia Appropriate therapy will address each of these disturbances quickly.

Remember: The goal of treatment is the resolution of DKA, not the resolution of hyperglycemia.

1. Dehydration: Dehydration may be quite profound in DKA secondary to the osmotic diuretic effect of glucose. Once a patient is sufficiently dehydrated to affect renal clearance of glucose, then hyperglycemia is further exacerbated by the dehydration. Treat with normal saline boluses. Although 3-6 liter deficits are most common, as much as 8-10 liters may be needed. Be extremely careful in patients with CHF or renal insufficiency, and be mindful of the risk of inducing pulmonary edema.

2. Hyperglycemia: Hyperglycemia is not the cause of DKA, but rather a marker of insulin deficiency and dehydration. Treat with IV insulin infusion and normal saline boluses. Insulin must be continued until the patient is out of DKA – most readily assessed by normalization of the anion gap. (The only exception is life-threatening hypokalemia.) If blood glucose drops below the target range prior to resolution of DKA, then a glucose source must be started (e.g. 5% dextrose infusion).

3. Anion gap metabolic acidosis: Insulin is needed in order for glucose to enter cells and be used for metabolism. Insulin deficiency results in a state of cellular starvation. Ketoacids are produced as an alternative fuel source, and manifest as unmeasured anions in the serum. The result is anion gap metabolic acidosis. A respiratory alkalosis will usually be present, especially in an otherwise healthy patient, as they attempt to compensate for the acidemia.

4. Hypokalemia: Diuresis results in potassium losses, frequently profound. Measured serum potassium level is often within normal limits or even elevated at initial presentation. Serum potassium level can be expected to drop precipitously with correction of acidosis and dehydration. Initially, begin potassium replacement if potassium is <5.0 mEq/mL. Monitor potassium level very frequently, and replace as needed (being especially careful in patients with renal insufficiency). If measured potassium is elevated at presentation, avoid other attempts to lower it (e.g. Kayexalate), as total body stores of potassium are depleted, and DKA treatment will lower it.

5. Hypophosphatemia: Phosphorus is also wasted during diuresis. Rarely causes a serious problem. Replace as needed.

6. Hyponatremia / pseudohyponatremia: Serum sodium is wasted during diuresis. Calculate the corrected sodium, accounting for the degree of hyperglycemia and hypertriglyceridemia (if known). If true hyponatremia is present, it is generally treated with NS.

When a patient is eating, mealtime rapid-acting insulin (e. g When a patient is eating, mealtime rapid-acting insulin (e.g. Aspart) should be given, in addition to the insulin drip, to avoid wide glycemic swings post-prandially. If a patient remains in DKA after IV insulin and hydration for >24 hours, consider consulting Endocrinology.

Serum K+ on last BMP K+ > 5 mEq/L K+ between 4.1 and 5 mEq/L Version October 25, 2007 7. Potassium replacement: a) Give potassium chloride as follows: Serum K+ on last BMP Amount and rate of administration K+ > 5 mEq/L Do not give extra potassium. Recheck serum potassium in 2 hours. K+ between 4.1 and 5 mEq/L 10 mEq IV piggyback over 1 hours, or, 40 mEq PO (packets) if not NPO K+ between 3.3 and 4 mEq/L 40 mEq IV piggyback over 4 hours, or, 40 mEq PO (packets) if not NPO K+ < 3.3 mEq/L Give 10 mEq/hour IV piggyback and 40 mEq PO (packets) Q 1 hrs if not NPO and recheck serum potassium hourly until serum K+ > 3.3 mEq/L.

Contact Prescriber for further orders Version February 11, 2010 3. Potassium Replacement – Caution with impaired renal function a) Replace Potassium as indicated in table: Serum Potassium Level Replacement < 3.3 Contact Prescriber for further orders 3.3 – 4 40 mEq KCL IVPB or 40 mEq PO (packets) 4.1 – 5 10 meq KCL IVPB or 40 mEq PO (packets) > 5 No KCL replacement necessary

To compare the changes that have been made to the Multiplier Table and Target Blood Glucose Ranges, please see both versions of the orders posted in the ICU break room

Clarification on #11 and #12 and new #13 on Hyperglycemia orders Not to be used for DKA! See Hyperglycemia orders posted in the ICU break room for the changes in the wording of the orders

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