Treatment of Diabetic Ketoacidosis

Establish IV access with two large-bore catheters or central venous catheter placement.


Fluids

Sodium Chloride 0.9% IV run at 15 to 20 ml/kg/hour or 1 to 1.5 liter (s) during the first hour, THEN
If severe hypovolemia continue Sodium Chloride 0.9% IV run at 1000 ml/hour
Evaluate corrected serum Sodium
If Serum sodium is high or normal continue
Sodium Chloride 0.45 % IV run at 250 to 500 mL/hour depending on volume status
If serum sodium is low then
Sodium Chloride 0.9% at 250 to 500 mL/hour depending on volume status
When serum glucose reaches 200 mg/dL change to 5% dextrose with Sodium Chloride 0.45 % IV run at 150 250mL/hr


Insulin

If serum potassium is less than 3.3 mEq then do not start insulin
Regular insulin 0.1 U/ kG as IV bolus, then 0.1 U/kg/ hr IV continuous insulin infusion
OR
Regular insulin 0.14 unit /kG/hour IV infusion
If serum glucose does not fall by 50 -70 mg/dL in first hour then increase insulin infusion rate
When serum glucose reaches 200 mg/dl reduce insulin infusion to 0.02 to 0.05 U/Kg/hr IV
Keep serum glucose between 150 and 200 mg until resolution of DKA


Potassium

If Serum K is > 5.2 do not give K, but check serum K every two hours
If serum K is 3.3 to 5.2 mEq/L give 20 to 30 mEq K in each liter of IV fluid to
keep serum K between 4 -5 mEq/L
If serum potassium is Less than 3.3 mEq/L give potassium 20-40 meEq/hr until K is greater than 3.3


Bicarbonate

If pH is less than 6.9
Dilute NaHCO3 100 mmol in 400mL H2O with 20mEq KCl. Infuse over two hours
Repeat every two hours until pH greater than or equal to 7 .Monitor serum K every two hours

Kitabchi AE, et al., Hyperglycemic crises in adult patients with diabetes. Diabetes Care. 2009 Jul;32(7):1335-43.

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