This document provides guidelines for the management of diabetic ketoacidosis (DKA) in patients presenting to the hospital. It outlines an algorithm with multiple tiers of treatment based on the patient's symptoms, vital signs, lab results and response to initial therapy. The initial focus is fluid resuscitation and insulin therapy to lower blood sugar levels. Ongoing assessment of electrolytes, pH, bicarbonate and osmolality are recommended to guide further treatment and monitor for complications. Criteria for admission to higher levels of care like the ICU are also presented.

1. 3a
i
.
Prof Azeem Taj , Prof. Dr. Uthman Ahmad EXTRACTED FROM UPTODATE & NHS GUIDELINES Dr Zara Farooq , Dr
Mehreen
IV 0.9 %
N/Saline
Systolic BP ≤
90
over ½-1
hr
tPA/anticoagulation Inotropes Diuresis Hemodialysis
Systolic BP >
90
over 2- 4
hrs
R
E
A
S
S
E
S
S
Any history of
Polyuria, polydipsia, polyphagia, confusion, dizziness.
fever Pain abdomen, vomiting, Constipation, diarrhea
Shortness of breath, Urine output, missing of drugs
Look for:
Hydration status: (pulse,BP, PP,CRFT, skin turgor, color & temp of
peripheries)
→Conscious level/GCS
→Chest and cardiac examination & Bowel sounds
→Secure IV access & pass urinary
catheter
→Check BSL & Ketones 1-2 hrly
→ABGs, S/E, RFTS—4-8 hrly
→ECG , CXR/CBC ,Urine R/E, Septic
screen
Eu-natremia
CorrectedNa+
130-144
Corrected Na
OnceBSL≤ 200 mg/dl, shift to 5%D/W with 0.45%NaCl
R
E
A
S
S
E
S
S
0.9% normal saline
0.45%
(1/2
) saline
@ 250-500
ml/hr acc. to
vol status
Hypernatremia
Corrected Na+
> 145
Calculatewater deficit
Hyponatremia
CorrectedNa+
< 130
Warm
peripheries
Wide PP,
Oliguria
Follow
sepsis
algorith
m
Confusion
Postural
dizziness
Cramps Delayed
CRFT
Right Heart Failure
Pulmonar
y
embolis
m
No Pul.
Embolis
m
afeet
Raised
JVP.Edem
Tender Hepato
megaly
Clear
Chest
LVF
Non-cardiogenic
Cardiogenic
PULM EDEMA
SOB/ORTHO
PN Fine
CREPTS.N
EA/PN
D o
JVP
Anuria
NO anuria
HR ↓ BP BP less/Pulseless
Septic Shock Cardiogenic Shock
Moderate/Severe
Dehydration
1st action:
within ½
hr of
arrival
Potassium (mEq/L) Insulin
Regular insulin IVbolus @0.1 unit/kg
Regular insulin infusion @0.1 U/kg/hr
EIncrease rate by 0.5 units foreach50 mg/dl
rise in BSLor if it staysstatic.
EKeep target of lowering BSLat 50mg/dl/Hr
EOnce BSL≤200mg/dl:
Decreaseinfusion rate to 0.02-0.05u/kg/hr
 Shift fluid to 5%D/salineor D/0.45%Saline
Shift to S/C regimen when
appropriate (follow Transition to
S/C algorithm)
HCO3
-(mEq/L)
→Dilute 100mmol
of NAHCO3 in
400ml of water to
be infused
over 2-4hr
→Repeat
NAHCO3
pH > 6.8 + HCO3 < 8
mEq/L
Give K+ @ 20 - 40
mEq/hr) under
cardiac monitoring
Maintain Serum
K+ by adding KCL
20 mEq/L in each
fluid)
Absent bowel
sounds ECG
Changes
ECG
Changes
Start Insulin
Hemodialysis
if refractory
3.3 to 5.2 ≥5.3
<3.
3
HOLD Insulin
Ensure adequate renal
function (UOP ≈ > 50 ml/hr)
Patient presenting to
hospital
Assess pt. has ALL of 3
On arrival and repeated assessment include
RE- ASSESS
P A S S C V P / S H I F T T O I C U / C C U
after each step—for further treatment changes
pH ≤6.8
Criteria for HDU/ICU Admission Be Warned About Formulae
E E
E Elderly o
E Pregnancy o
E o
E o
E o
E o SpO2 < 92% on room air
E
 Never replace K+@>10 mEq/hr via peripheral & >20 mEq/hr
via CVline
 Changein corrected Na+SHOULDNOTBE>0.8–1.2 mmol/L /hr
 Decline in serum osmolality SHOULDNOTBE>1.2–1.8mOsm/L/hr
 Decline in BSLSHOULDNOTBE>70mg/dl/hr
 Changein rate of infusion & infusate should be basedon repeated
evaluation of clinical status , serum osmolality,HCO-
3 , BSLand
urinary electrolytes.
 Serum Osmolality=2(Na)+ BUN/2.8 + BSL/18  Free water deficit:
0.5 x weight(kgs) (current Na/ideal Na – 1)
 Anion Gap=(Na+ +K+)–(Cl- +HCO
-
)
 Bicarbonate replacement:
0.5 TBW (Desired HCO3 - Measured HCO3)
 To prepare 0.45% saline:
add 500 ml of 5% DW to 500 ml of 0.9% saline
 K+ replacement: deficit + daily requirement
0.4 {(4 – K+ level) body weight} + 1 mEq/kg
 To prepare 150 ml of 3% saline:
add 40 ml of NaHCO3 to 110 ml of 0.9% saline
 Corrected Na:
serum Na+ +1.6 x (BSL mg/dl- 100)
100
DEPARTMENT OF MEDICINE & MEDICAL ICU SZFPGMI LAHORE
DKA MANAGEM ENT ALGORITHM SZH FPGM I LAHORE
TIER 1 TIER 2
TIER 3A TIER
3B TIER 3C TIER 3D TIER 3E
TIER
4A
TIER 4B TIER 4C
TIER 5A
TIER
5B
TIER 5C TIER
6A
TIER
6B
TIER 7
I V Fluid T herap y
until pH> 7.0
RE- ASSESS after each step—for further
B
e
t
C
r
a
e
u
t
a
i
o
t
u
m
s
of
e
S
n
er
t
um
c
K
h
+
anges