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1. Management of
Diabetic Ketoacidosis
SAMIR EL ANSARY

2. Objectives
•Management of DKA:
•1) Fluids
•2) Insulin
•3) Electrolyte replacement

3. Management: Fluids
• Glucose osmotic diuresis causes
dehydration
• Give between 4-6 liters, then reassess
(caution in CHF)
• Fluids help decrease the blood glucose
levels
• Always start with NS
• Bolus and then steady rate (i.e. 150cc/hr)

4. Management: Fluids
• Switch to 0.45% NS when
“corrected” sodium within normal
limits
•Add 1.6 mEq to sodium for every
100 glucose is above 100.
• Switch to D5 1/2NS when glucose
between 200-250

5. It is important to switch to D51/2ns when
glucose reached 200-250 as risk of
hypoglycemia is high.
Caution boluses in CHF patients (check
EF and clinical status)

6. Management: Insulin
• IV insulin dripbolus approx 10 units
(or .1unit/kg), then initiate drip at 0.1
unit/kg/hr
• Avoid bolus if K<3.3
• Replete K before starting drip
• Insulin drives potassium into the
cells so if potassium starts off very
low can make hypokalemia life
threatening.
• Switch to SC insulin when anion gap
closed signifying acidosis cleared.

7. Management: Insulin
• SC insulin must overlap with
insulin drip over 2 hours.
• Use patient’s outpatient insulin dose
OR
• In insulin-naive patients, a multi-dose
insulin regimen should be started at a
dose of 0.5 to 0.8 U/kg per day,
including bolus and basal insulin until
an optimal dose is established OR

8. Management: Insulin
Calculate 24 hour insulin
requirements and use 50% as long
acting
•Once the AG closes, can feed the
patient.
•Remember to add sliding scale
insulin (preferably lispro) with meals
in addition to basal SC insulin dose.

9. Lispro is a great sliding scale insulin
for patients with renal insufficiency
as it does not “stack” like insulin and
decreased risk of hypoglycemia.

10. Management: Electrolyte
Replacement
• Bicarbonate:
•If pH<6.9 (controversial) or K>6 with
ECG changes
• Potassium:
•If potassium <5.3
•20-60 meq/L of ½ NS given when K
<5.3 with severe acidosis
Bicarbonate helps drive potassium into cells ( H/K atpase channels)

11. Management: Electrolyte
Replacement
• Phosphate:
•If phos <1, especially if muscle
weakness
•When needed 20-30mEQ/L of
potassium phosphate can be
added to replacement fluids

12. Overall Management
•Be sure to check q1hour
glucose checks
•and q 2-4hrs to monitor
anion gap and acidosis

13. CASE
• A 24 year old female with past medical
history of diabetes mellitus I is brought to
the ER by her mother with complaints of
fatigue and increased thirst and urination.
• Of note patient states she ran out of her
insulin last week.
• She also has had a runny nose and
cough for the past week.
• She noticed her glucose levels have
been running “very high” and got
concerned.

14. CASE
• On Exam:
• BP 101/72; heart rate: 113; respirations: 32;
Temperature: 36.8 °C; pulse oximetry: 100% on
room air.
• General: No apparent distress, AA and Ox3.
• HEENT: dry mucous membranes
• CV: tachycardic, normal s1, s2. No murmurs
• Lung: CTAB
• Abdomen: +bs, non distended, slight tenderness to
deep palpation, no HSM no rebound or guarding
• Ext: no cyanosis, clubbing or edema

15. Kussmaul: deep, labored breathing, form of
hyperventilation(compensation for metabolic
acidosis)- RR 32
Often times they have abdominal pain
(ileus from electrolyte abnormalities) and are
very dehydrated
Patient does have tachycardia and slightly
lower blood pressure indicating dehydration.
Non compliance is one of the main reasons
pts go into DKA. Also new onset type II
diabetics present this way too.

16. •CMP
•Complete blood count with
differential
•Urinalysis and urine ketones by
dipstick
•Arterial blood gas
What labs do you want to order

17. Lab Results:
• Glucose 450
• AST:40
• ALT:41
• Alk phos:67
• Arterial blood gas:
pH 6.9, CO2 9, bicarb 10
• WBC 13K, Hb14.4 mg/dL,
• and Hct 43.5%.
• 75% neutrophils
• UA +glucose, +protein, -leuko esterase, -nitrite
NO KETONES
• EKG sinus tachycardia
• BMP:
• Na: 124
• K: 5.0
• Cl: 95
• CO2: 11
• BUN: 38
• Cr: 1.8

18. Anion gap (124- (95+11)= 18
Patient also has acute kidney injury
secondary to dehydration will resolve with
fluids (pre-renal)
Ph<6.9 should start bicarb
WBC=inflammatory response BUT need to
rule out infection as it is a precipitating factor
U/a does not show ketones!!! IF SUSPECT
ORDER serum ketones (nitroprusside urine
test does not test for betahydroxybutyrate in
urine)
Patient with hyponatremia after correction 124
+1.6 (3.5). Need to start normal saline.

19. • U/a does not show ketones!!! IF
SUSPECT ORDER serum
ketones (nitroprusside urine test does not
test for betahydroxybutyrate in urine)

20. • Bolus 10 units insulin, then start insulin
drip
• Bolus with normal saline, then start
maintence
• Blood cultures, chest x-ray to rule out
other sources of infection
• Empiric antibiotics?
• Bicarbonate?
• What would you do next?

21. Leukocytosis likely inflammatory
response..need to look for other sources of
infection, chest x-ray, blood cultures etc..No
need to start antibiotics unless highly
suspicious of infection
Ph 6.9 indication for bicarbonate use

22. •BUN 28
•Creatinine 1.4
•Glucose 280
• ABG:
•pH 7.2, CO2 of 18 and a bicarb of
12
• Q 2 hour
BMP checks:
• After 6 hours:
•Na: 139
•K: 2.5
•Cl: 108
•Co2: 13
AG= 139- (108+12)= 19, sodium normal
range, can now switch to ½ normal
saline so pts don’t have iatrogenic
hypernatremia.
Creatinine slowly improving with fluids

23. • Switch to 0.45% saline with potassium
supplements
• Repeat BMP in 4 hours:
• Na: 142
• K: 4.5
• Cl: 110
• Co2: 15
• BUN 38
• Creatinine 1.2
• Glucose 230
•What do you do next?
Glucose <250 so will
switch to D51/2Ns on
next slide, Ag still open
at 17

24. • Repeat BMP in 4
hours:
• Na: 140
• K: 4.0
• Cl: 110
• Co2: 23
• BUN 28
• Creatinine 1.1
• Glucose 105
• Start on d5 ½ NS with K supplements
• Continue insulin drip
Anion gap closed!
(140-(110+23)= 7

25. •Continue insulin drip
•Start patient on home regimen
of SQ insulin
•or calculate last 24 hour total
dose and give 50% in form of
long acting (i.e lantus)

26. Need to emphasize leaving drip on for 2
hours after starting SQ insulin as gap
can open.
Can ask students why do we keep drip
on for 2 hours after gap already closed?
It is important to have patient eat a meal
in ICU first before transferring to floor and
monitoring their anion gap

27. •Stop drip (after 2 hours of
starting the SQ insulin)!!
•Feed patient!
•If anion gap remains closed
after meal can transfer to floor.

28. Key Points
• Close monitoring is crucial with glucose
checks and bmps as electrolytes respond
quickly and management depends on these
numbers
• Early fluid resuscitation is important
• Insulin gtt must overlap SQ insulin for 2
hours prior to discontinuation of the drip
Pts often very dehydrated (glucose osmotic effect). Think of it like sepsis and that
you need to give fluids early.

30. GOOD LUCK
SAMIR EL ANSARY