DKA Management

Question 1

what are the diagnostic criteria for DKA?

Answer 1

• serum glucose > 250 mg/dL
• arterial pH < 7.3
• serum HCO3- < 18
• at least moderate ketonuria or ketonemia

Question 2

first step in treating DKA, after:

• complete initial evaluation
• check capillary glucose
• check serum/urine ketones
• confirm hyperglycemia
• check for ketonuria/ketonemia

Answer 2

start IVF: 1 L of 0.9% NS/hr

Question 3

first step when determining which IVF to give

Answer 3

hydration status:

• severe hypovolemia
• mild hypovolemia
• cardiogenic shock

Question 4

IVF if DKA pt has severe hypovolemia

Answer 4

0.9% NS 1 L/hr

Question 5

next step if DKA pt has mild hypovolemia

Answer 5

evaluate CORRECTED serum Na+

Question 6

next step if DKA pt has cardiogenic shock

Answer 6

hemodynamic monitoring/pressors

Question 7

IVF if DKA pt has mild hypovolemia and HIGH serum Na+

Answer 7

0.45% NS, 250-500 mL/hr, depending on volume state

Question 8

IVF if DKA pt has mild hypovolemia and NORMAL serum Na+

Answer 8

0.45% NS, 250-500 mL/hr, depending on volume state

Question 9

IVF if DKA pt has mild hypovolemia and LOW serum Na+

Answer 9

0.9% NS, 250-500 mL/hr, depending on volume state

Question 10

when do you change IVF to D5W/0.45%, and at what rate?

Answer 10

• serum glucose reaches 200 mg/dL

- 150-200 mL/hr

Question 11

what are the 2 different options for insulin administration?

Answer 11

IV, or SC (if uncomplicated)

Question 12

what is the dose of the insulin bolus?

Answer 12

0.1 U/kg

Question 13

at what dose and rate is regular insulin given?

Answer 13

0.1 U/kg/hr IV continuous infusion

Question 14

at what rate should regular insulin be given in continuous infusion if an initial bolus is not given?

Answer 14

0.14 U/kg/hr

Question 15

what is the goal rate that serum glucose should fall?

Answer 15

50-70 mg/dL

Question 16

next step if serum glucose does not fall by 50-70 mg/dL w/i FIRST hour

Answer 16

double insulin bolus

Question 17

next step when serum glucose reaches 200 mg/dL

Answer 17

reduce regular insulin infusion to 0.02-0.05 U/kg/hr

Question 18

between what levels should serum glucose be maintained, and until when?

Answer 18

• 150-200 mg/dL

- until RESOLUTION OF DKA

Question 19

when is DKA considered to be resolved?

Answer 19

• normalization of serum AG (< 12 mEq/L) and blood beta-hydroxybutyrate levels
• when pts w/ hyperosmolar hyperglycemic state (HHS) are mentally alert and plasma Osm < 315 mOsmol/kg
• pt is able to eat

Question 20

how often should labs (electrolytes, BUN, venous pH, creatinine) be checked?

Answer 20

2-4 hrs, until STABLE

Question 21

next step after resolution of DKA/pt able to eat

Answer 21

• initiate SC multidose insulin regimen

- CONTINUE IV insulin infusion for 1-2 HOURS after SC insulin is given

Question 22

in insulin NAIVE pts, what is the starting dose for SC insulin?

Answer 22

0.5 U/kg to 0.8 U/kg body weight per day (adjust as needed)

Question 23

first step in assessing potassium in DKA

Answer 23

establish adequate renal function (UO about 50 mL/hr)

Question 24

if serum K+ < 3.3 meq/L

Answer 24

• HOLD INSULIN

- give K+ 20-40 meq/hr until > 3.3 meq

Question 25

if serum K+ > 5.3 meq/L

Answer 25

• do NOT give K+

- check K+ every 2 hrs

Question 26

if serum K+ is 3.3-5.3 meq/L

Answer 26

give K+ 20-30 meq/LITER of IVF

keep K+ between 4-5 meq/L

Question 27

assessing need for HCO3-:

pH 6.9 or MORE

Answer 27

NO HCO3-

Question 28

assessing need for HCO3-:

pH LESS THAN 6.9

Answer 28

dilute NaHCO3 (100 mmol) in 400 mL H2O w/ 20 meq KCl; infuse over 2 hrs

Question 29

NaHCO3 administration should be given how often, and until when?

Answer 29

Q2H until pH > 7.0