management of diabetic ketoacidosis (DKA) in adults

DKA Basics
-Definition:  Blood glucose >250 (e.g. diabetic), moderate ketonemia, anion gap >10, Bicarbonate <15, and pH <7.3 (acidosis)

-Metabolic acidosis, hyperglycemia, hyperosmolality, potassium depletion, and hypovolemia

-Infection is often a precipitating event

Initial Labwork:

-Serum electrolytes

-Calculate Anion gap
-CBC
-UA
-Plasma osmolality
-ABG
-EKG
-Blood cultures, urinalysis, CXR to determine possible infectious cause

Hyperglycemia and Serum Sodium:

-Corrected Serum Na = Measured Na + 0.024 * (Serum glucose - 100)

-boils down to this: add 1.2 to the sodium for every 50 mg/dL over 100

Management:
Order of priorities is volume first, correction of potassium deficits, and then insulin administration
1.      ABCs
2.      get labwork and investigate source of DKA/HHS (infectious causes)
3.      Fluid resuscitation with isotonic saline (Increases insulin responsiveness by lowering plasma osmolality)
4.      Insulin therapy (after confirmation of potassium greater than 3.3) --bolus of Regular Insulin IV followed by an insulin drip

5.      KCl is generally added to the replacement fluid once the serum K+ falls below 5.3
6.      When the serum glucose reaches 200 in DKA or 250-300 in HHS, saline is switched to dextrose containing solution
NOTE:  Use of supplemental bicarbonate in the DKA is not recommended

Submitted by J. Grover.

Reference(s): Tintinalli’s 7^th edition, uptodate.com, picture