Diagnosis

• BMP including Ca/Mg/Phos, CBC, UA, EKG
• Lactate and beta-hydroxybutyrate (B-HB > 3 is consistent with DKA)
• If source unclear blood cultures, urine cultures, CXR, CT chest and pelvis, lipase (DKA itself can cause elevated lipase)

Treatment

Fluids

• Fluids first! Patients will likely need 2-4L of LR boluses at 1L/hr, once euvolemic a continuous infusion at 200cc/hr of LR
• Once BG < 200 and K 3.3-5.3 add D5W/NS/KCl 20mEq infusion at 200cc/h. If K > 5.3 then just D5W/NS

Insulin

• K < 3 : Hold insulin and replete K
• K 3 to 3.5 : Regular insulin drip 0.1u/kg/h
• K > 3.5 : Regular insulin bolus 0.1u/kg
• Then check POCT glucose q1h
• If BGL decreases by 50 or greater in 1h then continue infusion 0.1u/kg/hr
• If BGL does not decrease by 50 or greater in 1h then double to 0.2u/kg/hr
• Once BGL < 200 then decrease to 0.05u/kg/h
• Then you want BGL 150-200
• Hold insulin if BGL < 70
• If BGL 71-149 then decrease rate by half

Potassium

• K < 3 : Replete potassium before insulin 60mEq
• K > 5.3 : No potassium supplementation
• K 3 to 5.3 : Potassium containing maintenance fluids

Phosphorous < 1.5

• K < 4 : KPhos 15mmol q4h IV x 2
• K > 4 : NaPhos 15mmol IV q4h x 2

If NAGMA develops

• Often happens when patients are resuscitated with NS and makes it harder to transition off insulin
• Give 3 50mEq amps of bicarb (150mEq total) to target a bicarb > 20
• You can calculate their bicarb deficit using calculator below

Bicarbonate Deficit Calculator

How do you know they're out of DKA?

• Glucose < 250
• Bicarb > 20
• Venous pH > 7.3
• Anion gap < 12
• Tolerates PO