DKA (adult) Be familiar with Christ Medical Center DKA protocol
Remember the entity is the definition
-Diabetic (hyperglycemic usually >250mg/dL)
-Ketotic (acetoacetic acid and beta-hydroxybutyric acid in blood and urine)
-Acidotic (bicarb usually < 15 and pH usually < 7.3)
-May see only increased anion gap with normal bicarb if also met alkalosis
-A VBG is as useful as an ABG and is less painful and easier to obtain
Check EKG FIRST (to r/o hyperkalemia)
Labs: d-stick/CBC/PA7/CMP/VBG/UA/serum ketones
Goals are to replace fluid and electrolyte deficits, identify precipitating cause and supply insulin
Place two IV’s
-Initially IV#1 has 0.9NS in at bolus, IV#2 is at TKO
-First two liters in IV#1 over first 1-2hrs (pts usually have 100ml/kg water deficit)
-Then change IV#1 to 0.9NS at 250cc/hr
-If initial K+ > 5.5 begin insulin drip at 0.1u/kg/hr and repeat K+
-If initial K+ from 3.5 to 5.5 begin IV#2 with 1/2NS + 40meq KCl at 250cc/hr and insulin -gtt at 0.1u/kg/hr
-If initial K+ < 3.5 hold insulin for 30min and begin IV#2 with 1/2NS + 60meq KCl at 250cc/hr (thru central line)
**When d-stick < 250 change IV#2 to D5 1/2NS + (__)KCl
IV Regular insulin is started at 0.1u/kg/hr with NO bolus dose needed
-Continued until ketonemia clears and AG resolves (occurs AFTER glucose normalizes)
-Typically takes 12-18hours
Replace phosphate only if level < 1.0mg/dL
Replace magnesium if level < 1.2mg/dL or symptoms (tetany) develop
MUST RECHECK lytes q1-2hrs in the initial treatment phase
Remember FICKU:
-Fluids
-Insulin
-Check urine output
-K+
-Underlying cause (AMI, infection, noncompliance…)
DKA (pediatric)
Only bolus 10cc/kg 0.9NS to start to prevent possible cerebral edema
-Literature varies on importance of this entity and its cause, but be cautious with IVF