- 1 -

  1. Initiate IV Fluids STAT: IVF should be started in the ED and continued in ICU as needed
  2. Estimate intravascular volume status (via BUN/Cr, VS, orthostatic BP, urine output, physical exam, HgB)to estimate saline requirement.
  3. Assess free water deficit using corrected serum Na.
  1. Initial Fluid Orders:
  1. First correct intravascular fluid volume deficit with normal saline at a rate dependant on severity (being more cautious if cardiac or renal disease)

a)0.9% NaCl at 1-3 Liters /hr (15-20ml/kg) over 1 hour

b)Give additional 0.9% NaCl IV rapidly if patient remains volume depleted.

  1. While Blood Glucose greater than 250 mg/dL -- Subsequent Fluid Orders:
  1. Calculate corrected Na:

a)Corrected Sodium less than 134 mEq/L: continue 0.9% NaCl IV at 250-500 ml/hr until glucose less than 250 mg/dL, or corrected Na greater than 134 mEq/L.

b)Corrected Sodium greater than or equal to 134 mEq/L: continue with 0.45% NaCl IV at 250-500 ml/hour until glucose less than 250 mg/dL, or corrected Na less than 134 mEq/L.

  1. If corrected Na decreases more than 2 mEq per hour, consider slowing the infusion rate.
  1. WHEN Blood Glucose less than 250mg/dL -- Subsequent Fluid Orders:
  1. Calculate corrected Na:

a)Corrected sodium less than134 mEq/L: D5W/0.9% NaCl IV at 100 - 200 ml/hr

b)Corrected Sodium greater than or equal to 134 mEq/L: D5W/0.45% NaCl IV at 100 - 200 ml/hr

  1. Insulin Administration:
  • Hold all home anti-diabetic medications.
  • Initiate Insulin therapy AFTER IV fluid resuscitationhas begun (500 ml or greater) and when potassium is 3.2 mEq/L or greater.
  • Insulin Infusion starting dose: (See Step 1 in Insulin Infusion Protocol; Page 4)
  • Blood Glucose greater than or equal to 300mg/dL give 0.1 units/kg IV bolus and begin insulin infusion at 0.1 units/kg/hour, rounded to 0.5 unit increment, and useInsulin Infusion Protocol.
  • Blood Glucose less than300mg/dL begin insulin infusion at 0.05 units/kg/hour,rounded to 0.5 unit increment, and follow Insulin Infusion Protocol.
  1. Look for DKA Precipitant
  • If clinically indicated consider: Cardiac Enzymes, Blood Cultures, Urine Culture, CXR, EKGSerum lactate.
  1. Metabolic Monitoring
  • Check POC Blood Glucose on arrival to ICU and repeat every 30-60 minuteswhile on continuous insulin infusion. For detailed POC glucose monitoring seeInsulin Infusion Protocol (Page 3).
  • Order STAT basic metabolic panel/BMP (Glucose, Sodium, Potassium, Chloride, CO2, BUN, Creatinine) every 2-4 hours depending on disease severity and clinical response to treatment.
  • Calculate anion gap and corrected serum Na+with every basic metabolic panel.

Adult Diabetic Ketoacidosis (DKA) Treatment GuidelinePage 1 of 4

- 1 -

  1. Potassium (K+) Correction:
  • Per UPHS formulary, maximum peripheralIV infusion rate of Potassium Chloride is 10 mEq/hr. Maximum centralIV infusion rate of Potassium Chloride is 20 mEq/hr.
  • If serum K+ is less than 2.8 mEq/L,consider a central line to enable Potassium Chloride infusion rates of 20mEq/hr. Monitor K+ every 2 hours until serum K+ is greater than 2.8 mEq/L.
  • If serum K+ is 2.8 mEq/L or greater use tablefor suggested repletion regimen. Note suggested repletion assumes normal renal function.
  • If oliguria or kidney injury is present, re-check K+ every 2 hours. If patient does not have oliguria or kidney injury re-check serum K+ every 4 hours.
  • For patients able to tolerate clear liquids by mouth, oral K+ repletion should be considered.

Serum Potassium / Suggested Repletion Regimen
2.8 - 3.2 mEq/L / administer 60 mEq of Potassium Chloride IV
3.3 – 3.5 mEq/L / administer 40 mEq of Potassium ChlorideIV
3.6 – 4.9 mEq/L / administer 20 mEq of Potassium ChlorideIV
greater than 4.9 mEq/L / No repletion

Patient Weight = ______kg *Anion Gap = ([Na+] ) - ([Cl-]+[HCO3-]), as measured on a basic metabolic panel

*Correct Anion Gap for low albumin. Corrected anion gap = Measured anion gap + (4-albumin) X 2.5

Step 1. Initial Insulin Infusion Dosing
If Blood Glucose is greater than or equal to 300 mg/dL: Give 0.1units/kg IV insulin bolus. Start insulin infusion rate at 0.1 units/kg/hour and round to 0.5 unit increment. (Example: weight = 70 kg, 70 x 0.10 = 7 infusion rate is 7 units/hour)
If Blood Glucose is less than 300 mg/dL: Start insulin infusion rate at 0.05 units/kg/hour and round to 0.5 unit increment (Example: weight = 71 kg, 71 x 0.05 = 3.55 infusion rate is 3.5 units/hour)
Titrate Insulin infusion using Table 1 below. Continue to round dose to the nearest 0.5 units/hour
  • Target GOAL: drop in serum glucose is 50-100 mg/dL/hour
  • When Blood Glucose less than or equal to 250 mg/dL go to Step 2

Table 1 – Insulin Infusion Titration for BG greater than 250 mg/dL (NOT on D5 containing fluid)
Blood Glucose Change / Insulin Infusion / POC Glucose Monitoring
decrease less than 50 mg/dL / Increase rate by 50% (current rate x 1.5) / Repeat blood glucose in 1 hour
decrease 50-100 mg/dL / Continue current rate
decrease greater than 100 mg/dL / Decrease rate by 25% (current rate x 0.75)
Hypoglycemia Treatment
less than or equal to80 mg/dL / HOLD insulin infusion
Notify MD/NP/PA
Give 25 ml D50 IVP
Add D5 containing fluids
when BG 100 mg/dL restart insulin infusion at 0.05Units/kg /hr or continue current rate if already less than 0.05Units/kg/hr
Subsequent infusion titration per Table 2 / Repeat blood glucose in 30 minutes
Step 2. Subsequent Insulin Infusion Dosing:
  • When blood glucoseless than or equal to250 mg/dL, contact MD/NP/PAfor order to change of insulin infusion rate to 0.05 units/kg/ hour OR continue current rate- if already equal to or less than 0.05 units/kg/hour
  • Contact MD/NP/PAfor an order for dextrose containing IV fluids: Usual rate is 100-200 ml/hr
Titrate Insulin infusion using Table 2 below. Continue to round dose to the nearest 0.5 units/hour
  • Target GOAL: Keep Blood Glucose between 150 - 200 mg/dL until corrected anion gap is less than 14 for two consecutive measurements
  • Notify MD/NP/PA if two consecutive rate increases are required

Table 2 – Subsequent Insulin Infusion (on D5 containing fluid)
Blood Glucose / Insulin Infusion / POC Glucose Monitoring
greater than 250 mg/dL / Increase rate 50% (current rate x 1.5) / Repeat blood glucose in 1 hour
201-250 mg/dL / Increase rate 25% (current rate X 1.25)
150-200 mg/dL / Continue current rate
80-149 mg/dL / Decrease rate by 50%(current rate X 0.5)
less than or equal to80mg/dL / HOLD insulin infusion
Notify MD/NP/PA
Give 25ml D50 IVP
Restart at 25% of previous rate (current rate X 0.25) when Blood Glucose greater than99 mg/dL / Repeat blood glucose in 30 minutes

6.Transition from IV to Subcutaneous Insulin (SQ)

A. When to transition:

  • Three requirements should be met before you transition to SQ Insulin:

1. The anion gap has normalized in 2 consecutive blood samples (greater than 14 when corrected for albumin).

2. The glucose values are within target of 150-200mg/dLand insulin requirements are stable.

3. The patient is alert and able to tolerate clear liquids.Note full dietary intake is not required when above requirements are met.

B.Dosage and Type of Insulin to administer:

  • Definition:Total Daily Dose of Insulin (TDD) = estimated number of units of all types of insulin to be given in 24 hours, e.g aspart (prandial and correction factor) plus glargine (Lantus)

1. Calculate the estimated Total Daily Dose (TDD)

  1. Patient receiving outpatient insulin therapy: Estimated TDD is equal to the sum of all insulin types prescribed in outpatient insulin regimen.

~OR~

  1. Patient NOT previously on insulin therapy: Estimated TDD is equal to0.5 units/kg/day.
  1. Compare the estimated TDD to current intravenous insulin therapy:

(Current hourly insulin infusion rate x 24 hours = 24 hour IV insulin requirement)

  1. If estimated TDD is less than current 24 hour intravenous insulin requirement then use the average of the estimated TDD and 24 hour intravenous insulin requirement as the “Acute” TDD to calculate subcutaneous regimen.

{(TDD + 24 hour intravenous insulin requirement) ÷ 2 = Average TDD}

  1. If estimated TDD is greater than current 24 hour intravenous insulin requirement then use the lesser TDD value to calculate subcutaneous regimen (consider a diabetes management consult).
  1. Dosing and type of Insulin:
  1. Administer50% of the TDD calculated from above as long acting Insulin, given once daily (basal, insulin glargine) and administer 50% of the TDD calculated from above as rapid actingInsulin (aspart), usually divided 3 times daily, administered with meals (prandial).
  2. GIVE THE Long acting Subcutaneous Insulin (Insulin Glargine)2 hours priorto discontinuing IV insulin INFUSION.
  3. Order Correction factor subcutaneous insulin, blood glucose monitoring and hypoglycemia protocol.

4. Important Caveats:

The instructions given above are based on consensus recommendations considering general populations of patients

Individual inpatient requirements for insulin may vary significantly:

  • For patients taking insulin at home, the adequacy of glucose control at baseline will have an impact on transition efficacy.
  • In all patients with DKA or HHS, any unresolved precipitant may result in an underestimation of the total insulin requirement (this would be reflected in the amount of insulin required in the prior 1-2 hours vs. the estimated value based on weight).

In all patients with resolving DKA or HHS, glucose and metabolic panels should be carefully monitored to determine the optimal insulin regimen needed to obtain adequate glucose control

The Diabetes Management Service, available through consult pager, can address questions regarding insulin transition dosing or any other on-going diabetes management issues.

Adult Diabetic Ketoacidosis (DKA) Treatment GuidelinePage 1 of 4