If the patient has an insulin pump, make sure it is shut off or disconnected
Administer 20-30cc/kg normal saline bolus during the first hour
Most important step in treatment since osmotic diuresis is the major driving force
Most adult patients are  3-6L depleted
Increased systemic perfusion may transport insulin to previously unreached receptor sites, inhibiting ketogenesis
Increased renal perfusion promotes renal hydrogen ion loss
Use of LRs vs NR has failed to show increased benefit
When blood sugar(BS) < 250 switch to Dextrose 5% 50-200ml/hr (+/- KCl if the patient is voiding urine)
Most important step in treatment since osmotic diuresis is the major driving force
Most adult patients are  3-6L depleted
Increased systemic perfusion may transport insulin to previously unreached receptor sites, inhibiting ketogenesis
Increased renal perfusion promotes renal hydrogen ion loss
Use of LRs vs NR has failed to show increased benefit
Potassium (most important!)
<3.5mEq/L:
Start potassium repleation: 20-30 mEq KCl to IVF/hr
Do not administer insulin (to avoid worsening of hypokalemia)
>3.5mEq/L and <5.5 mEq/L:
Start potassium repleation: 20-30 mEq KCl to IVF/hr
May start insulin (see below)
>5.5 mEq/L:
Hold potassium repletion and recheck electroltyes after initiaton of insulin (see below)
Sodium
Hyponatremia
Correct for hyperglycemia
Na+ decreases by 1.6mEq/L for every 100mg/dL increase in glucose (ie pseudohyponatremia)
If truly hyponatraemic, start NS 250-500ml/hr
Hypernatremia
Consider half-strength NS 250-500ml/hr after initial fluid bolus
Hypophosphatemia
<1.0 mEq/L, start repletion:
IV K2PO4 at 1mL/hour (contains 4.4meqK+ & 93mg phos)
Severe hypophosphatemia can cause cardiac and respiratory dysfunction
Hypomagnesemia
Mg<2.0mg/DL, start repletion:
2g MgSO4 IV over 1h
<3.5mEq/L:
Start potassium repleation: 20-30 mEq KCl to IVF/hr
Do not administer insulin (to avoid worsening of hypokalemia)
>3.5mEq/L and <5.5 mEq/L:
Start potassium repleation: 20-30 mEq KCl to IVF/hr
May start insulin (see below)
>5.5 mEq/L:
Hold potassium repletion and recheck electroltyes after initiaton of insulin (see below)
Start potassium repleation: 20-30 mEq KCl to IVF/hr
Do not administer insulin (to avoid worsening of hypokalemia)
Start potassium repleation: 20-30 mEq KCl to IVF/hr
May start insulin (see below)
Hold potassium repletion and recheck electroltyes after initiaton of insulin (see below)
Hyponatremia
Correct for hyperglycemia
Na+ decreases by 1.6mEq/L for every 100mg/dL increase in glucose (ie pseudohyponatremia)
If truly hyponatraemic, start NS 250-500ml/hr
Hypernatremia
Consider half-strength NS 250-500ml/hr after initial fluid bolus
Correct for hyperglycemia
Na+ decreases by 1.6mEq/L for every 100mg/dL increase in glucose (ie pseudohyponatremia)
If truly hyponatraemic, start NS 250-500ml/hr
Na+ decreases by 1.6mEq/L for every 100mg/dL increase in glucose (ie pseudohyponatremia)
Consider half-strength NS 250-500ml/hr after initial fluid bolus
<1.0 mEq/L, start repletion:
IV K2PO4 at 1mL/hour (contains 4.4meqK+ & 93mg phos)
Severe hypophosphatemia can cause cardiac and respiratory dysfunction
IV K2PO4 at 1mL/hour (contains 4.4meqK+ & 93mg phos)
Severe hypophosphatemia can cause cardiac and respiratory dysfunction
Mg<2.0mg/DL, start repletion:
2g MgSO4 IV over 1h
2g MgSO4 IV over 1h
Check potassium prior to insulin treatment (see above)! Do not administer insulin until potassium supplementation is underway.
A bolus dose is unnecessary and may contribute to increased hypoglycemic episodes
If the patient comes in wearing an insulin pump, turn off the pump and remove the subcutaneous catheter.
Expect BS to fall by 50-100mg/dL per hr if you administer 0.1units/kg/hr of insulin
Refractory hyperglycemia may be due to an associated infectious process contributing to the DKA
Two main practices exist: 1) Close the anion gap, then start basal insulin 2-3 hours before stopping insulin infusion, 2) Early basal insulin
Potential benefits of early basal insulin (glargine or detemir) include protecting against erroneously stopping insulin infusion prematurely and eliminating the 2-3 hour waiting period of starting basal insulin while on IV infusion
Early basal insulin:
Consider glargine at 0.25 - 0.30 U/kg SQ
OR
Determine total 24 hour home dose of basal insulin and deliver that q24 hours
Consider glargine at 0.25 - 0.30 U/kg SQ
OR
Determine total 24 hour home dose of basal insulin and deliver that q24 hours
Initial infusion 0.1 to 0.14 units/kg/hr of insulin (or 0.05units/kg/hr per local protocol)
When BS <250mg/dL, halve the rate of infusion to 0.05units/kg/hr IV OR give subQ 0.1 U/kg q2hr and switch IV fluids to Dextrose 5% at 150cc/hr
Maintain BS between 150 and 200mg/dL until resolution of acidosis
May require IV fluids to be switched to Dextrose 10% when BS <150mg/dL
Continue IV infusion for 2 hrs after subcutaneous insulin is begun
SubQ route (appropriate only for mild DKA and if able to eat and void urine; poor perfusion may hamper its absorption)
May require IV fluids to be switched to Dextrose 10% when BS <150mg/dL
A subcutaneous regimen must use short acting insulin and follow either a 1hr or 2hr dosing protocol. Regular insulin is not effective
Initial dose SC Aspart: 0.3 units/kg body wt, followed by
SC aspart insulin at 0.1 units/kg every hour
When blood glucose <250mg/dl (13.8 mmol/l), change IV fluids to D5<sub 0.45%NS and reduce SC aspart insulin to 0.05 units/kg/hr
Keep glucose at 150mg/dl (11 mmol/l) until resolution of DKA.
SC aspart insulin at 0.1 units/kg every hour
When blood glucose <250mg/dl (13.8 mmol/l), change IV fluids to D5<sub 0.45%NS and reduce SC aspart insulin to 0.05 units/kg/hr
Keep glucose at 150mg/dl (11 mmol/l) until resolution of DKA.
Initial dose SC Aspart: 0.3 units/kg body wt, followed by
SC aspart insulin at 0.2 units/kg 1 hr later followed by Q2hr dosing
When blood glucose <250mg/dl (13.8 mmol/l), change IV fluids to D5 0.45% saline and reduce SC aspart insulin to 0.1 units/kg/ 2hr
Keep glucose at 150mg/dl (11 mmol/l) until resolution of DKA.
SC aspart insulin at 0.2 units/kg 1 hr later followed by Q2hr dosing
When blood glucose <250mg/dl (13.8 mmol/l), change IV fluids to D5 0.45% saline and reduce SC aspart insulin to 0.1 units/kg/ 2hr
Keep glucose at 150mg/dl (11 mmol/l) until resolution of DKA.
No evidence supports the use of sodium bicarb in DKA, with a pH >6.9
However, no studies have been performed for patients with pH <6.9 and the most recent ADA guidelines recommend it for patients with pH <7.1
Pitfalls of sodium bicarbonate therapy in DKA (outside of last ditch efforts in severe acidemia)
Paradoxical CSF acidosis
Hypokalemia from H+ and K+ shifts
Large sodium bolus
Cerebral edema
Shifts oxygen-hemoglobin dissociation curve to left, decreasing O2 delivery to tissues
Paradoxical CSF acidosis
Hypokalemia from H+ and K+ shifts
Large sodium bolus
Cerebral edema
Shifts oxygen-hemoglobin dissociation curve to left, decreasing O2 delivery to tissues
Glucose check Q1hr
Chem 10 Q4hr (initially Q2hr)
Check pH PRN based on clinical status (eval respiratory compensation)
Check appropriateness of insulin dose Q1hr (see below)
Corrected Electrolytes
Insulin Sliding Scale to be started once patient's DKA has resolved and eating a full diet.
Avoid intubation unless patient cannot generate respiratory alkalosis compensation due to extreme fatigue
Risks associated with intubation in DKA:
During sedation/paralysis, a rise in PaCO2 can decrease pH considerably
Severe gastroparesis in DKA creates a significant risk for aspiration
Strong DKA patients generally can achieve greater hyperventilation than mechanical ventilated patients
See Intubation for more information
During sedation/paralysis, a rise in PaCO2 can decrease pH considerably
Severe gastroparesis in DKA creates a significant risk for aspiration
Strong DKA patients generally can achieve greater hyperventilation than mechanical ventilated patients
Diabetic ketoacidosis
Insulin or oral hypoglycemic medication non-compliance 
Alcoholic ketoacidosis
Infection
Starvation ketoacidosis
Cardiac Ischemia
Cerebral edema in DKA
Intra-abdominal infections