Management of Diabetic Ketoacidosis

1. Confirm diagnosis (­ plasma glucose, positive serum ketones, metabolic acidosis).

2. Admit to hospital; intensive-care setting may be necessary for frequent monitoring or if pH < 7.00 or unconscious.

3. Assess:  Serum electrolytes (K+, Na+, Mg2+, Cl-, bicarbonate, phosphate)

                 Acid-base status¾pH, HCO3-, PCO2

                 Renal function (creatinine, urine output)

4. Replace fluids: 2-3 L 0.9% saline over first 1-3 h (5-10 mL/kg per hour); subsequently, 0.45% saline at 150-300 mL/h; change to 5% glucose and 0.45% saline at 100-200 mL/h when plasma glucose reaches 14 mmol/L (250 mg/dL).

5. Administer regular insulin: 10-20 units IV or IM, then 5-10 units/h by continuous IV infusion; increase 2- to 10-fold if no response by 2-4 h.

6. Assess patient: What precipitated the episode (noncompliance, infection, trauma, infarction, cocaine)? Initiate appropriate workup for precipitating event [cultures, chest x-ray, electrocardiogram (ECG)]

7. Measure capillary glucose every 1-2 h; measure electrolytes (especially K+, bicarbonate, phosphate) and anion gap every 4 h for first 24 h.

8. Monitor blood pressure, pulse, respirations, mental status, fluid intake and output every 1-4 h.

9. Replace K+: 10 meq/h when plasma K+ < 5.5 meq/L, ECG normal, urine flow, and normal creatinine documented; administer 40-80 meq/h when plasma K+ < 3.5 meq/L or if bicarbonate is given.

10. Continue above until patient is stable; glucose goal is 8.3-13.9 mmol/L (150-250 mg/dL), until acidosis is resolved. Insulin infusion may be decreased to 1-4 units/h.

11. Administer intermediate or long-acting insulin as soon as patient is eating. Allow for overlap in insulin infusion and subcutaneous insulin injection.