DKA

DKA/HHS Treatment Algorithm
Fluid Replacement
↓
Initial fluid bolus of 2 to 4 L of lactated ringer’s
*Consider reduced fluid load if CHF or CKD*
↓
Assess volume status
Calculate corrected sodium
Rebolus fluids as above until euvolemic
Once euvolemic, begin maintenance fluids
↓
BG ≥ 250mg/dL
↓
K+ <3.3 mEq/L

NaCl* / KCl 40 mEq/L
IV infusion 200 mL/hr
K+ 3.3 to <5.3 mEq/L

NaCl* / KCl 20 mEq/L
IV infusion 200 mL/hr
K+ ≥5.3 mEq/L

NaCl* or LR
IV infusion 200 mL/hr
*use corrected sodium for saline concentration
↓
Once BG <250mg/dL
↓
K+ <3.3 mEq/L

D5W/NaCl* / KCl
40 mEq/L IV infusion
200 mL/hr
K+ 3.3 to <5.3 mEq/L

D5W/NaCl* / KCl
20 mEq/L IV infusion
200 mL/hr
K+ ≥5.3 mEq/L

D5W/NaCl* or LR
IV infusion
200 mL/hr
*use corrected sodium for saline concentration
RESOLUTION CRITERIA
DKA
Bicarbonate > 18 mmol/L +
Anion gap < 12 or baseline

HHS
Calculated serum osmolality < 300mOsm/kg +
Urine output >0.5mL/kg/h +
BG <250mg/dL
IV Insulin
↓
K+ < 3mEq/L

Hold insulin infusion
Replace potassium
Start insulin when potassium ≥ 3 mEq/L
K+ 3 to <5.3 mEq/L
K+ ≥ 5.3 mEq/L

Start insulin infusion
but do not give K+
↓
Give insulin glargine 0.2 units/kg SUBQ or home dose (whichever is less)
↓
Initiate insulin infusion at 0.1 units/kg/hr
↓
Recheck blood glucose every 1 hour
↓
BG <250mg/dL

Change maintenance fluids to be D5 based
BG ≥ 250mg/dL

Maintain current infusion rate
AVOID DECREASING
GLUCOSE BY >100mg/dL
PER HOUR
↓
Insulin infusion maintenance (once BG <150mg/dL)
↓
BG <70 mg/dL

Hold insulin
Follow hypoglycemia
protocol for treatment
BG 71-149 mg/dL

Decrease infusion
rate by 50%
↓
Once BG >150, restart insulin
infusion as 50% of previous rate
Continue insulin infusion until DKA/HHS is resolved, then transition to subcutaneous insulin if not already done

*Continue insulin infusion for 1-2 hours after first dose of subcutaneous insulin is given*
Electrolyte Repletion
Phosphorous (<1.5 mg/dL)
Magnesium (<1.5 mg/dL)
Potassium
↓
Recheck potassium 2 hrs after starting repletion (may be appropriate to space out to every 4-6 hours potassium checks after initial management)

Initiate insulin once potassium ≥ 3 mEq/L*
Sodium
↓
*Corrected sodium = measure sodium + 0.024 (glucose - 100)
↓
Sodium ≥ 140 mmol/L
0.45% NaCl at 200 mL/hr
Sodium <140 mmol/L
0.9% NaCl at 200 mL/hr
Transitioning to SubQ Regimen
↓
Insulin glargine subQ 0.2 unit/kg or home dose (whichever is less)

Higher doses may be considered on a case-by-case basis
Short acting insulin
0.05 - 0.1 units/kg/dose subQ
Insulin sliding
scale
+
If NPO, utilize insulin regular
If tolerating PO, utilize insulin lispro
Maintenance Fluid
Corrected Sodium (mEq/L)
CURRENT GLUCOSE (mg/dL)
<250 mg/dL
CURRENT GLUCOSE (mg/dL)
≥250 mg/dL
≥ 140 mEq/L
D5 ½ NS
½ NS
<140 mEq/L
D5NS or D5LR
NS or LR
Potassium > 5.3 mEq/L
Potassium 3.3 - 5.3 mEq/L
Potassium <3.3 mEq/L
*Fluids*
*Fluids* with KCl 20 mEq/L IV infusion at 200 mL/hr
*Fluids* with KCl 40 mEq/L IV infusion at 200 mL/hr

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

IVF

  • 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

K

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

Phos

Phos < 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

Deficit = 0.2 × weight × (20 − current HCO₃)
Uses desired bicarbonate of 20 mEq/L

How do you know they're out of DKA?

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