CCM Notes
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Internal Medicine · Endocrinology
DKA Management
Diabetic Ketoacidosis — Diagnosis · Fluid Resuscitation · Insulin Protocol · Electrolytes · Monitoring
🔬 Diagnostic Criteria & Severity Classification (ADA 2024)
| Parameter | Mild | Moderate | Severe |
|---|
| Plasma Glucose | >250 mg/dL | >250 mg/dL | >250 mg/dL |
| Arterial pH | 7.25–7.30 | 7.00–7.24 | <7.00 |
| Serum Bicarbonate | 15–18 mEq/L | 10–15 mEq/L | <10 mEq/L |
| Urine / Serum Ketones | Positive | Positive | Positive |
| Anion Gap | >12 | >12 | >12 |
| Mental Status | Alert | Alert/Drowsy | Stupor/Coma |
Anion Gap = Na⁺ − (Cl⁻ + HCO₃⁻) | Corrected Na = Measured Na + 1.6 × [(glucose − 100)/100] | Effective osmolality = 2×Na + glucose/18
💧 Fluid Resuscitation Protocol
1
0.9% NaCl — 1 L over 1st hour (15–20 mL/kg/h). Correct shock first.
2
Hours 2–4: 0.45% NaCl at 250–500 mL/h if Na corrected; continue 0.9% NaCl if low Na
3
When glucose reaches 200 mg/dL, add Dextrose 5% with 0.45% NaCl at 150–250 mL/h
4
Target: Replace ~50% deficit in first 8h, remainder over 16–24h. Total deficit ~3–6 L.
5
Monitor for cerebral edema — especially in children. Avoid rapid osmolality changes.
💉 Insulin Protocol
1
K⁺ must be ≥3.5 mEq/L before insulin. Replace K⁺ first if low. Do NOT start insulin if K <3.5
2
Regular insulin IV infusion: 0.1 U/kg/h (no bolus needed per ADA 2024)
3
Target glucose fall: 50–75 mg/dL/hour. If <50 mg/dL/h fall → double rate.
4
Maintain glucose 150–200 mg/dL until anion gap closes and pH >7.30
5
Transition to SC insulin: give long-acting insulin 2h before stopping IV. Overlap mandatory.
⚗️ Electrolyte Replacement
🧂 Potassium (K⁺)
K⁺ <3.5: Give 40 mEq/h, hold insulin
K⁺ 3.5–5.0: Add 20–40 mEq/L IV fluid
K⁺ >5.0: No replacement; recheck q2h
Target K⁺: 4.0–5.0 mEq/L
🫧 Phosphate & Bicarbonate
Bicarb only if pH <6.9: 100 mmol NaHCO₃ over 2h
Phosphate: replace if <1.0 mg/dL or symptomatic
KPhos: 20–30 mmol over 2h if severe
Magnesium: replace if Mg <1.8 mg/dL
📋 Resolution Criteria
Glucose <200 mg/dL
Anion gap ≤12 mEq/L
Serum HCO₃ ≥15 mEq/L
Venous pH ≥7.30
Patient able to eat/drink
📊 Monitoring Parameters
Glucose: q1h initially
Electrolytes, BUN, Cr: q2–4h
Venous blood gas (pH, HCO₃): q2–4h
Urine output: Foley catheter, target ≥0.5 mL/kg/h
Cardiac monitor: Watch for K⁺-related arrhythmias
Anion gap: Close q4h to confirm resolution
⚠️ Precipitants & Pitfalls
●6 I's: Insulin (omission), Infection, Infarction, Intoxication, Iatrogenic, Ignorance of diagnosis
●Gulf context: T2DM very common — SGLT2 inhibitors can cause euglycemic DKA (glucose may be normal!)
●Never withhold K⁺ replacement — hypokalemia is a leading cause of DKA death
●Pseudo-hyponatremia: corrected Na must be calculated before interpreting