Diabetic Ketoacidosis

Objectives

1. Learn to recognize DKA
2. Learn initial management of DKA as well as maintenance therapy
3. Learn about complications and best therapy to avoid them

Learning material

Basic information (really the first page is a good general overview of DKA management)

Video

CHOP clinical pathway with helpful links to articles

• DKA is a problem of lack of insulin
• Diagnosis
  • pH <7.3 or HCO₃^- <15
  • Hyperglycemia, >200
  • Ketonemia or ketonuria
• These are the main labs and conditions to be concerned about
  • Glucose
  • Potassium
  • Volume status (as indicated by blood pressure, HR, spec grav)
  • Ketones (β-hydroxybutyrate, urinary ketones)
• Initial management
  • Obtain electrolytes to get potassium levels
    • If K is too low, starting insulin would reduce that further
  • 20cc/kg fluid bolus, most children have 70cc/kg water loss
• Further management
  • Once K is stable, start insulin at 0.1units/kg/hr and start IV fluids
  • Fluid resuscitation via 2-bag system based on weight and glucose levels
    • Bag 1: NS with K
    • Bag 2: NS with K and dextrose
  • Frequent BMPs to assess HCO₃^-, anion gap, and K
  • Aim is to bring glucose to <250
• DKA is resolved once
  • Anion gap has closed or β-hydroxybutyrate <1 mmol/L
  • Venous pH >7.3 or HCO₃^- >15
  • Blood glucose <200
  • Tolerating PO intake
• Once DKA is resolved, can transition to subQ insulin
  • Should overlap subQ and IV insulin for at least one hour