What are the steps to initiate a Diabetic Ketoacidosis (DKA) protocol?

Diabetic Ketoacidosis (DKA) Protocol Implementation

To initiate a DKA protocol, begin with aggressive fluid resuscitation with 0.9% saline at 15-20 ml/kg/hr for the first hour, followed by insulin therapy only after initial fluid resuscitation is complete. 1

Initial Assessment and Diagnosis

• Confirm DKA diagnosis with:

  • Blood glucose >250 mg/dl
  • Venous pH <7.3
  • Bicarbonate <15 mEq/l
  • Moderate ketonuria or ketonemia 2, 1

• Obtain STAT laboratory tests:

  • Blood glucose
  • Venous blood gases
  • Electrolytes
  • Blood urea nitrogen
  • Creatinine
  • Calcium
  • Phosphorous
  • Urinalysis 2

Step-by-Step DKA Protocol

1. Fluid Resuscitation (First Priority)

• Begin with 0.9% saline at 15-20 ml/kg/hr during the first hour 1
• Continue fluid resuscitation based on hemodynamic status
• For pediatric patients: 1.5 times the 24-hour maintenance requirements (5 ml/kg/hr) for smooth rehydration; do not exceed twice the maintenance requirement 2

2. Insulin Therapy (Start AFTER initial fluid resuscitation)

• Important: Check potassium level before starting insulin - delay insulin if K+ <3.3 mEq/l to avoid arrhythmias 2
• For moderate-to-severe DKA:
  • Administer IV regular insulin bolus of 0.1 U/kg
  • Follow with continuous infusion at 0.1 U/kg/hr 1
• For mild DKA:
  • Give "priming" dose of regular insulin 0.4-0.6 U/kg body weight
  • Half as IV bolus, half as subcutaneous/intramuscular injection
  • Then 0.1 U/kg/hr subcutaneously or intramuscularly 2
• Target glucose reduction: 50-70 mg/dl per hour 1

3. Electrolyte Management

• Potassium replacement:

  • Begin when serum K+ <5.5 mEq/l (if adequate urine output)
  • Add 20-30 mEq potassium (2/3 KCl and 1/3 KPO4) per liter of IV fluid 2
  • If significant hypokalemia present, start potassium replacement before insulin 2, 1

• Bicarbonate therapy (generally not recommended unless severe acidosis):

  • pH <6.9: 100 mmol sodium bicarbonate in 400 ml sterile water at 200 ml/hr
  • pH 6.9-7.0: 50 mmol sodium bicarbonate in 200 ml sterile water at 200 ml/hr
  • pH >7.0: No bicarbonate needed 2, 1

• Phosphate replacement:

  • Consider only for patients with cardiac dysfunction, anemia, respiratory depression, or serum phosphate <1.0 mg/dl 2, 1

4. Monitoring Protocol

• Blood glucose: Every 1-2 hours
• Serum electrolytes, BUN, creatinine: Every 2-4 hours
• Venous pH and anion gap: Monitor to assess acidosis resolution 1
• Continue monitoring for signs of hypoglycemia (sweating, drowsiness, dizziness, tremor) 3

5. Transition from IV to Subcutaneous Insulin

• Transition when:
  • Blood glucose <200 mg/dl
  • Serum bicarbonate ≥18 mEq/l
  • Venous pH >7.3
  • Anion gap normalized
  • Patient hemodynamically stable 1
• Calculate subcutaneous insulin dose based on average insulin infused during previous 12 hours 1

Common Pitfalls and Cautions

• Never delay fluid resuscitation - it's the first priority in DKA management
• Never start insulin before checking potassium levels - hypokalemia can lead to cardiac arrest 2
• Avoid too rapid correction of glucose - target 50-70 mg/dl per hour to prevent cerebral edema 1
• Don't rely on urinary ketone levels to monitor response to therapy - they may persist despite improvement 2
• Monitor for signs of hypoglycemia during insulin therapy - be prepared to add dextrose to IV fluids when glucose <200 mg/dl while continuing insulin infusion 3
• Watch for euglycemic DKA (blood glucose <250 mg/dl with ketoacidosis) - especially in patients on SGLT2 inhibitors or ketogenic diets 1, 4

By following this structured protocol, you can effectively manage DKA while minimizing complications and improving patient outcomes.