What are the ICU admission orders for Diabetic Ketoacidosis (DKA)?

From the Guidelines

For DKA ICU admission orders, I recommend starting with IV fluids using 0.9% normal saline at 15-20 mL/kg/hr for the first hour, then reducing to 250-500 mL/hr based on hemodynamic status, as this approach is supported by the most recent guidelines 1.

Initial Assessment and Management

The management of Diabetic Ketoacidosis (DKA) requires careful clinical and laboratory assessment, with goals including restoration of circulatory volume and tissue perfusion, resolution of ketoacidosis, and correction of electrolyte imbalance and acidosis 1.

• The initial fluid resuscitation is crucial and should be tailored to the patient's hemodynamic status.
• IV fluids should be administered at a rate of 15-20 mL/kg/hr for the first hour, typically 1-2 L, to rapidly restore circulatory volume.

Insulin Therapy

Begin regular insulin as an IV infusion at 0.1 units/kg/hr after fluid resuscitation has started, as recommended by recent guidelines 1.

• Insulin therapy is essential to reduce blood glucose levels and suppress ketogenesis.
• The use of continuous intravenous insulin is the standard of care for critically ill and mentally obtunded individuals with DKA or HHS 1.

Electrolyte Management

• Check electrolytes, particularly potassium, every 2-4 hours and replace as needed, starting potassium replacement when K+ <5.3 mEq/L and urine output is adequate.
• Careful electrolyte monitoring is crucial to prevent complications like arrhythmias from hypokalemia that can occur during treatment.

Monitoring and Adjustments

• Monitor blood glucose hourly, and when glucose reaches 200-250 mg/dL, transition to 5% dextrose with 0.45% saline while continuing insulin to clear ketosis.
• Monitor vital signs, mental status, and fluid balance hourly.
• Check serum ketones and venous or arterial blood gases every 2-4 hours until acidosis resolves.
• Add bicarbonate only if pH <6.9 or if there are severe cardiovascular complications, as its use is generally not recommended 1.

From the Research

ICU Admission Orders for Diabetic Ketoacidosis (DKA)

• The standard for initial fluid resuscitation in DKA patients is isotonic normal saline, although balanced solutions have been shown to have faster DKA resolution 2.
• Current guidelines recommend using continuous IV insulin for DKA management after fluid status has been restored and potassium levels have been achieved 2.
• The British guidelines recommend using SQ insulin glargine along with continuous regular IV insulin, which has shown faster DKA resolution and shorter hospital stays compared to continuous IV insulin alone 2.
• DKA frequently involves multiple electrolyte abnormalities, such as hypokalemia, hypophosphatemia, and hypomagnesemia, and regular monitoring is essential for DKA management 2.
• Early initiation of oral nutrition has been shown to reduce intensive care unit and overall hospital length of stay 2.
• For impending respiratory failure, intubation and mechanical ventilation, with monitoring and management of acid-base and fluid status, are recommended 2.
• The use of sodium bicarbonate is discouraged due to the potential for worsening ketosis, hypokalemia, and risk of cerebral edema (CE), but can be considered if the serum pH falls below 6.9, or when serum pH is less than 7.2 and/or serum bicarbonate levels are below 10 mEq/L, pre-and post-intubation, to prevent metabolic acidosis and hemodynamic collapse that occurs from apnea during intubation 2.
• A low-cost treatment protocol for DKA includes using low-dose intravenous insulin and 2 to 3 liters of isotonic saline at 500 ml/hr to replace extracellular fluids, followed by 2 to 4 L of 5% glucose in 0.45% saline with potassium chloride and/or potassium phosphate to replace intracellular fluids at 250 ml/hr 3.
• Large-volume resuscitation with isotonic normal saline in DKA patients is associated with increased ICU length of stay, prolonged insulin infusion, and a higher incidence of non-anion gap metabolic acidosis, suggesting the use of balanced crystalloids, such as lactated Ringers, for initial resuscitation in DKA patients 4.
• Elements of DKA management include making the appropriate diagnosis, coordinating fluid resuscitation, insulin therapy, and electrolyte replacement, and awareness of special populations such as patients with renal disease presenting with DKA 5.
• DKA can be treated in the intensive care unit or general medical/surgical ward, depending on the institution and the patient's condition, with close monitoring and recognition of potential complications 6.