What is the initial management for a 60 kg male patient with Diabetic Ketoacidosis (DKA)?

DKA Management Protocol for 60 kg Male

For a 60 kg male with DKA, begin immediate fluid resuscitation with 0.9% normal saline at 900-1200 mL in the first hour (15-20 mL/kg/h), followed by continuous IV regular insulin at 0.1 units/kg/h (6 units/hour) once potassium is ≥3.3 mEq/L. 1, 2

Initial Assessment and Diagnosis

Diagnostic Criteria:

• Blood glucose >250 mg/dL 1
• Arterial pH <7.3 1
• Serum bicarbonate <15 mEq/L 1
• Moderate ketonuria or ketonemia 1

Immediate Laboratory Evaluation:

• Arterial blood gases, complete blood count with differential, urinalysis 1
• Blood glucose, BUN, creatinine, electrolytes with calculated anion gap 1
• Serum ketones, osmolality, electrocardiogram 1, 2
• Obtain bacterial cultures (urine, blood, throat) if infection suspected 1, 2

Fluid Resuscitation Protocol

Hour 1 (Initial Bolus):

• Administer 0.9% NaCl at 15-20 mL/kg/h 1
• For this 60 kg patient: 900-1200 mL in first hour 1

Subsequent Fluid Management:

• Calculate corrected sodium: add 1.6 mEq for each 100 mg/dL glucose above 100 mg/dL 1
• If corrected sodium is normal or elevated: use 0.45% NaCl at 4-14 mL/kg/h (240-840 mL/h for 60 kg patient) 1
• If corrected sodium is low: continue 0.9% NaCl at 4-14 mL/kg/h 1
• Total fluid deficit for DKA: approximately 6 liters (100 mL/kg) 1
• Correct estimated deficits within 24 hours 1
• Change in serum osmolality should not exceed 3 mOsm/kg/h 1

Insulin Therapy

Critical Pre-Insulin Check:

• DO NOT start insulin if potassium <3.3 mEq/L - correct potassium first to prevent life-threatening arrhythmias 2

Insulin Initiation:

• Start continuous IV regular insulin at 0.1 units/kg/h 2
• For this 60 kg patient: 6 units/hour 2
• Alternative for mild-moderate uncomplicated DKA: subcutaneous rapid-acting insulin analogs with aggressive fluids 2

Insulin Adjustment:

• If glucose does not fall by 50 mg/dL in first hour, check hydration status 2
• If hydration adequate, double insulin infusion rate hourly until steady decline of 50-75 mg/h achieved 2

When Glucose Reaches 250 mg/dL:

• Change fluids to 5% dextrose with 0.45-0.75% NaCl 1, 2
• Continue insulin infusion at reduced rate 2
• Target glucose 150-200 mg/dL until DKA resolves 2

Potassium Management

Critical Potassium Protocol:

• If K+ <3.3 mEq/L: Hold insulin, aggressively replace potassium until ≥3.3 mEq/L 2
• If K+ 3.3-5.5 mEq/L: Add 20-30 mEq/L potassium to IV fluids (2/3 KCl and 1/3 KPO₄) once urine output confirmed 1, 2
• If K+ >5.5 mEq/L: Withhold potassium initially but monitor closely as levels will drop rapidly with insulin 2
• Target serum potassium: 4-5 mEq/L throughout treatment 2

For this 60 kg patient with typical deficit of 3-5 mEq/kg:

• Total body potassium deficit: approximately 180-300 mEq 1

Monitoring Protocol

Frequency:

• Draw blood every 2-4 hours for electrolytes, glucose, BUN, creatinine, osmolality, venous pH 2
• Venous pH adequate for monitoring (typically 0.03 units lower than arterial) 2
• Monitor β-hydroxybutyrate directly if available (preferred over nitroprusside method) 2

Hemodynamic Monitoring:

• Blood pressure, fluid input/output, clinical examination 1
• Mental status assessment 1

Resolution Criteria

DKA is resolved when ALL of the following are met:

• Glucose <200 mg/dL 2
• Serum bicarbonate ≥18 mEq/L 2
• Venous pH >7.3 2
• Anion gap ≤12 mEq/L 2

Transition to Subcutaneous Insulin

Critical Timing:

• Administer basal insulin (intermediate or long-acting) 2-4 hours BEFORE stopping IV insulin 2
• This overlap prevents recurrence of ketoacidosis and rebound hyperglycemia 2
• Once patient can eat, start multiple-dose schedule with short/rapid-acting and intermediate/long-acting insulin 2

Bicarbonate Administration

NOT recommended for pH >6.9-7.0 2

• Studies show no benefit in resolution time or outcomes 2
• May worsen ketosis, cause hypokalemia, and increase cerebral edema risk 2

Critical Pitfalls to Avoid

Common Errors:

• Starting insulin before excluding hypokalemia (K+ <3.3 mEq/L) - can cause fatal arrhythmias 2
• Stopping insulin when glucose falls to 250 mg/dL - continue insulin until acidosis resolves 2
• Failing to add dextrose when glucose <250 mg/dL while continuing insulin 2
• Premature termination of IV insulin before complete ketosis resolution 2
• Overly rapid correction of osmolality (>3 mOsm/kg/h) - increases cerebral edema risk 1
• Inadequate potassium monitoring and replacement - leading cause of DKA mortality 2

Precipitating Factor Management

Identify and treat underlying causes:

• Infection (most common) - obtain cultures, start antibiotics if indicated 1, 2
• New diabetes diagnosis 2
• Insulin non-adherence 2
• Myocardial infarction, stroke, pancreatitis 2
• SGLT2 inhibitors - discontinue 3-4 days before any planned surgery 2