-H&P, performed.
-Patient meets diagnostic criteria for DKA.
DKA Protocol.
*DKA 2/2 1) Noncompliance w insulin/diet, 2) Infection, 3) MI (Get EKG)
*BUN/Cr elevation due to dehydration
*WBC due to DKA, dehydration, r/o infection
*Abd. pain due to DKA vs Gastroenteritis or Gastritis or PUD or Pancreatitis or Cholecystitis or Diverticulitis or UTI
Initial workup
Labs: CMP (glucose, BUN, Creatinine, electrolytes), CBC with diff, ABG/VBG, UA, ECG, AG, A1C, lipase, urine and serum ketones. CXR and BCx as needed. Trend troponins as needed.
CHF?:___
ESRD?:___
Pt in shock?:___
Treatment
Admit to ICU
NPO except for meds
Strict I/Os
Morphine 2 mg IV q 2-4 hr PRN pain
Prn Zofran for N/V
Orthostatic vitals
O2 to keep SpO2 >92%
IV Fluids, Potassium replacement, and Insulin therapy.
Bicarb if needed.
Monitoring
-BMP (for electrolytes, glucose, BUN, Cr.), Ketones, and venous pH q2-4hrs. No need to get ABG for monitoring, venous pH from VBG is enough.
-Accuchecks (capillary BS) every 1 hour
-Will Keep serum glucose between 150 and 200 mg/dL until resolution of DKA. Will do that by infusing D5 1/2 NS when the blood sugars are between 150 and 200.
-If Glu<100, use D10 at 50 ml/hr while on insulin drip
-Continue to monitor for s/s of infection
-CBC w/ diff, BMP, and ECG in AM
Disposition:
Pending DKA resolution.
Bridging insulin & feeding pt: When DKA resolves and the patient is able to eat, start insulin glargine SC. D/C Insulin drip 2 hr after the SC insulin glargine. In addition to the basal insulin, order pre-meal insulin boluses AC TID.

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Amylase may be increased even if there is no pancreatitis.

Related Articles

  1. Fluid Replacement in DKA
  2. Potassium Replacement in DKA
  3. Insulin Therapy in DKA
  4. Bridging and Feeding the Patient after DKA

 

DKA Pearls

  • Insulin deficiency is the main precipitating factor. So these patients need insulin.

 

Reference

Diabetes Metab Syndr Obes. 2014; 7: 255–264. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4085289/

Am Fam Physician. 2013 Mar 1;87(5):337-346. https://www.ncbi.nlm.nih.gov/pubmed/23547550

 

 

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