Diabetic Ketoacidosis (DKA) Clinical Pathway — Emergency Department, ICU and Inpatient

Initial Management of DKA

Fluid and Electrolyte Management

General Concepts for Rehydration

Volume depletion from osmotic diuresis
PE and VS underestimate deficits
Assume 5-10% dehydration
Frequent PE assessment and careful I/O are important

Initial Fluid Resuscitation

Initial resuscitation is 20mL/kg of NS over 1 hr
Improve circulatory volume
Consider additional 10-20 mL/kg NS bolus as indicated by VS, PE

Maintenance Fluids and Electrolytes

Begin NS at 1.5 times maintenance after bolus until BMP results available
Urinary replacement is not necessary
Maintenance Calculation, mL/hr, use weight in kg:
- 4 mL/kg for the first 10 kg
- + 2 mL/kg for the next 10 kg
- + 1 mL/kg for each kg over 20 kg

Electrolyte Replacement

Dextrose in fluids required before initial electrolyte results:
- Use D10 with 0.45% NS, replaces D10NS due to availability
Elevated chloride, concern for a hyperchloremic metabolic acidosis
- Consider switching fluids to 0.45% NS, review with endocrine

Serum K	KCL	Ordered Amount of KPhos Use potassium acetate if KPhos is not available
< 4	30 mEq	30 mEq, 20.4 mM
4-5.4	20 mEq	20 mEq, 13.6 mM
5.5-6	10 mEq	10 mEq, 6.8 mM
> 6	None	None

Electrolyte Abnormalities in DKA

Glucose

Aim to lower glucose 50-100 mg/dL per hr
Begin 2 bag system:
- One bag D10 NS, one bag NS (no dextrose)
- Dextrose provided based on BG
- Electrolytes content based on K+ level
- Rate 1.5 maintenance

Glucose Concentration in IVF

Blood Glucose (BG)	Dextrose
< 200	All D10
200-299	Half D10, half NS
> 300	All NS

Insulin

Insulin	Reverses the acidosis Stop insulin pump during DKA treatment Initiate regular insulin at rate of 0.1 u/kg/hr after initial NS bolus completed Do not use IV insulin bolus; may increases risk of cerebral edema Rarely, the rate of the infusion may need to be adjusted Delayed/No IV access Consult Endocrinology 0.15 units/kg IM or SQ rapid-acting insulin (Humalog/Novolog/Apidra) q2hr Lantus dose may be given while on insulin infusion

Reverses the acidosis
Stop insulin pump during DKA treatment
Initiate regular insulin at rate of 0.1 u/kg/hr after initial NS bolus completed
Do not use IV insulin bolus; may increases risk of cerebral edema
Rarely, the rate of the infusion may need to be adjusted
Delayed/No IV access
- Consult Endocrinology
- 0.15 units/kg IM or SQ rapid-acting insulin (Humalog/Novolog/Apidra) q2hr
Lantus dose may be given while on insulin infusion

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The clinical pathways are based upon publicly available medical evidence and/or a consensus of medical practitioners at The Children’s Hospital of Philadelphia (“CHOP”) and are current at the time of publication. These clinical pathways are intended to be a guide for practitioners and may need to be adapted for each specific patient based on the practitioner’s professional judgment, consideration of any unique circumstances, the needs of each patient and their family, and/or the availability of various resources at the health care institution where the patient is located.

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