Management of DKA

Thank you to those who participated in our small group discussion on management of DKA. This was a first attempt at running such a session, so hopefully the next one will be even more effective.

The takeaway points (as I see them are):
* Stabilize the patient first while doing everything else

• large bore IVs with NS for hypovolemia
• foley as required
• think about arterial line in the sicker patients
  

* History/Px/Labs to look for volume status and precipitant
* Insulin:

• When you know the K+ isn't very low start the insulin
• 0.1u/kg bolus then rate 0.1u/hr titrated to IV sliding scale
  
• If glucose not falling can increase the dose, but be sure they are volume replete
• Add dextrose (D5W or 2/3-1/3) when glucose <~13
• Continue until patient has normal glucose and no anion gap and is ready to eat

* Potassium

• Add K+ to the IV as soon as they are urinating and K+ <5
• Oral repletion for hypokalemia in addition to IV.
  
• Hold insulin when K+ <3.3

* Sodium/Water Balance

• Use IV NS until you have reversed the signs of shock
• Then change to a hypotonic fluid like 1/2NS or 2/3-1/3 or D5W

* Treat the precipitant

As promised, here is my favorite article on the management of DKA/HONK.

This is my favorite figure from the article if you don't want to read it all: