Management of adult diabetic ketoacidosis

Figures & data

Table 1 Checklist of DKA management milestones

□ Phase I (0–6 h)	□ Phase II (6–12 h)	□ Phase III (12–24 h)
□ Perform history and physical exam and order initial laboratory studies	□ Continue biochemical and clinical monitoring	□ Continue biochemical and clinical monitoring
□ Implement monitoring plan (biochemical and clinical)	□ Change isotonic fluids to hypotonic fluids if corrected Na normal/high	□ Adjust therapy to avoid complications
□ Give intravenous bolus of isotonic fluids	□ If glucose is <200–250 mg/dL, add dextrose to intravenous fluids	□ Address precipitating factors
□ Start insulin therapy (after fluids started and only if K >3.3 mmol/L)	□ Adjust insulin infusion rate as needed	□ If DKA resolved, stop intravenous insulin and start subcutaneous insulin
□ Consult diabetes team	□ Maintain K at 3.3–5.3 mmol/L range	□ Consult diabetes educator

Abbreviations: DKA, diabetic ketoacidosis; h, hours.

Figure 1 Workflow of management of adult DKA.

Abbreviations: BG, blood glucose; DKA, diabetic ketoacidosis; h, hour; IV, intravenous; SC, subcutaneous.

Table 2 Pharmacokinetics and pharmacodynamics of subcutaneous insulin preparations

Insulin	Onset of action	Time to peak	Duration	Timing of dose
Regular	30–60 min	2–3 h	8–10 h	30–45 min before meal
Aspart	5–15 min	30–90 min	4–6 h	15 min before meal
Glulisine	5–15 min	30–90 min	5.3 h	15 min before meal
Lispro	5–15 min	30–90 min	4–6 h	15 min before meal
NPH	2–4 h	4–10 h	12–18 h	Twice a day
Detemir	2 h	No peak	12–24 h	Once or twice a day
Glargine	2 h	No peak	24 h	Once a day

Abbreviations: h, hours; min, minutes; NPH, neutral protamine Hagedorn.