Few processes in medicine are as simple as the treatment of
DKA (diabetic ketoacidosis) or have been as gratuitously complicated by anal
retentive micromanagers of physiology. Here is a departure from that custom that I
have refined iteratively during the past four years. It is guided by the goal of reversing ketoacidosis (and associated dehydration) and getting patients eating and back on subcutaneous insulin as expeditiously as possible, while reducing waste and burdens of care and without compromising safety. It does not have as a goal to rigidly govern lab values or usurp control of physiology during the process. The caveat to be aware of is that
I have refined it in young(ish), adult, non-compliant Type I diabetics without
insulin resistance who have moderate to severe
acidosis and hyperglycemia. (I do not treat "DKA" with a serum
HCO3- greater than or equal to 14 with an insulin infusion - I treat it with
fluids and reinstitution of subcutaneous insulin.) It also presumes that there was no trigger
other than non-compliance, or that the trigger (e.g. UTI) has been investigated
and addressed. I will briefly discuss
the 5 orders, their benefits and potential drawbacks. First, the orders:
1.) Bolus with 5 liters of Lactated Ringers
Solution
2.) Begin insulin infusion at 5 units per hour
(FIXED DOSE, NO BOLUS, NO TITRATION).
3.) Check blood sugar every 2 hours; When blood
sugar less than 200 mg/dL, reduce insulin drip to 1 unit per hour.
4.) If blood sugar is less than 100 mg/dL (on any
insulin dose) or greater than 300 mg/dL on 1 unit per hour, call MD.
5.) Check serum K+ and HCO3- 12 hours after the
start of treatment.
