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Characterize the symptoms: ❑ Abdominal pain ❑ Altered mental status ❑ Fever ❑ Kussmaul breathing ❑ Vomiting Identify precipitating factors: ❑ Infections ❑ Insulin deficiency ❑ Myocardial infarction ❑ New onset DM type 1 ❑ Pregnancy ❑ Stress

Examine the patient

Consider alternative diagnosis: ❑ Starvation ketosis ❑ Alcoholic ketoacidosis ❑ Drug abuse (salicylate, methanol, ethylene glycol) ❑ Lactic acidosis ❑ Other causes of high anion gap metabolic acidosis

Order tests: ❑ Serum glucose ❑ ABG ❑ CBC ❑ Electrolytes ❑ Serum & urinary ketones ❑ Urinalysis ❑ BUN ❑ Creatinine ❑ Plasma osmolality ❑ EKG ❑ CXR ❑Urine, sputum, blood cultures (not routine)

Diagnostic criteria ❑ Anion gap > 10 ❑ Blood glucose > 250 mg/dL ❑ pH < 7.3 ❑ Serum bicarbonate < 18 mEq/L ❑ Serum ketones (+)

IV fluid therapy ❑ Check hydration status ❑ Mild dehydration ❑ Evaluate for corrected Na+levels ❑ High/Normal Na+levels ❑ Switch to 0.45% NaCl (250-500mL/hr) ❑ Low Na+ levels ❑Continue to 0.9% NaCl (250-500mL/hr) ❑ Check blood glucose levels ❑ At serum glucose levels ~ 200 mg/dL, switch to 5% dextrose with 0.45% NaCl (150-250 ml/hr) ❑ Severe dehydration ❑ Start 0.9% NaCl (1L/hr) initially ❑ Cardiogenic shock ❑ Pressors/ Monitor hemodynamics

Insulin ❑ IV - Complicated DKA ❑ Regular insulin (0.1 U/kg) bolus ❑ Continuous infusion (0.1 U/kg/hr) ❑ SC - Uncomplicated DKA ❑ Rapid action insulin 0.3 U/kg then 0.2 U/kg after 1 hr ❑ SC insulin 0.2 U/kg every 2 hrs ❑ Double insulin infusion if blood sugar doesn't fall by 50-70 mg/dL in first hr ❑ At serum glucose = 200 mg/dL reduce IV insulin to 0.02-0.05 U/kg/hr or SC insulin (0.1 U/kg) every 2 hrs ❑ Target blood sugar to 150-200 mg/dL till DKA resolves

Need for K+replacement? ❑ < 3.3 mEq/dL ❑ Hold insulin ❑ supplement K+ (20-30 mEq/hr) till K+ > 3.3 mEq/L ❑ 3.3-5.3 mEq/dL ❑ Administer 20-30 mEq/L K+ ❑ >5.3 mEq/dL ❑ Don't supplement, check 2 hourly

Need for bicarbonate replacement? ❑ pH < 6.9 ❑ Dilute NaHCo3(100 mmol) in 400 ml H2O with 20 mEq KCl infused over 2 hrs ❑ Reassess ❑ pH > 7.0 ❑ No bicarbonate needed

❑ Check labs every 2-4 hrs ❑ Transition to SC insulin (0.8 U/kg/day) when pt tolerates oral feeding ❑ Stop IV insulin gradually ❑ Monitor for complications: ❑ Hypogylcemia ❑ Hypokalemia ❑ Cerebral edema ❑ Respiratory distress ❑ Sepsis ❑ Acute gastric dilation

Adapted from the recommendations given by American Diabetes Association (ASA) and other sources.