| Agent | Mechanism of Action | Dosage | Benefits | Side Effects | Notes |
|---|
| Insulin (regular insulin;
insulin aspart;
insulin lispro;
insulin glulisine;
isophane insulin [NPH];
lente insulin;
ultralente insulin;
insulin glargine;
insulin detemir;
insulin lispro, insulin lispro protamine;
insulin aspart, insulin aspart protamine;
regular insulin, isophane insulin [NPH];
semilente insulin;
protamine zinc insulin [PZI]) | Corrects
insulin deficiency and overcomes insulin resistance. Allows shift of
glucose into cells and suppresses hepatic glucose production | Initial bolus of 0.15 U/kg, then 0.1 U/kg·h iv. Hold insulin until K is >3.3 mEq/L | Correct hyperglycemia and stop ketogenesis | Hypoglycemia, hypokalemia.
Low-dose insulin less likely to cause hypoglycemia or hypokalemia | Once blood glucose level is ~200 mg/dL, switch fluids to include dextrose 5%-10%. Target blood glucose to 150-200 mg/dL.
Once DKA is resolved (blood glucose  200 mg/dL, bicarbonate  18
mEq/L, pH >7.30) subcutaneous insulin therapy with multiple dose
insulin can begin at 0.5-0.8 U/kg·d. Overlap therapy for 1-2 h before
stopping iv regular insulin. If patient is unable to eat, continue iv
insulin therapy |
| Potassium | Replace potassium deficit | Replace at rate of 20-30 mEq/h if K is <3.3 mEq/L. Use 20 mEq/h if >3.3 and <5.0-5.5 mEq/L | Reverse hypokalemia and associated complications | Risk of over treatment leading to hyperkalemia.
Use cautiously in anuric patients and only if K+ is <3.3 mEq/L | Monitor potassium at least every 2 hours until normal.
KCl is most common form of potassium replacement. Can use 2/3 KCl and 1/3 KPO4 to prevent excessive Cl levels |
| Sodium bicarbonate | Corrects metabolic acidosis | If pH is <6.9 give 100 mmol NaHCO3 in 400 mL water at 200 mL/h. If pH is 6.9 to 7.0, give 50 mmol of NaHCO3 in 200 mL sterile water at 200 mL/h, repeat every 2 hours until pH is >7 | By
correcting severe metabolic acidosis, decreases risk of cardiac
arrhythmias, decreases cardiac output, cerebral vasodilitation | Hypokalemia,
metabolic alkalosis, ketoacid overproduction. Other theoretical risks
include: paradoxical CSF alkalosis, altered tissue oxygenation,
increased CO2 production | Consider use if arterial pH 7.0
Infuse slowly, to prevent shift of potassium to intracellular space |
| Fluid therapy | Volume expansion | Initial
bolus of 0.9% NaCl, ~1 L in first hour (15-20 mL/kg·h), continue 0.9%
NaCl if fluid deficit is large or corrected serum Na and osmolality are
high. Once major deficit is corrected, and corrected serum Na is normal
or high, use 0.45% NaCl, continue at 4-14 mL/kg·h | Corrects dehydration, improves insulin sensitivity, improves hyperkalemia, improves metabolic acidosis | Fluid overload, cerebral edema (may be associated with rapid change in serum osmolality) | Careful
monitoring of fluid status is needed; estimate volume depletion using
physical exam. Orthostatic tachycardia ~10% fluid deficit, orthostatic
drop ~15%-20% deficit, supine hypotension ~20% decrease in
extracellular fluid volume. Shock would require hemodynamic monitoring
and pressors |
|
Glucose
therapy | Provide adequate blood glucose level while maintaining insulin therapy | Once glucose is 200
mg/dL, begin 5% dextrose with 0.45% NaCl at 150-200 mL/h. Maintain
insulin infusion at 0.05-0.1 U/kg·h, use 10% dextrose if needed | Allows continuation of adequate insulin therapy that is required to treat the metabolic acidosis and stop ketogenesis | May require ongoing adjustment of insulin dosage to maintain glucose ~150-200 mg/dL | Early
reduction or cessation of insulin therapy because of normalization or
low blood glucose may result in worsening of DKA and delay of cure |
|
Phosphate
therapy | Replacement | 20-30 mEq of KPO4 over several hours. Add to replacement fluid if serum PO4 is <1 mg/dL | Correct severe hypophosphatemia | Risk of hypocalcemia | Although
phosphate level may be low, replacement is not necessary except in
unusual circumstances of extremely low phosphate level.
Phosphate
administration may lead to severe hypocalcemia and deposition of
calcium phosphate. If phosphate is used, monitor calcium levels. Use
20-30 mEq of KPO4 over several hours if needed |
