What is treatment protocol of DKA

I'll look up the DKA treatment protocol from the medical library right away.

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"diabetic ketoacidosis" AND management

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I now have comprehensive information. Let me compile the full DKA treatment protocol.

Treatment Protocol of Diabetic Ketoacidosis (DKA)

Diagnostic Criteria / Initial Workup

Before treatment, confirm DKA with:

Serum glucose, electrolytes, ketones, ABG
CBC with differential, urinalysis, chest X-ray, ECG (if indicated)
Calculate anion gap: AG = Na - (Cl + HCO3) - normal is 8-12 mEq/L

Severity classification:

Severity	pH	HCO3	Anion Gap	Mental Status
Mild	7.25-7.30	15-18	>10	Alert
Moderate	7.00-7.24	10-14	>12	Alert/drowsy
Severe	<7.00	<10	>12	Stupor/coma

Step 1 - IV Fluid Resuscitation (FIRST PRIORITY)

Fluid deficit is typically 7-9% of body weight (3-5 L in adults).

Phase 1 - Restore circulating volume:

0.9% Normal Saline: 1 L bolus, then 500-1000 mL/h (if cardiac and renal function normal)
If in hypovolemic shock: give NS as rapidly as possible until systolic BP >80 mmHg
Children: 20 mL/kg NS in the first hour

Phase 2 - Replenish total-body water deficit:

Switch to 0.45% saline at 150-500 mL/h (use 0.9% NS if hyponatremic)
Goal: positive fluid balance over 12-24 hours
Rate must not correct osmolality faster than 3 mOsm/kg/h (risk of osmotic encephalopathy)
Aim for urine output 1-2 mL/kg/h in children

Note: Fluid resuscitation alone can drop plasma glucose ~18% and improve acidosis before insulin is given, by improving tissue perfusion, lactate clearance, and renal glucose excretion.

Step 2 - Potassium Repletion (BEFORE Insulin)

Serum K is often normal or high on presentation despite total body depletion (acidosis shifts K out of cells). It drops rapidly once insulin is started.

Serum Potassium	Action
<3.3 mEq/L	Do NOT give insulin - replete K first; give 20-40 mEq/h IV until K ≥3.3 mEq/L
3.3-5.5 mEq/L	Add 20-40 mEq KCl per liter of IV fluid; start insulin
>5.5 mEq/L	Hold potassium supplementation; start insulin; recheck K frequently

Telemetry monitoring is recommended given the risk of arrhythmias from electrolyte shifts.

Step 3 - Insulin Therapy

Do NOT start insulin until K ≥3.3 mEq/L.

IV bolus (optional): 0.1 units/kg regular insulin IV (no longer routinely recommended per ADA)
Continuous infusion (standard): Regular insulin 0.1 units/kg/h (up to 5-10 units/h) in 0.9% NS
- Preparation: 100 units regular insulin in 100 mL 0.9% NS → 10 mL/h = 10 units/h

Glucose targets during infusion:

Goal drop: 50-75 mg/dL/h (2.8-4.2 mmol/L/h)
Do NOT correct faster than 100 mg/dL/h (risk of osmotic encephalopathy/cerebral edema)

When glucose drops to ≤250-300 mg/dL:

Add Dextrose 5% to IV fluids (prevent hypoglycemia while continuing insulin to clear ketones)
Reduce insulin infusion to 0.05 units/kg/h OR use the two-bag approach (separate glucose + insulin infusions - shown to shorten treatment duration)

Continue insulin until ketoacidosis resolves (not just until glucose normalizes):

pH >7.30
HCO3 ≥18 mEq/L
Anion gap closed

Transition to subcutaneous insulin:

Administer SC basal insulin 2 hours before stopping IV infusion to prevent rebound hyperglycemia
In mild DKA, SC/IM insulin is a proven alternative to IV infusion

2024-2026 evidence update: A recent meta-analysis (PMID 39090718) confirmed subcutaneous insulin is comparable to continuous IV infusion in adult DKA. A 2026 meta-analysis of RCTs (PMID 41208563) found that early co-administration of SC basal insulin alongside IV infusion reduces rebound hyperglycemia and may shorten DKA resolution time.

Step 4 - Phosphate and Magnesium

Phosphate: Not routinely replaced unless serum phosphorus <1.0 mEq/L - use potassium phosphate (KPhos) if not eating
Magnesium: Give 1-2 g MgSO4 IV if ventricular arrhythmias or symptomatic hypomagnesemia; serum levels may not reflect body stores

Step 5 - Bicarbonate (Selective Use Only)

NOT routinely recommended. Consider only in:

Shock or coma
pH <6.9
HCO3 <5 mEq/L
Cardiac or respiratory dysfunction
Severe hyperkalemia (to shift K intracellularly temporarily)

Dose: 50-100 mEq in 1 L of 0.45% saline over 30-60 min; always add 10 mEq KCl to avoid hypokalemia; follow arterial pH closely.

Step 6 - Monitoring

Parameter	Frequency
Blood glucose	Every hour
Serum K+, Cl-, HCO3, Na	Every 2-4 hours
ABG / venous pH	As needed (especially if severely acidotic)
β-hydroxybutyrate	Serial measurements to track ketosis resolution
Urine output	Continuous
Vital signs	Continuous

Key monitoring points:

Serum Na should rise as hyperglycemia corrects. If it doesn't, patient may be over-hydrated with free water.
Hyperchloremia (from NS) can close the anion gap before HCO3 normalizes - use serum HCO3 normalization as the more reliable marker of DKA resolution.
ICU/telemetry admission is preferred; mild-moderate DKA may be managed in a step-down unit.

Step 7 - Treat the Precipitant

Always identify and treat the underlying cause:

Infection (most common - note: DKA itself causes leukocytosis, so fever specifically suggests infection; start empiric antibiotics if sepsis suspected)
Missed insulin doses
New-onset diabetes
Myocardial infarction, stroke, pancreatitis (check lipase, not amylase)
Medications (steroids, SGLT2 inhibitors - euglycemic DKA)

Special Populations

Children: Same principles apply; be especially cautious with fluid rates to avoid cerebral edema (leading cause of death in pediatric DKA). Avoid rapid osmolality correction.

Pregnancy: A 2025 systematic review (PMID 40447103) highlights that DKA in pregnancy carries significant fetal risk; aggressive early treatment and fetal monitoring are essential.

Criteria for DKA Resolution

Blood glucose <200 mg/dL
Serum HCO3 ≥18 mEq/L
Venous pH >7.30
Anion gap ≤12 mEq/L
Patient tolerating oral fluids

Sources: The Washington Manual of Medical Therapeutics, p. 890-891; Rosen's Emergency Medicine, p. 2543-2544; ADA Guidelines as cited in Tintinalli's Emergency Medicine.

Create a quick-reference DKA protocol card (PDF) for the ICU

Reading File

Running Command

ls /home/daytona/workspace/ 2>/dev/null || echo "workspace empty or not found"

Running Command

mkdir -p /home/daytona/workspace/dka-protocol && python3 -c "from reportlab.lib import colors; print('reportlab ok')"

Writing File

~/dka-protocol/generate_dka_card.py

from reportlab.lib.pagesizes import A4
from reportlab.lib import colors
from reportlab.lib.units import mm, cm
from reportlab.platypus import (
    SimpleDocTemplate, Table, TableStyle, Paragraph,
    Spacer, HRFlowable
)
from reportlab.lib.styles import ParagraphStyle
from reportlab.lib.enums import TA_CENTER, TA_LEFT
from reportlab.platypus import KeepTogether

OUTPUT = "/home/daytona/workspace/dka-protocol/DKA_Protocol_Card.pdf"

# ── Colour palette ─────────────────────────────────────────────────────────────
NAVY      = colors.HexColor("#0D2B4E")
TEAL      = colors.HexColor("#0B7A75")
AMBER     = colors.HexColor("#E07B00")
RED       = colors.HexColor("#C0392B")
LIGHT_BG  = colors.HexColor("#F4F8FB")
AMBER_BG  = colors.HexColor("#FFF7E6")
RED_BG    = colors.HexColor("#FFF0EE")
WHITE     = colors.white
GREY      = colors.HexColor("#6B7280")
MID_GREY  = colors.HexColor("#E5E7EB")

# ── Styles ─────────────────────────────────────────────────────────────────────
def S(name, **kw):
    return ParagraphStyle(name, **kw)

H_CARD  = S("hcard",  fontSize=18, leading=22, textColor=WHITE,      fontName="Helvetica-Bold", alignment=TA_CENTER)
SUBHEAD = S("subh",   fontSize=9,  leading=11, textColor=WHITE,       fontName="Helvetica-Bold", alignment=TA_CENTER)
SEC_HDR = S("sechdr", fontSize=9,  leading=11, textColor=WHITE,       fontName="Helvetica-Bold")
BODY    = S("body",   fontSize=8,  leading=10, textColor=colors.black, fontName="Helvetica")
BODY_B  = S("bodyb",  fontSize=8,  leading=10, textColor=colors.black, fontName="Helvetica-Bold")
SMALL   = S("small",  fontSize=7,  leading=9,  textColor=GREY,         fontName="Helvetica")
WARN    = S("warn",   fontSize=8,  leading=10, textColor=RED,          fontName="Helvetica-Bold")
TBL_HDR = S("tblh",   fontSize=7.5, leading=9, textColor=WHITE,        fontName="Helvetica-Bold", alignment=TA_CENTER)
TBL_CEL = S("tblc",   fontSize=7.5, leading=9.5, textColor=colors.black, fontName="Helvetica")
TBL_B   = S("tblcb",  fontSize=7.5, leading=9.5, textColor=colors.black, fontName="Helvetica-Bold")
NOTE    = S("note",   fontSize=7,  leading=9,  textColor=GREY,         fontName="Helvetica-Oblique")
FOOT    = S("foot",   fontSize=6.5,leading=8,  textColor=GREY,         fontName="Helvetica", alignment=TA_CENTER)

def section_header(text, bg=NAVY):
    return Table(
        [[Paragraph(text, SEC_HDR)]],
        colWidths=["100%"],
        style=TableStyle([
            ("BACKGROUND", (0,0), (-1,-1), bg),
            ("LEFTPADDING",  (0,0), (-1,-1), 6),
            ("RIGHTPADDING", (0,0), (-1,-1), 6),
            ("TOPPADDING",   (0,0), (-1,-1), 4),
            ("BOTTOMPADDING",(0,0), (-1,-1), 4),
            ("ROUNDEDCORNERS", [3]),
        ])
    )

def p(txt, style=BODY):
    return Paragraph(txt, style)

def sp(h=4):
    return Spacer(1, h)

# ── Document setup ─────────────────────────────────────────────────────────────
doc = SimpleDocTemplate(
    OUTPUT,
    pagesize=A4,
    leftMargin=12*mm, rightMargin=12*mm,
    topMargin=12*mm, bottomMargin=12*mm,
    title="DKA ICU Protocol Quick-Reference Card",
    author="Orris Clinical Reference"
)

W = A4[0] - 24*mm   # usable width
story = []

# ══════════════════════════════════════════════════════════════════════════════
# HEADER BANNER
# ══════════════════════════════════════════════════════════════════════════════
header_tbl = Table(
    [[
        Paragraph("DKA ICU PROTOCOL", H_CARD),
        Paragraph("Quick-Reference Card<br/><font size=8>Adult &amp; Paediatric</font>", SUBHEAD)
    ]],
    colWidths=[W*0.62, W*0.38],
    style=TableStyle([
        ("BACKGROUND",   (0,0), (-1,-1), NAVY),
        ("LEFTPADDING",  (0,0), (-1,-1), 10),
        ("RIGHTPADDING", (0,0), (-1,-1), 10),
        ("TOPPADDING",   (0,0), (-1,-1), 8),
        ("BOTTOMPADDING",(0,0), (-1,-1), 8),
        ("VALIGN",       (0,0), (-1,-1), "MIDDLE"),
        ("ROUNDEDCORNERS", [5]),
    ])
)
story += [header_tbl, sp(6)]

# ══════════════════════════════════════════════════════════════════════════════
# SEVERITY CLASSIFICATION
# ══════════════════════════════════════════════════════════════════════════════
story += [section_header("SEVERITY CLASSIFICATION"), sp(3)]

sev_data = [
    [p("Parameter", TBL_HDR), p("Mild", TBL_HDR), p("Moderate", TBL_HDR), p("Severe", TBL_HDR)],
    [p("pH",         TBL_B),  p("7.25–7.30", TBL_CEL), p("7.00–7.24", TBL_CEL), p("< 7.00", TBL_CEL)],
    [p("HCO₃⁻",     TBL_B),  p("15–18 mEq/L", TBL_CEL), p("10–14 mEq/L", TBL_CEL), p("< 10 mEq/L", TBL_CEL)],
    [p("Anion Gap",  TBL_B),  p("> 10", TBL_CEL), p("> 12", TBL_CEL), p("> 12", TBL_CEL)],
    [p("Mental Status", TBL_B), p("Alert", TBL_CEL), p("Alert / Drowsy", TBL_CEL), p("Stupor / Coma", TBL_CEL)],
    [p("Setting",    TBL_B),  p("Ward / SC insulin", TBL_CEL), p("HDU / IV insulin", TBL_CEL), p("ICU mandatory", TBL_CEL)],
]
sev_tbl = Table(sev_data, colWidths=[W*0.22, W*0.22, W*0.26, W*0.30],
    style=TableStyle([
        ("BACKGROUND",   (0,0), (-1,0),  NAVY),
        ("BACKGROUND",   (0,1), (0,-1),  LIGHT_BG),
        ("ROWBACKGROUNDS",(1,1),(-1,-1), [WHITE, LIGHT_BG]),
        ("GRID",         (0,0), (-1,-1), 0.4, MID_GREY),
        ("VALIGN",       (0,0), (-1,-1), "MIDDLE"),
        ("ALIGN",        (1,0), (-1,-1), "CENTER"),
        ("TOPPADDING",   (0,0), (-1,-1), 3),
        ("BOTTOMPADDING",(0,0), (-1,-1), 3),
        ("LEFTPADDING",  (0,0), (-1,-1), 5),
    ])
)
story += [sev_tbl, sp(6)]

# ══════════════════════════════════════════════════════════════════════════════
# TWO-COLUMN LAYOUT: Fluids | Potassium
# ══════════════════════════════════════════════════════════════════════════════
# Left col: IV Fluids
fluid_inner = [
    [p("• Fluid deficit: <b>7–9% body weight</b> (~3–5 L adult)", TBL_CEL)],
    [p("<b>Phase 1 – Restore circulation:</b>", TBL_CEL)],
    [p("  0.9% NS: <b>1 L bolus</b>, then <b>500–1000 mL/h</b>", TBL_CEL)],
    [p("  Shock: NS wide open (child: 20 mL/kg) → SBP >80 mmHg", TBL_CEL)],
    [p("<b>Phase 2 – Replenish total water:</b>", TBL_CEL)],
    [p("  0.45% NS at <b>150–500 mL/h</b>", TBL_CEL)],
    [p("  (Use 0.9% NS if hyponatraemic)", TBL_CEL)],
    [p("  Max correction: <b>3 mOsm/kg/h</b>  UO target: 1–2 mL/kg/h", TBL_CEL)],
    [p("  Positive balance over <b>12–24 h</b>", TBL_CEL)],
    [p("• Add D5W when BG ≤250 mg/dL (consider 2-bag approach)", TBL_CEL)],
]
fluid_tbl = Table(fluid_inner, colWidths=[(W/2)-4],
    style=TableStyle([
        ("LEFTPADDING",   (0,0), (-1,-1), 5),
        ("RIGHTPADDING",  (0,0), (-1,-1), 5),
        ("TOPPADDING",    (0,0), (-1,-1), 2),
        ("BOTTOMPADDING", (0,0), (-1,-1), 2),
        ("BACKGROUND",    (0,0), (-1,-1), LIGHT_BG),
    ])
)

# Right col: Potassium
k_data_inner = [
    [p("Check K⁺ before insulin — DO NOT give insulin if K < 3.3 mEq/L", WARN)],
    [sp(2)],
    [Table(
        [
            [p("<b>K⁺ level</b>", TBL_HDR), p("<b>Action</b>", TBL_HDR)],
            [p("< 3.3 mEq/L", TBL_B), p("Give 20–40 mEq/h IV; hold insulin", TBL_CEL)],
            [p("3.3–5.5 mEq/L", TBL_B), p("Add 20–40 mEq KCl/L fluid + start insulin", TBL_CEL)],
            [p("> 5.5 mEq/L", TBL_B), p("Hold K⁺ supplement; start insulin; monitor", TBL_CEL)],
        ],
        colWidths=[W*0.15, (W/2 - W*0.15 - 8)],
        style=TableStyle([
            ("BACKGROUND",   (0,0), (-1,0),  TEAL),
            ("ROWBACKGROUNDS",(0,1),(-1,-1), [WHITE, LIGHT_BG]),
            ("GRID",         (0,0), (-1,-1), 0.3, MID_GREY),
            ("TOPPADDING",   (0,0), (-1,-1), 2),
            ("BOTTOMPADDING",(0,0), (-1,-1), 2),
            ("LEFTPADDING",  (0,0), (-1,-1), 4),
        ])
    )],
    [p("• Telemetry monitoring throughout", NOTE)],
]
k_inner_tbl = Table(k_data_inner, colWidths=[(W/2)-4],
    style=TableStyle([
        ("LEFTPADDING",   (0,0), (-1,-1), 5),
        ("RIGHTPADDING",  (0,0), (-1,-1), 5),
        ("TOPPADDING",    (0,0), (-1,-1), 2),
        ("BOTTOMPADDING", (0,0), (-1,-1), 2),
        ("BACKGROUND",    (0,0), (-1,-1), AMBER_BG),
    ])
)

col2_tbl = Table(
    [[
        Table([[section_header("IV FLUIDS", TEAL)], [sp(3)], [fluid_tbl]], colWidths=[(W/2)-4]),
        Table([[section_header("POTASSIUM REPLACEMENT", AMBER)], [sp(3)], [k_inner_tbl]], colWidths=[(W/2)-4]),
    ]],
    colWidths=[W/2, W/2],
    style=TableStyle([
        ("VALIGN",       (0,0), (-1,-1), "TOP"),
        ("LEFTPADDING",  (0,0), (-1,-1), 0),
        ("RIGHTPADDING", (0,0), (-1,-1), 4),
        ("TOPPADDING",   (0,0), (-1,-1), 0),
        ("BOTTOMPADDING",(0,0), (-1,-1), 0),
    ])
)
story += [col2_tbl, sp(6)]

# ══════════════════════════════════════════════════════════════════════════════
# INSULIN PROTOCOL
# ══════════════════════════════════════════════════════════════════════════════
story += [section_header("INSULIN PROTOCOL  (only after K⁺ ≥ 3.3 mEq/L)"), sp(3)]

ins_data = [
    [p("Route", TBL_HDR), p("Dose", TBL_HDR), p("Target / Notes", TBL_HDR)],
    [p("IV infusion (preferred)", TBL_B),
     p("Regular insulin 0.1 units/kg/h<br/><i>Prep: 100 u in 100 mL NS → 10 mL/h = 10 u/h</i>", TBL_CEL),
     p("BG drop: <b>50–75 mg/dL/h</b> (2.8–4.2 mmol/L/h)<br/>Do NOT exceed 100 mg/dL/h drop", TBL_CEL)],
    [p("IV bolus (optional)", TBL_B),
     p("0.1 units/kg bolus before infusion", TBL_CEL),
     p("Not routinely recommended (ADA)", TBL_CEL)],
    [p("When BG ≤ 250 mg/dL", TBL_B),
     p("Reduce infusion to 0.05 units/kg/h<br/>+ Add D5W to fluids", TBL_CEL),
     p("Continue insulin until ketoacidosis resolves, not just until BG normalises", TBL_CEL)],
    [p("Transition to SC", TBL_B),
     p("Give SC basal insulin <b>2 h before</b> stopping IV infusion", TBL_CEL),
     p("Prevents rebound hyperglycaemia", TBL_CEL)],
    [p("Mild DKA (SC route)", TBL_B),
     p("SC / IM regular insulin acceptable", TBL_CEL),
     p("IV preferred if poor perfusion / sicker patient", TBL_CEL)],
]
ins_tbl = Table(ins_data, colWidths=[W*0.20, W*0.40, W*0.40],
    style=TableStyle([
        ("BACKGROUND",    (0,0), (-1,0),  TEAL),
        ("ROWBACKGROUNDS",(0,1),(-1,-1), [WHITE, LIGHT_BG]),
        ("GRID",          (0,0), (-1,-1), 0.4, MID_GREY),
        ("VALIGN",        (0,0), (-1,-1), "MIDDLE"),
        ("TOPPADDING",    (0,0), (-1,-1), 3),
        ("BOTTOMPADDING", (0,0), (-1,-1), 3),
        ("LEFTPADDING",   (0,0), (-1,-1), 5),
    ])
)
story += [ins_tbl, sp(6)]

# ══════════════════════════════════════════════════════════════════════════════
# BICARBONATE  |  PHOSPHATE & MAGNESIUM
# ══════════════════════════════════════════════════════════════════════════════
bicarb_rows = [
    [p("NOT routinely recommended", WARN)],
    [p("<b>Consider ONLY if ANY of:</b>", TBL_CEL)],
    [p("  • Shock or coma", TBL_CEL)],
    [p("  • pH < 6.9", TBL_CEL)],
    [p("  • HCO₃⁻ < 5 mEq/L", TBL_CEL)],
    [p("  • Cardiac / respiratory dysfunction", TBL_CEL)],
    [p("  • Severe hyperkalaemia", TBL_CEL)],
    [p("<b>Dose:</b> 50–100 mEq in 1 L 0.45% NS over 30–60 min<br/>Always add <b>10 mEq KCl</b> to avoid hypokalaemia<br/>Monitor arterial pH closely", TBL_CEL)],
]
bicarb_inner = Table(bicarb_rows, colWidths=[(W/2)-4],
    style=TableStyle([
        ("LEFTPADDING",   (0,0), (-1,-1), 5),
        ("TOPPADDING",    (0,0), (-1,-1), 2),
        ("BOTTOMPADDING", (0,0), (-1,-1), 2),
        ("BACKGROUND",    (0,0), (-1,-1), RED_BG),
    ])
)

phos_rows = [
    [p("<b>Phosphate:</b> Not routinely replaced", TBL_CEL)],
    [p("  Replace if PO₄ < 1.0 mEq/L → use KPhos IV", TBL_CEL)],
    [p("<b>Magnesium:</b>", TBL_CEL)],
    [p("  1–2 g MgSO₄ IV if ventricular arrhythmia", TBL_CEL)],
    [p("  Serum Mg may not reflect body stores", NOTE)],
]
phos_inner = Table(phos_rows, colWidths=[(W/2)-4],
    style=TableStyle([
        ("LEFTPADDING",   (0,0), (-1,-1), 5),
        ("TOPPADDING",    (0,0), (-1,-1), 2),
        ("BOTTOMPADDING", (0,0), (-1,-1), 2),
        ("BACKGROUND",    (0,0), (-1,-1), LIGHT_BG),
    ])
)

col3_tbl = Table(
    [[
        Table([[section_header("BICARBONATE", RED)], [sp(3)], [bicarb_inner]], colWidths=[(W/2)-4]),
        Table([[section_header("PHOSPHATE & MAGNESIUM", TEAL)], [sp(3)], [phos_inner]], colWidths=[(W/2)-4]),
    ]],
    colWidths=[W/2, W/2],
    style=TableStyle([
        ("VALIGN",       (0,0), (-1,-1), "TOP"),
        ("LEFTPADDING",  (0,0), (-1,-1), 0),
        ("RIGHTPADDING", (0,0), (-1,-1), 4),
        ("TOPPADDING",   (0,0), (-1,-1), 0),
        ("BOTTOMPADDING",(0,0), (-1,-1), 0),
    ])
)
story += [col3_tbl, sp(6)]

# ══════════════════════════════════════════════════════════════════════════════
# MONITORING
# ══════════════════════════════════════════════════════════════════════════════
story += [section_header("MONITORING"), sp(3)]

mon_data = [
    [p("Parameter", TBL_HDR), p("Frequency", TBL_HDR), p("Key Point", TBL_HDR)],
    [p("Blood glucose", TBL_B), p("Every 1 h", TBL_CEL), p("Target drop 50–75 mg/dL/h; start D5W when BG ≤250 mg/dL", TBL_CEL)],
    [p("K⁺, Na, Cl, HCO₃⁻", TBL_B), p("Every 2–4 h", TBL_CEL), p("Na should rise as BG falls; if not → over-hydration with free water", TBL_CEL)],
    [p("ABG / venous pH", TBL_B), p("As needed", TBL_CEL), p("Use HCO₃⁻ normalisation (not AG closure) as DKA resolution marker", TBL_CEL)],
    [p("β-hydroxybutyrate", TBL_B), p("Serial", TBL_CEL), p("Best direct measure of ketosis resolution", TBL_CEL)],
    [p("Urine output", TBL_B), p("Continuous", TBL_CEL), p("Target ≥0.5 mL/kg/h adult | 1–2 mL/kg/h child", TBL_CEL)],
    [p("ECG / telemetry", TBL_B), p("Continuous", TBL_CEL), p("Detect K⁺-related arrhythmias early", TBL_CEL)],
]
mon_tbl = Table(mon_data, colWidths=[W*0.22, W*0.18, W*0.60],
    style=TableStyle([
        ("BACKGROUND",    (0,0), (-1,0), NAVY),
        ("ROWBACKGROUNDS",(0,1),(-1,-1), [WHITE, LIGHT_BG]),
        ("GRID",          (0,0), (-1,-1), 0.4, MID_GREY),
        ("VALIGN",        (0,0), (-1,-1), "MIDDLE"),
        ("TOPPADDING",    (0,0), (-1,-1), 3),
        ("BOTTOMPADDING", (0,0), (-1,-1), 3),
        ("LEFTPADDING",   (0,0), (-1,-1), 5),
    ])
)
story += [mon_tbl, sp(6)]

# ══════════════════════════════════════════════════════════════════════════════
# RESOLUTION CRITERIA  |  COMMON PRECIPITANTS
# ══════════════════════════════════════════════════════════════════════════════
res_rows = [
    [p("All of the following must be met:", TBL_B)],
    [p("  ✓ Blood glucose < 200 mg/dL", TBL_CEL)],
    [p("  ✓ Serum HCO₃⁻ ≥ 18 mEq/L", TBL_CEL)],
    [p("  ✓ Venous pH > 7.30", TBL_CEL)],
    [p("  ✓ Anion gap ≤ 12 mEq/L", TBL_CEL)],
    [p("  ✓ Tolerating oral fluids", TBL_CEL)],
    [p("Give SC basal insulin 2 h before stopping IV", NOTE)],
]
res_inner = Table(res_rows, colWidths=[(W/2)-4],
    style=TableStyle([
        ("LEFTPADDING",   (0,0), (-1,-1), 5),
        ("TOPPADDING",    (0,0), (-1,-1), 2),
        ("BOTTOMPADDING", (0,0), (-1,-1), 2),
        ("BACKGROUND",    (0,0), (-1,-1), LIGHT_BG),
    ])
)

prec_rows = [
    [p("• Infection (most common) — fever suggests sepsis", TBL_CEL)],
    [p("• Missed insulin / new-onset T1DM", TBL_CEL)],
    [p("• Myocardial infarction (get ECG)", TBL_CEL)],
    [p("• Pancreatitis (check lipase ×3 ULN)", TBL_CEL)],
    [p("• Stroke / acute illness", TBL_CEL)],
    [p("• SGLT2 inhibitors → euglycaemic DKA", TBL_CEL)],
    [p("• Steroids, thiazides, antipsychotics", TBL_CEL)],
]
prec_inner = Table(prec_rows, colWidths=[(W/2)-4],
    style=TableStyle([
        ("LEFTPADDING",   (0,0), (-1,-1), 5),
        ("TOPPADDING",    (0,0), (-1,-1), 2),
        ("BOTTOMPADDING", (0,0), (-1,-1), 2),
        ("BACKGROUND",    (0,0), (-1,-1), AMBER_BG),
    ])
)

col4_tbl = Table(
    [[
        Table([[section_header("RESOLUTION CRITERIA", TEAL)], [sp(3)], [res_inner]], colWidths=[(W/2)-4]),
        Table([[section_header("COMMON PRECIPITANTS", AMBER)], [sp(3)], [prec_inner]], colWidths=[(W/2)-4]),
    ]],
    colWidths=[W/2, W/2],
    style=TableStyle([
        ("VALIGN",       (0,0), (-1,-1), "TOP"),
        ("LEFTPADDING",  (0,0), (-1,-1), 0),
        ("RIGHTPADDING", (0,0), (-1,-1), 4),
        ("TOPPADDING",   (0,0), (-1,-1), 0),
        ("BOTTOMPADDING",(0,0), (-1,-1), 0),
    ])
)
story += [col4_tbl, sp(6)]

# ══════════════════════════════════════════════════════════════════════════════
# COMPLICATIONS TO WATCH
# ══════════════════════════════════════════════════════════════════════════════
story += [section_header("COMPLICATIONS TO WATCH"), sp(3)]
comp_data = [
    [p("Complication", TBL_HDR), p("Cause", TBL_HDR), p("Prevention / Action", TBL_HDR)],
    [p("Hypokalaemia", TBL_B),    p("Insulin shifts K⁺ into cells", TBL_CEL),    p("Potassium replacement protocol above; monitor every 2 h", TBL_CEL)],
    [p("Hypoglycaemia", TBL_B),   p("Insulin without glucose replacement", TBL_CEL), p("Add D5W when BG ≤250; reduce insulin to 0.05 u/kg/h", TBL_CEL)],
    [p("Cerebral oedema", TBL_B), p("Rapid osmolality correction", TBL_CEL),     p("Correct ≤3 mOsm/kg/h; especially critical in children", TBL_CEL)],
    [p("Hyperchloraemic acidosis", TBL_B), p("Large NS volumes", TBL_CEL),       p("AG closure ≠ DKA resolution — always check HCO₃⁻", TBL_CEL)],
    [p("Aspiration", TBL_B),      p("AMS + vomiting", TBL_CEL),                 p("Intubate if comatose / vomiting; avoid if possible", TBL_CEL)],
]
comp_tbl = Table(comp_data, colWidths=[W*0.22, W*0.30, W*0.48],
    style=TableStyle([
        ("BACKGROUND",    (0,0), (-1,0), NAVY),
        ("ROWBACKGROUNDS",(0,1),(-1,-1), [WHITE, LIGHT_BG]),
        ("GRID",          (0,0), (-1,-1), 0.4, MID_GREY),
        ("VALIGN",        (0,0), (-1,-1), "MIDDLE"),
        ("TOPPADDING",    (0,0), (-1,-1), 3),
        ("BOTTOMPADDING", (0,0), (-1,-1), 3),
        ("LEFTPADDING",   (0,0), (-1,-1), 5),
    ])
)
story += [comp_tbl, sp(8)]

# ══════════════════════════════════════════════════════════════════════════════
# FOOTER
# ══════════════════════════════════════════════════════════════════════════════
story += [
    HRFlowable(width="100%", thickness=0.5, color=MID_GREY),
    sp(3),
    p("Sources: Washington Manual of Medical Therapeutics | Rosen's Emergency Medicine | Tintinalli's Emergency Medicine | ADA Guidelines  •  July 2026", FOOT),
    p("⚠ This card is a clinical aide-memoire. Always apply individual patient clinical judgement. Not a substitute for local institutional protocols.", FOOT),
]

# ── Build ──────────────────────────────────────────────────────────────────────
doc.build(story)
print(f"PDF saved to {OUTPUT}")

Running Command

python3 /home/daytona/workspace/dka-protocol/generate_dka_card.py

Running Command

ls -lh /home/daytona/workspace/dka-protocol/DKA_Protocol_Card.pdf

Your DKA ICU Quick-Reference Card is ready to download:

DKA Protocol Card

PDF Document · PDF

What's on the card (single A4 page, colour-coded for fast scanning):

Section	Colour
Severity Classification - pH, HCO₃, AG, mental status, setting	Navy
IV Fluids - Phase 1 (NS bolus/shock) & Phase 2 (0.45% NS, 2-bag approach)	Teal
Potassium Replacement - 3-tier table with insulin hold rule	Amber
Insulin Protocol - IV infusion prep, dose, BG targets, transition to SC	Teal
Bicarbonate - "NOT routine" warning + 5 criteria for use	Red
Phosphate & Magnesium - replacement thresholds	Teal
Monitoring - BG/electrolyte/ABG/telemetry frequencies	Navy
Resolution Criteria - all 5 must be met before stopping	Teal
Common Precipitants - including SGLT2i / euglycaemic DKA	Amber
Complications - hypokalaemia, cerebral oedema, hyperchloraemic acidosis	Navy

The footer includes a disclaimer and source references (Washington Manual, Rosen's, Tintinalli's, ADA Guidelines).

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