Exact IP Prescription for DKA (Diabetic Ketoacidosis)

1. Admission Orders / Initial Assessment

• Blood glucose (stat + hourly)
• Serum electrolytes (Na, K, Cl, HCO3) - every 2-4 hours
• Venous blood gas (pH, pCO2) - repeat every 2-4 hours
• Serum/urine ketones
• Blood urea nitrogen (BUN) and creatinine
• CBC with differential
• Serum phosphorus and magnesium
• Serum osmolality (calculated)
• ECG (to assess for hypokalemia changes)
• Urine analysis + culture (rule out infection as precipitant)
• Blood culture, CXR (if sepsis suspected)
• Serum amylase / lipase (interpret cautiously - often elevated without pancreatitis)

Diagnosis criteria (all three required):

• Glucose > 250 mg/dL (hyperglycemia)
• Urine ketones 2+ or serum ketones ≥ 3.0 mmol/L
• Venous/arterial pH < 7.3 (HCO3 < 18 mmol/L)

2. IV Fluid Prescription

• Total deficit is approximately 3-5 L in a typical adult
• 2 L total in the first 1-3 hours is standard

• Switch to 0.45% NS (half-normal saline) at 250-500 mL/hr
• Target urine output: 1-2 mL/kg/hour

• Switch IV fluid to D5W + 0.45% NS (5% dextrose in half-normal saline)
• This prevents hypoglycemia while insulin continues to clear ketones

Note: Balanced crystalloids (e.g., PlasmaLyte) may achieve faster normalization of pH compared to large volumes of NS.

3. Insulin Prescription

CRITICAL: Do NOT start insulin if serum K+ < 3.3 mEq/L - correct potassium first!

• 50 units Regular Insulin in 500 mL NS = 0.1 unit/mL
• Flush 50 mL through line before use (to saturate tubing)

Target: Glucose 150-200 mg/dL while ketoacidosis resolves. Do NOT stop insulin prematurely - continue until pH > 7.3 and HCO3 > 15-18 mEq/L and anion gap normalizes.

• Only when patient can eat, pH normalized, anion gap closed
• Overlap IV insulin with first SC dose by 1-2 hours before stopping the infusion

4. Potassium Replacement

• Potassium given as: KCl 20 mEq IV in 1 L NS or 40 mEq KCl per liter depending on level
• Max safe IV rate: 10-20 mEq/hr (faster rates require cardiac monitoring)

5. Phosphate / Magnesium

• Routine replacement is usually NOT necessary
• Replace if serum phosphate < 1.0 mEq/L using potassium phosphate
• Excessive phosphate supplementation can cause hypocalcemia

• If symptomatic hypomagnesemia: MgSO4 1-2 g IV over 1-2 hours

6. Sodium Bicarbonate (HCO3)

Bicarbonate is NOT routinely used in DKA

• Acidosis corrects with insulin and fluids alone in most cases
• Consider only if: pH < 6.9, severe hyperkalemia with ECG changes, or life-threatening hemodynamic instability
• Dose if used: 50-100 mEq NaHCO3 in 400 mL sterile water + 20 mEq KCl over 2 hours; repeat if pH remains < 7.0

7. Monitoring & Flow Sheet (Hourly)

8. Supportive Measures

• NPO initially; NG tube if vomiting or altered consciousness (prevents aspiration)
• Foley catheter if unable to monitor urine output (altered sensorium)
• Nasogastric tube if gastric paresis / ileus present
• DVT prophylaxis: Low-molecular weight heparin (e.g., Enoxaparin 40 mg SC OD) - especially in immobile/critically ill patients
• Antibiotics: Only if infection is confirmed as precipitant (culture-directed)
• Airway management: If comatose - intubate; maintain hyperventilation to compensate for metabolic acidosis
• Insulin pump patients: Do NOT disconnect pump - continue or adjust basal rate

9. Treating the Precipitant

10. Resolution Criteria (When to Stop IV Protocol)

1. Blood glucose < 200 mg/dL
2. Serum HCO3 ≥ 15-18 mEq/L
3. Venous pH > 7.3
4. Anion gap normalized (< 12 mEq/L)
5. Patient able to eat and drink

Summary "One-Line" IP Prescription

IV 0.9% NS 1 L stat, then 500 mL/hr x 2 hrs, then 0.45% NS 250 mL/hr; Regular insulin 0.1 u/kg/hr IV infusion (hold if K+ < 3.3); KCl 20-40 mEq/L in each IV bag when K+ 3.3-5.5; Switch to D5W/0.45% NS when glucose ≤ 300 mg/dL; Monitor vitals + glucose hourly, electrolytes q2-4h; Treat precipitant.

• ROSEN's Emergency Medicine, Chapter 115 (DKA management protocol, fluid/insulin/potassium tables)
• Goldman-Cecil Medicine, Chapter 210 (DKA diagnosis and treatment)
• American Diabetes Association recommendations for potassium and phosphorus repletion (cited in Rosen's)

Important note: Always individualize the prescription based on the patient's age, weight, renal function, cardiac status, and severity of DKA. Pediatric DKA protocols (especially fluid rates) differ significantly from adults - consult pediatric endocrinology guidelines.