• A 60kg 24 year old female with past medical history of

diabetesellitus I is brought to the ER by her mother with

CASE
complaints of fatigue and increased thirst and urination. Of
note patient states she ran out of her insulin last week. She
also has had a runny nose and cough for the past week. She
noticed her glucose levels have been running “very high”
and got concerned.

• On Exam:
• BP 101/72; heart rate: 113; respirations: 32; Temperature: 36.8 °C; pulse
oximetry: 100% on room air.
• General: No apparent distress, AA and Ox3.
• HEENT: dry mucous membranes
• CV: tachycardic, normal s1, s2. No murmurs
• Lung: normal
• Abdomen: +bs, non distended, slight tenderness to deep palpation, no
HSM no rebound or guarding
• Ext: no cyanosis, clubbing or edema
• What labs do you want to order?
• For diagnosis:
• Serum glucose
• RP
• Ketone measurement
• VBG (or ABG if indicated)
• + calculate anion gap and serum osmolarity

• Other:
• FBC
• UFEME
• Cultures if indicated
• HbA1c
• ECG
• CXR
 Lab
• EKG sinus Results:
tachycardia
• BMP:
• Na: 124
• K: 5.0
• Cl: 95
• CO2: 11
• BUN: 7
• Cr: 38
• Glucose 25
• AST:40
• ALT:41
• Alk phos:67
• Arterial blood gas:
pH 6.9, CO2 9, bicarb 10
• WBC 13K, Hb14.4 mg/dL, and Hct 43.5%.
• 75% neutrophils
• UA +glucose, +protein, -leuko esterase, -nitrite NO KETONES
• Serum ketones test ordered is positive for beta-hydroxybutyrate
• What is anion gap and serum osmolality ?
Serum osmolarity and Anion gap
• Calculated serum osmolality =
[2 x Na (mmol/L)] + glucose (mmol/L)
• Normal: 285-295 mosm/L
• May vary in DKA, consider Hyperosmolar hyperglycemic state if >320
mosm/L and pH >7.3

• Anion gap = [Na – (Cl + HCO3)]

• Normal: 3-10 mmol/L
• In DKA >10-12 mmol/L
• AG : 24
• SO: 273
• What would you do next?
• Bolus iv insulin 0.1unit/kg ( 6 unit)
• Fixed rate of insulin of 0.1unit/kg/hr – 6unit/hr
• Start fluid regime
• Tro precipating cause and infection – cultures, cxr
• Empirical antibiotic
Insulin therapy
• Choice of insulin regimen:
A. Fixed-rate IV insulin infusion (IVII): infuse
insulin at 0.1 units/kg/hour
B. Variable-rate IV insulin infusion (IVII):
‘sliding-scale’ insulin

• Proponents of fixed-rate IVII argue that

weight-based regimens result in:
1. More rapid clearance of ketonemia
2. Take into account effect of body weight on
insulin requirements; eg obesity, pregnancy

• Evidence: No evidence to fully support

either regimen
Insulin therapy
• UpToDate recommendation:
• IV bolus 0.1 units/kg of regular insulin,
• Followed by fixed-rate IVII at 0.1 units/kg/hour

• This dose usually decrease serum glucose concentration by

about 3-4 mmol/L/hour.
Insulin therapy
• Higher doses generally do not produce a more
prominent hypoglycemic effect as the insulin
receptors are already saturated

• If the serum glucose does not fall by at least 3

to 4 mmol/L from the initial value in the first
hour, check the IV access to be certain that the
insulin is being delivered and make sure that no
IV line filters that may bind insulin have been
inserted into the line.

• After these possibilities are eliminated, the

insulin infusion rate should be doubled every
hour until a steady decline in serum glucose of
3-4 mmol/L/hour is achieved.
Insulin therapy
• Fall in serum glucose is the result of both insulin activity and volume
repletion

• Volume repletion alone can initially reduce serum glucose by 2-4

mmol/L/hour due to ECF expansion and dilution, and increased urinary
losses resulting from improved renal perfusion and glomerular filtration.

• When the serum glucose reaches ≤11.1 mmol/L, dextrose should be added
to the maintenance fluid and it may be possible to decrease the insulin
infusion rate to 0.02 to 0.05 units/kg/hour

• Aggressive insulin therapy when serum glucose is already below 11.1

mmol/L may promote the development of cerebral oedema
Metabolic targets in DKA

• Recommended targets [1]

• Reduction of blood ketone concentration by 0.5
mmol/L/hour
• Increase of venous bicarbonate by 3.0 mmol/L/hour
• Reduction of capillary blood glucose by 3.0
mmol/L/hour
• Maintenance of serum potassium 4.0 – 5.0 mmol/L

• If these rates are not achieved, then the fixed

rate IVII rate should be increased

1. American Diabetes Association

• Q2 hour BMP checks:
• After 6 hours:
• Na: 139
• K: 2.5
• Cl: 108
• Co2: 13
• BUN 28
• Creatinine 1.4
• Glucose 12
• ABG:
• pH 7.2, CO2 of 18 and a bicarb of 12
• What is the anion gap ?
• AG?
• Is this patient still in DKA ?
• What do you do next?
• Switch to 0.45% saline with potassium supplements with maintanence of
dextrose (D10%)
• Repeat BMP in 4 hours:
• Na: 140
• K: 4.5
• Cl: 118
• Co2: 25
• BUN 3
• Creatinine 39
• Glucose 10
• VBG: pH 7.25, Co 25 HCO3 15
, HCO3
• What is the AG ?
• Is this pt is still in DKA?
• Do you want to change to insulin to sliding scale ?