diabetic ketoacidosis (DKA)

see also:

• SGLT2 inhibitor induced diabetic ketoacidosis (gliflozin DKA)
• diabetes mellitus
• endocrinology
• insulin
• hypoglycaemia
• hyperosmolar hyperglycaemic state (HSS or HONK)
• diabetes mellitus in children
• Western Health procedures (intranet only):
  • Insulin infusion (docx)
  • Initial Management of Hyperosmolar Hyperglycamic State (doc)
  • initial Mx of diabetic ketoacidosis (DKA) (doc)
• AFTB lectures - DKA
• RCH - Mx of DKA in children
• no benefit of an initial insulin bolus prior to infusion

• type I insulin-dependent diabetic or new diabetic (or on a gliflozone - see SGLT2 inhibitor induced diabetic ketoacidosis (gliflozin DKA))
• blood glucose > 11.1mM (may be normal if SGLT2 inhibitor induced diabetic ketoacidosis (gliflozin DKA)),
• and raised ketones in either blood or urine
  • serum ketones 0.6 - 1.5mmol/L = slightly increased risk of DKA, test again in 2 hours
  • serum ketones 1.6 - 2.9mmol/L = increased risk of DKA
  • serum ketones > 3.0mmol/L = high risk of DKA - check blood gases
  • urine ketones 2+ or more = high risk of DKA - check blood gases
• and pH < 7.3 or venous bicarb < 15
  • NB. pH may be greater than 7.3 but less than 7.4 if there is respiratory compensation in which case CO₂ will be low

• transfer to a resus room
• 2 x IV access
• take bloods for FBE, U&E, blood gas, ketones, glucose, osmolality, troponin (if adult), blood cultures
• stat IV 0.9% saline 15-20 mL/kg in first hour (eg. for adults 1-1.5L stat)
• generally no need to Rx initial hyperkalaemia as this will fall with insulin Rx
• if initial K+ < 4mM, give iv KCl to correct K= before starting insulin
• if initial K+ > 4mM, commence insulin infusion ASAP:
  • Actrapid 100 units in 100ml 0.9% Saline (giving a concentration of 1 units/ml)
  • give as per protocol up to 5 units/hr depending upon blood glucose level
• if pH < 6.9, consider iv sodium bicarbonate (see below)
• search for a cause such as sepsis, AMI, trauma, surgery, alcohol, drugs, non-compliance
  • ECG
  • CXR
  • examine for rash, meningism, acute abdomen, check limbs to exclude acute thrombosis (arterial or venous)
  • FWT urine and send for culture
• consider empirical iv antibiotics
• nil orally
• fluid balance chart
• AVOID central line unless either:
  • unable to gain iv access,
  • elderly, or,
  • evidence of cardiac failure
• AVOID arterial line unless severe DKA with pH < 6.9
• AVOID IDC unless patient obtunded or is oliguric
• consider prophylactic anticoagulation, esp. if elderly with hyperosmolar state
• early endocrinology consult, and if severe DKA, also ICU consult

• aims of Rx:
  • restore normal hydration over 24hrs (48hrs for children as they are at higher risk of cerebral oedema) to avoid 3 mOsm/kg per hour
  • halve the blood glucose within 8-16 hours and avoid hypoglycaemia
    • if glucose drops more rapidly than this, reduce insulin infusion rates by 50%
    • if glucose falls below 5mMol/L, with-hold insulin infusion for 1hr, then re-start at 0.3 units/hr
  • increase venous bicarb by 3 mmol/L/hr
  • reduce blood ketone level by 0.5 mmol/L/hr
  • anticipate hypokalaemia thus start iv KCl with the 2nd or 3rd liter of saline once K+ level is known and is below 5.5mM/L
  • close monitoring
  • further search for cause
• re-hydrate with 0.9% NS at 4-14 mL/kg/hr
• ongoing insulin infusion as per protocol
• 5% dextrose infusion once glucose falls below 15mMol/L at rate of 1L over 8hrs
• iv KCl:
  • if K+ 4.5-5.5 then give 5 mmol/hr
  • if K+ 3.5-4.5 then give 10 mmol/hr
  • if K+ <3.5 then give 20 mmol/hr
  • for adults, after the initial stat 1-2L in 1st hour, give 1L over next 1-2 hours, then 1L over the following 2-4hrs
• regular blood glucose, blood gas, K+ assessments (eg. hrly initially then 4hrly)
• check blood ketones 4hrly
• strict fluid balance chart
• monitor for complications:
  • hyperchloraemic acidosis
    • if corrected Na > 150mMol/L then change from 0.9% saline to 0.45% saline
    • NB. add 1 mmol/L to [Na] for each 3 mmol/L rise in glucose level above normal
  • cerebral oedema
    • if develops sudden headache and/or confusion
    • usually children/adolescents
    • give mannitol 0.5 – 2.0 g/kg (2.5 – 10 mL/kg 20% mannitol) IV
    • supplemental oxygen
    • consider 3% hypertonic saline 5-10 ml/kg over 30 min instead of mannitol
  • thromboembolism
    • esp. elderly with hyperosmolar state

• this is still controversial with little evidence to support its use given the potential adverse effects ¹⁾
• the WH guideline does give the option of using it if pH falls below 6.9 after d/w endocrinology
  • advise use of bicarbonate 8.4% 50mmol diluted in 500ml 0.45% saline
• see also: LITFL summary