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dm_dka

diabetic ketoacidosis (DKA)

diagnosis

initial Mx of adults with DKA in 1st hour in ED

  • 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

next 24hrs of Rx of adults

  • 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

the role of sodium bicarbonate Rx in severe DKA

  • 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
dm_dka.txt · Last modified: 2019/06/27 11:32 by wh