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dm_dka

diabetic ketoacidosis (DKA)

diagnosis

  • 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

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: 2020/06/04 18:10 by gary1