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Approach to DKA
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Approach to DKA

Topics / Diabetes Mellitus

Diagnosis

Symptoms: Polyuria, Polydipsia, Loss of appetite, Nauseas and vomiting, Abdominal pains, decreased level of consciousness
Signs: Signs of dehydration, decreased GCS, Acidotic breathing, signs of a precipitant
Investigations: ( Remember DIABETIC-KETO-ACIDOSIS)

  1. Hyperglycemia of > 15
  2. Acidosis ( blood pH < 7.3 ± Bicarbonate <17 ± Anion gap > 10)
  3. Urine/blood ketones

Precipitants

Precipitants (The “I”s)

  1. Infection: UTI, LRTI, Pancreatitis
  2. Infarction: MI
  3. Ischemia : CVA, Mesenteric
  4. Intoxication: Alcohol
  5. Ignorance: Poor compliance to treatment
  6. Infant: Patient is pregnant
  7. Iatrogenic: Drug interactions
  8. Idiopathic: newly diagnosed DM

Step-Wise Approach

  1. Emergency Management
    1. Airway and Breathing: If required, provide the patient with O2 supplementation with a facemask or nasal prongs.
    2. Circulation/Fluids: IV Access and begin fluid management immediately.
  2. Insulin: Start the insulin protocol
  3. Potassium: Start K+ supplementation
  4. Investigations:
    1. Bloods Gas
      1. This is done at the beginning. Will provide the doctor with an idea of acid base status, others include HGT as well.
    2. Formal Blood
      1. FBC/U&E/Blood Cultures
    3. Urine dipstick and send urine for MCS, and urinary ketones. A urinary catheter may also be inserted.
    4. HGT
    5. Others: CXR (rule out LRTI)
  5. Depending on the severity of the disease, eg. Nausea/vomiting or level of consciousness you will also need to insert an NGT to decompress/drain the gastric content.
  6. Other medications: Broad spectrum Antibiotics, start prophylactic subcutaneous heparin
  7. NB: Remember to find a precipitant

Monitoring

  1. Vitals (BP, HR, T, GCS) 6 hourly, U&E preferably 6 hours (otherwise daily), Urine dipstick 6 hourly
  2. HGT: 2 hourly until the blood glucose is < 14, then you can change to 4 hourly.
  3. Blood gases, 1-4 hourly depending on severity of patient.
  4. Fluid input and output should be strictly monitored.
  5. NB: Monitor patient fluid status clinically as well, a drop in GCS signifies the possibility of cerebral oedema and bilateral basal crepitations
Fluid Therapy (1st IV Access) Insulin Therapy (2nd IV Access) Potassium Supplementation
  1. Give 1 litre of Normal Saline IV stat
  2. Then: 1 litre over 2 hours, 1 litre over 4 hours, then another litre over the next 6 hours.
  3. NB: Once HGT becomes < 14 and you are still using Insulin then replace the Normal Saline vaculiter with 5% Dextrose water
 Preparation: Add 100 units of Actrapid to 1L NS, results in 0.1 units/ml. OR 20 units in 200ml to get 0.1 units/ml.
  1. Run infusion @ 0.1 units/kg/hour IV using an IVAC pump. Hence, a 100kg patient, needs 10units/hour = 100ml/hour of insulin infusion. If there is no infusion pump or adequate monitoring, this IV insulin can be given as IV bolus every hour.
  2. Adjust the infusion rate according to the HGT (Monitor HGT every 2 hours, and then every 4 hours once HGT is < 14.
  1. Check K+ levels before starting insulin therapy (blood gas). Insulin will cause a decrease in K+ levels.
  2. If K+ > 5 mmol/L: Do not give K+, repeat U&E at least daily
  3. If K+ 3.1 – 5 mmol/L; Add 20mmol to each litre of IV fluid in order to maintain a K+ concentration between 4-5mmol/L
  4. If K+ < 3 mmol/L: Add 40mmol to the initial IV fluid. DO NOT GIVE INSULIN until the K+ > 3.
Adjustment Adjustment Adjustment
  • If HGT < 5mmo/L – Give a 20ml 50% Dextrose water IVI and decrease the infusion rate by 10ml/hour (hence give 1 unit less in the next hour)
  • If HGT 5.1 - 10mmol/L then decrease the infusion rate by 10ml/hr
  • If HGT 10.1 – 15mmol/L – then there is no change in the infusion rate
  • If HGT 15.1 – 20mmol/L – increase the infusion rate by 10ml/hr
  • If HGT 15.1 – 20mmol/L – increase the infusion rate by 10ml/hr
Caution Caution Caution
Ideally, there should be a CVP inserted.
  • Should only use IVAC Pumps, especially where the environment allows it and there is adequate monitoring
  • Avoid using Dial-a-flows since they may not be very accurate
 Remember not to give K+ at more than 20mmol/hour. If more than 20mmol/hour is given, then cardiac monitoring needs to be done. Ideally, K+ should be given via a central line. If the concentration of potassium exceeds 40mmol/L, at higher strengths it may result in phlebitis and pain.

Resolved DKA

A patient has been adequately treated from DKA if the following are achieved.

  1. HGT < 11.1 mmol/L
  2. Serum Bicarbonate > 19 mmol/L, pH >7.3
  3. Clearance of serum ketones. Urinary ketones take longer to resolve. However, it is a good indicator for relapse of DKA once it has been cleared.
  4. Treat associated precipitants.
Published on 5 July 2022
Dr. RW Becerra Estevez
Dr. RW Becerra EstevezMBChB (WSU)

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