Management of Diabetic

Ketoacidosis (DKA)
Case study
Jane,76year old, Female
Emergency admission with confusion and
vomiting
◦ Found by career
◦ Known type 1 diabetic patient since 1994
Examination
◦ Bp 100/72, HR 120, RR 33, T 37°C
◦ Dry mucous membrane(dehydration), Rapid deep
breathing(kussmaul breathing)
◦ Blood result: pH 7.17,Glucose 33mmol/l, ketone
4.8
Definition of DKA
 Definition : severe uncontrolled diabetes with
◦ Ketoaneamia/ketonuria
◦ Metabolic acidosis
◦ Hyperglycaemia
 Most common clinical sign and symptoms are:
◦ Hyperventilation
◦ Dehydration
◦ Abdominal pain
◦ Impaired consciousness
 Precipitating conditions
◦ Infection
◦ Non complicance/ inadequate insulin
◦ Undiagnosed diabetes
◦ Other medical ilness
Principal component of treatment of
DKA
4 key aspects
◦ Correct dehydration
◦ Insulin administration
◦ Potassium replacement
◦ Treatment of precipitating illness
Acute management of DKA
Stage 1, Immediate management
◦ IV access
◦ Fluid replacement, normal saline at 1L/hr
◦ IV insulin, soluble 6 units/hr
Stage 2, On going management
◦ Continue normal saline infusion
◦ Add in 10%dextrose 100ml/hr when BG≤14mmol/l
◦ Potassium replacement
 20mmols/L (K=3.5-5mmol/L) or
 40mmols/L (K˂3.5mmol/L)
◦ Rate of IV insulin 6unit/hr initially, 3unit/hr when
BG˂ 14
◦ Hourly laboratory BG
◦ Consider precipitating factors
Stage 3, subsequent management
◦ 10% dextrose+20mmol/L KCL (100ml/hr)
◦ Normal Saline 250ml/hr
◦ Measure HCO3 ,K twice daily
◦ Measure BG hourly
◦ Insulin 3units/hr to maintain BG 9-14
◦ Convert insulin to sub-cut when biochem
stable
Stage 4, continuing care
◦ Review by diabetes team
◦ Discharge only when eating normally,
biochem normal and established on normal
sub-cut insulin
◦ Follow up at clinic
Conclusion
DKA is a medical emergency
Principal of treatment is simple
◦ Insulin administration
◦ Fluid replacement
◦ Potassium replacement