DIABETIC KETOACIDOSISMANAGEMENT

PHYSICAL SIGNS: tachycardia, capillary filling, rapid and labored breathing with fruity odour, gi symptoms, abdomen tenderness, dehydration, resp. distress, shock & coma. INVESTIGATIONS: 1)PH,HCO3,pco2 (to r/o anion gap metabolic acidosis 2) serum ketones 3)blood glucose4)urine ketones 5) electrolytes, osmolality & ammonia levels 6)ECG(to R/O electrolyte abnormality&MI) 7) amylase, transaminase,triglyceride 8)urine output & RFT 9)cultures,chest xray,usg +ve signsAnion gap. PH, HCO3, PCO2, Na. serum and urine ketones, blood glucose, K, osmolality.

I.V line Fluid administration(.9% or .45% Nacl according to Na levels) 1) restoration of circulatory volume: If cardiac status-N ---1L rapid infusion followed by .5-1l/hr until vitals stabilized and urine output normal(usually 2-3hrs) 2) replenish total body water deficit:150-500ml/hr 3) maintenance fluid replacement: until i/o chart - +ve balance

insulin therapy Imp: do not start insulin if K levels are <3.3 meq/l. first correct the K levels. .15u/kg i.v stat .1u/kg/hr( a in b.s of 5075 mg/ dl/hr is appropriate. If not raise the dose by 2-3 folds.) maintenance insulin infusion 1to 2u/hr until pt is clinically improved, serum HCO3 to >15 meq/l and anion gap is closed.

Once b.s is 250mg/dl start DNS infusion & to .o5u/kg / hr .

insulin infusion

Once oral feeds start start s.c insulin - 1 hr before stopping the infusion preferabally in early morning or evening

K correction Kcl added to the 2ndor3rd litre of fluid replacement at 10-20 meq/hr. If Nahco3 infusion started additional K of 10 meq/ infusion. If patients present with hypokalemia at a rate of > 40 meq/hr. Nahco3 correction-50-100meq in 1L .45%NS in c/o1)shock/coma2)Ph<7.1 3)HCO3<5eq/l4)acidosis- cardioresp dysfunction5)severe hyperkalemia. Treat the cause: I.V antimicrobials for infections , anti anginals for infarction. DOS:CBG and electrolytes every 2hrs. ABG every 4hrs. Serial ECG. Monitor vitals, respiration, mental status & i/o chart. DO NOTS: start insulin if k<3.3meq, correct glucose>100mg/dl/hr, k correction in renal failure,oliguria &k>6meq.rapid D inf. with low insulin dose.