Management of DKA
DKA is a medical emergency that should be treated in hospital, preferably in a high-dependency unit.
Regular clinical and biochemical review is essential, particularly during the first 24 hours of treatment.
Time: 0–60 mins
• Establish IV access, assess patient and perform initial investigations• Commence 0.9% sodium chloride:
If systolic BP > 90 mmHg, give 1 L over 60 mins.
If systolic BP < 90 mmHg, give 500 mL over 10–15 mins, then re-assess.
Commence insulin treatment:
50 U human soluble insulin in 50 mL 0.9% sodium chloride infused intravenously at 0.1 U/kg body weight/hrContinue with SC basal insulin analogue if usually taken by patient
if intravenous administration is not feasible, soluble insulin can be given by intramuscular injection (loading dose of 10–20 U, followed by 5 U hourly), or a fast-acting insulin analogue can be given hourly by subcutaneous injection (initially 0.3 U/kg body weight, then 0.1 U/kg hourly).
Establish monitoring schedule:
-- Hourly capillary blood glucose and ketone testing-- Venous bicarbonate and potassium after 1, then every 2 hrs for first 6 hrs --
-- Plasma electrolytes every 4 hrs
-- Clinical monitoring of O2 saturation, pulse, BP, respiratory rate and urine out put every hour
-- Treat any precipitating cause
Time: 60 mins and later
• IV infusion of 0.9% sodium chloride with potassium chloride added as indicated later: --1 L over 2 hrs--1 L over 2 hrs
--1 L over 4 hrs
--1 L over 4 hrs
--1 L over 6 hrs
Add 10% glucose 125 mL/hr IV when glucose < 14 mmol/L (250 mg/dL)
• Be more cautious with fluid replacement in older or children, pregnant patients and those with renal or heart failure.if plasma sodium is > 155 mmol/L, 0.45% sodium chloride may be used
Plasma potassium Potassium replace
< 5.5 nill3.5 – 5.5 40 mmol/L infusion
> 3.5 senior review –
additional required
By 24 hrs, ketonaemia and acidosis should have resolved (blood ketones < 0.3 mmol/L, venous bicarbonate > 18 mmol/L)
• If patient is not eating and drinking: Continue IV insulin infusion at lower rate of 2–3 U/hr
Continue IV fluid replacement and biochemical monitoring
Additional procedures of DKA
• Consider urinary catheterization if anuric after 3 hrs or incontinent• Insert nasogastric tube if there is persistent vomiting
• Insert central venous line to allow fluid replacement to be adjusted accurately in:
-- cardiovascular system is compromised.
-- older patients
-- pregnant women
-- renal failure, and other serious comorbidities and severe DKA
• Measure arterial blood gases.
Repeat chest X-ray if O2 saturation < 92%• Institute ECG