Management of DKA
1- Intravenous Fluid (Normal saline) 2- Insulin 3- PotassiumTime: 0 – 60 mins • Establish IV access, assess patient and perform initial investigations • Commence 0.9% sodium chloride (normal saline): If systolic BP > 90 mmHg, give 1 L over 60 mins. If systolic BP < 90 mmHg, give 500 mL over 15 mins.
Insulin treatment: 50 U human soluble insulin in 50 mL 0.9% sodium chloride infused intravenously at 0.1 U/kg body weight/hr
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 and 2 hrs, 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 nill 3.5 – 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
• If ketoacidosis has resolved and patient is able to eat and drink: Re-initiate SC insulin.
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