Management of Diabetic Ketoacidosis Done by: Mohammed S. Samannodi MBBS, ID demonstrator

Definition DKA is life threatening complication of DM, occur predominantly in type1 DM but it can occu in those with type2 DM. The definition of DKA according to American Diabetes Association is shown in the following table:

Diagnostic criteria for DKA Severe Moderate Mild More than 250 Plasma glucose(mg/dl) Less than 7.00 7.00 – 7.24 7.25 – 7.30 Arterial PH Less than 10 10 - 14 15 - 18 Serum bicarbonate(mEq/L) +ve Urine ketones Serum ketones Variable Effective serum osmolality(mOsm/kg) More than 12 More than 10 Anion gap Stupor / coma Alert / drowsy Alert Alteration in sensoria

Treatment of DKA :Treatment of DKA divided into 4 parts # Correction of body’s fluid. # Administration of insulin. # Correction of electrolyte abnormalities. # Identification and treatment of precipitating events.

1. Correction of body’s fluid: # 10 – 15 ml / kg isotonic saline with max. less than 50 ml / kg in 1st 4hrs. # If hydration state is improved, look at serum Sodium, if nomal or high, continue with 250 – 500 ml/hr 0.45% saline. If low continue with 250 – 500 ml/hr isotonic saline. # When serum glucose reach to 200 mg/dl, change to 150 -200 ml/hr D5% 0.45% saline.

2. Administration of insulin: # 0.1 U / kg IV bolus of regular insulin, followed by 0.1 U / kg continuous infusion of regular insulin. # If the serum glucose does not fall by 50-70 mg/dl in the 1st hr, double the dose of infusion. # When the serum glucose reach 200 mg/dl, reduce insulin infusion to 0.02 – 0.05 U/kg/hr

Continue Or shift to rapid acting insulin at 0.1 U/kg, SC every 2hrs. # Keep serum glucose between 150 – 200 mg/dl until resolution of DKA. # After resolution of DKA and when the pt. able to eat, initiate SC insulin( start at 0.5-0.8U/kg) with contiuation of IV insulin for 1 – 2 hrs to ensure adequet plasma insulin level.

3. Correction of electrolyte abnormalities: # Mainly potassium , bicarb and phosphate. # Check lytes every 2 – 4 hrs. # If K less than 3.3 mEq/L, hold insulin and give 20-30 mEq/L KCl until K become more than 3.3 mEq/L. # If K more than 5.3 mEq/L , check serum K every 2 hrs.

Continue # If K more than 3.3 but less than 5.3, give 20-30 mEq/dl KCl in each liter of IVF to keep K between 4-5.

Continue # If the PH less than 6.9 , replete HCO3. # Dilute 100 mmol of NaHCO3 in 400 ml H2O with 20 mEq/L KCl then, infuse it every 2 hrs until PH become more than 7. # PO4 depletion usually self-limited but if less than 1 mg/dl, give 20-30 KPO4.

4. Identification and treatment of precipitating events: # Non-compliance and inadequet insulin dose # New onset DM. # Acute illness: Infection, CVA, MI, acut pancreatitis. # Drugs: Clozapine, Lithium, Cocaine, Terbutaline.

Reference: # UpToDate 2012. # Current 2012, Internal Medicine.

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