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

2. 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:

3. 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
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

4. 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.

5. 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 ml/hr D5% 0.45% saline.

6. 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 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

7. 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 U/kg) with contiuation of IV insulin for 1 – 2 hrs to ensure adequet plasma insulin level.

8. 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 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.

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

10. 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 KPO4.

11. 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.

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

13. Thank you