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Diabetic Ketoacidosis (DKA) Adults

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Version Jan 2023

DKA is typically seen in Type 1 Diabetes but a significant number of causes occur in Type 2 Diabetes and it usually comes on over several days and should be preventable. Give a fixed-rate infusion the goal is to correct ketones and dehydration secondly the glucose

Initial Management Summary
Diagnostic Criteria for DKA CBG = 11 mmol/L Ketones = 3.0 mmol/L or urine ketones 2+ Venous pH < 7.3 (Arterial blood gases not routinely needed) HCO₃ = 15 mmol/L Fluids 1 L 0.9% Saline given over first 1 hr. Fluids 1 L 0.9% Saline given over next 2 hrs with added K if low Assess if needs ITU bed and if so escalate Start Insulin at a fixed rate of 0.1 units/kg/hr + continue long acting ABCDE: Assess whether ITU bed needed. VBG, U&E, FBC, CXR, ECG, Culture, Lactate Needs VTE risk assessment. Nausea and vomiting consider NG tube

Initial Management Summary

Diagnostic Criteria for DKA
- CBG = 11 mmol/L
- Ketones = 3.0 mmol/L or urine ketones 2+
- Venous pH < 7.3 (Arterial blood gases not routinely needed)
- HCO₃ = 15 mmol/L
Fluids 1 L 0.9% Saline given over first 1 hr.
Fluids 1 L 0.9% Saline given over next 2 hrs with added K if low
Assess if needs ITU bed and if so escalate
Start Insulin at a fixed rate of 0.1 units/kg/hr + continue long acting
ABCDE: Assess whether ITU bed needed. VBG, U&E, FBC, CXR, ECG, Culture, Lactate
Needs VTE risk assessment.
Nausea and vomiting consider NG tube

Introduction

Mortality is 1-5 %. Significant complications include brain injury with cerebral oedema

Definition

Ketonaemia = 3 mmol/L or ketonuria > 2+ on standard urine sticks
Blood glucose > 11 mmol/L (200 mg/dl) or known diabetes mellitus
Bicarbonate (HCO₃^-) < 15 mmol/L and/or venous pH < 7.3

Typical deficits in DKA in adults

Water: 100 ml/kg
Sodium: 7-10 mmol/kg
Chloride: 3-5 mmol/kg
Potassium: 3-5 mmol/kg

Cause

Missed insulin doses, sepsis, MI, pneumonia, UTI
Drugs, acute abdomen, meningitis.
Pregnancy. Surgery, pancreatitis
Look for and treat any cause

Clinical

Comatose, polyuria, dehydrated, hypotensive, tachycardic
Kussmaul breathing, acetone breath

Markers that indicate consideration for HDU

Blood ketones > 6mmol/L or K < 3.5 mmol/L
HCO₃ < 5mmol/L or Venous/arterial pH < 7.0
GCS < 12 or Abnormal AVPU scale
O₂ saturation < 92% on air
Systolic BP < 90mmHg
Pulse > 100 or Pulse < 60bpm
Anion gap > 16 [AG = (Na+ + K+) - (Cl- + HCO₃^-) ]
Senior discussion and assess for Level 2 HDU bed

Investigation

FBC, U&E, LFTs, Glucose, Lactate
Venous blood gas unless low SaO₂ and needs ABG
Blood cultures, urine culture, CXR if signs/symptoms

Management: Fluids (70 kg man) 6L in first 18 hrs

If SBP < 90 mmHg give 0.5 L 0.9% Saline IV over 10–15 min and repeat if BP < 90 mmHg and seek senior medical advice. Once BP > 90 mmHg continue as below
1L 0.9% Saline over 1st hour
1L 0.9% Saline with KCl over 2 hours x 2
1L 0.9% Saline with KCl over 4 hours x 2
1L 0.9% Saline with KCl over next 6 hours
Cautious fluid replacement in young adults
Avoid over hydration in 18-25 year old, Elderly, Pregnant
Caution with Cardiac/Renal failure or other serious co-morbidities.

Potassium per bag in first 24 hours

Include KCl unless anuria suspected. Adjust according to plasma-potassium concentration (measured at 1 hr, 2 hours, and 2 hourly thereafter; measure hourly if outside the normal range).
K > 5.5 mmol/L: Give none
K 3.5-5.5: 40 mmol in each Litre
K <3.5 : 40 mmol/L + Senior review

Re-assessment of cardio-vascular status at 12 hours is mandatory, further fluid may be required

Insulin: Do not use a priming (bolus) dose of insulin

Start fixed rate IV Insulin infusion (FRIII) weight adjusted in kilograms. Use an infusion pump with 50 U Actrapid in 50ml with NS. Make up to 1 unit per ml. Ensure mixed thoroughly.
Infuse Insulin IV at 0.1 unit/kg/hr. Multiply Weight in Kg
Give bolus (stat) dose of IM insulin (0.1 unit/kg x weight in Kg) if delay in setting up a FRIII
Continue any long-acting insulin analogues Lantus, Levemir or Tresiba SC at usual dose and time.

Glucose

Once CBG < 14 mmol/litre, start glucose 10% IV infusion (into a large vein and large-cannula) at a rate of 125 mL/hour, in addition to the sodium chloride 0.9% infusion.

Recommended Treatment goals

Blood-ketone concentration should fall by at least 0.5 mmol/litre/hour and blood-glucose concentration should fall by at least 3 mmol/litre/hour.
Continue insulin infusion until blood-ketone concentration is below 0.3 mmol/litre, blood pH is above 7.3 and the patient is able to eat and drink; ideally give subcutaneous fast-acting insulin and a meal, and stop the insulin infusion 1 hour later.
Ensure venous bicarbonate falls by 3.0 mmol/L/hour and maintain potassium between 4.0 and 5.5mmol/L
If these rates are not achieved, then the FRIII rate should be increased

Complications

Cerebral oedema, Mortality 3-5%
Mucormycosis, Heart failure, Hypokalaemia, Hypoglycaemia

Condensed Pathway

Link here

References

PLEASE NOTE LEGAL ADVICE: The contents are under continuing development and improvements and may contain errors of omission or fact. The official launch will be at the end of 2018. Feedback vital and always welcome at drokane at gmail.com. This is not to be used for the assessment, diagnosis or management of patients. It should not be regarded as medical advice. It is only for educational purposes. Please adhere to your local protocols. If you are unwell please seek healthcare advice from your doctor. This does not replace senior or specialist advice. If you do not accept this then please do not use the website. If you need medical advice, please consult a doctor or other appropriate medical professional. If you are a medical professional and you need advice then speak to your senior or colleagues.

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