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Related Subjects: Type 1 DM | Type 2 DM | Diabetes in Pregnancy | HbA1c | Diabetic Ketoacidosis (DKA) Adults | Hyperglycaemic Hyperosmolar State (HHS) | Diabetic Nephropathy | Diabetic Retinopathy | Diabetic Neuropathy | Diabetic Amyotrophy | Maturity Onset Diabetes of the Young (MODY) | Diabetes: Complications |

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

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

References

• The management of DKA in adults September 2013
• Adult Diabetic Ketoacidosis Diabetes.org.uk