Type 1 DM |
Type 2 DM |
Diabetes in Pregnancy |
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
|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
- Mortality is 1-5 %. Significant complications include brain injury with cerebral oedema
- 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
- Missed insulin doses, sepsis, MI, pneumonia, UTI
- Drugs, acute abdomen, meningitis.
- Pregnancy. Surgery, pancreatitis
- Look for and treat any cause
- 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
- 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.
- 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
- Cerebral oedema, Mortality 3-5%
- Mucormycosis, Heart failure, Hypokalaemia, Hypoglycaemia