Diagnostic criteria:

·       Serum glucose >250mg/dl

·       Arterial pH <7.3

·       Serum bicarbonate <18mEq/L

·       Ketonuria or ketonemia

Management:

1.      Complete history and initial evaluation/physical examination/ Look for precipitating cause.

2.      Investigations:

·     Capillary glucose to confirm hyperglycemia

·     serum/urine ketones for presence of ketonemia/ketonuria

·     Arterial blood gas for metabolic profile before initiation of intravenous fluids

·     Complete blood count

·     Serum glucose level

·     BUN

·     Serum electrolytes

·     Chemistry profile

·     Creatinine level

·     Urinalysis

·     ECG

·     CXR if needed

·     Specimens for bacterial cultures

3.      Correction of Fluid Loss:

a)    A crystalloid fluid is the initial fluid of choice for Initial correction of fluid loss either by isotonic sodium chloride solution or by lactated Ringer solution. The recommended schedule for restoring fluids is as follows:

·       Administer 1-1.5 L during the first hour.

·       Administer 1 L during the second hour.

·       Administer 1 L during the following 2 hours

·       Administer 1 L every 4 hours, depending on the degree of dehydration and central venous pressure readings

b)   When the patient becomes euvolemic, the physician may switch to half the isotonic sodium chloride solution, particularly if hypernatremia exists. Isotonic saline should be administered at a rate appropriate to maintain adequate blood pressure and pulse, urinary output, and mental status.

c)  If a patient is severely dehydrated and significant fluid resuscitation is needed, switching to a balanced electrolyte solution may help to avoid the development of a hyperchloremic acidosis.

d) When blood sugar decreases to less than 180 mg/dL, isotonic sodium chloride solution is replaced with 5-10% dextrose with half isotonic sodium chloride solution.

e)  After initial stabilization with isotonic saline, switch to half-normal saline at 200-1000 mL/h (half-normal saline matches losses due to osmotic diuresis).

Insulin Therapy:

·       Start insulin therapy about an hour after IV fluid replacement and only if serum K >3.3 mmol/L

·       The initial insulin dose is a continuous IV insulin infusion by infusion pump at a rate of 0.1 U/kg/h. A mix of 24 units of regular insulin in 60 mL of isotonic sodium chloride solution usually is infused at a rate of 15 mL/h (6 U/h) until the blood glucose level drops to less than 180 mg/dL; the rate of infusion then decreases to 5-7.5 mL/h (2-3 U/h) until the ketoacidotic state abates.

·       When plasma glucose reaches 200–250 mg/dL, the insulin rate can be decreased by 50% or to the rate of 0.02–0.05 U/kg/h or

·       In absence of infusion pump, larger volumes of an insulin and isotonic sodium chloride solution mixture can be used, providing that the infusion dose of insulin is similar (eg, 60 U of insulin in 500 mL of isotonic sodium chloride solution at a rate of 50 mL/h).

·       The optimal rate of glucose decline is 100 mg/dL/h. Do not allow the blood glucose level to fall below 200 mg/dL during the first 4-5 hours of treatment. Hypoglycemia may develop rapidly with correction of ketoacidosis due to improved insulin sensitivity.

·       Blood glucose level to be checked hourly if insulin is given by infusion.

Points to remember with insulin therapy:

·       A low-dose insulin regimen has the advantage of not inducing the severe hypoglycemia or hypokalemia that may be observed with a high-dose insulin regimen.

·       Only short-acting insulin to be used for correction of hyperglycemia.

·       Subcutaneous absorption of insulin is reduced in DKA because of dehydration; therefore, using intravenous routes is preferable.

Electrolyte Correction:

·       If the potassium level is greater than 6 mEq/L, do not administer potassium supplement.

·       If the potassium level is 4.5-6 mEq/L, administer 10 mEq/h of potassium chloride.

·       If the potassium level is 3-4.5 mEq/L, administer 20 mEq/h of potassium chloride.

·       Monitor serum potassium levels 6-8 hourly (hourly monitoring is advocated if possible), and the infusion must be stopped if the potassium level is greater than 5 mEq/L. The monitoring of serum potassium must continue even after potassium infusion is stopped in case of (expected) recurrence of hypokalemia.

·       In severe hypokalemia, not starting insulin therapy is advisable unless potassium replacement is under way; this is to avert potentially serious cardiac dysrhythmia that may result from hypokalemia.

Correction of Acid-Base Balance:

·       Sodium bicarbonate is infused only if decompensated acidosis starts to threaten the patient's life, especially when associated with either sepsis or lactic acidosis.

Treatment of Concurrent Infection:

·       Blood and urine culture and sensitivity

·       Start empiric antibiotics on suspicion of infection until culture results are available.

DVT prophylaxis:

·       DVT prevention either by low molecular weight heparin or conventional heparin OR

·       By graduated compression stockings or sequential compression device in patient where heparin is contraindicated.

Management of Treatment-Related Complications: Cerebral edema-

·       0.5-1 g/kg intravenous mannitol over 20 minutes.

·       Repeat if no response is seen in 30-120 minutes.

·       If no response to mannitol, give hypertonic saline (3%) at 5-10 mg/kg over 30 minutes.

Cardiac dysrhythmia-

Cardiac dysrhythmia may occur secondary to severe hypokalemia and/or acidosis either initially or as a result of therapy in patients with DKA. Usually,

·       Correction of the cause sufficient to treat cardiac dysrhythmia,

·       If it persists, consultation with a cardiologist mandatory.

·       Important to continue cardiac monitoring on patients with DKA during correction of electrolytes.

Pulmonary edema-

·       Although initial aggressive fluid replacement is necessary in all patients, particular care must be taken in those with comorbidities such renal failure or congestive heart failure.

·       Diuretics and oxygen therapy often suffice for the management of pulmonary edema.

Myocardial injury-

·       Myocardial biomarkers (troponin T and CK-MB) and

·       ECG to be done Diabetic retinopathy-

·       Microvascular changes consistent with diabetic retinopathy have been reported prior to and after treatment of diabetic ketoacidosis.

Hypoglycemia-

·       In patients with diabetic ketoacidosis, hypoglycemia may result from inadequate monitoring of glucose levels during insulin therapy. Insulin sensitivity improves after clearance of ketones.

Hypokalemia-

·       Hypokalemia is a complication that is precipitated by failing to rapidly address the total body potassium deficit brought out by rehydration and insulin treatment, which not only reduces acidosis but directly facilitates potassium re-entry into the cell.

WORKFLOWOFMANAGEMENTOFADULT DKA

Checklist of DKA management milestones