HDU/level 2 facility and/or insertion of central line may be required in the following circumstances (request urgent senior review in pregnant female)
Heart or kidney failure
Other serious comorbidities
Severe DKA by following criteria:
Blood ketones above 6 mmol/L
Venous bicarbonate below 5 mmol/L
Venous pH below 7.1
Hypokalemia on admission (below 3.5 mmol/L)
GCS < 12
Systolic BP below 90 mmHg
Pulse over 100 or below 60 bpm
Anion gap above 16 [anion gap = (Na+ +K+)– (Cl− + HCO3−)]
Immediate Management upon Diagnosis 0–60 min
Aim
Clinical and biochemical assessment of patient
Expansion of intravascular volume by IV 0.9 % sodium chloride solution
Correction of deficit in fluids, electrolytes, and acid base status
Initiation of insulin therapy to correct hyperglycemia
Monitoring of the patient – hourly blood glucose, hourly ketone measurement and two hourly potassium measurements, 4 hourly plasma electrolyte
Diabetes specialist team to be involved at the earliest
Action 1: Rapid Initial Assessment
ABC – respiratory rate, temperature, blood pressure, pulse, oxygen saturation – assessment is to be done as soon as patient arrives in DKA.
Full clinical examination – if patient is drowsy, put NG tube with airway protection to prevent aspiration. Large-bore IV cannula is introduced to start fluid replacement. If systolic BP is below 90 mmHg, 500–1000 ml of 0.9 % saline is infused rapidly over 15–20 min.
Oxygen is to be given to the patients with severe circulatory impairment or shock.
Antibiotics are to be given to febrile patients after obtaining appropriate cultures of body fluids.
Patient is catheterized if unconscious or unable to void on demand Simultaneously.
Initial investigations to be sent include:
Blood ketones
Capillary blood glucose
Venous plasma glucose
Urea and electrolyte
Venous blood gases
Full blood count
Blood cultures
ECG
Chest radiograph
Urine analysis and culture
Continue cardiac monitoring.
Continue pulse oximetry.
Establish usual medication for diabetes.
Action 2: Fluid Administration
Most important initial step is appropriate fluid replacement and the main aims are:
Restoration of circulatory volume
Clearance of ketones
Correction of electrolyte imbalance
It is recommended that crystalloid rather than colloid is used for fluid resuscitation. 0.9 % sodium chloride solution is the fluid of choice, and it should be cautiously administered as fluid replacement in pregnancy. In a woman of about 70 kg, there may be up to 7 l deficit of fluid. The aim of the first few liters of fluid is to correct any hypotension, replenish the intravascular deficit, and counteract the effects of the osmotic diuresis with correction of electrolyte disturbance. Below is a table outlining typical fluid replacement regimen:
Fluid | Volume over time |
|---|---|
.9 % sodium chloride 1 L with potassium chloride | 1000 ml over 1st h |
.9 % sodium chloride 1 L with potassium chloride | 1000 ml over next 2 h |
.9 % sodium chloride 1 L with potassium chloride | 1000 ml over next 2 h |
.9 % sodium chloride 1 L with potassium chloride | 1000 ml over next 4 h |
.9 % sodium chloride 1 L with potassium chloride | 1000 ml over next 4 h |
.9 % sodium chloride 1 L with potassium chloride | 1000 ml over next 6 h |
Reassessment of cardiovascular status at 12 h is mandatory |
Action 3: Potassium Replacement
Hypokalemia and hyperkalemia are life-threatening conditions and are common in DKA. Serum potassium is often high on admission (although total body potassium is low) but falls precipitously upon treatment with insulin. Regular monitoring is mandatory.
Potassium level in first 24 h (mmol/L) | Potassium replacement in mmol/L of infusion solution |
|---|---|
Over 5.5
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