Dr Samreen Sheikh

MANAGEMENT OF
DIABETIC
KETOACIDOSIS
Pathophysiology of DKA
A collection of severe and potentially life-
threatening metabolic disturbances:
• Hyperglycemia  Osmotic diuresis
» Urinary loss of fluids & electrolytes
» ECFv contraction
» Depletion of total body K+ stores
(even though may be hyperkalemic 2° to cell
shift d/t insulin deficiency and acidosis)
• Ketone production  Metabolic acidosis
» Compensatory Respiratory alkalosis (hopefully)

• Uncontrolled lipolysis  severe  TG

DKA risk factors

• Type 1 DM
• 1st presentation
• Acute-illness
• Insulin omission (inappropriate sick-day management,
noncompliance, Eating Disorders)
• Type 2 DM
• During stress
• Ethnicity: African-American, Hispanic
• Extremes of age
• Poor glycemic control
DKA: Precipitating Factors

Acute illness
(MI, trauma,
10-20% pancreatitis)
20-38%
New-onset DM

5-39% Insulin omission

33%
Infections
DKA: Diagnosis

• Symptoms & Signs:

• Polyuria, polydipsia
• Fatigue
• Nausea,vomitting, abdominal pain(may simulate
acutevabdomen)
  ECFv(increase heart rate,hypotention,dry mucous
membran decrease skin turgor,
• Kussmaul’s( deep) respiration, Acetone (fruity) breath, mild
impairment in cognition
1 Step: Confirm diagnosis
st

• Diabetes: RBS > 250 mg% (occasionally

normal or only mild  BS)

• Ketones: Raised serum ketones (and urine

ketones)

• Acidosis: pH < 7.3, serum HCO3 < 15

mEq/L, AG > 14 mM
2nd Step: Admit

• Admit to hospital

• Intensive-care setting may be necessary

for frequent monitoring or if pH < 7.00 or
unconscious
3rd Step: Assess & Manage

• Serum electrolytes (K+, Na+, Mg2+, Cl-,

bicarbonate, phosphate)
• Acid-base status—pH, HCO3-, PCO2, Beta-
hydroxybutyrate
(Acetone is volatile & expired via lungs;
Ketones may become negative after prolonged
duration between sampling and testing)
• Renal function (creatinine, urine output)
Goals of DKA Management

1. Replace Fluids
2. Halt Ketogenesis and Correct Acidosis
3. Maintain Acid-Base and Electrolyte
Balance
4. Identify & Treat Underlying Cause(s)
Note: Maintainance of euglycemia is not the
sole target of Insulin Infusion in DKA
1st Goal of Management:
Repletion of ECV and ICV
Why?

• There is Extracellular and Intracellular

volume loss due to Osmotic Diuresis
1st Goal of Management:
Repletion of ECV and ICV
• Choice of Fluids:
– 2–3 L of 0.9% saline over first 1–3 h (10–15
mL/kg per hour)
– subsequently, 0.45% saline at 150–300 mL/h
– change to 5% glucose and 0.45% saline at
100–200 mL/h when plasma glucose reaches
250 mg/dL (14 mmol/L).
 2nd Goal of Management:
Halt the Process of Ketosis; Role
of Insulin and Simultaneous
Dextrose Infusion
• Administer short-acting insulin: IV (0.1 units/kg) or IM (0.3
units/kg)
• Then 0.1 units/kg per hour by continuous IV infusion,
increase 2- to 3- fold if no response by 2–4 h
• Adjust rate of Insulin to achieve 30 - 50 mg% / hour
decrase in RBS
3rd Goal of Management:
Maintain Acid-Base and Electrolyte
Balance
• Maintenance of Normokalemia
• Correction of Acidosis via Bicarbonate
Replacement
3rd Goal of Management:
Maintenance of Normokalemia
• K+ defecit: 3-5 mEq/Kg (350 mEq for 70Kg)
• Normal to high serum K+

Ketoacidosis
H+ H+

K+ K +

Insulin
 DKA: Potassium
• Overall, K+ deficit 3-5 mEq/kg (350 mEq in 70kg)
• Need K+ with initial IV fluid & insulin Rx unless:
• Anuric
• K > 5.5 mEq/L or hyperkalemic ECG changes

Initial [K] Replacement > 20 mEq/h:

> 5.5 mEq/L nil (initially) •With Cardiac monitor
• Via Central line
5.2-5.5 mEq/L 10 mEq/h
4-5.2 mEq/L 20 mEq/h
3-4 mEq/L 30 mEq/h
< 3 mEq/L 40 mEq/h
Additional electrolyte replasement

PHOSPHATE
• Required only if phosphate<1.5mg%
• Replase with potassium phosphate
MAGNESIUM
• For mild hypomagnesemia( 1-1.5mg%) give16-
24mEq magnesium sulfate over 8 hours in IV fluids
• For severe hypomagnesemia (<1.0 mg%) give 32-48
mEq magnesium sulfate over 24 hours in IV fluids
 3rd Goal of Management:
Correction of Acidosis via
Bicarbonate Replacement
• The ADA advises bicarbonate [50 mmol/L (meq/L) of
sodium bicarbonate in 200 mL of sterile water with 10
meq/L KCl over 1 h if pH = 6.9–7.0

• or 100 mmol/L (meq/L) of sodium bicarbonate in 400 mL

of sterile water with 20 meq/L KCl over 2 h if pH < 6.9].
Monitoring via Flow Chart

time VS UOP pH HcO AG keto Glc K PO4 IVF insu

3 nes lin
Transition from insulin infusion to
subcutaneous insulin
• Can consider switch to SC insulin when:
• AG normalized
• BS < 270 mg%
• Insulin IV requirements < 2U/h
• Patient able to eat
• Overlap insulin IV infusion with 1st SC insulin by
2-4h to avoid recurrent ketosis
• Type 2 DM patients with DKA:
• Don’t necessarily have to be d/c on insulin SC (Type I DM
do require Insulin for life)
• Once acute stress resolved, many do well on Oral Anti-
Diabetic medictaions
4th Goal of Management:
Identify & Treat Underlying
Cause(s)
• Antibiotics for infection
• Appropriate Cultures and Infection screen
• Look for Occult Abscess
• Rule out ACS
4th Goal of Management:
Identify & Treat Underlying
Cause(s)
• Counselling for:
– Non-compliance
– Appropriate monitoring of blood glucose
during stress
– Adequate increase in Insulin, if in any stress
– Addressing cost issues
– Proper storage and insulin administration
technique
Thank You