Transcript Management of Diabetic Ketoacidosis

Management
of Adult
Diabetic
Ketoacidosis
Adapted from the WHO
IMAI District Clinician
Manual Vol. 1
Dr. Linda Hawker, June 2014
Presentation of DKA

Three Main Features:

1. Hyperglycaemia : blood sugar over 17
mmol/litre (more than 300 mg/dl))

2. Ketones increased in urine and blood

3. Acidosis: Blood pH less than 7.3 due to
Ketoacidosis and Lactic acidosis

Slide 1
Dehydration
 DKA
causes significant fluid loss, usually 3
to 6 litres and causes lactic acidosis
 Expect
to give many litres of fluid during
treatment
 Rehydration
is very important

Slide 2
Potassium Loss
 With
acidosis comes potassium (K+) loss
 All
patients will require potassium
replacement

Slide 3
Who can have DKA?
Can be child or adult, type 1 or type 2
diabetes (more common in Type 1).
Common triggers:



Infection (example: pneumonia,
gastroenteritis, urinary tract infection)
Stopped medications
Long duration of disease

Slide 4
What does the patient look
like?

Usual presentations:








Nausea, vomiting, abdominal pain
Fatigue, muscle cramps
Increased voiding (polyuria), increased drinking
(polydipsia)
Lethargy, eventually coma
Deterioration starting with infection
Shortness of breath, deep breaths
Shock (dehydration or sepsis)
Ketotic (sweet smelling) breath
Slide 5
Important !
The
dehydration, acidosis and
electrolyte problems are
more dangerous than the
high blood sugar and must be
treated first

Slide 6
Investigations
 Blood
glucose, should be more than 14
mmol/l (252 mg/dl)
 Electrolytes, creatinine, bicarbonate
 ECG
 Urine dipstick for glucose and ketones
 Whole blood count, blood culture if fever
 Chest X ray if suspect pneumonia

Slide 7
Treatment

Step 1: Give IV fluids, start promptly

Step 2: Correct potassium problems

Step 3: Give insulin

Step 4: Treat precipitating cause (eg: infection)

Slide 8
Manage Fluids
Step 1
 Start
IV - if in shock (SBP < 90) give 1 litre
normal saline (NS) immediately , give as
quickly as possible. Do not add K+ to this
litre
 If no shock, IV NS at 5-10 ml / kg body
weight per hour ( about 1 litre per hour in
average adult)
 Replace fluid more cautiously if pregnant,
heart failure, kidney failure, elderly

Slide 9
Manage potassium (K+)
Step 2
 K+
will fall quickly as you give IV fluids, can
cause heart arrhythmias
 Monitor K+ levels or ECG hourly for 4 hours
 Give IV K+ slowly over an hour, never by
bolus, can add to IV Normal saline
 Keep K+ at 4-5 mEq/litre
 If can’t do blood K+, monitor by ECG

Slide 10
Manage Potassium (K+)
 If
lab can do blood potassium level, do
not start replacing K+ until less than 3.3
and urine output is at least 50 ml per hour.
 If lab can’t do K+, use ECG to see if signs
of low or high K+.
 If can’t do K+ or ECG, starting with the
second hour of IV fluids, add 20mmol K+
to each litre of fluid and slow IV rate
once the patient is producing urine.

Slide 11
ECG and low or high K+
Low K+ (hypokalemia) Level under 3.3:
 Small or absent T waves, large U wave,
 Add 40 mmol per litre of fluid and run at one litre
per hour until EKG normal
High K+ (hyperkalemia) Level over 5.3:


Tall, pointed T waves and widened QRS
Don’t add K+ to IV, check again in 1 hour

Slide 12
ECG: normal and low K+ levels
Slide 13
ECG: high K+ levels
Slide 14
Manage Glucose
Step 3
 Start
short-acting (soluble) insulin
subcutaneous (SC),intramuscular (IM) or
intravenous(IV) once you have begun
fluid replacement, and if K+ is over 3.3
 Children under 18 years are at increased
risk of cerebral oedema and it is better to
wait until fluids have been given for 1-2
hours before starting insulin

Slide 15
First Hour: fluids, K+, insulin
Insulin : Add 100 units of regular (soluble) insulin to 100 ml of sodium chloride 0.9% (normal
saline) to make a standard concentration of 1unit insulin/ml of IV solution
Source of table: WHO IMAI District Clinician Manual Volume 1 pages 138, 139
Slide 16
After first Hour: fluids, K+, insulin
Note:
Col. 1
Col. 2
K+ < 3.3
Col. 3
K+ 3.3 – 5.3
Col. 4
K+ > 5.3
Col. 5
Slide 17
Monitoring DKA
 Check
pulse, BP, hydration status and
level of consciousness every hour and
confirm that the fluids are being infused
 If possible, check blood glucose every
hour until it is less than 14 mmol/l, then
switch to dextrose in saline infusion
(dextrose 5% +sodium chloride 0.45%)
 Check K+ level or ECG on arrival, then
every hour x 4 hours, then after 4 hours

Slide 18
Monitoring DKA



May stop IV therapy and hourly insulin when
patient can eat and drink and there are no
signs of acidosis (deep breathing), and if
blood glucose is under 12 mmol/l ( 216
MG/DL)
Then patients can receive maintenance
insulin shots according to glucose levels and
weight
Assess for signs of infection and start
antibiotics as soon as possible

Slide 19
Giving Insulin after IV

If patient is drinking and eating:
Resume home insulin if glucose controlled
 If new to insulin:
0.7 units lente x patent’s weight in kg = total daily
dose (usually given at bedtime or split 50% at
breakfast and 50% at bedtime)*
Eg: 80 kg pt. x 0.7 = 56 units lente (28 U qAM + 28 U
qHS)
Don’t give insulin if blood glucose under 4

* Based on Interior Health SC Insulin PPO for adult pt. eating
Slide 20
Key Messages
 Start
IV fluids early, patients are
dehydrated
 Monitor K+ by blood or ECG, replace
slowly by infusion, never bolus
 Monitor blood sugar, give short acting
insulin SC or IV (IV infusion requires
extremely close monitoring)
 Treat infection promptly

Slide 21
Core Reference Sources
Available on WHO Publications Web site
 WHO
Integrated Management of
Adolescent and Adult Illness (IMAI) District
Clinician Manual : Hospital Care for
Adolescents and Adults Volume 1
 Quick
Check in Emergency/OPD: pages
18 – 25 of IMAI Manual – a very useful
method of triaging ill patients in OPD.
Available as wall poster too.

Slide 22
Questions?
Zambezi floodplain
Slide 23