Diabetic Ketoacidosis
&
Severe Hyperglycemia
Objective:
For initial assessment (including the severity) of adults
patients of established cases as well as for first timers
presenting to with DKA/Acute severe hypoglycemia
To plan management of patients accordingly
Use: In all clinical areas by clinicians/
endocrinologists/physicians
Diabetic Ketoacidosis
Diagnosis:
Short history of polyuria, polydipsia, polyphagia, weight loss
Vomiting
Abdominal pain
Dehydration
Acidotic breathing
Hypotension
Tachycardia
Hypotension
Altered sensorium
Hematemesis
ICU admissions
Criteria:
Plasma glucose >250 mg/dl
Arterial pH <7.3
HCO3 < 18 mEq/L
Urine Ketones moderate to large
Anion gap > 10
1
st
Step
RBS by Glucometer (followed by Lab confirmation)
IV Cannula
ABG Analysis
Urgent Lab test: BL Glucose, BUN, Creatinine, CBC, Na, K,
ABG, Osmolality, c/s-blood/urine, CXR, ECG, Urine R/M
and Ketones, HBA1c, LFT
IV insulin 20U stat
1 L Normal Saline (without KCL)
2
nd
Step
RT, if comatose/gastric distension
CVP line, if in CHF or remain hypotensive
Urinary catheter, if conscious, oliguric or in retention
Connect to ECG monitor
Antibiotics IV Broad Spectrum
SC Heparin, if S.osm > 350 msm/L (Inj. Heparin 5000U SC 8
hourly)
Identify ppt factors- infection, MI, CVA etc
Alternatively use sliding scale of
IV Insulin infusion by syringe
pump
40 U Regular Insulin (U-40 vial)
in 39 ml Normal Saline
Reduce infusion rate in elderly
or h/o CHF
5 301-350
6 >350
3 251-300
2 201-250
1 121-200
0.5 81-120
0 < 80
Insulin dose RBS mg/dl
Monitor
q 2-4 hrly: Na, K BUN, Creatinine, ABG
q 1 hrly: RBS by Glucometer
q 1 hrly: Urine Output, Pulse, BP
Urine Ketones each time urine is passed
Avoid rapid correction of RBS to reduce risk of
Cerebral Edema
Precipitating Factors:
Infection
CVA
Alcohol Abuse
Pancreatitis
Trauma
Drugs
New Onset type 1 DM
Discontinuation or adequate insulin in established type 1
DM
Psychological problems complicated by eating disorders
Key Evaluation
Look for precipitating factors
Frequent patient monitoring
Regular lab monitoring as per protocol
Examination:
Vitals
Hydration status
Consciousness level
Systemic exam including neurological
Especially look for abdominal distention and
bowel sounds
Dos
Always look for Precipitating factors
Monitor hydration status closely
Monitor serum potassium (S.K) closely
Regular adjustment of insulin infusion scale, if targets
are not being met with
Don'ts:
No SC Insulin if moderate to severe DKA
Avoid rapid correction of blood sugar
Avoid Hyperkalemia
Key medications:
Insulin
IV Insulin: Regular (H.Actrapid/ Huminsulin R)
Preferably use U-40 vial with U-40 Syringe
SC Insulin (U-40- H.Actrapid/ Huminsulin R; U-100 Huminsulin
R; NPH, U-40 H. Monotard/ Huminsulin N; U-100
Huminsulin N)
Regular Insulin- given before meals
NPH at bedtime
U-100 insulin syringe for U-100 vial
Clinical Pearls
Identify precipitating factors
Frequent monitoring- hydration, blood sugar, serum K
Achieve and maintain targets
Avoid overzealous treatment- rapid correction of blood
sugar/ over hydration/ hypokalemia
Stupor/Coma Alert/ Drowsy Alert Sensorium
>12 >12 >10 Anion Gap
<10 10-5 5-18 Serum HCO3
<7.00 7.00-7.24 7.25-7.30 Arterial pH
>250 >250 >250 P.Glucose
Severe Moderate Mild
Severity of DKA
Other Lab findings
Leucocytosis
Low serum sodium
Serum Potassium: elevated/normal/low
Amylase/lipase elevated
Serum Osmolality >/= 320 mosmol/kg if stupor/coma
Differential diagnosis
Starvation ketosis; plasma glucose low, serum
HCO3 > 18 mEq/L
Alcoholic ketoacidosis: mildly elevated plsma
glucose, H/O alcohol abuse
Lactic acidosis: elevated blood lactate levels
Uremic acidosis
Treatment Principles
Correction of dehydration, hyperglycemia and
electrolyte imbalance
Identification of precipitating events
Frequent patient monitoring
Fluids
Adult patients
Initial fluids: 0.9% normal saline
Rate: 15-20 ml/kg in the first hour (~1 1.5 L in
average adult)
If hypovolemic shock: use plasma expander as well
If Cardiogenic shock: Hemodynamic moinitoring
Subsequent fluid:
Check serum sodium
Serum sodium high or normal: 0.45% saline at Rate of 4-14
ml/kg/hour
Serum sodium low: 0.9% saline at the rate of 4-14 ml/kg/hour
(1 L/hour x 3 hours)
Subsequent Fluid:
Check Plasma Glucose
If ~ 250 mg/dl
Change to 5% dextrose with saline (DNS) at rate of
150-250 ml/hour
Pediatric patients
Initial fluid : normal saline (for 10% hydration)
1
st
hour : NS 500 ml
2
nd
hour: NS 500 ml with 20 mEq KCL
For 3
rd
to 12
th
hour: 200ml/hour x 10 hours
Followed by 100 ml/hour x 24 hours
Total fluids: 5.4 L in 36 hours
Insulin:
Continuous IV insulin infusion
Dose: 0.15 U/Kg IV bolus (or 20 U) of regular insulin followed
by continuous IV infusion @ U/Kg/Hour (5-7 U/hour)
If plasma glucose does not fall by 50-70 mg/dl from initial
value in first hour, check hydration status
If acceptable, increase insulin infusion rate by 2 U every hour
until plasma glucose falls by 50-70 mg/dl
Once plasma glucose level reaches 250 mg/dl reduce
infusion rate to 0.05-0.1U/Kg/Hour (3-6 U/hour)
Insulin (Cont..)
Maintain plasma glucose between 150-200 mg/dl until
metabolic control is achieved
Monitor every 2-4 hourly: serum electrolytes, glucose,
blood urea nitrogen, creatinine, Osmolality, venous pH
Once DKA resolves, i.e. plasma glucose < 200 mg/dl,
S.HCO3> 18 mEq/L, venous pH > 7.3, anion gap < 12
mEq/L and the patient is able to take fluids orally,
switch over to subcutaneous insulin
Insulin use for Pediatric Patients
Insulin 0.1 U/Kg wt stat followed by 0.1
U/Kg/hour continuous infusion till RBS ~ 250
mg/dl
Then, reduce the dose to 0.05 U/Kg/hour
Potassium
Maintain serum potassium between 4.0 and 5.0
mEq/L
If S.K is between 3.3 5.5 mEq/L, add 20-30 mEq
KCL to each liter of IVF
If S.K is above 5.5 mEq/L, hold KCL but check S.K
every 2 hours
Bicarbonate
Its use is controversial
Prospective randomized controlled trials have failed to show
any benefit at pH between 6.9 and 7.1 and more than 7.0
No prospective randomized studies have been reported on use
of bicarbonate therapy at pH < 6.9
Given that severe acidosis may lead to adverse vascular
effects, it seems prudent to give bicarbonate when pH < 7.0
Bicarbonate (cont..)
For pH < 6.9, 100 mmol bicarbonate is added to 400 ml of
sterile water and infused at the @ 200 ml/hour
Bicarbonate is not used if pH > 7.0
In pediatric patients, if pH > 7.0, bicarbonate therapy is not
used
If pH < 7.0. repeat pH after initial hour of hydration.
If still < 7.0, give NaHC03 1-2 mEq/Kg added to 0.45% saline
over 1 hour
Check venous pH every 3 hours until pH > 7.0; repeat
treatment every 2 hours if necessary
Give @0 mmol KCL per 100 mM of HCO3; recheck S.K later
Phosphate
Indication:
1. Cardiac dysfunction
2. Anemia
3. Respiratory depression
4. Serum Phosphate < 1 mg/dl
Dose: 20-30 mEq/L Potassium phosphate added to replacement
fluids
Complications:
Hypoglycemia
Hypokalemia
Hyperchloremic metabolic acidosis
Cerebral edema
Hypoxemia
Non-Cardiogenic pulmonary edema
Cerebral Edema
Clinical features
Lethargy
Headache
Deterioration in sensorium
Seizures
Bradycardia
Respiratory arrest
Pathogenesis:
Too rapid fall in plasma
Osmolality with treatment of DKA
Prevention:
Gradual replacement of sodium
and water deficits: maximal reduction in
Osmolality 3 mosmol/kg/hour and addition
of dextrose to hydrating fluid once blood
Glucose reaches 250 mg/dl
Prevention:
Periodic review sick day management with all patients
Use supplemental short acting insulin during stress
Control fever and treat infection promptly
Initiate liquid diet containing carbohydrates and salt during sick
days if the patient cannot take meals
Never discontinue Insulin
Seek professional help early
Check urine ketone when blood glucose is > 300 mg/dl
Thank You
