how to treat DKA

1. Col. Dr. Tarek Abdelkader Aboulmagd

2. Approach Considerations
 Managing (DKA) in an intensive care unit during
the first 24-48 hours always is advisable.
 The following must be considered and closely
monitored:
Correction of fluid loss with intravenous fluids
Correction of hyperglycemia with insulin
Correction of electrolyte disturbances, particularly potassium loss
Correction of acid-base balance
Treatment of concurrent infection, if present

3. Correction of Fluid Loss
Aim:
Replace
Fluids
Electrolyte
Dilute
Glucose
Counter-regulatory
Hormones

4. Correction of Fluid Loss
The recommended schedule for restoring
fluids is as follows:
1-3 L during
the first hour.
1 L during
the second
hour.
1 L during
the following
2 hours
1 L every 4
hours,
depending
on the
degree of
dehydration
and CVP
readings

5. Correction of Fluid Loss
When
euvolemic,
switch to
half the
isotonic
sodium
chloride
solution
avoid
hypernatremia

6. Correction of Fluid Loss
When blood sugar
decreases to less than
180 mg/dl
Replace isotonic
sodium chloride
solution with 5-10%
dextrose + half
isotonic sodium
chloride solution.

7. Insulin should
be started
about an hour
after IV fluid
replacement
is started
to allow for
checking
potassium
levels
more
dangerous
less
effective

8. Insulin Therapy
• A low-dose insulin regimen is
preferable to avoid severe
hypoglycemia or hypokalemia.
insulin
regimen
• is used for correction of
hyperglycemia.
• IV is better than SC.
short-acting
insulin

9. Insulin Therapy
Initial
pump
0.1
U/kg/h.
Mix
24 units of regular
insulin in 60 mL of
isotonic sodium
chloride at a rate of
15 mL/h (6 U/h)
until the
blood glucose
≤ 180 mg/dL
Then
the rate of infusion
then decreases to 5-
7.5 mL/h (2-3 U/h).
until the ketoacidotic
state abates

10. Insulin Therapy
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.

11. Insulin Therapy
hypoglycemia is
a common
mistake
Rebound ketosis
derived by
counter-
regulatory
hormones.
necessitates a
longer duration of
treatment
other hazard ----
cerebral edema.

12. Electrolyte Correction
(potassium)
• do not administer
potassium> 6 mEq/L
• 10 mEq/h of potassium
chloride.4.5-6 mEq/L
• 20 mEq/h of potassium
chloride.3-4.5 mEq/L

13. Electrolyte Correction
(potassium)
Monitor hourly
infusion stopped K > 5
mEq/L.
continue monitoring
recurrence of
hypokalemia.

14. Electrolyte Correction
(potassium)
In severe
hypokalemia
not starting
insulin therapy
unless potassium
replacement
cardiac
dysrhythmia

15. Electrolyte Correction
(potassium)
Add 20-40 mEq/L of KCl when K
level < 5.5 mEq/L.
Potassium can be given as follows:
two thirds as KCl, one third as KPO4.

16. Correction of Acid-Base
Balance
if decompensated
acidosis
sodium
bicarbonate is
indicated, 100-150
mL of 1.4%
concentration is
infused initially.
repeated every
half hour if
necessary
Rapid and early
correction may
worsen
hypokalemia

17. Treatment of Concurrent
Infection
Proper antibiotics ----------
culture and sensitivity studies.
Starting empiric antibiotics.