6. Type of Diabetes
• Insulin dependent diabetes mellitus (IDDM)
• Autoimmunity to β-cell à insulin secretion ↓
• The most common first presentation is DKA.
Type 1 diabetes
• Non-insulin dependent diabetes mellitus (NIDDM)
• Obesity
• Insulin resistance à insulin secretion ↑/ insulin action ↓
Type 2 diabetes
• Defect of β-cell function
• Decfect of insulin action
• Drug-induced diabetes
• Infections
Other types
7. Katsarou A. et al. Type 1 diabetes mellitus. Nat Rev Dis Primers ,2017.
16. Goal of Management
• Correct acidosis and reveres ketosis
• Correct dehydration
• Restore blood glucose to near normal
• Monitor for complications
• Identify and treat precipitating causes
17. 1. Correct dehydration
1.1 Initial fluid resuscitation
• Moderate to severe DKA
• No shock > 0.9% NaCl 10-20 ml/kg iv in 60 min
• Shock > 0.9% NaCl 20 ml/kg iv in 15-30 min
• Actual Body weight (Ideal body weight in obese pt.)
• May repeat until improved tissue perfusion
• Maximum 1-1.5 L in 1st hour for obese pt.
(max 30 ml/kg in 2 hr)
• NPO in moderate to severe DKA
18. 1.2 Subsequent fluid
• Correct dehydration in 36 hours
• Calculate fluid
• Subsequent fluid = maintenance fluid + deficit fluid
• Maintenance fluid
• Holliday-Segar or
• Basal surface area: 1,500 ml/m2/day
• Deficit fluid
• Substract initial fluid resuscitation from calculated deficit fluid
• Replace half of deficit volume in first 12 hours then other half
in the next 24 hours
1. Correct dehydration
19. • Start insulin after rehydration 1-2 hr
• Start Regular insulin infusion 0.05 - 0.1 unit/kg/hr IV
• Add side-line seperated to IV fluid:
RI 100 units + 0.9%NaCl up to 100 ml (1unit : 1ml)
• Discard 30 ml of insulin from infusion set to saturate the binding site
• Always use insulin pump
• Monitor bedside BG hourly
2. Correct hyperglycemia
20. • Keep blood glucose 150-250 mg/dL
• Keep blood glucose ↓ 50-100 mg/dL/hr
• Switch to 5%DNSS, 5%DNSS/2 after BG 250-300 mg/dl or
BG is decreasing greater than 100 mg/dL/hr
• If BG < 150-250 mg/dL with positive ketone and acidosis may
require higher dextrose concentration (7.5%-12.5%)
• If BG < 70 mg/dL, add 10%glucose 2 mL/kg IV slowly push then
increase dextrose concentration
• Titrate insulin 0.01 unit/kg/hr
2. Correct hyperglycemia
21. 3.1 Potassium replacement
• Total body potassium deficit from osmotic diuresis
and poor intake
• Add K 40 mmol/L in subsequent IV fluid
• Monitor EKG 12 leads
• Contraindication: acute kidney injury, anuria, presence of
tall peak T wave in EKG (sign of hyperkalemia)
3. Electrolyte replacement
22. 3.1 Potassium replacement
Serum K (mmol/L) Supplement (mmol/L) in
1 L fluid
< 2.5 Hold insulin infusion and
bolus K 0.5 mmol/kg/hr
< 3.5 40-60
3.5-5.5 30-40
> 5.5 No K supplement then
monitor
*KCl or K2HPO4 (KCl 20 mmol/L + K2HPO4 20 mmol/L or KCl 40 mmol/L)
3. Electrolyte replacement
23. 3.2 Sodium replacement
• Corrected Na = measured Na (mmol/L)+ 1.6 x [(plasma glucose(mg/dL) - 100)/ 100]
• Effective serum osmolality (mOsm/kg H2O) = 2(serum Na) + plasma glucose (mg/dL)/ 18
• If corrected Na >150 mmol/L
• Correct dehydration slowly in 48-72 hr
• Consider using 0.9% NaCl initially
• Close monitor of cerebral edema
• Avoid rapid changing in serum osmolality
3. Electrolyte replacement
24. 3.3 Bicarbonate replacement
• NaHCO31-2 mmol/kg IV drip in 1 hr single dose
• No benefit for DKA treatment
• Consider in
• Life-threatening hyperkalemia
• Severe acidosis (pH <6.9) with shock
• Complications from HCO3 replacement
• Cerebral edema
• Left shift of oxyhemoglobin dissociation curve
• Severe hypokalemia
3. Electrolyte replacement
29. • Cerebral edema
• Management
• Admit ICU, monitor neuro signs
• Elevate the head of the bed to 30˚
• Keep the head in the midline position.
• Adjust fluid replacement to slower rate
• 20% mannitol or 3% NaCl infusion
5. Complication
30. Monitoring
- Vital sign
- Neurological sign
- Blood glucose
Every 1 hour
- Fluid intake/output
- Serum electrolyte
- BUN, Cr, Ca, PO4, Mg
- Blood gas
- Serum ketone or urine ketone
Every 2-4 hours
31. DKA flow chart
Time Pulse
BP
POCT Serum
ketone
Electro-
lyte
Corrected
Na
Serum
osmol
Anion
gap
Insulin IV fluid I/O
32. Consider ICU admission
• Severe DKA
• Prolonged onset
• Hemodynamic instability
• alteration of consciousness
• Patients with risk of cerebral edema:
age <5 yr old, severe acidosis, low pCO2 , high BUN
34. • Fluid: start oral intake after 12-24 hr of treatment
• If poor intake, continue IV fluid
• Insulin
• Stop RI IV after RI 0.25-0.5 unit/kg SC 1-2 hr then
RI q 6 hr, adjusted dose for normo-glycemia in 1st day
After resolution of DKA
35. • Insulin
• Following day
New case:
Total daily dose 1.0-1.5 unit/kg/day (1.0-2.0 unit/kg/day in puberty)
Modified conventional regimen
- 2/3 of TDD premeal morning (NPH:RI = 2:1)
- 1/3 of TDD (NPH:RI = 1:1) (RI: premeal evening) (NPH: hs)
Basal bolus regimen
- Rapid acting insulin (60% TDD) premeal
- Long-acting insulin (40% TDD) hs
After resolution of DKA
Old case: same regimen
36. After resolution of DKA
• Self-monitoring of blood glucose (SMBG)
• 4 times/day (premeal and hs)
• Suspected hypoglycemia or hyperglycemia
• Before exercise
• If >250 mg/dL, evaluate urine ketone
• DM education (patient and family)
• Disease
• Insulin
• Diet & exercise
• SMBG
• Hypoglycemia/hyperglycemia, school readiness, special events
• Complication
37. • 5 year old girl
• present with abdominal pain and vomiting for 3 days
• Hx of polyuria, polydipsia, weight loss (last BW 17 kg) for 2 weeks
• BW 15 kg at ER
• PE: T 38.5℃, P 120/min, BP 85/60 mmHg, RR 30/min
• Capillary refill 3 sec, sucken eyeballs, Kussmaul breathing +
• Good consciousness, others unremarkable
• Lab
• BG 500 mg/dL, serum ketone 6 mmol/L, Urine ketone 4+
• Na 128 (correct 135), K 3.0, Cl 96, HCO3 4
• Venous BG: pH 7.05, BE -14
• Normal EKG 12 leads
• CBC: WBC 20,000/mm3 (N predominate)
• UA: WBC 20-30/HPF
• H/C, U/C pending
38. • BW 15 kg at ER
• Severe DKA, BG 500 mg/dL
• Fluid deficit 10%
• 1st hour :Initial fluid resuscitation > 0.9% NaCl 10 ml/kg iv in 60 min
• 0.9% NaCl 150 ml iv in 60 min
• 2nd hour: vital sign stable, BG 420 mg/dL
• Subsequent fluid = Maintenance fluid + Deficit fluid
39. • 2nd hour: vital sign stable, BG 420 mg/dL
• Subsequent fluid = Maintenance fluid + Deficit fluid แก้ใน 36 hr
• MT = 1000 + 250 = 1250 ml > 1250/36 = 34.7 ∼ 35 ml/hr
• Deficit = 10% x BW x 10 = 1500 ml > หักลบ initial fluid > 1500 - 150 = 1350 ml
แบ่งแก้ครึ/งหนึ/งใน 12 hr แรก (675 ml) และแบ่งอีกครึ/งในอีก 24 hr ต่อมา (675 ml)
• Rate IV fluid ของส่วน deficit fluid 12 hr แรก = 675/12 = 56.25 ∼ 57 ml/hr
• Rate IV fluid ของส่วน deficit fluid 24 hr ต่อมา = 675/24 = 28 ml/hr
• K 3.0
• RI (1:1) 0.1 unit/kg/hr IV
• 0.9% NaCl 1000 ml + KCl 20 mmol/L + K2HPO4 20 mmol/L
IV 92 ml/hr x 12 hr then 63 ml/hr x 24 hr
• RI (1:1) 1.5 unit/hr
• Cef-3 750 mg IV OD
• Monitor V/S, BG q 1 hr !
• Monitor lab q 2-4 hr !!
• Monitor Complication !!!
