The document discusses the management of diabetic ketoacidosis (DKA). It begins by describing the pathophysiology of DKA, noting that ketone body breakdown produces hydrogen ions leading to metabolic acidosis. It then outlines the diagnostic criteria for DKA and grades of severity. The initial goals of therapy are to replace fluid and electrolyte deficits, slowly correct hyperglycemia, and treat any precipitating illnesses. The document provides detailed guidance on evaluation, monitoring, fluid resuscitation, insulin therapy, and electrolyte replacement to safely manage a patient in DKA. It emphasizes close monitoring and individualization of treatment based on the patient's clinical status and laboratory values.

1. EMERGENCY
MANAGEMENT OF
DKA
Dr okidi
DR JOHN OKIDI

2. PATHOPHYSIOLOGY OF DKA
DR JOHN OKIDI

3. KETONES
1. Ketones –Acetone,3-β
hydroxybutyrate and
acetoacetate
2. Predominant ketone -
3-β hydroxybutyrate
3. Dissociation of
ketones produces
hydrogen ions that
cause metabolic
acidosis
DR JOHN OKIDI

4. DKA DIAGNOSTIC TRIAD
I. Ketonemia
 ≥3mmol/l or
 significant ketonuria(≥ ++on urine
II. Blood glucose
 >200mg/dl (11.0mmol/l or known diabetic
III. Bicarbonate
 <15mmol/l,venous PH <7.3 or both
Other diagnostic creterion
 Anion Gap:>12
DR JOHN OKIDI

5. GRADES OF DKA
1.Mild –pH 7.21-7.3,HCO3 10mmol to
15mmol/l
2.Moderate –pH 7.11-7.2,HCO3 5mmol to
10mmol/l
3.Severe-pH<7.1,HCO3 <5mmol/l

6. INITIAL GOALS OF
THERAPY
To replace fluid and electrolyte deficits
Slowly correct the hyperglycemia
Treat the precipitating illnesses
Treat the potential complications that may
arise during medical therapy:
•Hypoglycemia
•Hypokalemia
•Hypophosphatemia
•Fluid overload-cerebral edema
DR JOHN OKIDI

7. MANAGEMENT OF DKA
Action 1:Initial evaluation
Action 2:Full clinical assessment
Action 3:calculate
 Anion Gap
 correcting sodium for hyperglycemia
 Osmolarity
 Interpret ABGS
Action 4:decide whether icu patient or not
Action 5:intervene
 Replace fluids
 Insulin therapy
 Serum potassium replacement
 Bicarbonate therapy
 Monitoring RX
DR JOHN OKIDI

8. MANAGEMENT OF DKA
Action 1:Initial evaluation
In the first minute assess the ABCs
Obtain venous access(large bore cannulae)
Obtain blood for:
•Serum Glucose levels
•serum electrolytes
•Blood ketone(superior to urine ketone)
•Creatinine.
•CBC
•Leukocytosis (common in DKA)
•BUN
•ABGs(venous or capillary)
Obtain urine for urinalysis and ketones
Obtain weight
DR JOHN OKIDI

9. ACTION 2:FULL CLINICAL
ASSESSMENT
a) Conscious level(GCS):NGT GCS <9
b) Airway: ensure patency & adequate ventilation
c) Breathing: Respiratory rate, supplemental oxygen till
shock if any is resolved
d) Circulation: check capillary refill time, peripheral
pulses, skin temperature, BP & urine output.
DR JOHN OKIDI

10. ACTION 3:FULL EXAMINATION
Full examination(particular interest on evidence
of:
o cerebral edema
(headache,vomiting,hypertension,bradycar
dia,hypoventilation,papilloedema(late sign)
o ileus
o Identify any precipitating factor
o Infection
o Myocardial infection
o Stroke
o Pulmonary embolism
DR JOHN OKIDI

11. ACTION
4:CALCULAT
E
ANION GAP
Anion Gap = ((Na+) + (K+) )–((Cl
-
)+
(HCO3
-
) ]
Normal Range :10-18 mmol/l
Mainly used in diagnosing different
causes of metabolic acidosis
In metabolic acidosis, plasma HCO3
-
is ↓
Na+ unexchange→↑ Cl
-
so as to maintain
electro neutrality thus
hyperchloremic metabolic acidosis
Ref :oxford clinical handbook of
medicine 10ed pg 670
DR JOHN OKIDI

12. INTERPRETI
NG ABGS
Normal blood pH range is 7.35- to
7.45
Normal bicarbonate level is 22 to 28
mEq/L.
Look at the pH
is the primary problem
acidosis (low) or alkalosis
(high)
2. Check the CO2 (respiratory
indicator)
is it less than 35 (alkalosis)
or more than 45 (acidosis)
3. Check the HCO3 (metabolic
indicator)
is it less than 22 (acidosis) or
more than 26 (alkalosis)
4. Which is primary disorder (Resp. or
Metabolic)?
If the pH is low (acidosis),
then look to see if CO2 or
HCO3 is acidosis (which ever
is acidosis will be primary).
If the pH is high (alkalosis),
then look to see if CO2 or
HCO3 is alkalosis (which ever
is alkalosis is the primary).
The one that matches the pH
(acidosis or alkalosis), is the
primary disorder. DR JOHN OKIDI

13. CALCULATE
:PLASMA
OSMOLALITY
Calculation of plasma Osmolality
= 2 x (Na + K)+ Glucose/18 +
BUN/3
•One osmole=1mole(6.02×1023 of
solute particles)
•Osmolality =osmole/kilogram water
•Osmolarity=osmole/litre of solution.
•Isotonic solution ; water concentration
is equal for the two compartment thus
solute cannot enter or leave the cell.
•D5
•0.9% N/S
•Hypotonic solution: solution having
lower conc of impermeant solute thus
H20 will diffuse into the cell causing it
to swell
•N/S < 0.9% n/s
•Hypertonic solution: soln having a
higher conc of impermeant solutes,
water will flow out of the cell into the
extracellular fluid, concentrating the
intracellular fluid and diluting the
extracellular fluid
•e.g Nacl soln > 0.9%
DR JOHN OKIDI

14. CALCULATE:
CORRECTING SODIUM
FOR HYPERGLYCEMIA
Corrected Na+ = measured Na +
1.6 meq/L x (glucose-100)/100))
Example:
Measured laboratory Na+ = 123 mmol/l/L and
Glucose = 1,250 mg/dl
1,250 – 100 = 1,150 / 100 = 11.5 x 1.6 = 18
mmol/l/L
Corrected Na+ = 123 + 18 = 141 mmol/L
From the above example if one
didn’t correct that patient would have
been managed for hyponatraemia yet
with correction he is not
hyponaetraemic
Calculating plasma osmolarity and
corrected sodium helps in choice of
fluids
Na+ is depressed by 1.6 mEq/L per 100
mg/dl glucose
 Normal [Na+]=133-146
mmol/l
 Mild hyponatraemia:
plasma Na >120mEq/l
but<133.
 Severe
hyponatremia:plasma Na
<109mEq/l
 Main extracellular cation
 Pathophysiology:
• Loss of sodium
• Water retention
DR JOHN OKIDI
Recall

15. ACTION 4:CRETERIA FOR
HDU/ICU ADMISSION
Patient WITH severe DKA or
has any of the following
1. Hypokalaemia on admission
(<3.5 mmol/L)
2. Bicarbonate <5 mmol/L
3. Anion gap >16
4. Blood ketones > 6 mmol/L
5. Venous/arterial pH below 7.1
Clinical assessment
1. GCS <12
2. SBP <90 mmHg
3. Pulse >100 or < 60 bpm
4. SPO2 < 92% on air
(assuming normal baseline
respiratory function)
DR JOHN OKIDI

16. MANAGEME
NT
Rehydration
Replace fluids: 1L of
0.9% saline over first
1hr (5–10 mL/kg per
hour); subsequently,
0.45% saline at 150–
300 mL/h;
 change to 5%-10%
glucose and 0.45%
saline at 100–200
mL/h when plasma
glucose reaches 250
mg/dL (14 mmol/L).
Rule of thumb
0.9% saline is the replacement
fluid of choice
Typical fluid deficit is
100ml/kg so an average 70kg
man=7litres
DR JOHN OKIDI

17. GUIDE TO FLUID REPLACEMENT IN A
70KG MAN WITH DKA
FLUID RATE DURATION OF
INFUSION
1 Liter 0.9% Saline 1000ml/hr 1 HR
1 Liter 0.9% Saline 500ml/hr(May add KCL) 2HR
1 Liter 0.9% Saline 500ml/hr 2HR
1 Liter 0.9% Saline 250ml/hr 4HR
1 Liter 0.9% Saline 250ml/hr 4HR
1 Liter 0.9% Saline 150ml/hr >6HR-8hours
1 Liter 0.9% Saline
Clinical assessment
Depends on clinical
judgement

18. FLUID REPLACEMENT
DILEMMA
Choice :
If corrected Na
+
> 150 mmol/l or osmolarity>350mosm/kg use
0.45%.
When blood sugar <14mmol/l change to 5% -10% but should also
continue with N/S
Caution:
If patient is old or has a heart rate or renal failure or sign of cerebral
edema ,titrate I.V fluids with caution.
Rate :
Faster if SBP<90mmHg
Procedures:
Catheter if has not passed fluid by 1hour of fluid therapy
Consider NGT if vomiting or drowsy or GCS <9
DR JOHN OKIDI

19. INSULIN THERAPY
Administer regular insulin: IV (0.1
units/kg) or IM (0.4 units/kg), then 0.1
units/kg per hour by continuous IV
infusion;increase 2- to 10-fold if no
response by 2–4 h.
DR JOHN OKIDI

20. INSULIN THERAPY
•Daily total body insulin requirement 0.5-0.7 u/kg
•Use only regular insulin
•Critical to resolve acidosis, not hyperglycemia
•Decreases blood glucose by 50-100 mg/dl/hr (2.7-
5.5mmol/l)/hr
•Must continue insulin therapy to correct acidosis
•How to constitute insulin: 250 units regular insulin in
250 cc of 0.9%NS or 50 units in 50mls of NS OR 100
units in 100mls of NS = (1.0 units/ml) =0.1 u/ 0.1 ml

21. MANAGEMENT-INSULIN THERAPY
 How to Dose insulin :
 initial load dose 0.1u/kg insulin regular ,then maintain on 0.1 unit/kg/hr continuous
drip (regular insulin ) e.g a 70kg man will require ; 70x0.1units=7 units/hr=7mls of
constituted insulin drip above and this can be easily given with the syringe or
volumetric pumps in HDU/ICU . This is called Fixed Rate I.V insulin
Infusion(FRIII) .Aim for a target fall in blood ketones of 0.5mmol/l/hr, or a rise in
venous bicarbonate of 3mmol/l/hr with a fall of 3mmol/l/hr. if not achieving this
,increase insulin infusion by 1unit/hr until target is achieved
 Continue FRIII until serum ketones <6mmo/l, venous PH >7.3,venous bicarbonate
>15mmol/l.
 If NOT IN HDU give :
 I.V soluble insulin 6-10units /hour till blood sugar is < 14 mmo/l.
 If no improvement in blood glucose or ketosis double insulin dose every 2 hours
 If blood sugar is in range of :
 >14 to < 16 mmol/l start subcutaneous insulin
 Start to run 5% -10% Dextrose or dextrose saline run at rate of 100-200ml/hr
alongside saline.
 Insulin infusion may be decreased to 0.05–0.1 units/kg per hour.
Administer intermediate or long-acting insulin as soon as patient is eating. Allow for
overlap in insulin infusion and subcutaneous insulin injection
DR JOHN OKIDI

22. INSULIN THERAPY…
If patient is a wake and can eat start on Basal-Prandial regimen.
If patient is still drowsy and can’t eat give 500mls of 5-10% dextrose
on one arm as you continue with normal saline and put on modified
sliding scale
Modified sliding scale should include insulitard insulin or any other
long acting insulin and soluble insulin.
This should be done for a short time i.e 24-48 hours and then patient
changed to Basal –Prandial insulin if he/she can feed
DR JOHN OKIDI

23. SLIDING
SCALE(SOLUBLE
INSULIN,DKA)
Check RBS @2-4 hours
Rbs(mmol/l) Unit of insulin(iu)
>20mmols/l 20iu
15-20mmol/l 15iu
10-15mmol/l 10iu
5-10mmol/l 5iu
<5mmol/l Don’t give
DR JOHN OKIDI

24. SERUM POTASSIUM
REPLACEMENT
If initial serum potassium is 3.3
mmol/L(3.3 mEq/L), do not administer
insulin until the potassium is corrected
to 3.3 mmol/L (3.3.mEq/L).
K+ level kcl per litre of
fluid(mmol/l)
>5.5 nil
3.5-5.5 30-40mmol/l
<2.2 60-
80mmol/l(ICU,HDU)
DR JOHN OKIDI

25. MANAGEMENT
Replace K: using KCl or Kphos
•10 mEq/hr when
•plasma K <5.5 meq/L
• ECG normal
•Adequate urine flow
• normal creatinine document
•NB:
•Administer 40–80 mEq/h when plasma K< 3.5 mEq/L
or if bicarbonate is given.
•If K >5.5 mEq/l , withhold the potassium therapy and
treat the hyperkalemia if ECG changes are present
DR JOHN OKIDI

26. BICARBONATE THERAPY
Bicarbonate therapy not always indicated as adequate
hydration and insulin correct it.
It may be indicated if ph< 7.1, bicarbonates are <
10mmol/l( profound acidosis)
Do not give in case of life threatening hyperkalemia
± Mannitol(↑ risk of cerebral edema)
DR JOHN OKIDI

27. MANAGEMENT: CONTINUOUS RE-
EVALUATION
1.Reassess patient for precipitating factors
 noncompliance, infection, trauma, infarction, cocaine
 Initiate appropriate workup for precipitating event (cultures, CXR, ECG).
2.Measure
• capillary glucose every 1–2 hours
• Electrolytes (especially K, bicarbonate, phosphate) every 4 hour for first 24
hour.
• Review patient’s response to Fixed Rate IV Insulin Infusion hourly by calculating rate of
change of ketone level fall (or rise in bicarbonate or fall in glucose).
• Assess for reduction in Ketones of 0.5mmol/hr and Blood sugar of 3mmol/hr or if
bicarbonates are not rising by 3mmol/hr
• Anion gap every 4 h for first 24 hour.
o 10-18mmol/l=anion gap=(Na++k+)-(Cl-+Hco3
-)
3. Monitor every 1–4 h.
Blood pressure
pulse
Respirations
mental status
fluid intake and output
DR JOHN OKIDI

28. KETOSIS MGT
Moderate DKA-KETOSIS resolves spontaneously with
standard Rx
Ph<6.9 requires bicarbonate therapy
Ph 6.9-7.0 50 mEq/l over 1hr 0f NaHCO3
PH <6.9 100 mEq/l of NaHCO3
Monitor arterial ph.
DR JOHN OKIDI

29. RESOLUTION OF DIABETES
KETOACIDOSIS
DKA is resolved when:
1. Serum ketones<0.3mmol/l
2. Venous PH>7.3
3. Venous Bicarbonates >18mmol/l
NB Do not rely on urinary ketone clearance to indicate
resolution of DKA
After resolution of DKA establish why it occurred.
Review patient’s regimen with glycosylated
haemoglobin. Adjust or change regimen accordingly

30. COMPLICATIONS OF DKA
Death
Hypokalemia
Acute Lung Injury
Infection
Venous Thromboembolism
Myocardial infarction
Cerebral edema (reperfusion of previously ischemic brain
tissue)

31. SUMMARY OF DKA
MANAGEMENT
1.Confirm diagnosis (plasma glucose, positive
serum ketones, metabolic acidosis).
2. Admit to hospital; intensive-care setting may
be necessary for frequent monitoring or if pH
<7.00 or unconscious.
3. Assess:
Serum electrolytes (K, Na, Mg, Cl ,bicarbonate,
phosphate)
Acid-base status(pH, HCO3, PCO ,
hydroxybutyrate)
Renal function (creatinine, urine output)
DR JOHN OKIDI