11 most common pitfalls in the management of DKA including diagnosis, when to call ICU team, potassium replacement, fluid replacement, transition to subcutaneous insulin, post DKA management including follow up after discharge

1. Pitfalls in DKA
management
Abu-Bakr Sowilem
Diabetes and endocrinology unit
Medical department Al Sabah Hospital

2. 1st pitfall: Is it DKA or not?

3. 1st pitfall: Is it DKA or not?
• The ‘D’ – a blood glucose concentration of >11.0 mmol/L or known
to have diabetes mellitus
• The ‘K’ – The ‘K’ – a capillary or blood ketone concentration of >3.0
mmol/L or significant ketonuria (2+ or more on standard urine sticks)
• The ‘A’ – a bicarbonate concentration of <15.0 mmol/L and/or
venous pH <7.3

4. 2nd pitfall: what could be the cause?

5. 2nd pitfall: what could be the cause?
• The cause or precipitating factors must be identified and
documented to educate the patient later.
• New onset type 1 diabetes
• Missed or inadequate insulin dose
• Infection
• Surgery
• Myocardial infarction
• Others: pancreatitis, alcohol abuse, trauma or drugs.

6. 3rd pitfall: When to call ICU team?

7. 3rd pitfall: When to call ICU team?
The presence of one or more of the following may indicate severe DKA:
• Blood ketones > 6.0 mmol/L
• Bicarbonate < 5.0 mmol/L
• Venous pH below 7.0
• Hypokalemia on admission (< 3.5 mmol/L)
• GCS < 12
• Oxygen saturation <92% on air
• Systolic BP < 90 mmHg
• Pulse >100 or < 60 bpm
• Urine output <0.5ml/kg/hr.

8. 4th pitfall: Do we need rapid vigorous
correction of dehydration?

9. 4th pitfall: Do we need rapid vigorous
correction of dehydration?
Type of
fluid
Rate of
infusion
Amount
of fluid

10. Type of fluid:
• 0.9% NaCl solution (‘normal saline’) is the fluid resuscitation of
choice.
• But once the blood glucose falls below 14.0 mmol/L, a 5% dextrose
infusion should be added to act as the substrate for the insulin, to
prevent hypoglycemia.

11. Amount of fluid:
• Typical water deficit is 100 ml/kg.
• Typical fluid replacement regimen for a previously well 70 kg adult
will be 7000 ml.
• Heart or kidney failure groups need specialist input as soon as
possible and special attention needs to be paid to their fluid balance.
• If body weight <40kg : 1500ml+(20ml/kg/day for each kg>20kg). This
deficit is replaced over 48 hours

12. Rate of infusion:
• A slower infusion rate should be considered in young adults.
• Re-assessment of cardiovascular status at 12 hours is mandatory,
further fluid may be required.
Volume
Fluid
1000 ml over first hr
0.9% sodium chloride 1L
1000 ml over next 2 hr
0.9% sodium chloride 1L
1000 ml over next 2 hr
0.9% sodium chloride 1L
1000 ml over next 4 hr
0.9% sodium chloride 1L
1000 ml over next 4 hr
0.9% sodium chloride 1L
1000 ml over next 6 hr
0.9% sodium chloride 1L

13. 5th pitfall: Potassium assessment

14. 5th pitfall: Potassium assessment
• Hypokalemia and hyperkaliemia are potentially life-threatening
conditions during the management of DKA.
• Regular monitoring is mandatory.
• Hold insulin infusion if potassium level is below 3.3 mmol/L.
Potassium level in first 24 hours
(mmol/L)
Potassium replacement in mmol/L of infusion
solution
Over 5.5 Nil
3.5-5.5 20-30
Below 3.5 40

15. 6th pitfall: How to start insulin?

16. 6th pitfall: How to start insulin?
• Using loading dose makes no difference as initial BG response is
largely dependent on rehydration.
• Commence a fixed rate intravenous insulin infusion (FRIII)via an
infusion pump.
• Infuse at a fixed rate of 0.1 unit/kg/hr. (i.e. 7 ml/hr. if weight is 70 kg)

17. 6thpitfall: How to start insulin?
• If the glucose falls below 14.0 mmol/L, consider reducing the rate of
intravenous insulin infusion to 0.05 units/kg/hr. to avoid the risk of
developing hypoglycemia and hypokalemia.
• If the individual normally takes long acting basal insulin continue this
at the usual dose and usual time.

18. 7th pitfall: Do we need a follow up sheet for
DKA

19. 7th pitfall: Do we need a follow up sheet for
DKA
• Patients with DKA should be carefully monitored to ensure adequate
response to treatment and to avoid any complications.
• Maintain an accurate fluid balance chart, the minimum urine output
should be no less than 0.5 ml/kg/hr.

20. 7th pitfall: Do we need a follow up sheet for
DKA
• The hourly glucose readings should be recorded directly into the
notes.
• Measure venous blood gas for pH, bicarbonate and potassium at 60
minutes, 2 hours and 2 hourly thereafter

22. 8th pitfall: Intravenous bicarbonate?

23. 8th pitfall: Intravenous bicarbonate?
• Adequate fluid and insulin therapy will resolve the acidosis in DKA
and the use of bicarbonate is not indicated.
• Intensive care teams may occasionally use intravenous bicarbonate if
the pH remains low (PH below 7 or Bicarbonate level below 5
mmol/L) and inotropes are required.

24. 8th pitfall: Intravenous bicarbonate?
• HCO3 (mEq) required = 0.5 x weight (kg) x [24 - serum HCO3].
• The required sodium bicarbonate diluted in 1 L of D5W to be
intravenously infused at a rate of 1 to 1.5 L/hour during the first hour.

25. 9th pitfall: When DKA is considered resolved?

26. 9th pitfall: When DKA is considered resolved?
PH>7.3
Ketones
<0.6
Closed
anion
gap

27. 9th pitfall: When DKA is considered resolved?
• Do not use bicarbonate as a surrogate at this stage because the
hyperchloremic acidosis associated with large volumes of 0.9%
sodium chloride will lower bicarbonate levels.
• Do not rely on urinary ketone clearance to indicate resolution of
DKA, because these will still be present when the DKA has resolved.

28. What do you expect?

29. Expectation:
• By 24 hours the ketonemia and acidosis should have resolved in most
people.
• People who have had DKA should be eating and drinking and back on
normal insulin within 24 hours.

30. Expectation:
• If this expectation is not met within this time period it is important to
identify and treat the reasons for the failure to respond to treatment.
• It is unusual for DKA not to have biochemically resolved by 24 hours
with appropriate treatment.

31. 10th pitfall: Conversion to subcutaneous
insulin

32. 10th pitfall: Conversion to subcutaneous
insulin
• The person with diabetes should be converted to an appropriate
subcutaneous regime when DKA resolved and they are ready and able
to eat.
• The intravenous insulin infusion should not be discontinued for at
least 30 to 60 minutes after the administration of the subcutaneous
dose given in association with a meal.

33. Conversion to subcutaneous insulin
• If the person was previously on a long acting insulin this should have
been continued and thus the only action should be to restart their
normal short acting insulin at the next meal.
• There should be an overlap between the insulin infusion and first
injection of fast acting insulin.
• The fast-acting insulin should be injected with the meal and the
intravenous insulin and fluids discontinued 30 to 60 minutes later.

34. Conversion to subcutaneous insulin
• The person’s previous regimen should generally be re-started if their
most recent HbA1c suggests acceptable level of control i.e. HbA1c
<8.0%
• If previously under inadequate control ,SC insulin can be given as 70%
of daily infusion dose as basal insulin and 30% as bolus insulin.

35. Conversion to subcutaneous insulin
• If insulin Naïve patients: estimate total daily dose TDD by:
1-Reviewing insulin requirements over last 24 hours.
2-0.5 to 0.75 units per kg.
• TDD should be divided as 50% basal and 50% premeal doses in
addition to a correction dose.

36. 11th pitfall: Plan for follow up and discharge

37. 11th pitfall: Plan for follow up and discharge
• Planning for follow-up and discharge should start at admission,
including diabetes education and selection of an appropriate and
affordable insulin regimen.
• Psychological support and proper education are integral components
of the management and prevention DKA.