management of an adult with diabetic ketoacidosis
Last reviewed 01/2018
Management of DKA is aimed at optimization of volume status; hyperglycemia and ketoacidosis; electrolyte abnormalities; and potential precipitating factors:
- fluid administration and deficits
- is the most important initial therapeutic intervention which is aimed at
- restoration of circulatory volume
- clearance of ketones
- correction of electrolyte imbalance
- 0.9% sodium chloride is recommended as the initial replacement fluid
- rate and volume of fluid replacement may need to be modified for patients with kidney or heart failure, the elderly and adolescents.
- insulin therapy
- a fixed-rate intravenous insulin infusion (FRIII) calculated on 0.1 units⁄ kg is recommended
- if the following metabolic targets are not achieved, the FRIII rate should be increased
- reduction of the blood ketone concentration by 0.5mmol/L/hour
- increase the venous bicarbonate by 3.0mmol/L/hour
- reduce capillary blood glucose by 3.0mmol/L/hour
- maintain potassium between 4.0 and 5.5mmol/L
- intravenous glucose infusion
- introduction of 10% glucose is recommended when the blood glucose falls below 14 mmol ⁄ l in order to avoid hypoglycaemia, while continuing the fixed-rate intravenous insulin infusion to suppress ketogenesis.
- continue 0.9% sodium chloride solution concurrently to correct circulatory volume if the fluid deficit has not been corrected.
- glucose should not be discontinued until the patient is eating and drinking normally
- potassium, bicarbonate, and phosphate therapy
- if serum potassium is
- <3.3 mEq/L – stop insulin and give potassium intravenously
- 3.3 and 5.3 mmol/L – small amounts of potassium may be added to the intravenous fluid
- >5.3 mmol/L. – no replacement is necessary
- adequate fluid and insulin therapy will resolve the acidosis in diabetic ketoacidosis and the use of bicarbonate is not indicated
- there is no evidence of benefit of phosphate replacement and the routine measurement or replacement of phosphate is not recommended.
- patients should be educated about t the precipitating cause and early warning symptoms (1,2)
The patient should be converted to an appropriate subcutaneous regime when biochemically stable (blood ketones less than 0.6mmol/L, pH over 7.3) and the patient is ready and able to eat (1).
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