Introduction
Diabetic ketoacidosis presents in patients with diabetes. Hyperglycaemia isn’t always present, but patients have raised blood and urine ketones and a metabolic acidosis.
Causes
Infection (30%)
Non-compliance with treatment (20%)
First presentation of diabetes (25%)
Presentation
Polyuria and polydipsia
Weight loss and weakness
Hyperventilation or breathlessness (Kussamaul’s respiration)
Abdominal pain
Vomiting
Confusion
Coma
Examination
General examination including assessment of fluid status.
Look for abscesses and foot ulcers.
ABCDE
Investigation
Blood Glucose
Blood Ketones
Normal Ketones = <0.6mmol/L
Increased risk of ketonaemia = >0.6mmol/L
Ketonaemia = >3 mmol/L.Venous blood gas
U&Es
Urinalysis
FBC
Septic screen
Urine or plasma ketones
(Preferably plasma as urine ketones can persist after resolution).
CXR (infection)
Amylase
Poor prognostic factors
pH <7.0
Oliguria
Serum osmolality >320
Newly diagnosed diabetes
Treatment
Patients with DKA should be managed in a high dependency setting. Cerebral oedema is the main risk.
The Integrated Care Pathway (ICP) for the Management of Diabetic Ketoacidosis (DKA) in Adults, [StaffNet Source] is a pink document in Tayside detailing the insulin and fluid prescribing, as well as further management. This should be used to start treatment.
General measures:
Use the Integrated Care Pathway (ICP) for the Management of Diabetic Ketoacidosis (DKA) in Adults, [StaffNet Source]
ABCDE
Oxygen
IV access
Continuous monitoring
Refer to Medical HDU, diabetes/endocrinology on call
CVP monitoring (if elderly/cardiac failure/CKD 4/5)
NG (if vomiting/unprotected airway)
Catheter (if oliguric or evidence renal/cardiac failure)
CVP monitoring if elderly/cardiac failure/CKD 4/5
Fluid replacement (including glucose once BG ≤ 14mmol/L) + Insulin Infusion
Check HbA1c. Check lab glucose hourly.
Other investigations for cause as appropriate, (ECG, chest XR, MSSU, pregnancy test, blood cultures..)
Electrolyte replacement. (Potassium concentration will fall with treatment).
Recheck U&Es at 1, 2, 4 and 8 hours.
Long acting insulin should be given as usual.
Once the patient is stabilised and eating and drinking S/C short acting insulin should be restarted. (IV infusion continues until ketone free, bicarbonate in target range, patient tolerating fluid and diet..).
Paediatric DKA Management, [StaffNet Source]
