continuing management in DKA
Continue monitoring and document input/output fluids.
- urinary catheterisation should be avoided but may be useful in the child with impaired consciousness
- if massive diuresis continues fluid input may need to be increased.
- if large volumes of gastric aspirate continue, these will need to be replaced with 0.45% saline with KCl.
Check biochemistry, blood pH, and laboratory blood glucose 2 hours after the start of resuscitation, and then at least 4 hourly. Review the fluid composition and rate according to each set of electrolyte results
If acidosis is not correcting, consider the following
- insufficient insulin to switch off ketones
- inadequate resuscitation
- sepsis
- hyperchloraemic acidosis
- salicylate or other prescription or recreational drugs
Use near-patient ketone testing to confirm that ketone levels are falling adequately
- if blood ketones are not falling, then check infusion lines, the calculation and dose of insulin and consider giving more insulin.
- if adequate insulin is being given think of sepsis, inadequate fluid input and other causes
Insulin management once ketoacidosis resolved
- continue with IV fluids until the child is drinking well and able to tolerate food
- only change to subcutaneous insulin once blood ketone levels are below 1.0 mmol/l, although urinary ketones may not have disappeared completely.
- discontinue the insulin infusion 60 minutes (if using soluble or long-acting insulin) or 10 minutes (if using Novorapid or Humalog) after the first subcutaneous injection to avoid rebound hyperglycaemia.
- subcutaneous insulin should be started according to local protocols for the child with newly diagnosed diabetes, or the child should be started back onto their usual insulin regimen at an appropriate time (discuss with senior staff) (1).
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