Management of an adult with diabetic ketoacidosis

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).

Reference:

• (1) Savage MW et al. Joint British Diabetes Societies guideline for the management of diabetic ketoacidosis. Diabet Med. 2011;28(5):508-15
• (2) Gosmanov AR, Gosmanova EO, Dillard-Cannon E. Management of adult diabetic ketoacidosis. Diabetes Metab Syndr Obes. 2014;7:255-64